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The AMA’s David Barbe, M.D.: Let’s Work Together to Optimize MD Outcomes Reporting

September 16, 2017
by Mark Hagland
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David Barbe, M.D., president of the AMA, speaks to the challenges and opportunities inherent in MD reporting requirements under MACRA

David Barbe, M.D., president of the AMA, speaks to the challenges and opportunities inherent in MD reporting requirements under MACRA

Developments continue to emerge around the MACRA (Medicare Access and CHIP Reauthorization Act of 2015) law, including around its two broad component programs, the MIPS (Merit-based Incentive Payment System) and APM (advanced payment model) sections of the overall program, administered by the Centers for Medicare and Medicaid Services (CMS), an agency within the Department of Health and Human Services (HHS).

Indeed, the June 20 release of the proposed rule for MACRA’s Quality Payment Program (QPP) for 2018 led to yet another wave of provider reactions and discussion—understandably so, given how important the QPP’s provisions will be, going forward.

It is in that context that virtually all of the major national healthcare professional associations have been actively involved in advocating for some form of optimization of the outcomes measure reporting process under MACRA/MIPS. Certainly, the American Medical Association (AMA; based in Chicago and in Washington, D.C.) has been very prominently involved in advocating for the streamlining and optimization of the reporting processes under MACRA, including under MIPS and under the APMs.

Recently, AMA president David Barbe, M.D. spoke with Healthcare Informatics Editor-in-Chief Mark Hagland about this subject. Dr. Barbe, a practicing family physician who lives and practices in the southern Missouri town of Mountain Grove, began serving his one-year term as elected president of the association in June. He leads and represents an association with 240,000 practicing-physician members nationwide. Below are excerpts from their recent interview.

With regard to the MACRA law and its MIPS and APM components, and in particular, with regard to the quality reporting measures involved in the QPP, where is the AMA right now in terms of its policy position?

We welcome the transition from the old legacy programs into the new more coordinated MIPS program. We appreciate that the number of measurements is fewer, that there is an opportunity for them to be more relevant to physicians and practices; and we appreciate the cooperativeness of CMS in making it easier for physicians to successfully transition into the program.


David Barbe, M.D.

Many physicians in practice are expressing that they’re feeling a growing burden from all the reporting requirements. What is your perspective on that broad complaint?

We absolutely recognize that, and that’s why the AMA has worked so hard to simplify the reporting in any way we can—the number of measures, and the whole issue of the Pick your Pace program—one patient, one measure, no penalty, this year. So if the physician needs more time to figure out how he or she is going to participate more fully, this gives them more breathing. room. We’re working to make the [QPP] measures more relevant; we also believe that shorter periods of more like 90 days, are adequate, and probably a 365-day reporting period probably isn’t necessary. And, outside the rules and regs as such, we need data to be able to be captured more automated way through the EHR [electronic health record]. Manual recovery of data elements doesn’t make much sense in this day and age. So we’re working with the EHR vendors and other developers to reduce the reporting burden.

What can CIOs, CMIOs, and other healthcare IT leaders in patient care organizations, do, to support physicians in practice around the reporting requirements and challenges?

That group is responsible for the infrastructure in hospitals and health systems, and they can play a critical role in helping physicians have the IT tools they need to do what we’ve just described, capture these data elements in an automated way rather than as a single activity. We encourage them to talk to their doctors, to the frontline physicians, and ask them what they need. What’s more, the AMA put out a white paper detailing nine changes the EHR sector can do to make things easier and better for physicians. That looks a little bit beyond what the local CIO can do, but the CIOs will be a significant voice in discussions with the EHR community. And they’re the ones who can say to the vendors, these products aren’t working yet for our doctors. So they have a critical role in this, and I encourage them to work with the medical community.

And could you speak to the role of CMIOs specifically also?

I’m practicing in a large health system myself, and we wrestle with, how do the CMIOs get the sense of what the practicing physicians are feeling? I encourage them to set up a structured format of listening sessions, ways to get feedback from their practicing physicians. I encourage them to become familiar with the tools and comments that organizations like the AMA are making. They need to avail themselves of the very robust information that we’ve collected, and studies we’ve done, and to supplement that with the physicians-on-the-ground feedback, and with useful data from their own systems. That would be a powerful combination.

