The week before Thanksgiving, the House Ways & Means Committee put forth a set of bipartisan year-end Medicare funding “extenders” to clarify changes to new Medicare payment rules. (One would have Medicare Advantage plans start paying for telemedicine, for example.)
But another that even more clearly signals Congressional support for value-based care (VBC) came with the inclusion of continued funding for the National Quality Forum to keep creating quality measures, reported within VBC payment models from ACOs to MACRA to other risk-bearing contracts used by public and private payers.
This was one signal from Congress that should continue to allay fears that the current administration and/or new leadership in HHS can – or even wants to – roll back VBC in favor of a retrenchment to fee-for-service.
In many ways Congress continues to be the gatekeeper in moving VBC forward, occurring within both the House and Senate. In the House, the Energy & Commerce Committee originates the most health IT and VBC legislation, mirrored in the other chamber by the Senate HELP and Finance committees. (Bipartisan Senate HELP members led the creation of the CHRONIC Care Act that would also advance telemedicine across several specialties and within existing Medicare ACOs.)
But the real accent on Congressional attitudes about VBC, specifically through the growth of alternative payment models, came November 8 during a nearly four-hour hearing by House Energy & Commerce.
Criticizing FFS in Congressional testimony
As a follow-up to the overwhelming bipartisan passage of MACRA in 2015, House E&C members scheduled the hearing to assess the healthcare industry’s participation and attitudes about VBC, with the hearing titled “MACRA and Alternative Payment Models: Developing Options for Value-based Care.”
What E&C got was in essence a love-in from a variety of healthcare delivery voices, noting the different models being undertaken, how MACRA can continue to lead advancement in specialty or innovative models, and most pointedly, how VBC must continue to supplant fee-for-service.
Testifying at the hearing were representatives from the:
- Physician-Focused Payment Model Technical Advisory Committee (PTAC)
- American College of Rheumatology
- American College of Physicians
- American Society of Radiation Oncology
- American College of Surgeons
- Texas Health Resources/Premier, Inc.
- Central Ohio Primary Care Physicians/CAPG
Arguably most noteworthy among those testifying was Jeffrey Bailet, MD, chair of PTAC. The committee was formed within the MACRA law to solicit and assess new physician-friendly VBC models and submit promising plans to HHS to develop into new CMS payment models.
So far some 30 ideas have been sent to PTAC and several have gone to HHS for further consideration.
During his testimony, Bailet noted that “fee-for-service is a barrier to improvement.” And by improvement he meant gains in sustainability, quality and outcomes.
Later in the day, Louis Friedman, MD, representing the American College of Physicians went further. “Fee-for-service was not working for us. We would have sold our practice.”
Overall, those testifying were preaching to the E&C choir about their support for VBC models and the desire for Congress to continue to support the movement.
The entire hearing and access to full transcripts of testimony can be found here.
The CMS and CMMI factor
Yet worries about FFS vs. VBC continue. What if CMS scuttles MACRA? What if Trump ends the CMS Innovation Center (CMMI), born of the Affordable Care Act and from which alternative payment models are designed?
There are a lot of barriers in the way, and the RFI CMS published a few months ago seeking comment on ways to recast CMMI did not signal doom in its language. (Meantime there is talk in Washington, D.C. that a new CMMI director is to be named soon, and that a new voluntary bundled payment model may be announced by CMS in time for MACRA 2018.) Speaking of barriers, MACRA itself is a law, and CMS has finalized the program for 2018. It includes the new ACO Track 1+ designed to bring more providers into ACOs, and it foreshadows multi-payer models beginning in 2019.
And looking closer at the CMMI RFI put out by CMS, the language is about expanding types of models, and as PTAC desires, finding ways to test models via limited demonstrations and episodes of care before they reach any requirement stage. The RFI sought comment on how to construct models in which providers could actually bid into episodes of care and in which beneficiaries could reap shared savings, along with solicitation on other types of specialty models. All told it’s hardly a blueprint to end value-based care.
The RFI also sought comment on Medicare Advantage, behavioral health integration and Medicaid models among others. Philips Wellcentive submitted comment to the RFI, and we will share its details once public.
Also a factor is the arguable instability of HHS. While the new secretary nomination hearings commence, the Tom Price scandal has trickled down to the agency’s cybersecurity program – and elsewhere – putting a virtual stop to that Congressional priority issue, and much spotlight on getting it fixed.
MIPS is where change may come
Up next for the Energy & Commerce committee on VBC and quality reporting is a promised hearing on the MIPS side of MACRA, and here is where the love-in can turn stormy. The MIPS reporting structure is where criticism from the healthcare delivery industry exists, based on whether MIPS is clinically relevant, too confusing or not worth the effort, born out in provider surveys like MGMA’s recent on regulatory burden I detailed in an earlier blog found here.
And it’s within MIPS that there’s much hope that recommendations on how to “fix” MACRA put forth in June by the Medicare Payment Advisory Commission (MedPAC) could and should get some love.
MedPAC’s overall assessment of MACRA is that MIPS is the problem, not the alternative payment models track, and its recommendation is to completely overhaul MIPS by:
- Scrapping current MIPS reporting categories and replacing them with population-based outcomes measures, such as:
- ED visits
- Preventable admissions
- Patient experience
- Healthy days at home
- Providing incentives by withholding FFS, with quality calculated via claims and surveys, meaning there would be no MIPS reporting.
- Moving the entire $500 million bonus pool from MIPS to the APM track to further motivate participation in APMs
These are just some of the recommendations E&C can ponder, and they too send a signal that fee-for-service medicine needs continued adjustment.
Said Rep. Michael Burgess, MD, R-Texas, chair of the E&C subcommittee on health, to open the hearing: “MACRA represents a fundamental change in a healthcare payment system that had remained static for many years … This bipartisan effort led to policies that sought to put power back in the hands of those who actually provide the care … It is critically important that MACRA succeeds and I am glad the committee continues to get payment reform right.”
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