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A Cloudy HIT Policy Picture is Beginning to Clear Up

May 29, 2018
by Rajiv Leventhal
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While there are many concurrent winds blowing in the health IT policy and payment world, the administration has taken a hard stance on many key areas

Although the health IT policy and payment landscape has plenty of moving parts, and continues to be fluid, one of the core principles that has not wavered among federal health administrators under President Trump has been a sustained emphasis on moving toward a market-driven value-based healthcare system in which consumers will be at the center of their care.

Indeed, at this time last year, healthcare stakeholders were filled with uncertainty, as the future of healthcare policy remained very much in limbo. But in the past several months, an air of stability has presented itself, and while providers, purchasers and payers undoubtedly still have their fair share of questions, things seem far more solidified than they did just one year ago. Consider the following:

  • In September 2017, Tom Price, M.D., resigned as Department of Health and Human Services (HHS) Secretary. Price, who only served in the role for about seven months, was replaced in January by Alex Azar, a former pharmaceutical industry executive who in just the last two months has been clearer about his desire to accelerate value-based transformation than perhaps Price ever was. “HHS has made shifting our healthcare system to one that pays for value one of our top four department priorities,” Azar recently said.
  • One of the clear themes of this year’s HIMSS (the Healthcare Information and Management Systems Society) conference was the federal administration’s public push toward a free market healthcare in which the patient is empowered through greater interoperability and access, as well as removing government burdens. Federal health officials said at the HIMSS conference, and elsewhere in recent weeks, that reducing clinician burden—such as the documentation stress that EHRs (electronic health records) cause, as well as the piled-up stacks of requirements from regulations and mandates over the years that must be processed—will enable providers to perform better in value-based payment programs, thus directly affecting their reimbursement.
  • Finally, year two of the Quality Payment Program (QPP), under the MACRA (Medicare Access and CHIP Reauthorization Act of 2015) law is underway, and in several instances, providers are asking for further flexibilities so that they continue to ease their way into a new era that pays them for the quality of care they provide rather than the volume of services rendered. What’s more, talk about a possible MIPS (the Merit-based Incentive Payment System, one of the two payment tracks under the QPP) repeal have ramped up, thanks to a recent Medicare Payment Advisory Commission (MedPAC) report to Congress, advocating for the elimination of MIPS and replacing it with an alternative model of reimbursement. But despite these MACRA/MIPS uncertainties right now, there is absolutely no talk about eliminating MACRA—a stark contrast from just a year ago.

When considering all of the policy and payment moving parts, one critically important point to keep in mind is that MACRA/MIPS for clinicians, and meaningful use for hospitals, are required activities, and for the most part, says Jeff Smith, vice president of public policy for the Bethesda, Md.-based AMIA (the American Medical Informatics Association), CMS (the Centers for Medicare & Medicaid Services) “is operated by virtue of the federal register, and there are almost immovable timelines by which change can happen.” What’s more, says Smith, “Over the last 18 months or so, there was definitely a period of time when the new administration was getting into place and officials from CMS and ONC (the Office of the National Coordinator for Health IT) started to get familiar with their surroundings. So, in 2018 we will start to see some of the fingerprints of the new administration make their way onto the policy landscape.”

Jeff Smith

What 2018 Has in Store

The 2018 QPP final rule under MACRA dropped last November, giving eligible clinicians just two months to get ready for the new reporting year. But questions have already emerged about the future of MIPS, following the MedPAC report to Congress, advocating for its elimination and replacing it with an alternative model of reimbursement. As Healthcare Informatics reported at the time, “MedPAC [a nonpartisan legislative branch agency that provides the U.S. Congress with analysis and policy advice on the Medicare program] submits two reports to Congress each year, in March and in June. Back in January, MedPAC voted 14 to 2 to recommend scrapping MIPS and replacing MIPS with a new clinician value-based purchasing program, called the Voluntary Value Program (VVP), and this proposal was included in the advisory group's recent report to Congress.”

MedPAC’s recommendations include an approach to a new value-based purchasing program that would allow clinicians to self-organize into groups that collectively assume responsibility for their patients’ outcomes. Under the VVP, clinicians can elect to be measured as part of a voluntary group, and clinicians in voluntary groups can qualify for a value payment based on their group’s performance on a set of population-based measures, according to the report. The VVP would measure all clinicians on the same set of measures—clinical quality, patient experience and value.

Moving forward, questions linger on if the MedPAC recommendations will be seriously considered by federal administrators, but as Smith points out, “When MedPAC says something, smart people would do well to listen.” At the same time, Smith and others do not believe that MIPS will be repealed and replaced.

“When [MedPAC] issues policies as dramatic and far-reaching as what it has proposed for the reformulation of the QPP and MIPS, you have to pay attention. But paying attention and seeing the work come to fruition are two different things,” says Smith. He adds that the granularity that resides inside of MACRA “far surpasses the ability of CMS to just take MedPAC’s recommendations and run with them. So, you would need a change to the statute, which is not [impossible], but it won’t be easy and it won’t happen on a timeline that most people are expecting.”

