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Healthcare Industry Leaders React to Quality Payment Program Proposed Rule for 2018

June 21, 2017
by Mark Hagland and Heather Landi
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One day after CMS released its proposed rule for 2018 requirements under MACRA’s Quality Payment Program, industry leaders express a spectrum of reactions

The day after the federal Centers for Medicare and Medicaid Services (CMS) released a proposed rule that would make changes in the second year of the Quality Payment Program (QPP) under the MACRA (Medicare Access and CHIP Reauthorization Act of 2015) law, affecting Medicare-participating physicians covered either under the MIPS (Merit-based Incentive Payment System) program, or participating in APMs (advanced payment models), healthcare industry leaders are reacting to the content of the proposed rule, mostly with a sense of relief, or of broad satisfaction, even as they wonder exactly how the final rule will play out.

In interviews with Healthcare Informatics editors, industry leaders say that the broad outlines of the proposed rule appear to be reasonable, and that it appears that CMS officials have taken a middle path as they try to prod U.S. practicing physicians forward into value-based reimbursement and quality measurement in the context of a rapidly shifting Medicare payment environment. Issues around pace, incentives, specificity of measurement, and the welter of data gathering- and information technology-related issues to consider, are keeping industry leaders focused on both the broad outlines and the complex details embedded in the 1,058-page proposed rule, which dropped late in the afternoon on June 20.

HIMSS and CHIME Weigh In

Leaders at the major healthcare IT professional associations expressed satisfaction over the moderate elements related to data and information technology in the proposed rule. Jeff Coughlin, senior director of federal and state affairs at the Chicago-based Healthcare Information and Management Systems Society (HIMSS), says, “I would say that the biggest takeaway is the flexibility that’s provided for providers, that’s in the rule. HIMSS spent time earlier this year, in 2017, talking about 2015 edition certified electronic health record technology (CEHRT) and about how where we were in terms of the level of adoption and availability of 2015-edition CEHRT products, and how we didn’t think we could get to the place we needed to be,” says the Washington, D.C.-based Coughlin. “This is one example of the flexibility in terms of allowing more time for providers to adopt 2015-edition CEHRT.”

What’s more, Coughlin says, “CMS also spent a lot time, in the rule, talking about the benefits of 2015 edition certified EHRs, and how important it is to transition and all the benefits from that transition for providers, and at the same time, providing more time for those providers, mostly likely small providers, that need the extra time to implement 2015 edition CEHRT products. But it does have bonus points, in the ACI [Advancing Care Information] performance category related to adopting and using that [2015-edition CEHRT] to report in 2018. It is, directionally, the right place to be,” he says. “I would emphasize,” he adds, “that we thought it was great to see the amount of time that CMS spent in the rule singing the praises of the 2015 edition CEHRT and what that transition would mean for providers and patients. There are several pages in the proposed rule focused on that, and that’s exactly the message that we tried to get across in April, that the 2015 edition CEHRT is definitely a step that we need to take, we just need a longer on-ramp to get there. I think at this point, I think it’s probably directionally appropriate.”

Leslie Kriegstein, vice president for congressional affairs at the Ann Arbor, Mich.-based College of Healthcare Information Management Executives (CHIME), said that, “Overall, it looks like CMS heeded a lot of the provider community’s calls for another transition year. So going from the minimum necessary of 3 points to 15 points, seems reasonable in terms of keeping people in the program and marching in the right direction,” said the Washington, D.C.-based Kriegstein. “The fact that 2015-certified technology would be bonus instead of mandatory, was positive, but also leaves a lot of questions for hospitals still participating in meaningful use,” under a program that was bifurcated when the meaningful use program for physicians was incorporated into the MIPS program after the passage of the MACRA law. “And you still have hospital-based and employed physicians leveraging technology they need for MIPS,” she noted.

Leslie Kriegstein

Meanwhile, despite the complexity of different sets of requirements for hospitals and physicians in terms of using federally certified electronic health record (EHR) technology under the terms of two different programs, Kriegstein says she is glad that this proposed rule does not require 2015 certification on the part of practicing physicians. “The extra time to be able to use 2014-certified technology was an imperative,” she says. “When we surveyed our members, a sizable proportion of our membership won’t have access to 2015 cert even before the end of the year. So in our IPPS [Inpatient Prospective Payment System rule-making] comment, we said, per CEHRT, that that’s a huge problem. So that should be a huge relief to the doctors that they can use 2014. Because it’s a huge fallacy that large numbers of doctors could use 2015 this year. So that gives us hope regarding what they might do for the hospitals.”

In sum, Kriegstein says, “On the whole, it looks like they’ve prioritized small practices, with all of the different bonus opportunities, and the fact that they can file for an exemption from ACI. So I would anticipate that the small providers must feel some relief. That’s not as applicable to our membership, but that’s something they should welcome.

Looking at the Incentives for Physicians of Different Types

What about the incentives embedded in the proposed rule, for physicians to move forward around payment for value? “What I see is that there’s more flexibility for sure, particularly for small practices,” in the proposed rule,” says Tom Lee, Ph.D., CEO of the Chicago-based SA Ignite consulting and software services firm. “That also means there are more levers for optimizing your score. But it also means there are more decisions to make, and no one wants to make a wrong decision and leave money on the table.”

