AUGUST 28, 2019

Welcome to the Pay for Performance Update eNewsletter
Editor: Philip L. Ronning
This issue is sponsored by the National ACO Summit, the National Bundled Payment Summit,
the National Medical Home Summit, and the National MACRA MIPS/APM Summit

Medical Groups Call for Value-Based Care Reforms to Reduce Burden
In response to CMS' push to reduce administrative burden, AMGA and MGMA offered value-based care reforms, such as aligning quality measures and updating the Stark Law. Operating with one foot in fee-for-service and the other in value-based care has created significant administrative burdens for providers, so medical groups are now offering CMS value-based care reforms to simplify the model and move more providers away from volume. In response to a request for information on how to reduce administrative burdens, AMGA (American Medical Group Association) and the Medical Group Management Association (MGMA) recently submitted formal comments to CMS. Within those comments, the associations called for value-based care reforms to alleviate provider burdens. "Our members are treating patients through delivery models that hold them accountable for the cost and quality of the care they provide," said AMGA President and CEO Jerry Penso, MD, MBA. "These models by design do not contain the same misaligned incentives seen in the fee-for-service environment, and Medicare's rules and policies need to recognize and account for this difference." Specifically, the associations called for quality measure alignment, more consistent waivers and rules across value-based care programs, and Stark Law reform. (RevCycle Intelligence, August 13, 2019)

Discharge Incentives in Emergency Rooms Could Lead to Higher Patient Readmission Rates

In an effort to address emergency department overcrowding, pay-for-performance (P4P) incentive programs have been implemented in various regions around the world, including hospitals in Metro Vancouver. But a new study shows that while such programs can reduce barriers to access for admitted patients, they can also lead to patient discharges associated with return visits and readmissions.

(Science Daily, August 20, 2019)

AHA Proposes Additional CMS Actions to Reduce Regulatory Burden
The AHA has proposed additional actions that the Centers for Medicare & Medicaid Services could take immediately "to reduce the regulatory burden on hospitals, health systems and the patients that we serve." The actions range from suspending and improving the hospital star ratings, to broadening and improving opportunities to participate in alternative payment models, to permanently prohibiting the enforcement of the 96-hour rule. "We very much appreciate the Administration's continued willingness to tackle this issue," AHA wrote, responding to the agency's request for information on the issue. "Reducing administrative complexity in health care would save billions of dollars annually and allow providers to spend more time on patients, not paperwork. CMS recently provided some important regulatory relief to hospitals, which we greatly appreciate. However, more work remains to be done." CMS recently withdrew the long-term care hospital 25% Rule; allowed hospital-based physicians to use their hospital's quality reporting and pay-for-performance measure performance in the Merit-Based Incentive Payment System; and finalized a 90-day reporting period for the Medicare Promoting Interoperability Program for fiscal year 2021, the letter notes. The agency also has proposed to eliminate the direct supervision requirement for outpatient therapeutic services for all hospitals, including critical access hospitals and small rural hospitals having 100 or fewer beds, as AHA has repeatedly urged. (American Hospital Association, August 12, 2019)

Oncology Market Projected to Grow Superlatively at a CAGR of 12.6% During the Forecast Period Of 2019 To 2025
The global oncology market size at $120 billion as of 2018, and the demand is projected to grow superlatively at a compound annual growth rate (CAGR) of size 12.6% during the forecast period of 2019 to 2025. The oncology market is undergoing drastic changes in recent times. With rising cancer rates and numerous advances in medical technology, the field offers tremendous opportunities for practice and research, and the oncology market share is flourishing. This can be conceived from a latest business intelligence publications by IndustryARC titled "Oncology Market: By Cancer Type (Breast Cancer, Lung Cancer); By Therapy Type (Medical Oncology, Radiation Oncology, Surgical Oncology); and By Region Forecast (2019 - 2025)". The companies have started to invest their shares in the capabilities that match the market evolution, and the companies in the Unites States have doubled their expenditure on cancer drugs. This report covers oncology Market Size by type and application, oncology Market share by top 5 companies and also the market share by start-ups during the forecast period. (The Expresswire, July 31, 2019)

