Medicare Payment Advisory Commission (MedPAC) public meeting, November 5, 2015

Excerpts from the transcript

MR. GRADISON: I think it’s really important not to get too carried away about the benefits of this proposal [paying primary care doctors a fee per patient]. … I’m not sure it’s the answer to a beneficiary’s prayer. Let me call attention to our own document on page 9. Basically, it says … [the] Commission was also concerned about the lack of evidence showing that practice requirements improved outcomes, such as higher quality or lower health care spending. Now, if that’s true, then … why are we doing this? [p. 210]

DR. ALICE COOMBS: So my question is – and then I’m going to be honest with you. I’m going to be real, okay? If I was an internist and I saw this coming at me like this and all the questions that I have, I would say, “That sounds like a good plan for someone.”

[Laughter.] [p. 212]

[MEDPAC CHAIR] DR. FRANCIS CROSSON: Well, I mean, I’ll answer it, to the extent that – I mean, again, we’re sort of starting out. We’re not really starting out, but we’re starting out in a new direction. [p. 214]

DR. [JON] CHRISTIANSON: I just wanted to say that I agreed with everything that Bill [Gradison] said. I think we don’t want to oversell this. If we really think the problem is better care management, we should figure out a way to pay for better care management. This is kind of a trickle-down theory of better care management. [p. 217]

The Medicare Payment Advisory Commission (MedPAC) has become so confused about the “patient-centered medical home” (PCMH) it will soon meet itself coming around the corner.

Since its March 2014 meeting, it has criticized the PCMH for having too many expensive “bells and whistles” that were never “validated” by evidence. But at that same meeting, and at meetings held since, it has discussed recommending the PCMH to Congress under a new name – a “per-beneficiary payment” for primary care doctors who treat fee-for-service Medicare patients. But this “new” payment would be no different in kind from the “care management fees” paid to PCMHs – it would be paid per “attributed” patient per month. And the commission is seriously considering tying the payment to some or all of the PCMH requirements, such as:

* hiring nurses to function as “care managers,”
* 24/7 office hours,
* electronic medical records, and
* “quality” reporting requirements.

In short, by swapping labels, MedPAC commissioners have deluded themselves into thinking they have set aside the PCMH and are now cooking up something new. This delusion caused Dr. Crosson, MedPAC’s new chair, to make the confused statement quoted above: “Well, I mean … I mean, again, we’re sort of starting out. We’re not really starting out, but we’re starting out in a new direction.”

Meanwhile, the commission continues to avoid the most obvious question: If MedPAC’s goal in endorsing the PCMH in 2008 was to raise the incomes of primary care doctors vis-à-vis specialists, why not simply propose raising Medicare’s rates for primary care services? If the commission’s goal was to pour more money into specific “care management” activities, why not name the activities and recommend that CMS pay for them?

But with the exception of the commission’s new vice-chairman, Jon Christianson, the commissioners have refused to raise these questions. During the commission’s discussion of the “per-beneficiary payment” notion at its November 2015 meeting, Christianson stated, “If we really think the problem is better care management, we should figure out a way to pay for better care management.” His comment triggered no further discussion.

If it seems hard to believe 17 smart commissioners could wrap themselves in such intellectual knots, please follow me as I recap first how critical they have become of the PCMH, and then how enthusiastic they have become about the PCMH with the new label – “per-beneficiary payment” – tied to requirements that walk like and quack like PCMH requirements.

At its March 2014 meeting, MedPAC commissioners heaped one criticism after another on the PCMH fad. Then-chairman Glenn Hackbarth began the criticism by calling the PCMH requirements “gold-plated.” He said “electronic medical records and … 24-hour coverage and a long list of other requirements” imposed on PCMHs were not supported by evidence and were too expensive. At least eight other commissioners added their own criticisms, for example, that requiring doctors to give their patients e-mail access merely overloads doctors and does little to improve quality. (For a description of those criticisms, see a comment I posted here.)

One month later, at its April 2014 meeting, one of MedPAC’s staff testified that the evidence on PCMH’s is “mixed” and another stated that the Veterans Health Administration’s “medical home” experiment has failed to improve quality (see pp. 74-75 of the transcript of that meeting).

I give MedPAC credit for doing what many other PCMH proponents refuse to do, which is to acknowledge that the PCMH has mixed effects on quality and no effect, or possibly a negative effect, on cost. But how could MedPAC take that position on the PCMH, then turn right around and propose the PCMH under a new label? I can find no rational explanation for their behavior. The best I can do is tell you what happened.

MedPAC’s discussion of the “per-beneficiary payment” began in earnest at the same March 6, 2014, meeting at which commissioners criticized the PCMH fad. At that meeting, Hackbarth asked the commissioners to discuss the expiration of a temporary 10 percent boost in Medicare payments to primary care doctors ordered by the Affordable Care Act.

