THCB

Categories

Tag: CMS

A Real (Living, Breathing) Health Care Reform Plan: Drop MACRA

• 8

By STEVEN SOUMERAI

Dear Washington,

Congratulations! You have listened to the AMA and practicing physicians and made it a little easier to comply (at first) with the Medicare Quality Payment Program, part of the massive MACRA “pay for value” law. 

But CMS’ announcements in The Federal Register and “fact sheet” are incomprehensible gobbledygook that will be understood by neither doctors, patients, nor the rest of society. The language personifies the complexity, unwieldiness and confused thinking in this huge national policy. 

MACRA is a $15 billion boondoggle that the best research shows will neither improve quality nor control costs. Paying doctors for quality (e.g., doing a blood pressure exam) or efficiency may make sense theoretically, but it doesn’t work. Rather than making a dent in the continuing upward spiral of healthcare costs in America, it can even result in some doctors avoiding sicker patients because it affects their quality scores and income.

Early, poorly designed research suggested that paying for health or cost savings was effective, but these research designs did not account for already occurring improvements in medical practice that the policymakers took credit for. Decades of stronger, well-controlled research debunked these early findings and conclusively showed no effects of these economic policies.

So why does the Congress and administration continue to press ahead with this same tired and impotent policy?

Continue reading…

How CMS Undermines ACOs and What to do About It

• 12

By KIP SULLIVAN

In my first post  in this three-part series, I documented three problems with Pioneer ACOs: High churn rates among patients and doctors; assignment to ACOs of healthy patients; and assignment of so few ACO patients to each ACO doctor that ACO “attributees” constitute just 5 percent of each doctor’s panel. I noted that these problems could explain why Medicare ACOs have been so ineffective.

These problems are the direct result of CMS’s strange method of assigning patients to ACOs. Patients do not decide to enroll in ACOs. CMS assigns patients to ACOs based on a two-step process: (1) CMS first determines whether a doctor has a contract with an ACO; (2) CMS then determines which patients “belong” to that doctor, and assigns all patients “belonging” to that doctor to that doctor’s ACO. This method is invisible to patients; they don’t know they have been assigned to an ACO unless an ACO doctor tells them, which happens rarely, and when it does patients have no idea what the doctor is talking about. [1]

This raises an obvious question: If CMS’s method of assigning patients to ACOs is a significant reason why ACOs are not succeeding, why do it? There is no easy way to explain CMS’s answer to this question because it isn’t rational. The best way to explain why CMS adopted the two-step attribution method is to explain the method’s history.Continue reading…

A Letter from CMS to Clinicians in the Quality Payment Program: We Heard You and Will Continue Listening

• 21

By ANDY SLAVITT

screen-shot-2016-10-14-at-8-43-48-amToday, we are finalizing policies to implement the new Medicare Quality Payment Program. Part of the bipartisan Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the Quality Payment Program aims to create a more modern, patient-centered Medicare program by promoting quality patient care while controlling escalating costs through the Merit-Based Incentive Payment System (MIPS) and incentive payments for Advanced Alternative Payment Models (Advanced APMs).

After issuing our proposal for how to implement the new program earlier this spring, we held a listening tour across the country to hear your thoughts and concerns first-hand about the Quality Payment Program. Whether you formally submitted one of the over 4,000 comments we received, or were one of the nearly 100,000 attendees at our outreach sessions, there have been record levels of clinician engagement. The interactions reflect the importance you place on serving the more than 55 million individuals that have Medicare coverage.

We found an eagerness to help the Medicare program improve and an interest in being engaged in how we address the challenges and opportunities ahead. We also heard concerns, which is not surprising, given the challenge of changing something as large and important as the Medicare program. But, we found that there is near-universal support for moving towards a future focused on patient care that pays for what works, reduces clinician burden, and better supports and engages the medical community.

