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The Healthcare Blog - Tue, 04/18/2017 - 11:30
“Health consumers” – the concept is a little foreign to our conception of health services in Europe. As Europeans we tend to think that if it touches our health it should be free. In this context, how can we count on health consumers to fuel the development of the Health 2.0 industry in Europe?
There are some cases where we are ready to get our wallets out. We’re more inclined, for instance, to pay for our wellness than we are to pay for our health. We’re OK to pay for an activity tracker; we think a diabetes management solution should be covered and reimbursed. There are also a few niches where we don’t hesitate to become health consumers: the market of fertility solutions is a good example.
With the wide range of Health 2.0 apps and solutions out there, we’re rediscovering the concept of choice along with a different kind of empowerment… as customers.
What are the other ways Europeans are turning into empowered health consumers?
Join a meaningful conversation at Health 2.0 Europe 2017, which will include insightful demos on this topic from Indigomed (France), Knok (Portugal), SpeechAgain (Germany), Thryve (USA), and Juno Fertility (Austria).
The Consumer Tools session will be about choice, convenience, added value, design, ease of use, service, customer experience and focus on apps and solutions that empower us as consumers of health services.
It’s not too late to join the discussion and Health 2.0 Europe. Register here!
Pascal Lardier is the International Executive Director of Health 2.0.
Categories: OIG Advisory Opinions
The Healthcare Blog - Mon, 04/17/2017 - 17:04
On April 13 CMS published the agency’s final “market stabilization” rule. The proposed rule was summarized by THCB’s editors on February 15, the day it was published, and on March 22 THCB published my essay in which I noted CMS provided no evidence any of the proposed reforms would actually stabilize the state marketplaces. The final rule, ostensibly a carbon copy of the proposed, finalizes the six proposed changes without, again, providing any evidence these changes will stabilize the markets by increasing enrollment and issuer participation.
Briefly, the final rule will reduce the 2018 enrollment window from three months or to six weeks, or from November 1 to December 15. The rule narrows the definition of guaranteed availability by allowing issuers to apply re-enrollment payments to outstanding debt. The rule will require 100 percent verification for enrollees’ attempting to acquire insurance during a Special Enrollment Period (SEP) and places other payment, eligibility and exceptional circumstances restrictions on SEP enrollment. The rule finalizes an increase in de minimus variation from +/- 2 percent to -4/+2 percent except for bronze plans which increases to -4/+5 percent. The rule will allow states to determine plan network adequacy or make a determination using an issuer’s accreditation status. The rule finalizes a reduction from 30 to 20 percent of plan providers being defined as an Essential Community Provider (ECP). For plans that cannot meet the 20 percent determination, CMS will allow for a narrative explanation.
In the final rule’s “impact analysis” CMS is again unable to provide any evidence these changes will produce the intended effect. In the proposed rule CMS stated “on the one hand” premiums could fall but “on the other hand” premiums could increase. In the final rule, CMS stated, “the net effect of these provisions on enrollment, premiums and total premium tax credit payments are uncertain.” “Premiums will tend to fall if more young and health individuals obtain coverage . . . .” “However,” CMS followed, “if changes such as shortened open enrollment period, pre-enrollment verification for special enrollment periods, reduced AV of plans, or less expansive provider networks result in lower enrollment, especially for younger, healthier adults, it will tend to increase premiums.”
What we do know or still know is these changes will likely reduce enrollment or destabilize the markets. As noted in my March 22 post, those aged 18 to 24 are far less likely to complete an enrollment verification process due to “hassle costs” than those aged 55 to 64. Expanding actuarial values would, per the Center for Budget and Policy Priorities estimates, increase out of pocket costs for families. A shorter open enrollment period will likely produce the same result. In a recent Health Affairs blog post, using Kentucky marketplace data, Paul Shafer and Stacie Dusetzina showed that 25 percent of new enrollments took place in the final week, 60 percent of those eligible for financial subsidies enrolled during the latter half of the enrollment period and those who changed their plans also did so in the latter half of the enrollment period. 1
CMS proposed and went final with this rule because the agency believes it must act. In the final rule CMS argued “we considered maintaining the status quo,” however, “we determined that the changes are urgently needed to stabilize markets, to incentivize issuers to enter or remain in the market and to ensure premium stability and consumer choice.”
