JULY 3, 2019

Welcome to the MACRA MIPS/APM Update eNewsletter
Editor: Philip L. Ronning
This issue sponsored by the National HIPAA Summit and the Population Health Colloquium.

Gov't Interference Is Hurting Docs, CMS Chief Tells AMA
Government interference has exacerbated the flaws in our healthcare system, but the Centers for Medicare & Medicaid Services (CMS) is working to correct that, CMS administrator Seema Verma told the American Medical Association (AMA) House of Delegates here Monday. Verma described the agency's efforts to relieve the administrative burden on physicians, promote value-based care, and allow physicians to return to their core mission: Taking care of patients. She zeroed in on the glut of paperwork, often driven by burdensome government regulations, which she said prevents physicians from spending the time they'd like with their patients and explains why "physician burnout ... is at an all-time high." "It's getting harder for physicians to finish their training, hang their shingle, and deliver care to their communities," she said. CMS is working to "untangle government regulations" through its "Patients Over Paperwork" Initiative, which included a nationwide "listening tour" where the agency gathered information on outdated and unnecessary regulations, she said, adding that the program so far has yielded savings of about $5.7 billion. "And if you're going to tell me about prior authorization, I'm on it -- we're going to get there," Verma said, to loud applause. She was referring to Medicare and other insurers requiring physicians to submit paperwork in advance in order to guarantee reimbursement for certain tests or procedures. (MedPage Today, June 11, 2019)

Quality Payment Program
The AAOS Quality Payment Program (QPP) Information Center offers tools and resources to help you and your practice prepare for and navigate through either of the two QPP tracks - The Merit-based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (APMs). For the most recent advocacy news, comment/congressional letters, and current AAOS position statements, see the "Advocacy" tab below. Have additional questions about the QPP? Contact macra@aaos.org. Questions can also be submitted directly to CMS via email at QPP@cms.hhs.gov or (866) 288-8292. (American Academy of Orthopaedic Surgeons, accessed June 27, 2019)

Providers Press CMS for Details Amid Lingering Uncertainty about New Primary Care Models
The possibility of conflicts between Medicare payment models joined the customary concern about benchmarking details in provider feedback on coming primary care models, an administration official said. s details on the Primary Care First (PCF) and Direct Contracting (DC) models continue to emerge, some of their components remain undecided -- even as the Centers for Medicare & Medicaid Services (CMS) aims to garner provider participants this summer. The models were introduced in the spring as mechanisms to move primary care to an outcomes-based focus, enhance care for high-need patients and reduce physicians' administrative burdens, among other goals. Physician responses to the models have been positive but cautious, given the many details that were unknown when CMS announced the models in April, with a goal of launching them in 2020. Pauline Lapin, MHS, director of the Seamless Care Models Group at the Center for Medicare and Medicaid Innovation (CMMI), described the industry's response during her address this week at the Bundled Payment and MACRA Summit in Washington, D.C. Emily DuHamel Brower, senior vice president of clinical integration for Trinity Health, said providers' shift away from focusing primarily on benchmarking issues is positive. Instead, providers also are seeking information about how Medicare beneficiaries will be selected or opt in to the models, how conflicting model enrollments will be handled, and how the models' cash flows will function. "That to me feels like an evolution -- that feels like progress, that we're having those conversations more than whether there is a decedent adjustment in the benchmark," Brower said. (hfma, June 20, 2019)

What Makes an Alternative Payment Model Successful?
The healthcare industry is moving beyond just the development and adoption of alternative payment models (APMs), according to Aparna Higgins, a former leader at the Health Care Payment Learning and Action Network (HCP-LAN). HCP-LAN is a public-private partnership that aims to accelerate the transition to value-based reimbursement and care through increased APM adoption. The organization recently found that just 41 percent of healthcare payments made by insurers covering 135 million lives in 2017 were paid through fee-for-service. Insurers tied the remaining payments to value, with about one-third of all payments linked to a formal APM. While the industry is progressing with APM adoption, providers and payers need to start thinking about adopting models that do more than tie payment to value. "We're not just about pushing forward the adoption of APMs, we really want to identify successful APMs," said Higgins, the current CEO of Ananya Health Innovations Inc. at AHIP's Institute & Expo in Nashville. "Ultimately, we want to be able to give guidance to the field in terms of what works and what doesn't work, so we can achieve the quadruple aim." So, what makes an alternative payment model successful at achieving the quadruple aim? Higgins' fellow panelists from major provider and payer organizations identified elements that have helped their organizations realize the benefits of APM adoption, including lower medical costs, higher care quality, and increased provider and patient satisfaction. The other panelists included Andrea Gelzer, MD, MS, FACS, senior VP and corporate chief medical officer at AmeriHealth Caritas; Kim Kauffman, chief value-based care officer at Summit Medical Group and Summit Strategic Solutions; and Renee McLaughlin, national medical director of value-based relationships at Cigna Corporation. (RevCycle Intelligence, June 24, 2019)