Is there a legitimate concern over physicians potentially becoming overwhelmed by all of this? Physician burnout is being talked about more and more now.

Absolutely: this whole issue of burnout and frustration with HIT—it is very real. Physicians are overwhelmed, they’re asked to collect data, they’re given tools that don’t do it, and our studies—the first one we did last fall that shows that physicians are doing twice as much time doing data entry and paperwork as in direct clinical time with patients. We just came out with a second study that says the same thing. That is very  demoralizing to physicians; we didn’t train to be data entry clerks, we trained to be clinicians; that’s very  demoralizing. And we’re essentially now doing some of the most menial tasks. It cuts across every specialty  and every setting, including among employed physicians in medical groups. And they may be in groups that aspire to be high-performing, but also

So, one of the issues that’s emerged recently has been a full-blown discussion about the increasing use of medical scribes. Research is beginning to show that there is tremendous variation in scribes’ effectiveness, and even in their accuracy. How do you see this? Are scribes a point of relief for practicing physicians, or are they a sub-optimal response to a deeper and broader problem in the U.S. healthcare system?

I think there is a role for scribes in some settings. Of course, the fact that scribes are even being considered is an admission of failure of health information technology to begin with. That said, given the fact that it’s going to take a while for the EHR to evolve to meet our needs, an interim step is the use of a scribe. And it’s like any other person on the healthcare team; their degree of usefulness is directly related to their training and collaboration with the rest of the team. And the higher-skilled they  can be, the more effective it will be. There’s nothing inherently inadequate about a well-trained individual doing the documentation, but the key is working closely  and well with the physician. We wrestle with this in my  system. We use scribes in the ED in our health system, as the vast majority of scribes are used. We wrestle with it in our primary care offices, and you either have to allow that to produce more throughput to make the business case for it, or you accept the extra cost in exchange for increased physician well-being. They each their advantages and drawbacks.

Do you think that CMS and HHS will be responsive to pleas on the part of organized medicine for broader relief from some of the EHR-related physician documentation burdens, overall?

The generic answer to that is yes. I think they’ve shown willingness to help physicians transition into MIPS, as we’ve alluded to. That’s a good sign. I think they are hearing us with regard to the number of measures and their relevance. I’m a family physician, and there are a lot of measures I can pick on that are relevant to my practice; that’s not quite true for many specialties—two issues related. One is, how many of these things can you take down to the individual physician level—you need adequate numbers. And the other issue relates to risk adjustment and how sick my patients are.

And it breaks my heart to hear doctors around the country say, ‘You know, I might have to stop seeing some of my complex patients, because they’re bringing down my scores.’ But in order to [avert physicians refraining from seeing those patients], we have to be able to identify and adjust for the complexity of individual patients and populations of patients, and we have to adjust the reimbursement system to match the resources available to treat the more complex patients.

And that brings us to the topic of the shift from volume to value in healthcare. What is your perspective on this very strong shift towards value that’s taking place on the policy and payment front right now, especially with regard to value-based care delivery and purchasing, accountable care organization development, population health management, and care management concepts?

The answer is, it is absolutely the right way to go, and the AMA fully endorses the concepts of population health, of value-based payment. I’m in Chicago now, attending ChangeMedEd, a conference that we’ve designed around, how do we better educate our medical students? The keynote speaker just a half-hour ago, was speaking about population health. He was one of the nation’s experts on population health. He was preaching to the choir, but makes the argument that it’s the only way we’ll accomplish the Triple Aim, improving the health of the country, improving the healthcare to the country, and improved or reduced cost. And population health is a big piece of the way we can move towards that. So yes, it’s the right goal. It is gaining considerably greater momentum over the last few years. And there are now journals devoted to this.

And, getting back to the AMA, we’ve developed through this ChangeMedEd consortium, a plan around three legs of medical training, with the third leg of health system sciences specifically around reporting of outcomes measures, population health, care management—that’s almost as important as the purely clinical, and these sciences will be important to medical schools and residencies, and to practice, as we make that shift.

So, in the past, there was a perception—perhaps unfair—that the AMA as an organization was primarily a resister to change. Can you address that perception, and speak to the organization’s focus in the present moment?