Julie Somers of MedPAC’s staff introduced the topic this way:

So now we come to today’s agenda. … [W]e’d like to provide some information about the experience with the primary care bonus program established by PPACA. The program expires at the end of 2015, so we’d also like to hear the commission’s views about extending the current program or replacing it with a per-beneficiary payment for primary care. If the commission is interested in a per-beneficiary payment, then there are design and funding issues that must be explored. [p. 240]

Continuing the bonus program in its current form, and not diving into the complex “design and funding issues” raised by the “per-beneficiary payment” idea, would have been the simplest thing to do. Somers called attention to the simplicity of this approach:

To continue to support primary care after the bonus expires, the primary care bonus program could be extended. It is administratively simple. Practitioners do not apply for the bonus. It is made automatically based on the provider’s specialty and claims history, and practitioners and administrators already have experience with it. [p. 241]

But, no, the commission couldn’t just call for the extension of such a simple mechanism. They agreed they had to take up the “per-beneficiary payment” idea and the convoluted “design and funding issues,” as Somers called them.

And what were those issues? Exactly the same issues raised by the PCMH – issues, incidentally, the commission should have discussed prior to endorsing the PCMH in 2008. Here is how Somers described the “design issues”: “Design issues include how much to pay, how to attribute a beneficiary to a practitioner, and should there be any practice requirements to be eligible for the payment.” (pp. 242-243)

And what “practice requirements” might those be? Somers had PCMH practice requirements in mind, but she didn’t say so. Instead, she said:

For example … practices could be required to improve access by, for example, increasing office hours or maintaining 24-hour phone coverage. A team based approach to primary care could also be encouraged by requiring a care manager to be on staff or processes that facilitate care coordination to be in place. [p. 245]

If you’ve been following the “medical home” fad, you know that “attributing” patients to “homes” is how patients wind up in “homes.” And you also know that “24-hour phone coverage” and hiring “care managers” are among the defining features of PCMHs.

Only one commissioner, Georgia Miller, noticed Somer’s pretense that she was not discussing PCMHs. He raised his hand and asked,

Could you just help me with the patient-centered medical home model, what the requirements are? [H]ow does it relate to this issue, or is that a separate issue, the PCMH model? [pp. 264-265]

Hackbarth replied, apparently without embarrassment, that the PCMH criteria were in fact the “practice requirements” Somers was talking about. He said the commission could decide which of them they wanted to attach to the per-beneficiary payment. “NCQA has various levels of medical home-ness,” he explained, “and the more … characteristics you have, the higher payment you qualify for in some of these [medical home] demonstration projects.” (p. 265)

Hackbarth went on to say that if the commission decided to replace the 10 percent primary care bonus with a per-beneficiary payment (aka the PCMH “care management fee”), it would have to set “some standards on who qualifies for this additional payment.” “And the only thing I’m suggesting,” Hackbarth continued, “is that you can make those standards really rich, you know, require electronic medical records and … 24-hour coverage, and a long list of requirements, or you can make them leaner.” (pp. 265-266)

But which of the “long list of PCMH requirements” did Hackbarth think the commission could do without? He offered no clue, and no member of the commission bothered to ask. By the time Hackbarth resigned in April 2015, he had shed no more light on which of the “long list” of requirements he could do without.

Hackbarth’s comment on “practice requirements” at the March 2014 meeting was the last time anyone on the commission acknowledged that what it is really is talking about is determining which of the features of PCMHs are worth retaining and which should be thrown out. Judging from the new chairman’s “explanation” of what they’re doing now – “[W]e’re sort of starting out. We’re not really starting out, but we’re starting out in a new direction” – no one has any memory of Hackbarth’s answer to Commissioner Miller’s question.

At this date, then, it seems possible that MedPAC will adopt two contradictory positions. It will continue to treat the PCMH with skepticism pending further research, but it will attach “practice requirements” to their proposed “care management fee,” er, rather, per-beneficiary payment, that are identical to requirements PCMHs must meet. In other words, they will propose the PCMH dressed up as something new. If you’re experiencing déjà vu, that’s because the same thing happened to the HMO. It was dressed up as the ACO and presented as something new.

The commission plans to continue discussion of the per-beneficiary payment notion and what requirements should be attached to the payments, possibly at its March 2016 meeting (see p. 231 of the November 5, 2015, transcript here). Will the commission finally get around to a discussion of whether evidence supports any of the PCMH bells and whistles? And if they decide few or none of the bells and whistles are supported by evidence, will they at long last ask, as Commissioner Gradison did, “Why are we doing this?”

Kip Sullivan, J.D., is a member of the board of Minnesota Physicians for a National Health Program. His articles have appeared in The New York Times, The Nation, The New England Journal of Medicine, Health Affairs, the Journal of Health Politics, Policy and Law, and the Los Angeles Times.