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Farzad Mostashari: Some Hospitals Engaging in “Very Active Information Blocking”

October 6, 2016
by Rajiv Leventhal
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Dr. Farzad Mostashari, M.D., also puts onus on EHR vendors to “commit to their pledge” regarding certification and transparency

In health IT circles, most people probably know Farzad Mostashari, M.D., as the former National Coordinator for Health IT, a role he served in for more than two-and-a-half years before founding Aledade in 2014—a Bethesda. Md.-based company focused on physician-led accountable care organizations (ACOs). Since then, Aledade has formed ACOs in New York, Delaware, Maryland, Arkansas, West Virginia, Tennessee, Mississippi, Florida, Louisiana, Virginia, and Kansas, which collectively care for more than 100,000 Medicare patients.

Recently, Dr. Mostashari, and Travis Broome, Aledade’s healthcare policy lead, co-authored a report, published in the American Journal of Managed Care, that made the healthcare IT media rounds as it took a deep dive into how Aledade-initiated ACOs fared in the 2015 Medicare Shared Savings Program (MSSP) ACO class. The report also largely looked at ways the Centers of Medicare & Medicaid Services (CMS) could prove its federal ACO programs. Broadly speaking, the authors noted that “there is no magic bullet for ‘transforming healthcare’ overnight, and that the work of redesigning our delivery systems to meet the expectations of the outcome-based payment models will be slow, hard, and uneven.”

Indeed, in August, CMS released performance and financial data for more than 400 ACOs in the MSSP and Pioneer government-led programs, revealing more than $466 million in total program savings in 2015, although nearly seven in 10 of those ACO organizations did not generate enough savings to receive bonuses. It should also be noted that CMS paid $646 million in shared savings bonus payments to high performing ACOs, leading to a net loss of $216 million, or a loss of slightly less than 0.3 percent for the government. The mixed results of ACOs to date have been a popular talking point for many healthcare leaders as maybe wonder about their sustainability.

Mostashari recently spoke with Healthcare Informatics Managing Editor Rajiv Leventhal on a myriad of healthcare IT issues, including information blocking and drilling down on the results of ACOs to date. Below are excerpts of that interview, edited for formatting purposes.

What’s new with Aledade? What are you working on these days?

You know that whole technology infrastructure we put in place and the whole volume to value shift? We’re basically [trying] to connect those. You have new payment models, so let’s help smaller and independent practices with those value-based contracts. And you have the technology infrastructure, meaning EHRs [electronic health records] and HIEs [health information exchanges], so how can we put those together and create workflows that can help smaller practices succeed in these value-based contracts using the technology, the information, and the business process redesign, which is maybe the hardest piece of this all. You need to rewire the workflows around the patient and his or her needs even if the patient is not in the office today. Aledade is in 11 states going on 15, and is working with 500 primary care physicians, going on 1,000, across the U.S. We are partnering with them and bringing them together on saying, “Enough with compliance; compliance with pay-for-performance, compliance with meaningful use, compliance with patient-centered medical home [PCMH] requirements.” Let’s keep people healthy and out of the hospitals and share in the affordability in healthcare that we help create.

Farzad Mostashari, M.D.

You recently published an in-depth report on Aledade’s ACOs in the field. At a high level, what did you learn most from that?

The first takeaway is that these things take time and people get better over time. This is not an overnight thing; you cannot transform healthcare overnight. But on the other hand, you can do a lot in a short period of time. Just within a year, in our “freshman experience,” we were able to cut ER visits by 5 to 6 percent and reduce 30-day all cause readmissions by 14 to 16 percent, relative to national trends. That’s huge—if there was a drug that cut readmissions by 14 percent, that would be a blockbuster drug! We reduced acute hospitalizations by 4 percent and 11 percent against national trends. So those are big things you can change in a short amount of time, even in these small practices. We’re very proud of the hard work our practices did and the technology that helps them succeed.

What are the key strategies and IT elements of these ACOs?