Old perceptions die hard. And it is remarkable to me how we’ll still see articles from time to time, including in the mainstream press, about how the AMA opposed Medicare in the 1960s. Give me break!! Seventy years ago? Come on. The AMA has become a substantially different organization over the last decade or so. We embraced and even led the fight to cover the uninsured in the mid-2000s. We were champions of that. And while I was on the Council on Medical Service, our internal policy think tank, were being adopted by both Democratic and Republican legislatures and legislators. And we supported the ACA [Affordable Care Act], not because it was perfect or flawless, but because it gave us the first structural approach to expanding Medicare and Medicaid. And we’ve opposed wholesale proposals for wholesale cuts in expansion to coverage. So anyone who takes a look at our policies over the last ten years, and says we’re not interested in expanding coverage, is consciously disregarding the truth.

Can you speak to the AMA’s desire to help physicians change their practices in order to move forward towards the requirements of the emerging healthcare delivery and payment system?

The answer is unequivocally yes, we are very engaged in that regard. Five years ago, we changed our policies, including around ChangeMedEd. A second big arc is around improving health outcomes, and it is the boldest patient-facing activity the AMA’s ever been involved in, around increasing awareness and management of pre-diabetes and diabetes and heart disease and the opioid crisis; and the third, a whole arc around practice tools and resources to help inform physicians about changes in the industry, and demands from payers, and how physicians can be successful in transitioning to new models of care and payment.

And let me drill down on that, and this takes us back to MACRA. Specifically around MACRA, we have an interactive payment evaluator module, to help physicians assess their practices’ readiness for MACRA, we have the MIPS Action Kit, which is another suite of interactive modules that allow physicians to go beyond that first product, and dig deeper and be successful, it helps them choose which measures are most relevant to them in their practices, it’s very practical. And then there’s a video, just a few minutes long, that walks a physician, step by step in how they participate in this one-patient one-measure process, if they’re not ready to go full-bore into MIPS. We literally walk them through screenshots of the electronic bill, and that gives them breathing room for 2017. We’re providing physicians with lots of tools, and we will continue to do so going forward.

 

 

 


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Has CMS Just Tipped the Scales Towards Provider Alienation, in its ACO Final Rule?

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CMS’s release of its final rule on MSSP ACO participation has pushed the healthcare industry into a very fraught moment in the ongoing evolution of the ACO experiment

As Healthcare Informatics Associate Editor Heather Landi reported on Dec. 21, that morning, “The Centers for Medicare & Medicaid Services (CMS) on Friday morning published a final rule that makes sweeping changes to the Medicare Shared Savings (MSSP) Accountable Care Organization (ACO) program, with the goal to push Medicare ACOs more quickly into two-sided risk models.”

Indeed, as Landi noted in her report, “Referred to as ‘Pathways to Success,’ the Trump Administration’s overhaul of Medicare’s ACO program will redesign the program’s participation options by removing the traditional three tracks in the MSSP model and replacing them with two tracks that eligible ACOs would enter into for an agreement period of no less than five years: the BASIC track, which would allow eligible ACOs to begin under a one-sided model and incrementally phase in higher levels of risk; and the ENHANCED track, which is based on the program’s existing Track 3, providing additional tools and flexibility for ACOs that take on the highest level of risk and potential rewards. At the highest level, BASIC ACOs would qualify as an Advanced Alternative Payment Model (APM) under the Quality Payment Program.”

And, Landi noted, “Currently, the MSSP model includes three tracks and is structured to allow ACOs to gain experience with the program before transitioning to performance-based risk. The vast majority of Shared Savings Program ACOs have chosen to enter and maximize the allowed time under Track 1, which is an ‘upside-only’ risk model. MSSP Tracks 2 and 3 involve downside risk, but participation in these tracks has been limited thus far.”

One of the biggest points of contention in recent months as centered on how aggressive a push on the part of CMS to compel providers forward into two-sided risk would be desirable, or even wise. Some in the industry tried to put a positive spin on the “low-income” element of the program, with that term referring to smaller physician groups choosing to participate in the MSSP. On Friday morning, in response to the final rule, Travis Broome, vice president of policy at Aledade, a Bethesda, Md.-based company focused on physician-led ACO development, tweeted, “One more change to Basic. Low-revenue ACOs will be able to stay in 1-sided risk for 3 years. Difference [between] 2 & 3 years is big. The decision to take risk is made summer before the year starts. So 2 years of 1-sided risk meant making the risk decision before year 1 results even came in.”