Dan Golder, principal at the Naperville, Ill.-based Impact Advisors, points out that CMS has outlined a core goal of wanting to shift folks into taking on more risk, and the agency has come out and said that moving toward advanced alternative payment models (A-APMs) is a top strategic priority. “The vehicle in which to do that is [through] MIPS,” he says.

Golder further explains that CMS has already enabled “super small practices” with low-volume Medicare revenues to bypass MIPS. And because much larger practices have the resources to go into the APM world, that leaves the medium to small groups who will be left in MIPS and who will be competing on the Cost category—a component of MIPS that uses Medicare claims data to collect payment information for care given to beneficiaries. And from there, Golder expects the practices that employ case managers who look at ways to control costs as the ones that will be effective.

Dan Golder

“If you don’t have the dollars to devote to those specialized resources, you won’t be able to compete on Cost, and will be penalized for not being as cost effective as some of the larger groups,” Golder asserts. “Those practices will then [have to] either accept low reimbursement or join an advanced APM. For CMS, the goal is to encourage people to move up to advanced APMs and go at-risk on their own. So, I think CMS will pick a Cost component percentage that will help facilitate that,” he says.

A New Outlook on ACOs and Bundles?

In regard to pushing Medicare clinicians into the A-APM track—and the 5-percent Medicare Part B bonus that comes with it—as opposed to the MIPS track under MACRA, while speaking at the recent American Hospital Association (AHA) annual membership meeting, CMS Administrator Seema Verma made strong remarks about the long-term sustainability of “upside-only” ACOs (accountable care organizations) that do not take on downside risk.

Verma said at that Washington, D.C.-based event that she, along with Azar, have been carefully reviewing payment models that were developed under the previous administration, with a close eye on Medicare ACOs specifically. Verma remarked, “Two-sided ACOs [that take on downside risk] have shown significant savings to the Medicare program while advancing quality.” But, she added, “The majority of ACOs, while receiving many waivers of federal rules and requirements, have yet to move to any downside risk.  And even more concerning, these ACOs are increasing Medicare spending, and the presence of these upside-only tracks may be encouraging consolidation in the market place, reducing competition and choice for our beneficiaries. While we understand that systems need time to adjust, our system cannot afford to continue with models that are not producing results,” Verma said.

Verma was referring to Medicare Shared Savings Program (MSSP) Track 1 ACOs, which do not qualify as A-APMs since they don’t take on downside risk. Indeed, CMS is on the hook for any financial losses in one-sided risk models all on its own.

As such, significant changes to ACO policy seem to be forthcoming. For instance, there is an ACO rule that was sent to the Office of Management and Budget (OMB) on May 1 and is currently pending review (at the time of publication). The proposed rule will likely call for changes to the duration of one-sided risk models and force people into two-sided risk, says Farzad Mostashari, M.D., CEO of Aledade, a Bethesda, Md.-based company that helps create and operate physician-led ACOs, and former National Coordinator for Health IT.

Farzad Mostashari, M.D.

Mostashari says that from Verma and Azar’s perspectives, they expected ACOs to take three years to figure things out before moving into downside-risk programs. “But now people have been in the program for six years, are still doing one-sided risk, and are asking for more time. I think what [CMS] will propose is that if your contract period is over, and you are in a one-sided risk model, you cannot renew that contract. You would have to get out or get up,” Mostashari says.

But just how ready are providers to take on downside risk? Mostashari points out that in the cohort of Track 1 ACOs that began in 2015, and thus had to make a decision in 2018 whether to move into a two-sided risk model or not, only 12 percent voluntarily moved to risk. As Yulan Egan, practice manager, research, at the Washington, D.C.-based Advisory Board, notes, “It is a huge shift for most providers—be it physician groups or hospitals. It requires them to change their care delivery patterns in a pretty drastic way, and add in new programs and strategies that they hadn’t necessarily considered in the past.

That said, a lot of organizations look at this as a “chicken-or-egg” problem, adds Egan. “Do you make the necessary preparations first and then dive into downside risk or do you need the burning platform of the financial incentive to get the organization to make the changes it needs to make and sustain those changes?” She continues, “Providers do recognize that ultimately if they’re going to do this well, they will need to make the commitment and dive into downside risk, even if they don’t feel 100 percent prepared for it. And some of the providers who have been in upside-only programs recognize that this program might not give them quite the incentive and push they need to truly transform the way they deliver care,” Egan says.

