By Kip Sullivan
The Health Care Blog, January 28, 2018
“This is tough. I don’t know how to proceed…. Lord help the staff who must bring all this together.”
That was how Dr. Francis Crosson, chairman of the Medicare Payment Advisory Commission (MedPAC), reacted to the commission’s baffling discussion at its January 11 meeting moments before it voted 14-2 to replace the Merit-based Incentive Payment System (MIPS) with something called the “voluntary value program” (VVP). MedPAC’s staff must now summarize the January 11 discussion and prepare a report for inclusion in MedPAC’s March 2018 report to Congress.
MIPS is a pay-for-performance (P4P) scheme imposed on the traditional fee-for-service Medicare program by an act of Congress known as MACRA. MIPS requires that CMS measure performance on cost and quality at the level of the individual doctor, something MedPAC recently acknowledged can’t be done after spending 13 years claiming it could be done.
The portion of the commission’s January 11 discussion that focused on the repeal of MIPS was not hard to understand. The commissioners agreed that MIPS cannot work for multiple reasons, the most important being that the pools of patients treated by individual doctors are too small to permit accurate measurement of cost and quality. “MIPS will not succeed in helping beneficiaries choose clinicians, helping clinicians … improve value, or helping the Medicare program to reward clinicians based on value,” explained MedPAC staffer Kate Bloniarz.
It was the commissioners’ discussion about what to replace MIPS with that will be very difficult to summarize. That’s because the discussion consisted largely of expressions of doubt about the VVP, which is essentially a proposal that all doctors who treat Medicare patients either join a “group” (aka ACO) or lose 2 percent of their Medicare payments. The discussion, which followed a vague opening presentation by two MedPAC staff members, consisted of numerous questions posed to the staff that neither the staff nor Dr. Crosson could answer. Because so many issues remained unresolved, ten of the 16 commissioners (one was absent) expressed reservations about voting for the VVP. How does the staff or anyone else summarize a discussion like that? How does the staff explain why the commission voted to recommend the VVP to Congress when a majority of commissioners have multiple concerns about it?
The two questions that got the most discussion were: Will functioning ACOs (as opposed to Potemkin village ACOs that have no internal cohesion) be available for all doctors to join, and; won’t CMS’s crude method of measuring “performance” punish doctors who treat poorer and sicker patients? These and other issues were raised not only at the January 11, 2018 meeting, but at five previous meetings in 2017. That these questions were still unanswered after six meetings is compelling evidence Dr. Crosson and the staff cannot answer them and never will.
Chronology of MedPAC’s latest lead balloon
MACRA (Medicare Access and CHIP Reauthorization Act), which authorized MIPS, was signed by President Obama in April 2015. Although the fatal defects in MIPS were obvious the day Obama signed MACRA, MedPAC waited nearly two years to begin a discussion about whether MIPS could work. Instead of sounding the alarm immediately, MedPAC wasted the rest of 2015 discussing some vague principles that should guide CMS in developing the “alternative payment model” (APM) portion of MACRA.
I have no idea how to explain the delay between April 2015, when Obama signed MACRA, and January 2017 when MedPAC finally started talking about repealing MIPS. I do know what caused the failure to act between January 2017 and January 2018: That was Dr. Crosson’s and the staff’s insistence that MedPAC should propose a replacement for MIPS at the same time they recommended its repeal. This insistence manifested the staff’s near-religious devotion to P4P despite a large body of evidence indicating P4P does not work at any level – at the individual physician level, the clinic or hospital level, or even at the level of large pools of providers.
Because of this devotion, staff and Dr. Crosson could not bear the thought of repealing MIPS and thereby leaving 80 percent of the doctors and nurses who treat Medicare patients unmolested by P4P. (Eighty percent appears to be the commission’s latest estimate of the percent of Medicare “clinicians” who will not be in ACOs or other entities that qualify as “advanced alternative payment models” [APMs] under MACRA by 2019, the first year MIPS penalties and rewards kick in.) It was this blind insistence on forcing some form of P4P upon that 80 percent that caused the staff to link repeal with replacement right from the start of the repeal discussion in January 2017.
The staff presented its replacement proposal – what they would eventually call the “voluntary value program” (VVP) – at the January 2017 and March 2017 meetings. At both meetings, and at four subsequent meetings (October, November, and December 2017 and January 2018), commissioners peppered the staff with questions about the VVP – to no avail. Dr. Crosson and the staff resolutely refused to add any details to the vague VVP proposal first presented in January 2017. For example, all the staff would say about the “groups” that doctors would have to join in order not to lose 2 percent of their payments is that they must be “sufficiently large to have statistically detectable performance on population-based measures” such as use of “low-value” services and “healthy days at home.” That was their story, and they stuck to it. The skeleton-like proposal the commission voted on at the January 11, 2018 meeting was identical to the skeleton-like proposal they first heard in January 2017.
(The excerpts are truncated here. If you are interested in reading the process which resulted in the decision to replace MIPS with the nebulous VVP then click the link for the rest of the article. – DMc)
Lessons from another “repeal and replace” campaign
All sentient readers will recall the sad ending of another “repeal and replace” campaign. It had a sad ending because it was driven by ideology, not evidence. MedPAC appears hellbent on repeating the same mistake Republicans made in declaring their intention to “repeal and replace” the Affordable Care Act. MedPAC linked repeal of MIPS with its replacement before they had time to research the replacement. MedPAC might as well have said, “We will replace MIPS with something terrific!”
Principles for a Framework for Alternative Payment Models
By Sam Nussbaum, M.D.; Mark McClellan, M.D., Ph.D.; Grischa Metlay, Ph.D.