From a certain perspective it’s unsurprising CMS went forward with this rule. The agency was responding to industry pressure that absent changes, they would withdraw from participating. The day the final rule was released, AHIP, not surprisingly, stated, “This final rule adopts some important changes that have been needed for some time in order to improve the functioning of the individual market, and we appreciate those changes. Those improvements include tightening up rules for special enrollment periods, greater flexibility in product and benefit design, and simplified administrative processes.”
What is surprising is the fairly obvious confirmation bias exhibited here. The Trump administration has stated over and again it believes the ACA is a failure. The marketplaces are in a death spiral. If you are biased toward a particular belief you are then prone to interpret information in such a way as to confirm your pre-existing beliefs. Even if CMS truly believed the agency had to act, what is also surprising is the agency, again, promulgated and finalized a rule lacking any evidence. Instead, the final rule is based simply on the agency’s beliefs. CMS’ explanation for these policy changes in sum amounts to “we believe” – a phrase the agency uses over 50 times in the final rule. In his recent work, The End of Expertise, The Campaign Against Established Knowledge and Why It Matters,” Tom Nichols cautioned when everything becomes a matter of opinion whether policy is made based on weak or no factual basis becomes irrelevant. Imagine if the FDA approved a drug that the FDA admitted would have an “uncertain” effect.
1. Paul Shafer and Stacie Dusetzina, “Looking Ahead to 2018: Will a Shorter Open Enrollment Period Reduce Adverse Selection in Exchange Plans?” Health Affairs Blog (April 14, 2017), at: http://healthaffairs.org/blog/2017/04/14/looking-ahead-to-2018-will-a-shorter-open-enrollment-period-reduce-adverse-selection-in-exchange-plans/.
Categories: OIG Advisory Opinions
The Healthcare Blog - Mon, 04/17/2017 - 11:13
Imagine the peace of mind and confidence you will feel if you had a quick, proven process to take your solution or concept from its current state to one that generates sustainable revenue, hoards of customers and value to the healthcare ecosystem.
Elena Lipson has been working with organizations and entrepreneurs in the digital health community for more than 15 years to help them successfully bring new products and services to market, identify and engage new customers and partners, and grow their market share.
For the first time, she is offering a free webinar training to the Health 2.0 community to share the three steps you need to create a blueprint for your digital health solution that will get you customers, accelerate your path to revenue, and help you go to market quickly even if:
- You haven’t worked in healthcare before
- You don’t have product development or sales experience
- You don’t have partners
Think about what happens if you can’t secure the customers, revenue and funding you need to grow your business?
Or worse, you don’t have enough to run the business?
According to Bloomberg, 80% of entrepreneurs who start businesses fail within the first 8-10 months. Most fail because they simply run out of cash.
But the cracks in the foundation start well before these companies run out of money.
What if you never had to worry about whether customers wanted your solution and impressing investors? What if you could focus instead on bringing valuable products and services to the market without hitting potholes?
What if you knew exactly how you were going to scale your business and could predict how customers, investors and the broader market would react to your offering?
If you’re a digital health entrepreneur and this is your first venture, or if you’re a more seasoned entrepreneur who has successfully launched other start-ups but you’re entering healthcare for the first time, then this training will be valuable for you.
You will walk away knowing about the broader trends shaping the digital health ecosystem in 2017, the unique challenges in this market and how your business can capitalize on them by creating a Digital Health Blueprint.
Join us on: May 1 at 1pm EST to get the exact Blueprint that will help you get customers, accelerate your path to revenue and give you the confidence so that you can go to market quickly in 2017.
You will walk away with:
- The main reason so many digital health entrepreneurs fail and how to avoid their mistakes
- The 3 steps to a proven Digital Health Blueprint that brings in money and customers
- Elena’s process to develop the Blueprint so that your business gets you customers, revenue and confidence to go to market quickly.