Meanwhile, on the bundled payment front, while former HHS Secretary Price and CMS’ Verma have said that they believe that bundled payment models offer opportunities to improve quality and care coordination while lowering spending, they do not support forcing providers into these programs with mandatory requirements. But Azar might feel differently; during a Senate Finance Committee hearing in January on his nomination for HHS Secretary, he said, on the topic of CMMI [the Center for Medicare and Medicaid Innovation] pilot programs, “I believe that we need to be able to test hypotheses, and if we have to test a hypothesis, I want to be a reliable partner, I want to be collaborative in doing this, I want to be transparent, and follow appropriate procedures; but if to test a hypothesis there around changing our healthcare system, it needs to be mandatory there as opposed to voluntary, then so be it.”

In January, CMS announced the launch of a new voluntary bundled payment model called Bundled Payments for Care Improvement Advanced (BPCI Advanced), which will qualify as an A-APM, and which will test a new iteration of bundled payments for 32 clinical episodes, such as major joint replacement of the lower extremity (inpatient), for example. This came just one month after the government finalized a rule that cancelled mandatory hip fracture and cardiac bundled payment models.

Speaking at the World Health Care Congress in Washington, D.C. in early May, Bipin Mistry, M.D., medical director at Remedy Partners, a Darien, Conn.-based company that helps hospitals and physicians with bundled payment programs, and which is the largest awardee convener under the BPCI program, said that this bundled payment program will likely double or triple in size, and if it does, commercial payers will become attracted. But, added Mistry, making the program mandatory “might not trigger that [kind of activity].”

In the end, time will tell if the administration will support mandatory bundled payment programs going forward, particularly around joint replacement procedures and cardiac care—as those are among the most common areas of care in U.S. hospitals and post-acute care organizations—but what’s especially interesting is how Azar could potentially steer HHS in a new direction, one that would be quite different from that promoted by Price, who had been an orthopedic surgeon and a conservative Republican congressman.

For Hospitals, New Payment Proposals Have Teeth

Another major health IT policy moment occurred in late April when a hospital payment proposed rule was dropped by CMS, one that made clear the government’s intention to overhaul meaningful use (the Medicare and Medicaid EHR Incentive Programs)—which has been around since 2011. But the new proposed rule, that applies to about 3,300 acute care hospitals and 420 long-term care hospitals, and which would go into effect in October, if finalized, includes an array of changes that certainly could impact how hospital providers are reimbursed under Medicare in the future.

In the rule, which re-names the meaningful use program to “promoting interoperability,” CMS has included a proposal that would essentially force eligible providers to participate in health information exchange activities. CMS wrote that it is seeking public comment, via an RFI (request for information) on whether participation in the Trusted Exchange Framework and Common Agreement (TEFCA) should be considered a health IT activity that could count for credit within the health information exchange objective in lieu of reporting on measures for this objective.

Those who have been close to the early meetings on TEFCA—which is ONC’s latest plan to jolt the sluggish pace of progress on interoperability between providers— have praised the fact that provider participation in the initiative is currently voluntary. But AMIA’s Smith believes that providers might actually be forced to participate after all.

As Smith noted at the time of the rule’s release, CMS is considering revising its current “Conditions of Participation” for hospitals that would require them to electronically transfer medically necessary information upon a patient discharge or transfer. Other activities could be mandated as well, such as requiring hospitals to send discharge information to a community provider via electronic means, if possible, and requiring hospitals to make information available to patients, or a specific third-party application, via electronic means, if requested.

What does all this mean for providers’ Medicare reimbursements? Well, as Smith pointed out, while CMS removed the meaningful use patient data access objective (view, download and transmit) in this new proposed rule, “what this RFI [on the possibility of revising Conditions of Participation to revive interoperability] seems to be signaling is that they are not saying it’s not important to allow patients to view, download and transmit their information, but quite the opposite. CMS is signaling that they think it’s more important than participating in this little program that could cost you a percentage point or two in reimbursement. They think it’s so important that you don’t get to participate in Medicare [if you don’t meet the Conditions of Participation],” he said.

Indeed, shortly after the release of the rule, Verma tweeted out, “To avoid a payment penalty, providers will have to provide patients with electronic access to their health information.” So, in the end, while providers’ long-standing frustrations with redundant and process-oriented meaningful use measures have finally been heard, CMS might still move forward with the Conditions of Participation RFI revision. If so, it will add yet another element that will be fascinating to follow in the world of health IT policy and payment. 

2018 Raleigh Health IT Summit

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Is the Discourse Over the MSSP Program Teetering Towards Potential Conflict?

September 21, 2018
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The joint statement by nine healthcare associations this week points to potential conflict ahead around the MSSP program

Things appear to be heating up quickly in the interactions between the senior leaders at the Centers for Medicare and Medicaid Services (CMS) and the leaders of some of the accountable care organizations (ACOs) participating in the Medicare Shared Savings Program (MSSP) for ACOs.