Some of it is high-touch and low-tech, so changing what the primary care practice does in terms of things like same day scheduling, so putting up posters, and smiling when a patient calls on a Friday at 4 p.m. and says he or she isn’t feeling well. Instead of saying “go to the ER,” say “come on in, we’ll see you.” So some of it is relationship based, but there are also things that [these ACOs do] that they couldn’t do before.

One example is around consistently reducing readmissions, and we now have the results from the five new ACOs that we started, and readmissions are down in all of them. The way we reproducibly and scalably get those results is by using event notifications from hospitals. So from the HIE, it’s an HL7 ADT [Admit Discharge Transfer] message that goes from the hospital to the HIE or to us, or from the hospital to us directly, or in some cases we create a real-time notification system for primary care practices to let them know when patients got admitted and discharged from hospitals. We get these to them quickly, within 48 hours, and have them contact the patient, see what’s going on with the patient, review medications, and schedule a visit with him or her within the next 7 to 14 days. That works; it’s what you would want for your mom, and most primary care practices don’t have the information, tools, and workflow to pull that off. We help them pull that off.

With Medicare ACOs, there are plenty of naysayers and Debbie Downers saying how poorly the programs are doing. Others are more optimistic. What’s your perspective?

We pointed out in our piece that there are some policy headwinds that Medicare has put in place particularly for physician-led ACOs that are hurting the success of program. I am a realist when it comes to saying this program needs to be improved. As currently constructed, it makes it hard for people to see the fruits of their efforts. I have the conviction that CMS wants to and will do the right thing, and they have shown a commitment to making the adjustments that will be necessary to make this program succeed. This comes slower than many would like, including me. Over the long run I think they will make the program work.

What improvements do you think are needed?

One of the most obvious things, and this is what every single Medicare Advantage and commercial contract does, is becoming more of what these other programs are like. There are two features that these contracts have that the MSSP doesn’t have: comparison into your regional trends and risk adjustment. So for example, if in Delaware we saw 5 percent year-over-year Medicare cost growth, but nationally the cost growth was totally flat the last few years, which means holding costs flat in Delaware is a huge accomplishment, but you get no credit for that. But in other parts of the country where costs are coming down, they are applauded even though they are just surfing the regional trend, rather than changing the regional trend. It’s an inaccuracy in calling balls and strikes that has to be fixed.

The second thing is around risk adjustment. Every single other program recognizes that patient populations can get sicker as well as healthier. But Medicare thinks it only goes on way; that your risk scores can only go down. That evaporated several millions of savings we accomplished based on that policy. So these are two changes Medicare can make to make the program more aligned with that others are doing, and keep folks more in the program who can see that their efforts are paying off.

From an IT standpoint, what other pain points are you hearing from providers in the trenches?

This is [an area] that I think your readers will find of interest. First, there is the real world data blocking that we’re seeing. The first example is EHR vendors—in order to fully develop that picture and really know your patient, and to know who needs your help, you need to do predictive modeling with the clinical data. It’s about getting clinical data out of EHRs that the practices have paid for and spent tens of thousands of hours putting data into them. Wanting to get your own data out is way too hard, expensive and slow. It’s neither cheap, easy nor fast; you get zero out of those three, and honestly I would settle for getting two out of those three. So that needs to be fixed.

The part that galls me the most is that the vendors can’t or won’t do what they pledged to do as part of the certification program for EHRs. These EHRs got tested in a lab to be able to produce batch downloads of patient care summaries, but in the field they either can’t or won’t do it. Some vendors actually implemented their technical solution in order to past the certification lab test, so it’s as if they “hardcoded” it to their lab test. It’s like knowing what the questions would be, they hardcoded their answers to that. But you can’t have a conversation with them in the field. They played a compliance game to pass the test, but they knew they didn’t actually have to have it working in production. That needs to have consequences. There needs to be a robust surveillance program response from ONC. If vendors don’t comply with the certification requirements they should be at risk of having their certification revoked. Or the vendors will charge you, say $40,000 for an interface engine that they didn’t originally say was needed as part of the certification program’s transparency requirements. They said it was a complete EHR.