But in a statement from the National Association of ACOs (NAACOS), an association comprised of more than 360 ACOs, Clif Gaus, Sc.D., NAACOS’s president and CEO expressed concern that CMS retained the two-year limit for other ACOs. “Becoming a well-functioning ACO takes time and requires building of IT infrastructure, hiring care coordinators, changing the culture of providers, among other tasks. Under CMS’s proposed rule, many ACOs would have just a single year of performance data available to them before evaluating the required move to risk in their third year of the program,” Gaus stated.

Gaus did include a conciliatory note in his statement, saying that "We appreciate CMS' effort in the final rule to provide greater stability to the Medicare Shared Savings Program with five-year agreement periods and more flexibility through waivers for telehealth and skilled nursing facility stays. We look forward to working with CMS to ensure that the Medicare Shared Savings Program, which has a track record of saving taxpayer hundreds of millions of dollars while demonstrably improving care for patients, continues to attract new participants and reap savings." NAACOS has been among the most vocal of healthcare professional associations this year, as CMS Administrator Seema Verma has intensified her call for providers to move forward quickly into more advanced forms of alternative payment models.

But, choosing not to sound any notes of conciliation on Friday, was the Chicago-based American Hospital Association, the largest U.S. hospital association, representing nearly 5,000 hospitals nationwide. A statement attributed to Tom Nickels, AHA vice president, on Dec. 21, said, “Today’s final rule will not be helpful in the move toward value-based care. None of the actions taken today will better empower ACOs to maximize their contribution to patient care and are not pathways for improving the value of the program for patients. We remain opposed to CMS drastically shortening the length of time in which ACOs can participate in an upside-only model. Hospitals and health systems have asked for a more gradual pathway because building a successful ACO that is able to take on financial risk requires significant investments in time, effort and finances.”

Further, the AHA statement said, “While CMS made some improvements to its shared savings rate policies from the proposed rule, they still are not sufficient to appropriately reward ACOs for improving quality and reducing costs. We are particularly concerned about the impact of these and other policies on high-revenue ACOs. We do appreciate that CMS took certain steps to expand participants’ ability to provide care to beneficiaries – for example, via telehealth and longer agreement periods.”

And, the AHA said, “As a whole, the policies in the rule will likely result in a significant decrease in program participation. That would be unfortunate, as we seek to transform care to better serve our patients and communities.”

While the Centers for Medicare & Medicaid Services (CMS) finalized some improvements to the Medicare Shared Savings Program (MSSP), the Premier healthcare alliance is extremely concerned that these are overshadowed by unrealistic expectations of the speed at which providers can transition to risk-based tracks, the un-level playing field created for hospital-led vs. physician-led ACOs and the imbalance of risk vs. reward.

Meanwhile, leaders at the Charlotte-based Premier Inc. were equally critical. In a statement released on Friday, Blair Childs, Premier’s senior vice president of public affairs said that while “Premier appreciates that CMS finalized the extension of waivers and the longer agreement period and heard our concerns about the reduction in shared savings,” “We are extremely disappointed, however, that CMS has moved forward in creating an unlevel playing field that disadvantages high-revenue ACOs—primarily hospital-led ACOs. Premier and other stakeholders, including MedPAC, oppose this policy,” the statement read. “Hospital-led ACOs in Premier’s Population Health Management Collaborative performed twice as well as all the other ACOs nationally. CMS should be taking steps to enhance, not limit, the inclusion of all innovative providers that are seeking to move to value-based care. For an Administration that has been outspoken in advocating for market solutions and level playing fields among competitors, it’s an enormous mistake to finalize a policy that pits providers against each other rather than focusing on collaboration, as the model intends.”

So, where does this leave the industry? Quite possibly, at an important inflection point, now that what was a proposed rule is now a final rule. One could argue this situation from a number of standpoints, but the bottom line is simple: in her desire to push providers forward quickly and decisively into two-sided risk—and even with the carrot-like incentives for smaller physician groups that have been added—Administrator Verma is now strongly risking a massive wave of defections from the MSSP.