As Healthcare Informatics Managing Editor Rajiv Leventhal noted in a just-published report, The National Association of ACOs (NAACOS) and eight other healthcare stakeholder groups have sent a letter to the Centers for Medicare & Medicaid Services (CMS), expressing concerns about the federal agency’s proposed changes to the Medicare Shared Savings Program (MSSP). In August,” he noted, “CMS proposed sweeping changes to the MSSP, by far the largest federal ACO model, with 561 participants. At the center of the proposed rule, called “Pathways to Success,” is a core belief that ACOs (accountable care organizations) ought to move more quickly into two-sided risk payment models so that Medicare isn’t on the hook for money if the ACO outspends its financial benchmarks.”

Further, as Leventhal noted, “Specifically, CMS is proposing to shorten the glide path for new ACOs to assume financial risk, reducing time in a one-sided risk model from the current six years to two years. This proposal, coupled with CMS’ recommendations to cut potential shared savings in half—from 50 percent to 25 percent for one-sided risk ACOs—will certainly deter new entrants to the MSSP ACO program. So far, the proposed rule has been met with varying degrees of scrutiny. NAACOS, comprised of more than 360 ACOs across the U.S., is one association that has been actively pushing back on the CMS proposal. The group believes that ACOs need, and deserve, more time in one-sided risk models since it takes years to develop the necessary infrastructure to be successful. What’s more, NAACOS is of the belief that one-sided risk ACOs actually save far more money than CMS gives them credit for.”

Appropriately, then, considering their offense at CMS’s proposed changes, “NAACOS and others—including the American Medical Association (AMA), Medical Group Management Association (MGMA), and Premier—said in a press release accompanying the letter to CMS that the proposed Pathways to Success program would create several positive changes and includes a number of improvements the value-based community has previously recommended.”

Nor did their press release statement emerge out of a vacuum; indeed, CMS Administrator Seema Verma has become increasingly vocal about her frustrations with the MSSP program in recent months. As Associate Editor Heather Landi noted in a report, in late August during a webinar sponsored by the Accountable Care Learning Collaborative, Administrator Verma spoke in very firm terms about her insistence that ACOs in the MSSP program move forward with alacrity to take on two-sided risk. “I think many people recognize that it’s time to take that next step and it’s time to evolve the program; it’s been six years,” she said on August 27. “We also understand that there may be providers that are not ready. But, our focus is to work with providers that are serious about making the investments and providing better care for lower cost.” And, she added, “I think the experience that we’re seeing is that there are some providers that don’t take a few years to transition, and have come into the program right away, taking full risk, so we know that this is possible. After six years, there is a lot of experience out there and we can learn from one another as far as best practices.”

Statements like those have been deeply concerning to many ACO leaders—thus Thursday’s joint statement. “The ACO community wants to help CMS work through other issues in the rule which, if finalized as proposed, would have unintended consequences of undermining the broader shift to value-based care,” the leaders wrote yesterday. “Specifically, we are very concerned with shortening the time new ACOs have in a shared savings only model from six to two years and cutting in half the shared savings rates for these ACOs from 50 percent to 25 percent. This is especially concerning because a spring 2018 survey showed that over 70 percent of ACOs facing mandatory risk for 2019 were likely to leave the program as a result of being forced to assume financial risk. When analyzing the recent performance year 2017 MSSP results, it shows that Track 1 ACOs achieved more savings per beneficiary than ACOs in the two-sided MSSP models. We request that CMS modify these proposals for all ACOs in the final rule, to allow more time for ACOs in a shared savings only model and to apply a shared savings rate of at least the current 50 percent.”

As the leaders noted, “The MSSP remains a voluntary program, and it’s essential to have the right balance of risk and reward to continue program growth and success. Program changes that deter new entrants would shut off a pipeline of beginner ACOs that should be encouraged to embark on the journey to value, which is a long-standing bipartisan goal of the Administration and Congress and important aspect of the Quality Payment Program.”

What’s more, the membership of this ad hoc group is in many ways as important as the content of their letter to CMS. In alphabetical order, they are: the Association of American Medical Colleges; American College of Physicians; America’s Essential Hospitals; America’s Health Insurance Plans; American Medical Association; Health Care Transformation Task Force; Medical Group Management Association; NAACOs; and Premier Inc.

What’s more, these groups represent a spectrum of stakeholders around the landscape of ACO evolution, including health insurers (AHIP), physicians in practice (AMA), medical group executives (MGMA), integrated health systems (Premier Inc.), and even medical colleges (AAMC). So their open letter to CMS is one that Administrator Verma and all the senior officials at the agency should consider very carefully.

As I said in a blog written after Verma made her comments in that webinar last month, and referring to Health and Human Services Secretary Alex Azar, Administrator Verma, and National Coordinator for Health IT Donald Rucker, M.D., “[I]t seems to me that Azar, Verma, and Rucker, and their colleagues, are in a bit of a challenging place here, because even as the progress has been measurably stronger in the Next Gen ACO program compared with that in the MSSP program, even in Next Gen, it hasn’t been spectacular. Meanwhile, Verma’s attempts to push down harder on the levers of payment and regulation in order to turbocharge ACOs, could very easily backfire, causing more ACOs to leave the MSSP program than to switch to two-sided risk.”