Elena Lipson is the Principal and Founder of Mosaic Growth Partners.
Categories: OIG Advisory Opinions
Medical Coding News - Mon, 04/17/2017 - 07:41
Medical coders play a crucial role in the revenue cycle process, as they help ensure health systems, hospitals and physicians are properly reimbursed for the services they provide. Here are 14 things to know about medical coding. 1. AAPC describes medical coding as “the transformation of healthcare diagnosis, procedures, medical services and equipment into universal […]
Categories: Healthcare News
The Healthcare Blog - Mon, 04/17/2017 - 07:35
I’ve been quite vocal about supporting only wellness done for employees and not to them…but what if there could be a “conventional” wellness program – even including screening, HRAs etc. – that both you and I could love?
People manage what’s measured and what’s paid for. If employers want people to stay healthy in the long run, why not measure and pay for health in the long run?
Why not give people the incentive to stay healthy during their working years, instead of giving them the incentive to pretend to participate in programs of no interest, just to make a few bucks? Or, worse, give employees the incentive to learn how to cheat on biometrics, and how to lie on health risk assessments. Attempts to create a culture of health often create a culture of resentment and deceit.
Short-term incentives haven’t changed weight, as noted behavioral economist Kevin Volpp has shown. Nor have they changed true health outcomes – it is easily provable that wellness has almost literally never avoided a single risk-sensitive medical event. So-called outcomes-based programs, ironically, are more about distorting short-term outcomes than achieving long-term outcomes. They have more in common with training circus animals to do tricks in exchange for treats than they do with helping employees improve long-term health.
The only thing that’s proven? Some vendors and some programs harm employees. Nor is wellness popular — look at almost any article in almost any major lay or academic publication in the last four years. Then read almost any comment to those articles.
Wellness industry leaders know that wellness has failed, and that’s why my proffered $2-million reward for demonstrating success remains unclaimed.
The 401W Wellness Savings Account
Why not discard all this year-to-year micromanagement?
The goal of wellness isn’t to interfere in employees’ personal lives. It’s for employees to be healthy enough in the long run to avoid expensive events. So you are rewarding/penalizing them annually…but the benefit to you as the employer is way down the road — if indeed someone who would have infarcted in the next 20 years, doesn’t.
Future event avoidance is the only healthcare outcome that matters.
So let’s align incentives so that everyone is focused on long term health. Instead of doling out money and otherwise micromanaging programs and micromanaging incentives, why not create a 401W Wellness Savings Account, the equivalent of a 401K for wellness? People who reach retirement without a major avoidable health event can collect their entire accumulated amount. Along the way, they can choose to participate or not in the programs your company offers. There is no money at stake for those offers, so no financial coercion. With or without your help — totally their option — employees need to reach the goal: no lifestyle-related events through retirement.
There are a few asterisks that go with this, including but not limited to:
- The ultimate reward would be based on years of service and retirement age – each employer would have its own formula;
- Because some people are unlucky and get events despite their best efforts, participation itself would earn the reward even if someone had a heart attack or other event. Put another way, by participating, employees are insuring themselves against their own possible bad luck.
- In order to avoid the optics of only caring about employees until they retire, the reward could be partially or totally swapped for an even larger payout after retirement that would take the form of subsidies and special deals on health-related endeavors.
- It wouldn’t just be heart attacks, but it would have to be discrete avoidable events. Bypasses, spinal fusions, and COPD come to mind– would also be included. Anything that is discrete, avoidable, common and expensive could be included, but there are some complexities as you move beyond those events.
The Wellness 401W Plan offers many advantages over traditional wellness, for both employers and employees:
- Employees can’t hate it because there’s nothing to hate. It’s truly opt-in. No annual money is at stake. They don’t lose money by not participating — as long as they patrol their own health. And whether they succeed in patrolling their own health is determined objectively.