As NAACOS’ Gaus noted in his statement, “Under CMS's proposed rule, many ACOs would have just a single year of performance data available to them before evaluating the required move to risk in their third year of the program.” Perhaps similarly importantly, he noted, "Although we are pleased that CMS finalized a new, limited exception to its high-low policy, we remain concerned that the high-low revenue ACO distinction could deter providers who want to embark on the path of value-based care and could unintentionally harm physician-led ACOs. We urged CMS in the rulemaking process to provide an equal playing field for all ACOs and will continue to advocate for changes to this policy. A NAACOS analysis of how ACOs would be classified under CMS's proposed definitions found almost 20 percent of physician-led ACOs would be considered high revenue ACOs. Furthermore, federally qualified health centers and rural health clinics would also have a fair proportion of high revenue ACOs.”

So, here we come to a very tricky set of issues. First, the entire point of adding in the “low-income ACO” distinction was to encourage more physician groups to join the MSSP; and that would be very important for the survival and thriving of the program, since the participation of hospital-based organizations has been slow to date, and one key way to encourage participation by all types of patient care organizations would be to be able to boast about rapidly increasing participation. But if, as Gaus has noted, NAACOS’ analysis finds that nearly 20 percent of physician-led ACOs would actually end up being “high-revenue ACOs,” that could indeed complicate CMS’s attempts to quickly gain new participants.

Further, the short period of time between initial participation and having to decide whether to stay in the voluntary program and take on mandated two-sided risk, poses one of the most serious barriers to increased participation; and therein lies the real rub for CMS, because if this final rule ends up causing mass defections in the next two years, the agency’s signature and largest federal ACO program could begin to fall apart, precisely at the time that Administrator Verma, Health and Human Services Secretary Alex Azar, and all their fellow senior federal healthcare policy officials, would be hoping to accelerate the shift from volume to value in U.S. healthcare, and prove that the broad ACO experiment is working.

On the other hand, it’s also true that if CMS allows the forward evolution of the MSSP program to progress too slowly, that could cause members of Congress and their staffs to determine that voluntary programs simply aren’t cutting it, and move towards massive Medicare cuts instead, in an attempt to get better control of overall U.S. healthcare inflation, at a time when all discretionary spending in the federal budget is increasingly becoming politically fraught.

For the time being, there is no simple answer to any of this. It’s as though the levers of power and influence must be used in an exquisitely calibrated way. There seems to be no “Goldilocks pace” of change here that will both maximize new participation, and ongoing participation, in the MSSP program, on the part of wary providers, and yet also fulfill all the demands and desires of senior federal healthcare policy officials. Only time will tell, but this moment feels more fraught than ever, in the ongoing evolution of the ACO experiment. There’s no doubt that 2019 could be a determinative year for MSSP.

 

 

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CMS: 93% of Clinicians Get Positive Payment Adjustments for MIPS Year 1

November 8, 2018
by Rajiv Leventhal, Managing Editor
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Ninety-three percent of MIPS (Merit-based Incentive Payment System)-eligible clinicians received a positive payment adjustment for their performance in 2017, and 95 percent overall avoided a negative payment adjustment, according to a CMS (Centers for Medicare & Medicaid Services) announcement today.

The first year of MIPS under MACRA’s Quality Payment Program (QPP) was dubbed by CMS as a “pick your pace year,” which essentially enabled clinicians to avoid payment penalties as long as they submitted at least the minimum amount of quality data. As such, in its announcement, CMS did admit that the overall performance threshold for MIPS was established at a relatively low level of three points, and the availability of “pick your pace” provided participation flexibility through three reporting options for clinicians: “test”, partial year, or full-year reporting.

CMS said that 93 percent of MIPS-eligible clinicians received a positive payment adjustment for their performance in 2017, and 95 percent overall avoided a negative payment adjustment. CMS specifically calculated that approximately 1.06 million MIPS-eligible clinicians in total will receive a MIPS payment adjustment, either positive, neutral, or negative. The payment adjustments for the 2017 program year get reflected in 2019.

Breaking down the 93 percent of participants that received a positive payment adjustment last year, 71 percent earned a positive payment adjustment and an adjustment for exceptional performance, while 22 percent earned a positive payment adjustment only. Meanwhile, just 5 percent of MIPS-eligible clinicians received a negative payment adjustment, and 2 percent received a neutral adjustment (no increase or decrease).

