NOVEMBER 12, 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

Data Has Become a Four-Letter Word in Primary Care
We primary care physicians hate data. Taken on their own, numbers are benign, but when we hear the word "data," physicians are reminded of a litany of related issues that make our lives far more difficult: checkboxes. Regulatory compliance. Prior authorizations. Unnecessarily complicated payment schemes. By virtue of our training and the principles that guided the decade we spent obtaining our degrees, we are empiricists by nature. It's sad to think that, to many of us, data equals garbage rather than better care. How in the world did we get here? It is likely that our frenemy-ship with data started a couple of decades ago when computing entered the realm of health care. Players in the health care system -- insurers, regulators, hospitals, and even physicians -- became enamored with the possibilities that computing presented, so we started collecting data haphazardly and, at some point, everyone lost sight of the why behind data collection. And, at some point, It started being weaponized against physicians. (KevinMD, October 31, 2019)

The "Behavioral Health Vital Signs" Initiative

Key Takeaways

  1. It is feasible to screen all primary care patients concurrently for depression, alcohol and substance use, and IPV across the lifespan, though disclosure rates of IPV on a screener are likely be lower than true IPV prevalence.
  2. The development of a Behavioral Health Vital Signs (BVHS) screening tool and quality improvement initiative that included depression, alcohol and substance use, and IPV across the lifespan enabled a safety-net health care system to prioritize addressing IPV, despite the lack of a payment incentive specific to IPV.
  3. The BHVS was a key component of an overall systems approach toward institutionalizing a trauma-informed IPV program that included provider and staff training, screening and response protocols, electronic health record (EHR) templates and data, continuous quality improvement, patient education, and expedited referrals.
  4. Designating BVHS to be a highly prioritized primary care metric (a "True North" metric) can be used to drive behavioral health leadership in trauma-informed care.
  5. The BVHS initiative is a promising mechanism to align health care system incentives to support a more trauma-informed approach to primary care–behavioral health integration.

(NEJM Catalyst, October 24, 2019)

Study Offers Alternative Explanation for Much-Heralded Decline in Hospital Readmission Rates Under Pay-for-Performance
The decline in hospital readmission rates that occurred following the launch of a federal program designed to improve quality of care and reduce repeat hospitalizations has been lauded as proof of the program's effectiveness. But a new analysis led by researchers at Harvard Medical School offers an alternative explanation for the outcome. The findings, published in the November issue of Health Affairs, suggest that an overall decline in hospital admissions may have driven the observed drop in readmissions. "The decline in readmission rates looked like the silver lining of pay-for-performance, but it seems to have lost its luster," said study lead author J. Michael McWilliams, the Warren Alpert Foundation Professor of Health Care Policy in the Blavatnik Institute at Harvard Medical School. "Our study makes a strong case that what looked like achievements of the program may have been a byproduct of factors driving a broader decrease in hospitalizations across the board." (MedicalXpress, November 4, 2019)

Medicare's Shared Savings Program Results Should Have Made Headlines. It Got a 'Collective Shrug' Instead
Like the proverbial tree falling in the forest, if the Centers for Medicare and Medicaid Services makes a major announcement about how its Shared Savings Program saved three-quarters of a billion dollars last year alone and no one notices, did the savings really matter? No prominent national business publication gave significant coverage to the late September announcement about the impressive savings from this value-based care program. CMS shared the announcement through a short series of tweets and an article in the Health Affairs blog by Seema Verma, the administrator of CMS. Coverage in trade publications was sparse. It was essentially a collective shrug about a government program that people were wringing their hands over just last year, one that health care insiders have suggested is as big a moment for health care delivery as we have seen in decades. As the CEO of a successful accountable care organization (ACO) participating in the Shared Savings Program, I find this frustrating. After all, this program is considered to be a significant indicator on how its key players -- physicians -- are doing in the biggest health care transformation in decades. (STAT, October 30, 2019)

Wanted: A Seat At The Table: Too Many Decisions on Healthcare Made by People Who Don't Provide It
Oh so many years ago when I was an intern, there was an attending on staff at our university hospital who only took cash for a very high-end panel of VIP patients, and he admitted them to the house staff service. What I recall most distinctly about those admissions was they were mostly for things that would never get admitted to the hospital today. His patients would be admitted for the workup of fatigue, or anemia, or headaches. And, more often than not, they would sit there for days and days, even weeks, getting a slow and steady progressive workup done. I recall when we discussed these cases, that many other senior physicians said this was a vestigial practice, from when almost nothing could get done as an outpatient, and in the "olden days" anytime anybody was the slightest bit sick, it made sense just to bring them into the hospital for a lengthy stay, tons of testing and consultations. Money was no object. (MedPage Today, November 30, 2019)

How Patients Pay the Price for Unintended Consequences of Government Health Care
Government central planners are generally full of great ideas to motivate people to act one way or another, with the goal of achieving a supposedly good result. The US tax code is chock full of such incentives, such as incentives to purchase certain kinds of energy-efficient automobiles, to buy a house (as opposed to renting), or to hire people with certain backgrounds (e.g., military veterans or ex-felons). However, all such incentive schemes also carry the risk of unintended consequences. I'd like to examine three recent examples in which government incentives designed to improve health outcomes has actually resulted in worse care for patients. Go to the article to review details on these three examples:

  1. Preventing Falls
  2. Reducing Readmissions
  3. Skewing Transplant Survival Rates

Good health care requires constant delicate balancing of pros and cons of various patient needs -- for instance, when and how to encourage a patient to get out of bed to improve their muscle function, while minimizing the risk of falls. The physicians and nurses on site who see the patient every day are best suited to make this determination, using their individual judgment to craft a treatment plan in the best interest of their individual patients. In contrast, government incentives discourage practitioners from using their independent best judgment. Rather, the medical team is incentivized to practice a crude "one size fits all" form of medicine to avoid government penalties. In effect, this replaces the rational judgment of the on-the-scene practitioners with the opinion of a bureaucrat hundreds of miles away who has never seen the patient. The government places its heavy thumb on the delicate scales of sound clinical judgment. It's bad enough when patients suffer due to deliberate and illegal violations of government guidelines. It's even worse when patients suffer and die because of physicians trying to adhere to government guidelines. As Americans debate proposals to radically expand government control over health care, we should ask ourselves if this is the kind of care we want for ourselves and our loved ones. (Forbes, October 28, 2019)

State-of-the-Union Report: A Look Into the Evolving Value-Based Payment Models

As a new decade approaches, payment models are continuing to evolve to meet both clinical and financial goals for payers, patients, and providers. Pioneering in the field of advanced payment models is crucial for organizations to tap into the right opportunities.

In this report, we have analyzed multiple APMs most responsible for driving the value-based landscape of the US. Major highlights of the report include:

  • An analysis of growing payment models
  • The clinical and financial aspects of delivering care with each model.

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.

The Physician Perspective on Value-based Care

Barbara L. McAneny, MD, FASCO, MACP
Board-Certified Medical Oncologist/Hematologist; President, American Medical Association; Co-founder and Managing Partner, New Mexico Oncology Hematology Consultants Ltd., Albuquerque, NM