CMS Releases Proposal for Radiation Therapy APM; Get Our 4 Key Takeaways

  1. The proposed model will be mandatory. This model would require participation from radiation therapy providers, including physician group practices, hospital outpatient departments, and freestanding centers, within randomly-selected Core Based Statistical Areas. When HHS Secretary Alex Azar first mentioned the model last winter, physician groups, especially ASTRO, were opposed to a mandatory model, expressing concerns that it could negatively affect patient access to care. (Note that certain participants are excluded, such as providers in Maryland and Vermont, as well as PPS-exempt cancer hospitals.) As proposed, the model would qualify as an Advanced Alternative APM and a MIPS APM.
  2. Beneficiaries with one of 17 different cancer types are included. They must be enrolled in Medicare Part B, and patients enrolled in clinical trials where Medicare pays routine costs would also be included. The model proposes to exclude patients in Medicare managed care, including Medicare Advantage.
  3. Participants will receive prospective payments for a 90-day episode of care. Payment will be broken into professional and technical components. The amounts will be based on national payment rates, trend factors, and adjustments for case mix, historical performance, and geographic location. CMS will apply a discount factor of 4% to the professional component payment and 5% to the technical component. The components of radiation therapy care to be included in the episode-based payment are: treatment planning, technical preparation (e.g., planning, dosimetry), delivery services, and treatment management (e.g., changes to dose delivery, follow-up care). Modalities included are: 3D-CRT, IMRT, SRS, SBRT, proton, IORT, IGRT, and brachytherapy (non-surgical). Services excluded are: E&M visits and low-volume radiation services, such as brachytherapy surgical procedures, neutron beam therapy, and radiopharmaceuticals.
  4. Participants could earn reconciliation payments based on Aggregate Quality Scores. There are four quality measures proposed:
    • Oncology: Medical and Radiation - Plan of Care for Pain -NQF41 #0383; CMS Quality ID #144
    • Preventive Care and Screening: Screening for Depression and Follow-Up Plan -NQF #0418; CMS Quality ID #134
    • Advance Care Plan -NQF #0326; CMS Quality ID #134
    • Treatment Summary Communication -- Radiation Oncology

In addition, participants can earn back withheld technical component payments based on their performance on the patient-reported CAHPS Cancer Care Survey for Radiation Therapy. (The Advisory Board, July 11, 2019)

Focusing on Consumerism to Drive Value
During last month's AHA Executive Forum for The Value Initiative, PillPack's Chief Product Officer Elliot Cohen shared this insight about consumerism: "As field, we often focus more on economic incentives than we think about how we can improve the consumer experience. If we were to switch gears and focus on making health care more convenient and enjoyable for our patients, he said, we would automatically arrive at lower costs and better outcomes." According to the American Customer Satisfaction Index, health care continues to trail other industries in customer service1. So, we know things need to improve. But what's a good first step? This blog reports the comments of many Forum participants. (American Hospital Association Blog, August 12, 2019)

The Path to Your New Investment Strategy

Pay for Performance Update e-Newsletter is one of a family of free e-Newsletters providing a complimentary video presentation and regularly updated news and key resources on major health care issues such as ACOs, comparative effectiveness, patient safety, bundled payment, readmissions, and Medicaid. To view and subscribe to other e-Newsletters go to www.HealthCareeNewsletters.com.

Making Downside Risk Work

Sanjay Doddamani, MD
Chief Medical Officer, Geisinger at Home, Geisinger Health System; Chief Medical Officer Keystone ACO, Danville, PA

Matthew Mazdyasni, MSc
Strategic Advisor and Board Member, COPE Health Solutions, Los Angeles, CA

Vincent L. McVittie
Executive Director, Signature Care Management, Pittsburgh, PA

Pamela M. Pelizzari, MPH
Principal, Milliman, New York, NY

Jay Sultan
Vice President, Healthcare Strategy, Cognizant, Watkinsville, GA (Moderator)