So we find ourselves at an excruciatingly delicate moment now in this “dialogue” between the leaders of ACOs and Administrator Verma. And this thing could “tip” in any direction. I would hope that Administrator Verma and her fellow CMS officials would take into consideration as they plan their next moves, anticipated to involve adding more rigor into the MSSP program. A careful balance will be required in order to avoid alienating perhaps the majority of ACO leaders, while still pushing the program forward. In any case, with regard to this entire subject, as we say in the news business, stay tuned.






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The CEO of a Nationwide Association of MD Groups Sees the Future—and It’s Not in Fee-For-Service

September 18, 2018
by Mark Hagland
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APG’s Don Crane shares his perspectives on the challenges and opportunities facing physician groups in the emerging healthcare landscape

The world of U.S. healthcare is undergoing massive change these days; indeed, the entire landscape around the healthcare system is shifting now, with new entrants, some of them disruptors, changing the realities on the ground for the leaders of patient care organizations. Meanwhile, the implications are legion, for physician-led organizations, including large and not-so-large multispecialty physician groups. Those subjects were topics of analysis in two of the Healthcare Informatics Top Ten Tech Trends, which appeared in the third-quarter 2018 issue of Healthcare Informatics.

For both the Trend article on the new disruptors entering the healthcare system, and the Trend article on the challenges and opportunities physician groups in the emerging landscape, Healthcare Informatics Editor-in-Chief Mark Hagland interviewed Don Crane, president and CEO of the Los Angeles-based America’s Physician Groups (APG), a nationwide association of physician groups involved in risk-based contracting. Crane, whose association represents more than 300 physician groups operating in 45 states, the District of Columbia, and Puerto Rico, is helping to lead a revolution in the medical group world, facilitating the collaboration around innovation among physician groups across the country.

Don Crane

Don Crane will be delivering a keynote presentation on November 9, during the Health IT Summit in Beverly Hills, sponsored by Healthcare Informatics. He will be speaking on the subject of value-based care and clinical transformation, sharing his perspectives as one of the leaders in the physician group world. Below are excerpts from his interview this summer with Hagland.

Looking at all these new business combinations and alliances—the Aetna-CVS deal, the Amazon/Berkshire Hathaway/JP Morgan Chase alliance, the inroads into healthcare being made by Microsoft, Google, and others—what do all of these business and technological incursions mean?

To me, they signal a very restive employer world, a restive and dissatisfied employer world, certainly, when you talk about Google and Amazon, and so, too, with the carrier-PBM combination. There, it’s more about the players looking for a new model, implying that there’s a dissatisfaction to the point of abandonment of faith in the existing model. So, has the inefficiency of our current healthcare delivery system now produced pain at such a high level that it’s no longer about academic conversations, but time for a variety of different actions? That’s what it’s telling me, that we’re about to hit a pain point. Healthcare is using up more and more of our GPD, and really is hitting our global competitiveness now. So yes, this is very significant.

With regard to the planned Aetna-CVS merger—should physicians feel unsettled?

I have an upcoming board retreat, where we’ll be speaking to the Walmart-Humana, CVS-Aetna, and Cigna-ExpressScripts arrangements; I don’t think that the architects of these various transactions see them all in the same way. They have slightly different strategies, and are facing different challenges. These are smart-darn people, and it’s different from the sort of minute-clinic concept we’ve seen in the past. That concept didn’t really take off. Someone said there’s a Walgreens or CVS within 3 minutes of every American, or something. But the minute-clinic concept didn’t exactly work. But what’s different about these diagonal mergers? I think some of it lies in the data—you’ll be combining the data of a health plan with a pharmacy with a PBM [pharmacy benefit management company]. And we’re moving into an era of artificial intelligence and machine learning and the ability to stack up algorithms to the nth degree and know things we didn’t know before.

There’s also the factor of the idea of the transformation of primary care. I think they envision a world where you don’t have to call your doctor six weeks in advance, drive through traffic, wait for hours, wait for days to get your results—and that just doesn’t seem cool in the second decade of the 21st century. It’s a model begging for revolution.

And how will all this impact physician groups? The short answer is, I don’t fully know. The longer answer is, we’re actively thinking about it. The one thing I have a massive amount of faith in is that when it comes to professional care by doctors, nurses, etc., the Pentium chip is organized physician groups; it’s not Dr. Marcus Welby all alone; nor is it health plans that sit on high in penthouse buildings; nor is it hospitals. It’s aggregations of doctors supported by data and analytics, and supported by a constellation of people—psychologists, social workers, even bus drivers, in terms of transportation. And there, you get quality, and you marry within an organization the desire to improve quality and the health of individuals and the population, and at the same time, be stewards of resources. And that’s important, because healthcare’s single biggest problem is unaffordability. So we need stewardship of resources married to expertise in care delivery. I think the new models to come will float to the top.

