Keeping Medicare’s Promise

screen-shot-2016-10-14-at-8-43-48-amSo, you decided to come to Washington to see what was new and how things might be changing… I am sure we did not disappoint.

I am honored to have been invited to address this summit, which I’m sure will be your first of many. It’s a certainty that making our delivery system work better for patients and spend money more wisely will always be in season no matter which party is in charge. And, while many new approaches and changes may come to bear, ultimately health is not a partisan issue.

However, I do hope you all think of a better name– the MACRA MIPS/APM summit sounds like the world’s hardest word scramble. We’ve tried to make MACRA more accessible by naming it the Quality Payment Program… something to think about.

Looking at your speakers today, you have gathered some of the most experienced people across the country focused on the most difficult health care problems we as a nation face. Simply put, how to complete the changes we have begun to make the system more patient centered and accountable. So today, I come here to add my perspective to this discussion and continue to ask for your valuable help.

You, as clinical and business leaders, represent an active and important voice in the delivery of health care for all Americans. As we make changes, you are part of the leadership who will be the first to know what is working and what is not. You will also be the best at articulating what you need from Washington. At CMS, we have worked hard over the last few years to transform from an opaque bureaucracy into an accessible service organization, getting us closest to making decisions based on where care is provided across the country.

I want to talk about the next evolution for our health care system. 

For nearly two years, I have had the incredible honor to serve at CMS and to oversee the Medicare, Medicaid, and Marketplace programs, which together provide health coverage to one in three Americans and likely pays for the majority of care that occurs in most health care communities across the nation.

There’s an old joke at CMS that if you find yourself in a tense conversation, you can usually diffuse it by saying, “Well, my mom is a Medicare beneficiary.” Inevitably, the other person will say, “Mine too.” And, from that shared sense of responsibility, you can go forward from the right place – one that is focused on figuring out what’s right for the beneficiaries we serve.

That is because Medicare is a uniquely American promise. One that – for more than a half-century – has said to all Americans that as you get older, or if you have a disability, you will be able to access care, and your family won’t go broke in the process. Before Medicare, do you know how many seniors in this country lived in poverty? One in three…. One in three. Today, it’s less than one in ten. Our promise to the millions of Americans –our neighbors — particularly when we are living on a low or fixed income– is part of what has made us who we are.

Medicare is what provides your parents’ health care and if we do our jobs right, one day, your children’s. Think of it. How we make decisions today will allow us and our children to one day put that Medicare card in our wallets to keep us secure.

So how are we doing to advance Medicare to keep its promise?

Since the passage of the ACA, over the last 8 years, together, we have made significant progress in cost and quality and in evolving to meet the new shape of health care.

  • Today, 30% of fee-for-service Medicare payments flow through alternative payment models, up from essentially none in 2010. And, millions more are covered through innovative Medicare Advantage programs.
  • Quality and safety have improved with the rate of hospital-acquired conditions declining by 17%, which has prevented an estimated 87,000 deaths over 4 years. The rate at which Medicare patients are readmitted to the hospital within 30 days after discharge has decreased sharply, resulting in 565,000 fewer total readmissions.
  • Medicare provides more access with new prescription benefits and, thanks to the Affordable Care Act (ACA), we’ve closed the Medicare donut hole and with that, 11 million beneficiaries have saved an average of more than $2,000.
  • The CMS Innovation Center, which the ACA created, takes best practices from the clinical field and has developed over 30 alternative payment models and initiatives, serving millions of Medicare beneficiaries. The CBO expects the Innovation Center to reduce federal spending by about $34 billion over the next 10 years as we find new and better ways to care of people.
  • And, with all of this, we have been spending tax payer resources more wisely with extended record low medical inflation. The ACA extended the life of the Medicare trust fund and has helped deliver $473 billion in savings.