- Employees no longer need to share PHI, except at the end if they want to collect. At that point presumably most employees wouldn’t care, because they are no longer insured by their employer. (In any event, it would be a third party looking at the claims and reporting thumbs up to the employer.)
- No cheating. These events/procedures are very discrete. And they won’t cheat on HRAs and biometrics because there is no reason to cheat – they are only cheating themselves. If they intended to cheat, they wouldn’t participate. They would patrol their own health.
- No need to make employees get screened or get checkups every year — or to pay for it. Rather, screening according to guidelines is fine. Screening would be available but not required and employees would be educated (most like using Quizzify) about optimal screening and checkup intervals.
- Incentives are completely aligned.
- Because a certain number of years of service would be required according to any given formula, retention is likely to increase. On balance, a company could retain and attract healthier people, since by definition they can make more money.
- Great PR is possible as well. “Wellness” and “great PR” are rarely found in the same sentence but this would be an exception.
This doesn’t even include the biggest advantages to employers. Finally, after thirty years of provably making zero impact on medical events nationwide, employer wellness programs will have a strong likelihood of being able to do just that. Employers don’t have wait to see savings, either. Savings will be close to immediate. There is no need to pay vendors to screen the stuffing out of employees. Employees can be screened –and participate in other programs – but only if they want to. You can offer guidance on USPSTF or Choosing Wisely guidelines, but you don’t have to push people into overscreening.
Also whenever someone quits before their 401W vests, their 401W becomes employer savings. (There are probably no specific regulations around the finances here, like there are for pensions. The 401W is like a deferred commission for a salesperson who keeps an account – only in this case the “account” is his or her own health.)
And what would a great idea be if it didn’t involve Quizzify? The explanation of this novel program to employees would benefit from a Q&A vehicle already in place. It would also educate them along the way in how to stay healthy, what they need to do to access their account, how their account would grow over time etc. Participating in Quizzify a certain number of times a year would “count” as participation in wellness, for the purposes of claiming the 401W. Further, the option of Quizzify allows employees to participate regardless of health status, with no disclosure of PHI.
Sure, there are loose ends. What if someone participates some years and not others? Would 401W’s be portable? Would portability depend on whether someone quits or was fired? (Remember, there are no regulations around 401Ws now. You can make your own rules.) Would you need an exam at the end of program or is claims data enough?
To start this program, a phase-in is recommended. It’s tough to take away people’s incentives, which many have come to view as part of their compensation. But as employees see their accounts growing, their excitement will grow too – not just about the state of their 401Ws which could reach well into the five figures by retirement, but also about the state of their own health.
Of course, some employees want their money now…and as you read the FAQs, you’ll see that issue, along with many others, can be elegantly addressed.
How is this different from a health savings account? (HSA)
You need to have an “official” high-deductible plan to have an HSA. HSAs can’t be tied to true health outcomes. Further, they can’t just be paid out. They are regulated in many other ways too, and consequently they don’t address the problem at hand. Even so, whatever fiduciary administers your HSA could also administer your 401W.
Is this taxable to the employee when earned, like a participation incentive?
No. It is contingent and deferred. It is taxed when paid out, meaning it can compound pretax. You are not constrained in how you invest it, as in a pension fund, so it can presumably compound faster.
We think our millennials want their money now. Can we do that?
Yes. You could let people take a haircut and get their incentive right away. This creates immediate savings for you, as the amount you would have to give right away is likely to be less than what you would be budgeting. Example: if your incentive is $400 today, your incentive in the 401W could still be $400, but if someone wants it now, they could participate, and get (for example) $200.
How does this address privacy concerns?
Employees are free to give up zero PHI with no penalty. They can do this either by picking the self-patrolling, self-underwriting option and do whatever they want to do on their own. Or they could “participate” by selecting Quizzify-type options requiring no disclosures. Only at the end, when they want their money, does the employer have to know (presumably through a third party).
Wellness is also criticized for ageism. How does this get addressed?