The second part of information blocking is not on the part of vendors, as many vendors say they are just responding to what customers want. It’s on the side of hospitals. We have seen multiple hospitals—and it is a minority, thank goodness—refusing to share this lifesaving discharging information with primary care physicians. It’s a way to keep patients in their own network, to encourage doctors to join their ACO, rather than an external ACO, out of concern there might actually be fewer admissions, maybe? I don’t know what it is, but we are seeing very conscious and active information blocking on the part of hospitals.

Some stakeholders seem to outright deny that information blocking takes place. What do you make of this?

These people are not walking in the shoes of the people who are in the field trying to get data across networks. There is increasingly information flow within networks, such as within an ACO. One hospital CIO [recently told me] that the organization views information as a strategic asset. That’s not ethical in my view. I am not a huge believer in compliance thinking, but for this, there has to be regulations and carrots and sticks that say you have to have to comply, especially if you are a hospital that took federal money or is getting low income pool patients. You have to share this information back with the patient’s primary care provider since it is right for the patient.

 


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NAACOS, AMA, Others Urge CMS to Reconsider MSSP Proposed Changes

September 21, 2018
by Rajiv Leventhal, Managing Editor
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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, 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.

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.

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.

However, the groups also explained their concerns about CMS’ proposals to reduce the time new ACOs have in shared savings-only models from six to two years and to decrease the shared savings rate from 50 percent to 25 percent. The letter urges CMS to instead 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 to ensure a viable business model.

The groups wrote, “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.”

It remains to be seen how CMS will respond to the pushback from NAACOS and others of late, though up to this point CMS has taken a firm stance that upside risk-only ACOs have not been effective. Thus, the federal agency seems to be fine with these ACOs leaving the MSSP if they are unwilling to take on more risk.

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Check and Checkmate: Is the Debate Around the MSSP ACO Program About to Get Super-Heated?

September 12, 2018
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Will NAACOS’s just-published study turn the tables on senior CMS officials? Or will it be ignored?

Something really quite extraordinary happened this week: NAACOS, the Washington, D.C.-based National Association of Accountable Care Organizations, published, in the august journal Health Affairs, a study based on research that NAACOS leaders had commissioned from Dobson DaVanzo & Associates, a healthcare economics consulting firm. And, as Healthcare Informatics Managing Editor Rajiv Leventhal noted in his report, “Medicare’s largest ACO (accountable care organization) initiative—the Medicare Shared Savings Program (MSSP)—generated gross savings of $1.84 billion for Medicare from 2013 to 2015, nearly double the $954 million estimated by the Centers for Medicare and Medicaid Services (CMS),” according to the NAACOS/Dobson DaVanzo & Associates study.

And here’s what’s extraordinary about that: this is the first time in my memory that I’ve seen a national association of provider organizations commission independent research that directly contradicted federal government findings and statistics. Could this be the start of a major conflict over the direction of the MSSP program? The potential for actual conflict here is quite real. But first, let’s look at what NAACOS and Dobson DaVanzo found. As Leventhal noted, “The study, which used similar scientific methods as a 2018 peer-reviewed paper by Harvard researchers published in The New England Journal of Medicine, found that MSSP ACOs reduced Medicare spending by $541.7 million during the 2013 to 2015 timeframe, after accounting for shared-savings payments earned by ACOs.”

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. As such, CMS has been reiterating in recent months that these “upside risk-only” ACOs are costing the government money.

What’s more, as Leventhal noted, “To this point, in a recent proposed rule that has so far been met with varying degrees of scrutiny, 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. 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. Importantly, CMS has essentially said they don’t mind if upside-only ACOs that are costing the government money leave the program if they aren’t willing to take on more financial risk. CMS Administration Seema Verma said in a press call following the proposed rule’s release that ‘[Upside-only] ACOs have no incentive, at all, to reduce healthcare costs while improving outcomes, as they were intended.’ Nonetheless, MSSP ACO participants seemingly performed quite well in 2017, despite CMS’ claims that they have been largely ineffective. In sum, the 472 ACOs that were in this model last year achieved $314 million in net savings to Medicare in 2017 after accounting for bonuses paid from the government, and $1.1 billion overall.”