Of course, there has been enormous progress extending beyond Medicare: 

  • 20 million people now have health insurance who didn’t have it before the ACA (and I am sure you understand that affordable coverage for every American helps keep Medicare costs low. A 62-year old who has affordable coverage and can manage or prevent a chronic disease will be much healthier and less costly when they enter Medicare three years later.)

You have heard the 20 million stat before. But the effects are much more profound in the everyday life and health of people.

  • Since the ACA went into effect in 2014, more people now have a personal physician (increase of 3.5%) and easy access to medicine (increase of 2.4%).
  • Just yesterday, the CDC reported that families struggling to pay medical bills dropped from about 21% in 2011 to 16% in the first half of 2016.
  • There have been substantial decreases in the share of people who are unable to afford care (decrease of 5.5%) reporting fair or poor health (decrease of 3.4%).
  • The Medicaid coverage expansion has improved the financial security of the newly insured (for example, by reducing the amount of debt sent to a collection agency by an estimated $600 to $1000 per person gaining Medicaid coverage).
  • States that expanded Medicaid also saw their hospitals reduce debt by about 13%; 10% more than in states that didn’t expand Medicaid. As former Arizona Governor Jan Brewer said, “I don’t know how you could deliver that population any more services better, more cheaply, than what we’ve already done here,” when asked about her state’s Medicaid expansion.

If you don’t think this progress has made a major difference in the day-to-day lives of all Americans, you have been paying more attention to politics than people. In fact, there hasn’t been a greater stretch of progress in our nation’s history as measured by the amount of positive change that has impacted people and their lives and our path to a sustainable future as in the last 8 years.

But this progress should only be the start if we are to fulfill the real promise of caring for people in our country and doing it in a way that reduces the overall burden of the health care system.

Today, taxpayers spend over $500 billion each year for the Medicare program. The question that needs to be addressed head on is how Medicare will continue to control costs in the face of a demographic boom as over 10,000 Americans enter Medicare each day, rising demand for health care’s new cures and technologies; and an epidemic of chronic disease.

This is an important way to understand the context behind MACRA.

To build on the foundation we have begun on reforming the delivery system so that value based care can reach every community in America. Given this magnitude of change, I asked the team to approach MACRA differently. After this historic legislation passed, the CMS team was eager to get to work on implementation. But they heard something different from me. Stop writing, get out of DC, and start listening. 

Through 4,000 formal comments, nearly 100,000 attendees at our events across the nation, focus groups, design sessions, workshops, physician office visits (and countless tweets), we got to hear patients and clinician points of view on things we can do to make healthcare better for them.

  • We heard the deep dedication that both patients and clinicians have to the Medicare program, but also the many frustrations.
  • We heard from clinicians who challenged us to prove that MACRA and the Quality Payment Program wasn’t one more check-the-box program and instead allows them to focus on care and quality improvement
  • We heard from physicians who are fed up that their EHRs do not support patient care. Clinicians want technology that make their jobs easier, match their workflows, and give them access to needed data.
  • We heard patients who were tired of lugging around or repeating their treatment history — who wanted more time with a physician who knows them personally, so that they can get the right treatment at the right time without unneeded repetition or miscommunications.Our challenge isn’t about accountability or quality or costs or whatever euphemism people use. It’s to recognize that the path forward isn’t through any one model or new three-letter acronym or quick fix, but by addressing the basic things, which lead to bad outcomes, physician burnout, or for patients, particularly needier ones, to feel displaced and not get the right care.

Your opportunity with MACRA isn’t to implement a new scorekeeping system. If we do that, we will not only miss the opportunity to transform, but we will add complexity to an already overly complex system.

Based on what we heard, we made major changes to how we approached this program holistically.

First, we focused on a lighter touch and less regulation. By adopting the idea that if we simplified and reduced what was measured and gave physicians back more time with patients and instead supported their quality efforts, we would make more progress. And, we reduced the number of requirements in half to help level the playing field for small or independent practices.