Depending on how the program is set up, it is likely that older employees will have more money in their kitties sooner, because they reach retirement sooner. So it’s quite the opposite: employers can design programs that are more appealing to older workers, since they are the ones who suffer by far the majority of the wellness-sensitive medical events. By contrast, under the current systems, older employees typically get charged for higher weights and blood pressure that are likely age-related rather than lifestyle-related.
Is this consistent with the Employee Health and Wellness Program Code of Conduct
Yes. It is totally voluntary. Any employee can qualify without even letting the employer know what they are doing for their health, let alone divulging information. So employee dignity is totally respected. Employees are free to adhere to USPSTF guidelines and still collect. And there can’t be any lying about outcomes. While crash-dieting contests are still legal in a 401W plan, there is no reason for an employer to offer them, since they harm employees.
Is the 401W consistent with clinical guidelines?
There is the assumption that much or all of what an employee can “opt in” for is clinically sound. That means HRA advice and the selection and recommended frequency of screening tests must conform to guidelines. The 401W could theoretically be done without adhering to guidelines, but that just means employers will pay more, both to the vendors and then in medical claims. One reason to include Quizzify in the selection of options for a 401W is that employees are assured of at least one option conforming to the Code, to clinical guidelines, and to the standards of the Validation Institute.
Is this consistent with creating a healthy environment?
It is quite consistent. Employees would likely support it and take advantage of it, since they are being paid to stay healthy. Further, you will have extra money in the pot to provide it, both from spending less on screenings and the incentives that get earned but didn’t vest.
You are giving the employees a stake in their own long-term health, self-underwriting as oppose to community rating, so to speak. Giving people financial responsibility for their own health creates a natural constituency to want employers to do something about it.
You say event avoidance is the only healthcare outcome that matters. What about non-healthcare outcomes, people feeling their best and giving their best work?
There is no reason at all to assume conventional “voluntary” participation programs or outcomes-based jump-through-hoops programs will help people feel their best. By contrast, giving people a menu of offerings and the chance to opt into their own offering would certainly make people feel better than charging insurance by the pound, reporting employee weight to shareholders, collecting employee DNA, and other ideas that have been seriously proposed by the wellness industry. There is no scenario under which people would feel better being economically coerced into wellness (and we all know how employees feel about that) than being able to chart their own path to health, with or without employer guidance.
What if spinal fusions and bypasses/transplants are part of the no-fly zone of invalidating events, but the person really needs one?
First, remember that an employee participating in the program doesn’t lose the kitty under any circumstances other than not satisfying vesting requirements. You could also define “participating” as “using a Center of Excellence hospital” (the model pioneered by Walmart and described in Chapter 5 of Cracking Health Costs) and have that be part of the program as well. In the case of those hospitals – at least the ones in Walmart’s model – they often find the admitting diagnosis and/or the recommended operation to be respectively incorrect and unneeded/likely harmful.
There could also be an appeals process for people who genuinely need one, whereby they don’t lose their kitty.
What if (for example) getting diabetes voids your 401W, but you got diabetes because you were on statins?
As long as an employee is participating in the program, he or she is still eligible. Remember, the event disqualifier only kicks in for non-participants. And one thing employees would learn in Quizzify is that, for people who aren’t at high risk of heart attack, statins increase the chances of diabetes more than they reduce the chances of a heart attack. So presumably inappropriate statin use would decline.
Categories: OIG Advisory Opinions
The Healthcare Blog - Sat, 04/15/2017 - 15:52
At its January 12, 2017 meeting, the Medicare Payment Advisory Commission (MedPAC) made it clear they had reached the conclusion that the Merit-based Incentive Payment System (MIPS) cannot work (see my last post ). MIPS is the larger of the two programs within MACRA; the Alternative Payment Model (APM) program is the other. The commission’s primary rationale for its conclusion about MIPS is that it’s not possible to measure physician “merit” (cost and quality) at the individual physician level.
But rather than recommend that Congress repeal MACRA (the Medicare Access and CHIP Reauthorization Act), MedPAC decided to try to fix it. At the January and March 2 meetings, the commissioners discussed a staff proposal to amend MIPS substantially and to tweak the APM program. Those discussions went nowhere.