Continue reading…

CMS’s Latest Report Is Bad News For Medical Homes

• 4

By KIP SULLIVAN

flying cadeuciiThe latest report  on one of CMS’s “patient-centered medical home” (PCMH) demonstrations is more bad news for the “medical home” movement. According to the report, the second-year evaluation of Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration released by CMS on May 11, PCMHs are not cutting Medicare costs and are having almost no impact on quality.  Here is how the report summarized its findings on the eight states participating in the demonstration: “Our quantitative analysis [finds] very few consistent, favorable changes associated with the MAPCP Demonstration across the eight states.” (p. 11-6)

The MAPCP demo is one of three “medical home” demonstrations CMS has conducted. As of last May, CMS had released reports on two of them, the Comprehensive Primary Care Initiative and the FHQC Advanced Primary Care Practice Demonstration.

As I reported in an article posted here  on May 5, those reports indicated the PCMHs in those demos are having almost no impact on quality and may be raising Medicare’s costs.

The news that all three of CMS’s PCMH experiments are failing is also bad news for proponents of MACRA. The PCMH is one of the three “alternative payment models” that Congress and CMS are counting on to lower Medicare’s costs under MACRA. (ACOs and bundled payments are the other two.)

Continue reading…

MACRA Comment: CMS + MIPS/APM = Death of the Private Practice Physician

• 5

By NIRAN AL-AGBA, MD

flying cadeuciiSmall, independent private practices are closing, increasing numbers of physicians are retiring early, and fewer medical school graduates are choosing primary care.  The old-fashioned practice my father and I have built is a dying entity.  Parents say coming to see us for an appointment feels more like a visit with a friend than a medical encounter.  I am fighting for the subsistence of rural primary care practices.  Most will not survive MACRA proposed changes to the reimbursement structure. 

Seven days ago, I attended an “informational listening session,” sponsored by the Center for Medicare and Medicaid Services (CMS) for rural physicians to learn more about the new MACRA proposal known as MIPS/APM (Merit-Based Incentive Payment System/Alternative Payment Model.)  This new plan will penalize 7 out of 10 small practices with 1-2 physicians in this country.  Why? Because they will be overwhelmed complying with fruitless statistical reporting demands that do nothing to enhance the quality of care, instead of spending precious time seeing patients. 

Continue reading…

Making Transparency Work: Why We Need New Efforts to Make Data Usable

• 6

By ASHISH JHA, MD

Ashish JhaGet a group of health policy experts together and you’ll find one area of near universal agreement: we need more transparency in healthcare. The notion behind transparency is straightforward; greater availability of data on provider performance helps consumers make better choices and motivates providers to improve. And there is some evidence to suggest it works.  In New York State, after cardiac surgery reporting went into effect, some of the worst performing surgeons stopped practicing or moved out of state and overall outcomes improved. But when it comes to hospital care, the impact of transparency has been less clear-cut.

In 2005, Hospital Compare, the national website run by the Centers for Medicare and Medicaid Services (CMS), started publicly reporting hospital performance on process measures – many of which were evidence based (e.g. using aspirin for acute MI patients).  By 2008, evidence showed that public reporting had dramatically increased adherence to those process measures, but its impact on patient outcomes was unknown.  A few years ago, Andrew Ryan published an excellent paper in Health Affairs examining just that, and found that more than 3 years after Hospital Compare went into effect, there had been no meaningful impact on patient outcomes.  Here’s one figure from that paper:

Ryan et al

The paper was widely covered in the press — many saw it as a failure of public reporting. Others wondered if it was a failure of Hospital Compare, where the data were difficult to analyze. Some critics shot back that Ryan had only examined the time period when public reporting of process measures was in effect and it would take public reporting of outcomes (i.e. mortality) to actually move the needle on lowering mortality rates. And, in 2009, CMS started doing just that – publicly reporting mortality rates for nearly every hospital in the country.  Would it work? Would it actually lead to better outcomes? We didn’t know – and decided to find out.