And, in terms of the disruptors, they envision a world where you don’t have to call your doctor six weeks in advance, drive through traffic, wait for hours, wait for days to get your results—and that just doesn’t seem cool in the second decade of the 21st century. It’s a model begging for revolution.

With regard to the pace of physician groups moving into risk, is it about at the level you’d expect?

As best as I can tell, the pace is going moderately well. Has it accelerated? No. Has it slowed? Probably not. It doesn’t feel like there’s a white-hot fire underneath it at the moment. There is a generalized belief that we need that movement to occur and succeed. At the same time, there are entrenched interests.

Our efforts rise and fall based on what’s going on around the country. And we continue to get new members out of interest in this, but they’re not pounding the doors down yet. They’re reading the signals from the government and commercial payers carefully, and they’re content to sit in the status quo and make a pretty good living, and don’t want to incur enormous cost and effort unless they have to. So the level of push is not as hard as we’d like. But some changes coming out of various rules sets coming out of a very bold and laudable administration, as far as I’m concerned.

When it comes to managing two-sided risk, everyone has spoken of the criticality of data. What’s being learned in that area?

Upside risk makes sense for a while; it’s baby steps. But it’s weak tea in terms of driving real change. If you get lucky with the right benchmarks, you can do well. But it doesn’t induce real structural change. But when an organization faces downside risk, also known as bankruptcy—that really forces change. When you take that higher risk, you’ve got to have the data. You’ve got to risk-stratify your population, and treble down on the resources you’re using on the patients at highest risk. All of a sudden, you move into the big leagues.

Are physician groups beginning to use artificial intelligence and machine learning, in earnest?

The answer is yes. I’m surveying my board next week. But the pioneers are starting to use AI and machine learning, yes.

Do you know yet what they’re learning in terms of process?

Well, of course they’re learning better what the ailments are in a population, etc. They’re just able to do a better job of diagnosis and then care management care planning—being able to treat people more intelligently than ever before.

What percentage of your organizations have unlocked the key around multidisciplinary care teams?

That percentage is very high. Some started a couple of decades ago with this. This is not rocket science, it’s fundamental blocking and tackling. So within my organization, you’ll see a high percentage of organizations making good use of multidisciplinary care teams. Outside my organization, not so much. It’s no secret that you should be using mid-levels to support physicians; but you kind of need the payment model to make it work. Otherwise, you still have doctors working per click, like hamsters on a wheel. As you get into risk-based capitation, that’s where the model changes, and voila—all of a sudden, you have big panels, risk management, and multidisciplinary care teams. You almost can’t separate the organizational model from the payment model.

In terms of physician groups working with social determinants of health data, what are you hearing?

Well, we’re in the early stages of physicians and physician groups moving into working with social determinants of health data. If you talk to a doctor who is still in fee-for-service about the social determinants of health, he’ll say, nice idea, but are you kidding? I didn’t go into healthcare to be a social worker! If you talk to APG members, you’ll see that they totally understand it. You so often need to get into the home, and into transportation, and nutritional support. If a patient can’t get to the doctor’s office, and isn’t eating and is living in a high-crime area, no amount of good diagnosis and prescription will produce a good outcome. In Medicare Advantage, given the latest rate note and the bipartisan Balanced Budget Act, Medicare is basically beginning to cover social determinants of health stuff; that’s in a nascent stage, but people are gearing up for it. I think I saw that Humana and Ascension Health had created a new venture around social determinants.

Meanwhile, we’ve entered into a partnership with Partners in Care, a foundation headquartered in Los Angeles, and they’re available for hire to do home visits and other similar sorts of social work items. And my members are hiring them to do that kind of outreach into patient’s homes. It’s really helpful with the frail elderly and such. So seeing where the puck is headed there, we entered into a partnership with Partners in Care. And that’s a whole new frontier. Now for physicians to be responsible for home visits, well, that’s new. So there’s a transformation underway there as well.

What do you see in the next couple of years around that?

I think it’s just another data set. And if you’re going to start to do home visits to the frail elderly, you’ll need their addresses, of course. And when you do your chops and cuts and sorts, you’ll need to be looking not only at their a1c, but their neighborhood, and their nutritional status, etc., and you’ll now have additional data to help you guide your care plan. It might involve home visits, or Lyft or Uber; so there needs to be data to support that.

How will the data analytics component evolve in the next few years for the leaders of physician groups?

Well, it starts with a recognition of the need for data. Those physicians just wondering what to do about MIPS, etc. They’ll realize they’re utterly unequipped to set up a data analytics shop themselves, so you’ll see movement into groups. And the next step is to get to the facility to do it, and that means joining a group or an IPA. That’s the dynamic we’re going to see. And then we’ll start seeing better results.

And, how do you see the future more broadly?