Second, we came to realize MACRA is many clinicians’ first experience with reporting and paying for quality for the first time. We created multiple timelines to allow clinicians to pick their own pace of entry and development.

Third, we also recognize that many practices are advanced and ready to go further, so we built more opportunities for clinicians and to allow more innovative models to flourish. We estimate that about 25% of eligible Medicare clinicians will be in an Advanced Alternative Payment Models by 2018, and we have a goal of creating options for physicians in all specialties and geographies in order to allow them to pick models that are right for them.

As we move forward, we all need to keep building on what works while systematically demanding improvement where we can do better. 

So how do I suggest we tackle the next opportunities?

One. Build from a foundation of progress, not head backwards. There can be no delivery system reform without building on the foundation of reaching universal coverage. That means building on the record 20 million people who have newly found coverage and continuing the security and protections Americans have found, including no-cost preventive care, the elimination of lifetime and annual coverage limits, and the end of pre-existing condition exclusions. If we want to fix how care is delivered, so that we’re providing value, then we must ensure that Americans can afford and access quality care at every point in their lives. If we lose even some of the coverage gains made under the ACA, or leave people in limbo, people will lose access to regular care and we will drive up long-term costs. This doesn’t mean we shouldn’t improve how coverage works in a bipartisan fashion. We must always do that and we should now as new leaders bring new approaches and solicit new ideas.

Two. Insist that modernization of Medicare must actually mean modernization. Progress is achieved by ingenuity, innovation, teamwork, and the use of data and technology, not by changing funding formulas.  

I’ll say this bluntly: MACRA can’t work as well without a CMS Innovation Center that can move quickly to develop and expand new approaches to paying for care. With changes to the Innovation Center, the advanced alternative payment approaches could slow significantly. We will have a much narrower path with fewer specialty options and approaches, which take in patient and physician feedback. Medicare and commercial payers would then fall further out of alignment, and more importantly, less patients would have access to innovative care methods.

Three. Start to demand technology that can exchange data, that supports care, and that is affordable. MACRA is an opportunity to move the focus away from paperwork and reporting and towards paying for what works. For a variety of reasons, EHRs became an industry before they became a useful tool. The technology community must be held accountable by their customers and make room for new innovators and to give clinicians more freedom and more flexibility to focus on their patients, to practice medicine, and deliver better care. We worked alongside physicians to design technology tools (QPP.cms.gov) and a support center that allows physicians to learn about, access, and even design their involvement in the Quality Payment Program.

Four. Don’t forget that people are the heart of every policy made. We are on a journey as a nation towards better health for all. Patients. Care givers. Consumers. You know them better than anyone because you care for them. View MACRA as a step in the journey to develop care together.

With 50 days to go, I want to close by thanking everyone who has provided the often tough but critical feedback that has helped CMS do our jobs better — and that have helped me by sharing the realities of what really matters. The CMS team is committed to being your partner, to being transparent, to leading and delivering a path to better care. Remind us that your mother, and any mother are at the center of every decision we make, and we will be too.

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13 replies »

  1. NEJM- Take this seriously. http://bit.ly/2hgvvEn
    Why 96% Burnout is serious problem? Regulations/clerical duty/EHRs. And that basically describes MU PQRS and MACRA. Andy boasts a listening tour and does VERY little listening. He is the LEADER. The positives AND negatives go with that. He should have led and told Congress that MACRA was too much, unworkable, that he “listened” to front line providers that they are at their limit of hyper-reguatlory action. MACRA was passed due to exhaustion about the yearly (sometimes more often) legislation that had to be passed due to the flawed SGR. Andy and team could not resist the temptation to allow a massive regulatory act be piled on to already burdened physicians, then point to Congress as if they were at fault. MACRA will end. MACRA will fail. MU and PQRS failed and failed miserably. We are now 10 years behind where we should be because of flawed policy. We have WORSE cost, WORSE satisfaction/quality/safety/security, AND WORSE burden. Congrats on that. If anything, learn from this election, we have had enough of Washington DC piling on their “sounds good” ideas on hardworking people that are costly, hyper regulatory, and produce worse results all the while driving MDs out of practice. So sorry if Andy cannot take the heat, get out of the kitchen. Its HIS legacy, along with every ONC leader (Farzad,DeSalvo, etc) that pumped misleading stats about MU and PQRS for years and could never seem to understand why it was failing. We are going to be VERY vocal and pushback VERY hard. So be prepared. We are going to kill MACRA or not participate, just like MU and PQRS, which kills it by attrition.