For the NAACOS leaders, the key element here is that, as the authors of the Health Affairs article pointed out, “Despite the positive 2017 results, gauging MSSP performance based on calculations using administratively derived spending targets (benchmarks) is simply not an accurate way to measure overall program savings. In fact, the published academic research on MSSP performance points to much higher savings than are suggested by the benchmarks.”

Explained further by the researchers, for its analysis of Medicare ACOs, “CMS calculates an initial risk-adjusted spending benchmark for each ACO based on its historical spending for a group of attributed Medicare beneficiaries; it then trends this benchmark forward to the current program year based on the national average growth in Medicare spending per beneficiary.” The article’s authors further point out that if an ACO’s spending is less than the benchmark, and has a savings rate of at least 2 percent—and the ACO meets MSSP quality thresholds—it earns a shared savings payment that is typically 50 percent of the calculated savings. CMS then calculates total MSSP savings as the sum of total savings for ACOs with spending below the benchmark, plus the sum of spending above the benchmark for ACOs that exceeded it. Using this method, CMS estimated MSSP savings of $954 million between 2013 and 2015. During this period, ACOs that saved money earned $1.3 billion in shared savings payments. CMS concluded that on a net basis, the program increased Medicare spending by $344 million between 2013 and 2015, according to the NAACOS analysis and Health Affairs commentary.

At this juncture, there is an obvious issue here, because CMS’s calculation method implicitly makes it difficult for ACOs to show progress, since savings are benchmarked against administratively derived targets, rather than actual savings. Who came up with that method, anyway???

And the implications of using such a method are clear. As the press release that NAACOS issued upon the publication of the Health Affairs article noted, “Despite the growing ACO track record of improving quality and saving Medicare money, CMS, in an August 17 proposed rule, moved to shorten the time new ACOs can remain in the shared-savings-only model from the current six years to two years. Data show ACOs need more than two years to begin showing the benefits of forming an ACO. That proposal, coupled with CMS’s move to cut shared savings in half — from 50 percent to 25 percent for shared-savings-only ACOs — would deter new Medicare ACOs from forming.”

What’s more, the press release quoted Stephen Nuckolls, CEO of Coastal Carolina Quality Care in New Bern, N.C., which includes 63 providers caring for 11,000 Medicare beneficiaries, as stating that “It takes time and money to transform entrenched care delivery practices in local communities and build the critical mass to successfully integrate care, manage risk, and improve quality while reducing spending growth. Unfortunately, the proposed changes will hold up the move to value-based care by significantly undermining the business case to voluntarily form new Medicare ACOs.” 

I take Mr. Nuckolls’s charge very seriously. I interviewed him recently, and as he noted in our interview, when asked the secret of his ACO’s success so far in the six-plus years in which Coastal Carolina Quality Care has participated in the MSSP program, “[I]t takes time for some of these strategies, such as population health, to pay off. Another thing that’s going on is that our care management program, I give credit for keeping our costs low and getting things in place. And in addition,” he told me, “we really made a lot of strides in our first contract cycle, specific to our market. All of our annual wellness visits and preventive care, we made our marks there and that positioned us well in our second contract cycle. And it just takes time, when you focus on the quality of care, for… when a greater percentage of your patients have their blood pressure under control, you’ll have fewer adverse events. And when you work to lower a1cs, that will avert events over time. And annual wellness visits, vaccinations, screening services—it costs money for screenings; and once you get things set up, that’s then in place. And care management services—when you go into your second contract cycle, you have some of those costs worked into your contract cycle the second time; so it takes time to achieve shared savings, and to get the staff to focus on the sickest population.”