Of the total population, just over one million MIPS-eligible clinicians reported data as either an individual, as a part of a group, or through an Alternative Payment Model (APM), and received a neutral payment adjustment or better. Additionally, under the Advanced APM track, just more than 99,000 eligible clinicians earned Qualifying APM Participant (QP) status, according to the CMS data.

CMS Administrator Seema Verma noted on the first pick-your-pace year of the QPP, “This measured approach allowed more clinicians to successfully participate, which led to many clinicians exceeding the performance threshold and a wider distribution of positive payment adjustments. We expect that the gradual increases in the performance thresholds in future program years will create an evolving distribution of payment adjustments for high performing clinicians who continue to invest in improving quality and outcomes for beneficiaries.”

For 2018, the second year of the QPP, CMS raised the stakes for those participating clinicians. And in the third year of the program, set to start in January 2019, a final rule was just published with year three requirements. Undoubtedly, as time passes, eligible clinicians will be asked for greater participation at higher levels. At the same time, CMS continues to exempt certain clinicians who don’t meet a low-volume Medicare threshold.

Earlier this year, CMS said that 91 percent of all MIPS-eligible clinicians participated in the first year of the QPP, exceeding the agency’s internal goal.

What’s more, from a scoring perspective in 2017, the overall national mean score for MIPS-eligible clinicians was 74.01 points, and the national median was 88.97 points, on a 0 to 100 scale. Further breaking down the mean and median:

  • Clinicians participating in MIPS as individuals or groups (and not through an APM) received a mean score of 65.71 points and a median score of 83.04 points
  • Clinicians participating in MIPS through an APM received a mean score of 87.64 points and a median score of 91.67 points

Additionally, clinicians in small and rural practices who were not in APMs and who chose to participate in MIPS also performed well, CMS noted. On average, MIPS eligible clinicians in rural practices earned a mean score of 63.08 points, while clinicians in small practices received a mean score of 43.46 points.

Said Verma, “While we understand that challenges remain for clinicians in small practices, these results suggest that these clinicians and those in rural practices can successfully participate in the program. With these mean scores, clinicians in small and rural practices would still receive a neutral or positive payment adjustment for the 2017, 2018, and 2019 performance years due to the relatively modest performance thresholds that we have established. We will also continue to directly support these clinicians now and in future years of the program.”

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HHS Secretary Azar: HHS Is Planning New Mandatory Bundled Payment Models

November 8, 2018
by Heather Landi, Associate Editor
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The Centers for Medicare & Medicaid Services (CMS) is revisiting mandatory bundled payment models, possibly for radiation oncology and cardiac care, according to Health and Human Services Secretary Alex Azar, which signals a strong about-face in the Trump Administration’s policy about bundled payment initiatives.

HHS is reexamining the role that mandatory bundled payment models can play in the transition to value-based care, Azar said in a keynote speech at the Patient-Centered Primary Care Collaborative Conference on Thursday. HHS published Azar’s comments.

In the published remarks, Azar said the Trump Administration is revisiting mandatory bundled payments and exploring new voluntary bundled payments as part of the Administration’s goal of paying for outcomes, rather than process.

“We need results, American patients need change, and when we need mandatory models to deliver it, mandatory models are going to see a comeback,” Azar said.

In his speech, Azar said, “Imagine a system where physicians and other providers only had to worry about the outcome, rather than worrying about their staffing ratios and the individual reimbursements for every procedure they do and every drug they prescribe. That kind of payment system would radically reorient power in our healthcare system—away from the federal government and back to those closest to the patient.”

He continued, “One way we can do that is through bundling payments, rather than paying for every individual service. This is an area where you have already seen testing from CMMI for several years now—and I want to let you know today that you are going to see a lot more such ideas in the future.”

Azar highlighted the Bundled Payments for Care Improvement (BPCI), which, he said, has shown significant savings in several common inpatient episodes, including joint replacement and pneumonia.

During his speech on Thursday, Azar said, “I want to share with all of you for the first time today: We intend to revisit some of the episodic cardiac models that we pulled back, and are actively exploring new and improved episode-based models in other areas, including radiation oncology. We’re also actively looking at ways to build on the lessons and successes of the Comprehensive Care for Joint Replacement model.