There’s no future around fee for service; it’s eroding out from under doctors. You look at the Medicare fee schedule and increases slated for the future. What are they? The anticipated increases to physician payment under Medicare are going to be 0.5 percent, 0.25 percent, from here out to as far as the eye can see, they’ll be nearly flat; and the increases in costs of running practices will be increasing 2, 3, 4, 5, 6 percent. So you’re quickly on the way to the poorhouse if you’re trying to stay in a fee-for-service world. So how will we make a living? To make a living doing what you want to do, you’re going to need to find a different way to make a profit under flat revenue. How do you do that? You keep the population healthier. You stare into the data and figure out who will get sick next, by using predictive analytics.


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On Capitol Hill, Healthcare Leaders Raise Concerns with CMS’ Proposed ACO Rule

September 17, 2018
by Heather Landi, Associate Editor
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Healthcare leaders also testified about the need for Stark Law modernization
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A panel of healthcare organization leaders voiced concerns about moving Medicare accountable care organizations (ACOs) to two-sided risk too quickly, as proposed in a recent federal draft rule, and highlighted the need for Stark Law reform during a U.S. House of Representatives Health subcommittee hearing last week.

The U.S. House of Representatives Energy and Commerce Committee subcommittee on Health held a hearing last Thursday examining the barriers to expanding value-based care in Medicare, and panelists used the opportunity to voice concerns to lawmakers about a number of polices and laws that they believe are impeding progress in the transition to value-based care and payment models.

Subcommittee chairman Michael Burgess, M.D. (R-Texas) said the purpose of the hearing was to focus on the evolving transition to value-based care as well as new ways of assuming risk, and the role technology can play in these efforts. In his opening statement, Burgess recognized that value-based care models have been effective at improving quality and lowering costs. “These models are the future of heath care, and it is important that Congress hear from the industry about how the implementation of such models work on the ground or, to the extent it’s not working, it’s important that we hear that as well,” he said.

Many of the panelists shared their opinions on a proposed rule issued by the Centers for Medicare & Medicaid Services (CMS) that proposes a new direction for ACOs in the Medicare Shared Savings program (MSSP), with the goal to push these organizations into two-sided risk models.

The MSSP is the largest value-based payment model in the U.S., growing to 561 ACOs with more than 350,000 providers caring for 10.5 million Medicare beneficiaries in 2018. Under current MSSP rules, new ACOs are eligible to share savings with Medicare for up to six years if they meet quality and spending goals but are not at financial risk for any losses. In the proposed rule, issued Aug. 9, CMS is proposing to shorten that glide path for new ACOs to assume financial risk, reducing time in a one-sided risk model from the current six years to two years. CMS also recommends reducing potential shared savings in half—from 50 percent to 25 percent for one-sided risk ACOs. As such, The proposed rule has so far been met with varying degrees of scrutiny.

During his testimony, Nishant Anand, M.D., chief medical officer for population health services and chief transformation officer for Adventist Health System, and chairman of the Adventist Health System ACO, said he was concerned that policies contained in CMS’ proposed redesign of the MSSP, if finalized, would discourage providers from participating in value-based care.

Anand, who is based at Florida Hospital Orlando and has led value transformations at other health systems, noted that Adventist has ACO arrangements in Kansas, North Carolina and Florida, where the system has 55,000 beneficiaries in its MSSP ACO.

“The existing financial benchmarks, especially in lower cost markets, make it financially prohibitive to transition to a two-sided risk model and will deter providers from participating in the program. If the benchmarks do not provide room for improvement, allowing providers to transition towards value-based care delivery over time, providers will not participate. We must find ways to adjust for the regional variations across the country,” he said.

Continuing, he said, “Second, benchmarks need to be accurately risk adjusted to reflect the underlying health status of the ACO’s population.” And, with regard to CMS’ proposal to limit shared savings payments to 25 percent, he said: “A lower shared savings rate means we will have less to reinvest into population management and care coordination. Limiting the shared saving payments to 25 percent will create an unsustainable business model.”

Anand urged Congressional leaders to consider a “deeper dive into value-based care reforms that will accelerate the journey. “We’re ready to go faster but need additional help with payment reform to focus on holistic care as well as regulatory reform. We need to help ACOs achieve critical mass in order to hit the tipping point where value-based care is what we deliver,” he said.

Michael Robertson, M.D., chief medical officer of Covenant Health Partners and Covenant ACO in Lubbock, Texas, also voiced similar concerns. Robertson, testifying on behalf of the National Association of Accountable Care Organizations (NAACOS), said Covenant Health Partners has operated a clinically integrated network for the past 11 years, through which it has instituted robust health information technology, contracts for hospital services, and quality metrics for measures like hospital-acquired infections.

“We then branched out to commercial contracts and, in 2014, made the quantum leap to a three-year Track 1 MSSP agreement. If we had not already had a clinically integrated network in place, where we had already done much of the work to get ready for MSSP participation, it is unlikely that we would have made the decision to participate in the MSSP. It was also important for us that we didn’t have to be concerned about taking downside risk, since we were in a shared savings-only model,” he said.