What’s more, what Nuckolls told me in our interview reflects what virtually every ACO leader I and my colleagues at Healthcare Informatics have heard from ACO senior executives—that it takes several years to lay the foundations for ACO success.

What’s more, Nuckolls told me, the results revealed in this data review-based study and article are important, as they speak to “the policy point—organizations are truly saving the government money, even if it doesn’t immediately show on paper. The evidence doesn’t support the idea that ACOs should be kicked out because they have a bad benchmark. The true savings to the Medicare Trust Fund will then be less. And that’s what they need to focus on, achieving true savings to the government.”

So, the obvious question now is, what will happen next? Will CMS Administrator Seema Verma lash out against NAACOS, denouncing this “rival” analysis of MSSP ACO savings? Will she ignore it? Or will she reach out to NAACOS’s leaders, and attempt to find common ground, as the “Pathways For Success” program potentially threatens the expansion of the voluntary MSSP program? It feels as though a lot is hanging in the balance right now, because if the national association representing ACOs has just come out with what is implicitly a denunciation of CMS’s method for calculating ACO progress and success, that is a fairly major “j’accuse” that Administrator Verma and her fellow senior CMS and HHS officials would do well to consider carefully. So the next move on this chessboard is Ms. Verma’s. And who knows what that move might look like?

 

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Seema Verma’s Big Picture: Tough Love, ACO Acceleration, Interoperability, and Consumer Empowerment?

August 29, 2018
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Will CMS Administrator Seema Verma’s strategy of pushing hard on providers around ACO development and interoperability help to accelerate the shift to value-based healthcare—or will it backfire?

Whatever may come, CMS Administrator Seema Verma is standing steadfast in her “tough-love” stances towards providers when it comes to ACO development. As Healthcare Informatics Associate Editor Heather Landi wrote on Monday, “During a webinar sponsored by the Accountable Care Learning Collaborative Monday morning, Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma reiterated the agency’s focus on pushing healthcare providers in accountable care organizations (ACOs) to take on two-sided risk while also addressing CMS’s commitment to try to remove barriers to value-based care.”

Further, Landi wrote, “During the 30-minute webinar sponsored by ACLC, a Salt Lake City-based accountable care collaborative, Verma discussed the sweeping changes that CMS is proposing for the Medicare Shared Savings Program (MSSP), noting that ‘it is time to take the next step.’ On August 9, CMS proposed a rule that included major changes to the existing MSSP ACO program, with the goal to push ACO organizations into two-sided risk models by shortening the duration of one-sided risk model contracts. Referred to as “Pathways to Success,” CMS’ proposal looks to 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 and the ENHANCED track. Verma’s comments on Monday morning emphasized CMS’s firm stance on pushing healthcare providers to take on more risk, as well as CMS’s strategy of giving providers more flexibility—such as waivers around telehealth—as a reward to transitioning to value-based care.”

What’s more, Administrator Verma came to the webinar with data. As Landi reported yesterday, “For the 2016 performance year, the Next Gen ACO Model generated net savings to Medicare of approximately $62 million while maintaining quality of care for beneficiaries, according to CMS. Overall, that represents a net reduction of 1.1 percent in Medicare spending within that program, Verma said. The Next Gen ACO model began in January 2016 with an initial cohort of 18 participants. It should be noted that 15 out of the 18 NGACOs had prior Medicare ACO experience.

Verma was not shy about what she thought those metrics meant. “What this really shows is that these Next Gen ACOs are taking the highest levels of risk and they’ve managed to maintain quality while still lowering cost,” Verma said during the webinar. “Much of the savings achieved by the Next Gen ACOs were largely due to reductions in hospital spending and spending in skilled nursing facilities, and that’s very consistent with what we’ve seen with how other two-sided ACOs have achieved savings. We’re excited about this; we think it’s a very strong start.”

Good cop, bad cop?