Importantly, Lee reminds everyone of the payment regime under MACRA, “It’s a competitive system, and winners will be paid by losers. And there’s a 2.9 percent maximum incentive estimated for 2018. And that incentive could actually go substantially higher if it turns out that the actual number of people who participate is only 10 percent lower than the number who participate. Also, they’ve repeatedly said that the 2019 performance year is locked into the legislation,” so that in 2019, the law will necessarily require physicians to be measured—and paid—against a system of national average-based performance measurement. In 2017, physicians are subject to only a 3-point differential, out of a total of 100 possible points measuring their performance across several categories; but the proposed rule calls for a 15-point differential for 2018, and, Lee points out, CMS officials openly state in their proposed rule release that they might raise that differential from 15 points to 30 or more points. “They’ve estimated that the actual value is significantly higher, because they want to give people a fair-step way of getting to 2019, where the MIPS performance threshold has to equal the national average of MIPS point value in a historical period,” he says. “So the 3 points this year and the 15 points next year, do not reflect a national average. The overall rigor of the proposed rule is about right, Lee thinks.

Not everyone agrees. Among those who feel that the proposed rule is not rigorous enough to stimulate rapid innovation is Chester A. (Chet) Speed, vice president, public policy, for the Alexandria, Va.-based American Medical Group Association (AMGA), which represents 440 large medical groups, encompassing more than 175,000 physicians. “The proposed rule recognizes that there’s a tension in getting to value,” Speed says. “On the one hand, everyone wants to get to value, which is essentially improved care quality at lower cost. At the same time, HHS [the Department of Health and Human Services] recognizes that getting to measured value can be a real burden on physician practices. So they’ve excluded a fairly big chunk of small practices from MACRA, recognizing that it’s a burden on them. At the same time, those who have invested in the people and technology to improve care and lower costs, the typical AMGA members, are not being rewarded for these investments and efforts, which frankly take millions of dollars and many hundreds of hours of people efforts, to get to value.”

Chet Speed

The problem, Speed says, speaking of CMS officials, is that “They expect that those groups with over 100 doctors, which represent 99 percent of AMGA members, their MACRA bonus will only be 1.4 percent. And the maximum is 5 percent. So by excluding all these small practices, you’re crunching the bell curve and reducing rewards to high performers. So that’s the tension involved; you’re not rewarding those that have done all the work to get to value. So I think about our members who have put millions of dollars into this and have spent so much leadership time and effort to get to value; 1.4 percent in MACRA hardly rewards you for all the effort you’ve made; and it’s not really the signal you want to say, we’re going to value.”

Moving Forward—Into Uncharted Territory

On Wednesday morning, the Bethesda, Md.-based American Medical Informatics Association (AMIA), a nationwide association of medical informaticists, released a statement attributed to Douglas B. Fridsma, M.D., Ph.D., the association’s president and CEO. “It is vital that we continue our collective march towards modernizing healthcare delivery and the patient’s experience,” Fridsma said in the statement. “While there are numerous details to review, AMIA is pleased that CMS has proposed a flexible set of requirements meant to encourage health IT-enabled care.  Specifically, the proposal to reward those clinicians who demonstrate more advanced use of health IT to support patient care through 2015 Edition CEHRT will improve interoperability for providers and provide patients with better access to their data.  Meanwhile, clinicians who need additional time to upgrade or adopt 2015 Edition CEHRT will benefit from another 90-day reporting period, and the option to use legacy versions of CEHRT in 2018. We also applaud CMS for expanding the list of Improvement Activities that can count as bonus payments for the MIPS Advancing Care Information performance category.  This approach helps credit clinicians for using health IT within a care improvement context, and we see this as a more outcomes-focused approach to measuring health IT use.  We look forward to looking into the rule in more detail and providing our feedback.”

Doug Fridsma, M.D., Ph.D.

There is much to unpack in the proposed rule, Fridsma says. One of the broad questions remains, will this proposed rule, as well as the entire set of regulations and requirements under the MACRA law, move the industry forward into payment for value in a way that is set at the right pace and with the right broad incentives to encourage physicians forward in an optimal way, in this moment in the evolution of U.S. healthcare? When presented with the “Goldilocks” metaphor of the mythical little girl who goes into a house in the woods in which three bears are eating porridge that is too hot, too cold, or just right, and sleeping in beds that are too hard, too soft, or just right, and so on, says, “Well, you know, we’ve never been to Grandmother’s house! Is it too hot, too cold, or just right? We don’t really know. We could always speculate about whether they did too much or not enough” in how this proposed rule was crafted, Fridsma says. But we have to recognize that we’re moving in this direction for the first time. And to what extent are the measures process-based or outcomes-based? Do we even have the right thermostat?? I think it’s hard to say.”

Fridsma goes on to say, “Given the regulatory climate and where we are, we’ve got to make sure that whatever we do is put in place to help the patient and to improve healthcare. That’s ultimately the only thing that matters, with regard to being too hot or too cold. If you create incentives that don’t align with that, it won’t be the porridge you want eat! But you know, the thing is, and I’ve said this before, we want to take the path of least regret. We want to make sure that we’re continuing to improve HIT such that it can improve care delivery and improve the quality of the patients’ lives, and of the work that the physicians do.”


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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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