  2. Hi,
    I agree with Steven, the traditional wisdom is that neither Price nor Verma will look for major changes or now in MACRA, but they will soften the rule for small and medium practices and accelerate the decline of MIPS (which is limited in time) Probably in late 2017 or Principles 2018. community health center

  3. The issue that now arises vis a vis MACRA is whether the new administration, with Tom Price at helm of HHS and Seem Verma at CMS, is going to seek changes to the rule. The rules are “Final with Comment” at the moment and due to be finalized this month. But regulations issued in the final months of an election year are subject to review by the new administration when it takes office. Price voted for MACRA, and I’m told was a solid supporter. But he also holds views at variance with MACRA’s structure and intent–specifically with reference to the government interference in the doc-patient relationship.

    So we will see. The conventional wisdom is DC is that neither Price nor Verma will seek any or big changes now in MACRA, but that they may further soften the rule for small and medium size practices and accelerate the demise of MIPS (which is designed to be time limited) in future rule making – probably in late 2017 or early 2018. We shall see.

    I certainly understand the anger/frustration out there…but, once again, find many of the comments below to be overly aggressive and unnecessarily personal (to Andy) and not particularly productive. Andy was/is not a guy driven by ideology or party affiliation per se. He had a job to do, implementing a law that Congress passed in strong bipartisan votes in both chambers. Most people think he did that job well, after taking criticism of the proposed rule to heart. Your anti-government beef is not primarily with him, or should not be. Go ask your members of Congress, Dem and Republican, why they voted for MACRA.

  4. Yes Andy, we are angry and we are going to fight your legacy/regulatory action from MACRA to cert EHR.

  5. “ We’ve tried to make MACRA more accessible by naming it the Quality Payment Program”

    That reminds me of the developments in my area. They have these fancy loving names like Oak Tree Village, but the first thing they do is level the land and kill all the Oaks. That is exactly what you are doing. Killing quality and people. A lot of talk, but in the end whatever benefit there is seems to travel in your direction and the direction of the people that put you where you are.

    Keep spinning for that is what seems to be your job. Impose draconian measures and then use a slightly lighter touch to make yourself look good. Make believe it is the physician’s fault that MACRA doesn’t really work for the longterm when the real fault is yours and the program. Tell us how advanced some practices have become while you consolidate doctors under hospitals and corporate management that doesn’t benefit the patient or society.

    Fortunately you and your kind will hopefully be out with the next administration. Maybe one day you or your family will face a horrible medical situation where the hands of your doctors will be tied due to your own actions. I hope that never happens, but if it does maybe then you will learn what your misdeeds have created.