There has been much debate and contention between CMS and healthcare industry stakeholders on just how much money one-sided risk ACOs are saving Medicare. An independent evaluation by NAACOs published last week found MSSP ACOs generated gross savings of $1.84 billion for Medicare between 2013 and 2015, nearly double the $954 million estimated by CMS. Last month, CMS data showed ACOs generated $314 million in net savings to Medicare in 2017 after accounting for payments earned by ACOs for hitting spending and quality targets.

Moving to value-based care is a massive undertaking that requires changing the behavior of multiple providers, Robertson testified. “Participation in the MSSP has allowed us to reinvest in technology and infrastructure to manage our patient population. In our first year of participation in the MSSP, we saved Medicare $5 million and our share was $2.5 million,” Robertson said. The organization used the bulk of those funds to reinvest in its IT infrastructure and to develop physician dashboard. “All of these things take time and money; pushing too quickly to achieve results and take on risk, without giving ample time for providers to develop the necessary infrastructure, will mean people don’t participate,” Robertson said.

CMS’ recently proposed MSSP ACO rule would improve the existing MSSP in a number of ways, he said, such as implementing ACO-specific payment rule waivers and beneficiary incentives. “Some of these improvements lend stability to the program, which is very positive,” he said.

“I do have significant concerns about the speed in which the agency is asking people to move to risk as well as the proposal to cut shared savings from 50 to 25 percent. Two years is not enough time to take on risk; it took us 11 years and we’re still hard at it,” Robertson testified. “The reduced shared savings amount is going to keep providers out of this program because it does not allow them to keep enough savings to reinvest in the IT infrastructure and the care coordination that is needed to make these programs work. The limitation of the risk score adjustment of +/- 3 percent over the five-year contractual period will also be harmful as it penalizes physicians financially for taking care of patients who are sicker.”

Stark Law and Anti-Kickback Statue Reforms

During the hearing, panelists also shared their perspectives on how legal barriers are preventing healthcare providers from accelerating toward value-based care.

Mary Grealy, president of the Healthcare Leadership Council, comprised of industry leaders from all sectors of the U.S. healthcare system, testified that the Stark Physician Self-Referral Law and the Anti-Kickback Statute were created to prevent overutilization and inappropriate influence in a fee-for-service environment in which healthcare sectors and entities operated in their own individual silos.

“Today, however, in order to make the transformation to value-based care, we need greater integration of services, improved coordination of care with cross-sector collaborations, and payment that is linked to outcomes rather than volume. Adopting these new delivery and payment models becomes difficult when faced with outdated fraud and abuse laws and potential penalties of considerable severity,” Grealy said.

She said, for example, that hospitals can run afoul of current law by offering physicians performance-based compensation to engage in coordinated care and meet high quality metrics.

Adventist’s Anand also highlighted the need for Stark Law modernization, noting that it is an “impediment” to value-based care. “The Stark Law is highly complex and has created a minefield for the health care industry due to its huge financial penalty risks and its unclear provisions. These risks result in health care providers avoiding value-based arrangements,” he said. While Congress authorized the U.S. Department of Health and Human Services (HHS) Secretary to issue regulatory waivers for models of care, such as the MSSP program, these waivers are issued program-by-program and are not permanent, he said.

Michael Weinstein, M.D., a practicing gastroenterologist and president of Capital Digestive Care, a physician practice with 65 GI doctors in the Washington, D.C. area, also urged policymakers to modernize the Stark Law, noting that fraud and abuse laws are an impediment to develop and implement innovative alternative payment models (APMs). “Physician practices are facing increasing challenges competing with mega-hospital systems, in part, because antiquated Medicare law and regulations generally favor hospital systems,” Weinstein testified.

CMS issued a request for information (RFI) this summer for public input on how to address any undue regulatory impact and burden of the Stark Law. HHS also is considering making changes to the anti-kickback statute as the HHS Office of the Inspector General (OIG) is looking for stakeholder feedback, via an RFI issued August 27.

Morgan Reed, president of ACT | The App Association and executive director of the Connected Health Initiative, told the Health subcommittee members that Medicare regulations and payment policies present serious challenges to the incorporation of technology-driven tools that can make healthcare more accessible and user-friendly. He specifically urged policymakers to take a number of steps, including passing the Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) to Health Act of 2017 and filing down regulations such as features of the Anti-Kickback Statute and the Stark Law. He also urged policymakers to enhance interoperability and access to data through better guidance from the Office of Civil Rights (OCR) and finalizing the “data blocking” rules.

In her testimony, Grealy also noted that the expanded use of telemedicine is essential in more efficient utilization of healthcare resources and expanding the reach of health providers. “We urge Congress and the administration to further address Medicare’s restrictions on reimbursement for telemedicine services. There is also considerable value to be found in making digital health applications more accessible for beneficiaries,” she said.

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