JAMA, January 29, 2018
The way physicians, hospitals, and other health care professionals are paid influences patient care because payment methods affect business models that clinicians and health care facilities use to prioritize investments, establish infrastructure, and design care processes. Fee-for-service medicine and its volume-based financial incentives can lead to overuse of low-value services and suboptimal care. A consensus is emerging among patients, health care professionals, payers, and purchasers that transitioning to alternative payment models (APMs) that better incentivize value for patients is essential for improving the quality and affordability of health care.
In 2014, the CMS published a system for classifying APMs.1 In the interim, the Health Care Payment Learning and Action Network (LAN), a public-private partnership driving multistakeholder consensus and coordinated action to accelerate the transition to APMs, built on, expanded, and refined the original system.
This Viewpoint reviews major themes in the framework principles as revised by LAN, illustrating how they are applied in the LAN classification scheme, and the LAN national goals for payment reform.
The Updated APM Framework
Category 1: Fee for service; no link to quality and value
Category 2: Fee for service; link to quality and value
1. Foundational payments for infrastructure and operations (eg, care coordination fees and payments for health care information technology investments)
2. Pay for reporting (eg, bonuses for reporting data or penalties for not reporting data)
3. Pay for performance (eg, bonuses for quality performance)
Category 3: APMs built on fee-for-service architecture
1. APMs with shared savings (eg, shared savings with up-side risk only)
2. APMs with shared savings and down-side risk (eg, episode-based payments for procedures and comprehensive payments with up-side and down-side risks)
Category 4: Population-based payment
1. Condition-specific population-based payment (eg, per-member per-month payments, payments for specialty services such as oncology or mental health)
2. Comprehensive population-based payment (eg, global budgets or full/percentage of premium payments)
3. Integrated finance and delivery system (eg, global budgets or full/percentage of premium payments in integrated systems)
The updated APM Framework rests on 8 principles, which can be summarized as follows:
1. Changing clinicians’ and health care facilities’ financial incentives is not sufficient to achieve person-centered care, so it will be essential to empower patients to be partners in health care transformation.b
2. Reformed payment mechanisms will only be as successful as the delivery system capabilities and innovations they support.b
3. The goal for payment reform is to transition health care payments from fee for service to APMs. While category 2C APMs can be the payment model for some clinicians and health care facilities, most national spending should continue moving into categories 3 and 4.b
4. Value-based incentives should ideally reach care teams who deliver care.
5. Payment models that do not take quality into account are not considered APMs in the APM Framework and do not count as progress toward payment reform.
6. Value-based incentives should be intense enough to motivate clinicians and health care facilities to invest in and adopt new approaches to care delivery without subjecting them to financial and clinical risk they cannot manage.b
7. Alternative payment models will be classified according to the dominant form of payment when using more than 1 type of payment.
8. Centers of excellence, accountable care organizations, and patient-centered medical homes are examples rather than categories in the APM Framework because they are delivery systems that can be applied to and supported by a variety of payment models.
Payment reform is not an end; it is a means to supporting better, more coordinated care for patients. Accordingly, APMs must help make patients better health care consumers and mitigate perverse incentives that reward low-quality patient care.
Protections for Health Care Professionals
Reformed payment mechanisms that hold health care professionals increasingly accountable for cost and quality performance and that allow more flexibility in care delivery are central to any efforts to transform care delivery.
Value-Based Goals for Payment Reform
The value of an APM should be assessed not only by its design elements but also by how well it promotes person-centered care.
APM Framework and Progress Tracking
As the nation approaches 30% of payments in value-based arrangements, the LAN APM Framework could provide a useful platform for helping to accelerate progress on payment reform by outlining principles for APM design, differentiating APMs based on potential value, and offering a tool to consistently measure progress toward national goals.
By Don McCanne, M.D.
Much of the history of health policy in the United States involves the application of policy concepts based on ideology rather than solid policy science. Policies are dreamed up and then executed broadly on a wish about what would happen rather than reliable predictions of what really will happen. The SGR, MACRA, MIPS, APM, and now VVP is a saga of such dreams in the policy community forced to meet reality.
SGR (sustainable growth rate) was a tool to slow the growth in health care spending. When implemented it was perceived to be too austere and thus annual adjustments were postponed until the cumulative deficit proved to be so great that SGR had to be abandoned. It was replaced by MACRA (Medicare Access and CHIP Reauthorization Act) which established MIPS (Merit-based Incentive Payment System) and APM (Alternative Payment Model).
MIPS has proven to be a dud, and thus MedPAC (Medicare Payment Advisory Commission) has recommended that it be abandoned and replaced with VVP (Voluntary Value Program). Kip Sullivan, who had previously warned us about MIPS (as did I), now explains why we should be concerned about VVP (and I emphatically concur). His full article available at The Health Care Blog website should be read to understand what a farce this is.
Recognizing the deficiencies in MIPS, many in the policy community have recommended that incentives be established to move everyone past MIPS into the Alternative Payment Models (APMs). But what are they? JAMA has just published the updated framework for APMs as established by LAN (Health Care Payment Learning and Action Network). Read the framework itself and the eight principles on which it rests. Then sit back and think about how this framework would define the future of our entire health care delivery system, putting the eight principles to work. In their dreams based on ideology, our policy community has come up with Comprehensive Revision of American Physician Payment Principles (CRAPPP).
Come on. We have solid policy evidence that a well designed single payer system would achieve their goals (and ours) of a high performance health care system that takes care of all of us and is affordable for each of us. Let’s cut out the CRAPPP and do it right.
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