“We’re not going to stop there: We will use all avenues available to us—including mandatory and voluntary episode-based payment models,” he said.

One industry group, the American Society for Radiation Oncology (ASTRO), already has voiced concerns about a mandatory payment model. In a statement issued Thursday afternoon, Laura Thevenot, CEO of ASTRO, made it clear that the organizaiton strongly supports a radiation oncology alternative payment model (RO-APM). "ASTRO has worked for many years to craft a viable payment model that would stabilize payments, drive adherence to nationally-recognized clinical guidelines and improve patient care. ASTRO believes its proposed RO-APM will allow radiation oncologists to participate fully in the transition to value-based care that both improves cancer outcomes and reduces costs."

Thevenot said ASTRO has aggressively pursued adoption of this proposed model with the Center for Medicare and Medicaid Innovation (CMMI). However, Thevenot said the group has concerns "about the possibility of launching a model that requires mandatory participation from all radiation oncology practices at the outset."

Further, Thevenot said any radiation oncology payment model will represent "a significant departure from the status quo." "Care must be taken to protect access to treatments for all radiation oncology patients and not disadvantage certain types of practices, particularly given the very high fixed costs of running a radiation oncology clinic," Thevenot stated.

Back in January, CMS announced the launch of the voluntary BPCI Advanced model, noting that it “builds on the earlier success of bundled payment models and is an important step in the move away from fee-for-service and towards paying for value.” The BPCI Advanced model includes more than 1,000 participants that are receiving episode-based payments for over 30 clinical areas, Azar said.

“BPCI Advanced is a voluntary model, where potential participants can select whether they want to join. But we’re not going to stick to voluntary models. Real experimentation with episodic bundles requires a willingness to try mandatory models. We know they are the most effective way to know whether these bundles can successfully save money and improve quality,” Azar said.

The Obama Administration introduced mandatory bundled payment for care for heart attacks and for cardiac bypass surgery in July 2016.

In the past, CMS Administrator Seema Verma has said that she does not support making bundled payments mandatory, and former HHS Secretary Tom Price, M.D. had strongly opposed mandatory bundles, going so far as to direct the end of two mandatory bundled payment programs—one existing and one previously announced. In November 2017, CMS finalized a rule, proposed in August 2017, that cancelled mandatory hip fracture and cardiac bundled payment models.

As per that final rule, CMS also scaled back the Comprehensive Care for Joint Replacement Model (CJR), specifically reducing the number of mandatory geographic areas participating in CJR from 67 areas to 34 areas. And, in an effort to address the unique needs of rural providers, the federal agency also made participation voluntary for all low-volume and rural hospitals participating in the model in all 67 geographic areas.

On Thursday, Azar acknowledged that his statements signaled HHS was reversing course on its previous stance, noting that last year the administration reduced the size of the CJR model and pulled back the other episode payment models, including those on cardiac care, before they could launch.

Azar, who was confirmed as HHS Secretary earlier this year, signaled early on that he diverged from Verma and Price on his views about mandatory bundled payments. 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.”

During his speech Thursday, Azar pointed to the Administration’s first mandatory model, which was unveiled two weeks ago, called the International Pricing Index (IPI) Model for payments for Part B drugs. Azar said the model is a “mandatory model that will help address the inequity between what the U.S. and other countries pay for many costly drugs.”

Further, Azar said CMMI also will launch new primary care payment models before the end of the year, with the aim of introducing a spectrum of risk for primary care providers, Azar said.

“Before the end of this year, you will see new payment models coming forth from CMMI that will give primary care physicians more flexibility in how they care for their patients, while offering them significant rewards for successfully keeping them healthy and out of the hospital,” he said.

“Different sizes and types of practices can take on different levels of risk. As many of you know, even smaller practices want to be, and can be, compensated based on their patients’ outcomes,” he said. “We want to incentivize that, with a spectrum of flexibility, too: The more risk you are willing to take on, the less we’re going to micromanage your work.”

Azar also noted HHS’ efforts to examine impediments to care coordination, such as examining the Stark Law, the Anti-Kickback Statute, HIPAA, and 42 CFR Part 2. CMS has already launched and concluded a request for information on the Stark Law, and the Office of the Inspector General has done the same on the Anti-Kickback Statute, he noted.

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