  6. I could not agree more with you Margalit. Andy has some cognitive dissonance in his mind about listening, hearing and responding. 99% of those 4000 comments on MACRA from actual practicing MDs were highly critical/negative which CMS ignored or basically said “we are CMS, too bad, we are not going to respond.” The select few MDs that he ACTUALLY faced were hand picked sycophants, not real front liners. As for societies, the professional societies (AMA, ABMS) love hypercomplex regulations as they make money off of courses, books and CME about that. If PQRS and MU were such a resounding success, we would not be having these conversations. But they were TOTAL failures, requiring yearly complete rewrites, an entire industry to compile, extract, register, complete and report the data. Spending 35 Billion to get many MDs computers was a waste from the start. EHRs were slowly making progress into the offices, arguably at the proper pace. IT vendors were working with MDs to be sure EHRs worked how they wanted. Then CMS and ONC comes barreling in, usurping the usual market and placing a nonsensical policy market. DC knows better. DC needs to fight back EVERY time they say to themselves doesn’t this “sound good”. “Sounds good” regulation by nonfront line MDs has driven the MU/PQRS/MACRA market with zero thought about cost, complexity, burden, real outcomes. Therefore it is all doomed to fail. Right now we have only a few inpatient EHRs vendors left. As the leader of physician IT at our hospital, I can tell you that EHRs are still BLINDINGLY complex, have unworkable workflows, still built to enhance billing/collecting, and are at least a decade from being safe/secure. Just this week we are trying to figure out how outpatient medication lists can match inpatient ones, ON THE SAME EHR!! To make matters worse, every attempt to make it less burdensome, complex, unsafe, has to deal with yearly 1000 page legislation /certification to see if it interferes with MU/MACRA/PQRS/Certification rules. We need to STOP EHR certification. It is hammering innovation, slowing progress immensely and we need to stop all these silly unworkable, unless, meaningless reporting programs like MACRA. These interfere with care and progress. If CMS wants data, then send out an ARMY of data people to get it. Stop asking MDs to enter it. Our expertise is in patient care, not data. As for interop, EVERY MD would love it. So don’t blame the lack of interop on us.But not a day goes by that some poor victim of hacking/cybercrime gets majorly fined as the victim, and you are asking MDs to control security/interop? Seems like a very dangerous game for MDs. Don’t ask for information to flow, if you pound us for a single byte lost.So you can forget interop at this point unless IT vendors can make it easy secure and safe. And safe also means if someone accidentally puts patient has diabetes in a data field, but its a mistake and its corrected AFTER the record is released to interop -land, how do we correct it EVERYwhere that incorrect data went? If that wrong record is blasted out, then incorporated into a zillion EHRs, how do we blast of a correction, find that problem and correct it in a zillion EHRs? See what I mean?
    So Andy, your team has been on Twitter, great. You speak in VOLUMES about listening, but you barely listened, and gave one half hearted attempt at a year transition. But after that? Walk slowly down the plank for a year then fall in? Beat with a belt for a year then a wrench next year and beyond? As a leader, Andy, you should have been WAY more vocal about the unworkable nature of MACRA’s reporting problems, complexity, and burden. The blowback is here. But who cares right? You are off to some post government position, most likely a position that you already have set up, that will net you millions as you have knowledge of inner workings of this complex system. Like nearly ALL the prior CMS leaders (Tavenner, sebelius, berwick), you will lead lobbying groups, think tanks, or maybe your old insurance panel UHC/Optum, where there were some serious ethical questions raised about that transition. Its funny how you and your types in DC, don’t give a second thought about that conflict of interest, but are willing to penalize hardworking MDs trying to care for patients. People wonder why Trump won (I didn’t vote for him btw). This is why. Those of us outside DC, get mauled by regulations are sick and tired of those in DC that are gaming the system for themselves, without a thought about how it affects us in the real world.

  7. I would just note that keeping it real with the “Stop writing, get out of DC, and start listening” thingy, is best done BEFORE “historic legislation” is drafted, let alone “passed”. So yeah, there is that….

  8. Dr. Nelson- I have said this same thing about spending some time volunteering to really understand the world he is trying to fix. I do believe Mr. Slavitt’s intentions are honorable, however, they are impractical. If you are reading this Andy, in the new year when things slow down a bit , there will always be an open invitation to my office. Please come see what is really going on out here in underserved areas. Your entire world view would be turned upside down after a few days in our tiny little clinic.

  9. Andy, it may be time to re-consider the permanent ‘lease’ (de-facto piggybacking and thus brand extension of MA operators) on the goodwill of the Medicare program to the contractor universe operating in effect under a ‘Medicare [false equivalency] license’ – fine print notwithstanding.