Continue reading…

More Than Adequate

By KOFI JONES

CMS recently unveiled a massive regulatory overhaul of Medicaid managed care requirements. Despite the fact that it’s being called a “mega-reg,” and taking some heat for its 1400+ page size, there’s certainly some interesting reading contained within, particularly for the telehealth community.

It’s all about network adequacy standards.

Health plans are regulated by states or CMS and measured based on their ability to demonstrate the adequacy of their in-network providers. How many are there? What’s the availability by specialty? Do consumers understand which providers are in-network? What does access look like in terms of wait times and distance? Answering these questions are the key to meeting the standard.

Continue reading…

Preparing Your Organization for MACRA 1.0

By BOBBI BROWN

flying cadeuciiWhat does the Medicare Access and CHIP Reauthorization Act (MACRA), signed into law in 2015, mean for healthcare organizations and providers? At HIMSS 2016, the CMS Center for Clinical Standards and Quality Director, Kate Goodrich, MD, stated MACRA’s goal: “to have a single, unified program with flexibility. The new Merit-Based Incentive Payment System (MIPS) will offer that flexibility and not be a one-size fits all program. The new rule will reimburse physicians based on four factors.”

Health systems are still waiting for additional details about the “four factors” Goodrich mentioned (listed in this article under “MIPS”) or how CMS will reward providers for delivering better care. We’re aware of MACRA’s general structure, but still waiting for clearly defined rules and regulations. Until then, it will be difficult to evaluate this new law.

Even though health systems are currently in a waiting period for clarifying details about the proposed MACRA regulations (with major impacts in 2019), MACRA’s base year will likely be 2017—and 2017 is just around the corner. This article provides an overview of MACRA and guidance about what health systems should do to prepare for MACRA now.

Continue reading…

The ACO Information Vacuum

• 4

By KIP SULLIVAN

flying cadeuciiIn my three-part series on why we know so little about ACOs, I presented three arguments:

  1. We have no useful information on what ACOs do for patients;
  2. that’s because the definition of “ACO” is not a definition but an expression of hope; and
  3. the ACO’s useless definition is due to dysfunctional habits of thought within the managed care movement that have spread throughout the health policy community.

Judging from the comments from THCB readers, there is no disagreement about points 1 and 3. With one exception (David Introcaso), no one took issue with point 2 either. Introcaso  agreed with point 1 (we have no useful information on ACOs), but he argued that the ACO has been well defined by CMS regulations, and CMS, not the amorphous definition of “ACO,” is the reason researchers have failed to produce useful information on ACOs.

Another reply by Michael Millenson did not challenge any of the three points I made. Millenson’s point was that people outside the managed care movement use manipulative labels so what’s the problem?

I’ll reply first to Introcaso’s post, and then Millenson’s. I’ll close with a plea for more focus on specific solutions to specific problems and less tolerance for the unnecessarily abstract diagnoses and prescriptions (such as ACOs) celebrated today by far too many health policy analysts.

Summary of Introcaso’s comment and my response

I want to state at the outset I agree wholeheartedly with Introcaso’s statement that something is very wrong at CMS. I don’t agree with his rationale, but his characterization of CMS as an obfuscator is correct.

Continue reading…

Quality v. Quantity

• 4

By MICHEL ACCAD, MD

A few weeks ago, the medical community received unexpected good news from the government about a “simplification of quality measures:”

Strictly speaking, and contrary to what Mr. Slavitt’s tweet would lead us to believe, the agreement to the new rules was primarily between commercial insurers and CMS, the Center for Medicare and Medicaid Services. Physicians were not actually party to the deal.

Nevertheless, doctors were expected to greet the news with cheers. As Rich Duszak reported, Adam Slavitt, acting administrator for CMS, also declared that “patients and care providers deserve a uniform approach to measure [sic] quality.”

Indeed, we all deserve uniform quality measures. Equality in quality!

Continue reading…