How Do You Measure Quality in Health Care?
The obvious answer, of course, is to develop measurements based on treatment protocols. Of which we have plenty. It seems these days that we have a measurement and documentation requirement for just about everything. In fact, quality measurement in health care has become an industry unto itself. Hospitals and health care systems across the country pay a lot of money to have their quality of care scrutinized and, hopefully, lauded, by a number of companies that charge them for such assessments. In many cases, those assessments are valuable. Nevertheless, I began to think about the value of measurement after exchanging some emails with my friend and college mentor, Deborah Stone. Deborah is a professor at Brandeis University's Heller School for Social Policy and Management who's been doing a lot of thinking lately about counting, measurement, and statistic and the ways in which numbers are used to distort and distract from reality. In a lecture she recently gave to the American Political Science Association, Deborah announced to her audience, "Numbers are figments of our imagination, fictions really, no more true than poems or drawings. In this sense, all statistics are lies." I'm not sure I'm willing to go as far as Deborah, who's quite a provocative thinker, but she did make me wonder whether our current health quality measures are offering the right information and, moreover, whether everything valuable in health care can be easily measured. At some level, I suspect, things that are important are not always quantifiable. For example, even if my facilities are spotless and my clinical staff is expert at avoiding preventable infections, does that mean they're good at explaining diagnoses to their patients? Do they know how to communicate effectively and sympathetically when delivering bad news? Do they return patient calls at night? In today's health care climate, physicians are often required to see a specific number of patients each day. But how effective are our measurements if a physician misses that quota because she devoted extra time to a single patient who really needed the extra attention and care? (Forbes, June 26, 2019)

Humana Asked Experts to Define 'Value-Based Care.' They Couldn't Do It
Humana convened some of the healthcare industry's greatest minds to build a consensus on the definitions of oft-used but rather nebulous concepts such as "value-based care" and "population health." There was just one problem: The experts couldn't figure it out, either. Humana released a look at the results of the panel's discussions first to FierceHealthcare, and although the participants could find common ground on what "value-based payment" is, they couldn't agree when it came to "value-based care" or "population health." The healthcare sector remains in flux as policy, regulation, technology and trends shape the market. The 18 panelists--which included representatives from Humana, the Robert Wood Johnson Foundation, the Geisinger Health System, the University of Pennsylvania and Centene Corporation--agreed, for instance, that value-based care would apply to both individuals and populations and would be determined by outcome and cost. But they were divided about whether patient experiences should be highlighted or whether there should be a duration factor in calculating value. "I was actually a little surprised," Meredith Williams, M.D., market president for Humana based in Louisville, Kentucky, told FierceHealthcare. "I thought there would be more consensus. It was a very revealing process to all involved." (FierceHealthcare, June 14, 2019)

Medicare and the Health Care Delivery System
As part of its mandate from Congress, each June the Medicare Payment Advisory Commission (MedPAC) reports on refinements to Medicare payment systems and issues affecting the Medicare program, including broader changes in health care delivery and the market for health care services.

The 12 chapters of this report include:

  • Beneficiary enrollment in Medicare: Eligibility notification, enrollment process, and Part B late enrollment penalties
  • Restructuring Medicare Part D for the era of specialty drugs
  • Medicare payment strategies to improve price competition and value for Part B drugs
  • Mandated report on clinician payment in Medicare
  • Issues in Medicare beneficiaries' access to primary care
  • Assessing the Medicare Shared Savings Program's effect on Medicare spending
  • Ensuring the accuracy and completeness of Medicare Advantage encounter data
  • Redesigning the Medicare Advantage quality bonus program
  • Payment issues in post-acute care
  • Mandated report: Changes in post-acute and hospice care after implementation of the long-term care hospital dual payment-rate structure
  • Options for slowing the growth of Medicare fee-for-service spending for emergency department services
  • Promoting integration in dual-eligible special needs plans

(MedPAC, June 14, 2019)

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The Seven Characteristics of Successful Alternative Payment Models: Designing, Evaluating and Modeling Value-Based Payment Arrangements

Marc Berg
Partner, Healthcare Innovation, McKinsey

Seema Parmar
Associate Partner and Senior Expert, McKinsey

Nick Bluhm
Senior Director, Strategy and Government Policy, Remedy Partners