    Lets face it Medicare Advantage is NOT Medicare. The contractors goodwill free ride need come to an end. They are NOT Medicare. They are Medicare alternatives and vary materially by market, share, and maturity of contractors in managing clinical risk, and marketing. They should be marketed as NOTE: WE ARE NOT MEDICARE. We contract with the Federal Government and our promises as only viable as long as we profit from participation in this program – or something like that.

    The blitz·krieg of unrelenting open enrollment marketing claims and references to ‘regular Medicare’ while tethering their product (a private option alternative) as if it’s seamless engagement in upside only, i.e., no premium, expanded benefits, and additional services, etc., is wreaks of misrepresentation of what the member is electing. Caveat emptor!

    As a Medicare Advantage enrollee via KP San Diego I am documenting my experience as I am not the average plan participant.


  10. There is too much being thrown at us. We are becoming too distracted. This gratuitous overhead in our brains is harming our focus on patients.

    Healthcare is like this long line of sherpas and porters climbing Mt. Everest, with the actual edge of the sword being a few actual climbers in the front. As the line gets longer–because the world thinks we need help–the packed food and oxygen gets more and more diverted to the sherpas and away from the climbers. This changes what the economists call the utility function of the entire effort: it becomes more of an effort to feed the porters than it is an effort to reach the summit of Everest.

    As our sector looks to a visitor from space, it is looking less like a group of people trying to fix health in others and more like a group of people trying to feed themselves and take nice vacations and buy new homes. The utility function of health care in the US seems to be to feed and give jobs to 17% of the population. Is this our real purpose?

  11. Andy,
    Meanwhile…the economic mandate for “Complex Healthcare Needs” has lead to a national healthcare industry that contributes to the poor growth of our national economy and lacks the ability to serve our nation’s social mandate (justly equitable) for the “Basic Healthcare Needs” of each citizen, community by community. There is no basis to assume that your optimism will succeed without a structured process to tackle healthcare reform at the community level. First, we need a nationally sanctioned and widely supported means to agree on a definition of HEALTH that is connected to the level of Social Capital within each community. Second, we need a recognition that innovative payment strategies will not solve that problem. Third, we need a recognition that the forces of change are beyond our current ability to assess and address them without the involvement of each community. One only has to recognize the prominently disruptive events that challenge the Family Traditions of each Family. This is particularly a problem for the importance of early childhood education during a child’s first 3 years of life. Becoming a caring and learning person is the most important initial strategy for life long STABLE HEALTH.
    Your effort to “fix this mess” is valiant and laudatory. But, please remember, that the continuing re-direction of capital to achieve healthcare reform only further aggravates the supreme level of cognitive dissonance that exists among the multiple levels of healthcare’s vested interests. The effect is devastating to the institutional governance for supporting the front lines of our healthcare industry. This was my role as a Primary Physician for the last 41 years.
    I suggest that you take one day a month to volunteer, for at least 3 consecutive months, at a homeless shelter. Then, you would most clearly understand the degree of emotional, economic, as well as, physical violence withstood by many, if not most, families in our land and how that contributes to the HEALTH of all citizens. Unfortunately, for you and for all of us associated with healthcare reform, we will all face another transition within the next few weeks. And, the proverbial Louisiana Bayou will continue to plague our nation’s healthcare reform, unless, we return to the heritage of our nation’s origins in the community. President Thomas Jefferson said it best many years ago.
    see http://www.nationalhealthusa.net/innovation/epilogue/

  12. “Before Medicare, do you know how many seniors in this country lived in poverty? One in three -Today, it’s less than one in ten. Our promise to the millions of Americans –our neighbors — particularly when we are living on a low or fixed income– is part of what has made us who we are”- Thanks for Andy Slavitt for reminding us that we seek to count ourselves among what are called civilized nations.