I’m impossible not to contrast Verma’s statements about the Next Gen ACO program with how CMS characterized the proposal it released just three weeks ago, on August 9. On that date, as Managing Editor Rajiv Leventhal and Associate Editor Heather Landi reported, “The Centers for Medicare & Medicaid Services (CMS) is proposing a new direction for ACOs (accountable care organizations) in the Medicare Shared Savings Program (MSSP), with the goal to push these organizations into two-sided risk models.”

Further, they wrote, “Referred to as ‘Pathways to Success,’ CMS’ proposal, which has been expected for a few months, looks to 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, Seema Verma has made numerous comments now in numerous speeches to numerous different healthcare groups, making it very clear that she is becoming impatient with the pace of change in U.S. healthcare, and is determined to do something about it—with the support of Health and Human Services Secretary Alex Azar, her boss.

Indeed, Verma’s first in a series of speeches around interrelated topics of value-based payment and care delivery, patient/consumer empowerment, interoperability, and technology advancement, came as early as the HIMSS Conference in Las Vegas, where, on March 6, she “spoke of the need to move forward to empower patients with their data and information, in remarkably personal terms, recounting an episode in which her husband had collapsed while the two of them were not together, and was rushed to an emergency department, for what turned out to be heart failure,” as I reported at the time.  In the wake of her husband’s health crisis, she experienced the difficulty of accessing her husband’s health record, as an authorized family member. And that experience, she said, particularly animated the development of the MyHealthEData initiative she was unveiling on that date.

“The reality,” Verma said, “is that once the information is freely flowing from patient to provider, the advances in coordinated, value-based care, will be greater than anything we could imagine today she said back in March. Things could have been different for my family if my husband could have authorized me to have his health records on his phone,” she said. “Or if he could have notified me that he was in distress. And better yet, maybe we could have predicted his cardiac arrest days before, if his watch could have tracked his health data, and sending that data to alert his doctor, and possibly prevent what happened. My husband is part of the 1 percent that survives his condition. We shouldn’t have to depend on chance” for that type of outcome, she emphasized.

The big picture: pushing on several levels at once?

It seems clear that Azar and Verma—certainly, with the help of Donald Rucker, M.D., National Coordinator for Health IT—are determined to acceleration the transition of U.S. healthcare providers into value-based healthcare, through a combination of different incentives, including a wide variety of carrots and sticks. And, not to mix too many metaphors here, but it also seems clear that her praise of the progress made by the Next Gen ACO program ACOs is evidently a “good cop” positioning, while she largely framed the relatively modest progress in the MSSP program in a “bad cop” sort of way, essentially telling MSSP ACO leaders that it was time to stop with upside-only risk, and move into two-sided risk as quickly as possible.

Of course, the risks in this kind of approach are significant. Not surprisingly, the National Association of ACOs (NAACOs) heaped scorn on the August 9 “Pathways to Success” proposal, with NAACOS CEO Clif Gaus saying in a statement released that evening, that “The administration’s proposed changes to the ACO program will halt transformation to a higher quality, more affordable, patient-centered healthcare industry, stunting efforts to improve and coordinate care for millions of Medicare beneficiaries.” According to Gaus, “The downside financial risk for patient care would be on top of the significant financial investments ACOs already make, jeopardizing years of effort and investment to improve care coordination and slow cost growth.” He continued, “CMS discusses creating stability for ACOs by moving to five-year agreements, but they are pulling the rug out from ACOs by redoing the program in a short timeframe with untested and troubling polices.”

So it 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 this is a delicate, complicated moment. Will “tough love” and “good cop, bad cop” strategies at HHS and CMS really work? Only time will tell—but this feels like an important moment in the evolution of value-based healthcare, with no clear answers as to how HHS (the Department of Health and Human Services) and CMS officials might be successful in forcing transformational change forward, at a time when the coming U.S. healthcare cost cliff is looming more closely than ever before, just up a head. As Bette Davis said, as Margo Channing, in Joseph L. Mankiewiecz’s 1950 film “All About Eve,” “Fasten your seat belts—it’s going to be a bumpy night!”

 

 

 

 

 

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