I give MedPAC credit for finally stating unequivocally that MIPS cannot work. But MedPAC should never have volunteered to fix MACRA. It can’t be done. By proposing modest amendments to MACRA and thereby implying it’s fixable, they stepped into an intellectual tar pit. I will illuminate this tar pit by describing the commission’s unproductive discussion about the staff’s proposed amendments to MACRA. To give you a sneak preview of what that discussion was like, I give you two excerpts from the transcript of the January meeting:
[Commissioner Kathy Buto] As I look at this whole [MACRA] system, I worry about the complexity of it and whether it’s going to achieve anything.… Medicare has sometimes a way of getting into a system it can’t get out of, and this has that feeling about it, that we could go down a rabbit hole and not be able to get out…. (p. 290, transcript )
[MedPAC director Mark Miller] And the reality of MIPS right now is it’s dead in the water because of those complexities. And that’s what we grind tons of time on, and I just wonder sometimes how we’re going to get out of this…. (p. 298, transcript, January meeting)
Allow me to introduce Scylla and Charybdis
MedPAC’s staff, under the direction of Chairman Francis Crosson, presented its alternative to the MIPS program at the January 12 meeting. The staff proposed reducing MIPS’ reporting burden substantially but also increasing the financial pressure on physicians who refuse to flee MIPS and join a group where, allegedly, physician “merit” would be measurable. According to the staff’s proposal, physicians could either stay in MIPS and sacrifice 1 to 2 percent of their Medicare revenue, or flee to: (1) a MACRA APM (the ACO is the main APM prototype); (2) a “virtual group” (the staff did not explain what that might be); or (3) a group defined solely by geographical criteria that CMS would select (the staff did not explain this ephemeral entity either).
The staff was essentially proposing that the commission abandon one impossible mission (figuring out how to measure “merit” at the level of the individual physician) for another – figuring out how to jam all doctors into functioning groups so that measurement of “merit” can be more accurate. The staff didn’t warn the commissioners they were asking them to swap one impossible mission for another. The staff merely asserted that measuring cost and quality at the individual physician level is impossible because each doctor serves relatively few patients and that herding doctors into large groups would solve the small-numbers problem. As Chairman Crosson put it at the March meeting, “[T]he whole point of [the staff’s proposal] is to achieve a volume of care of Medicare beneficiaries that is actually measureable….” (p. 228, transcript of the March 2 morning session)
As is so often the case when managed care advocates promulgate their proposals, the staff did not identify assumptions that have to be true for their proposal to work. The most fundamental of the unarticulated assumptions is that functioning groups of doctors (be they APMs, “virtual,” or geographically defined) will pop up all over the country so that all doctors who wish to flee MIPS will have a group to run to. In addition to being universally available, these groups must be real (not mere constructs on CMS or Dartmouth Atlas computers), and they must be functional – they must actually improve care and lower costs at the system level (not just for Medicare), something no previous managed care fad (HMO, ACO, “integrated” whatnot, “medical home”) has managed to achieve.
If Dr. Crosson and the MedPAC staff had bothered to articulate these and other assumptions, they might have grasped that measurement at the group level presents obstacles as insurmountable, and as mind-bending to contemplate, as measurement at the individual level. But they didn’t do that. Predictably enough, this failure to lay out the unarticulated assumptions caused the commissioners to descend swiftly down a rabbit hole where productive discussion became impossible.
Adventures in the rabbit hole: The January meeting
As I noted in my last post, when the staff finished presenting their proposal at the commission’s January 12 meeting, Commissioner Craig Sammit asked, “[D]o we have a sense of how accessible and feasible it will be for clinicians to join APMs?” Staff member David Glass replied, “I would say that’s a little hard to say right now.” (pp. 248-249, transcript) That was the commission’s first warning that a rabbit hole was opening under their feet. But no one noticed, and down they went.
The commission’s discussion of Dr. Sammit’s question focused at first on the difficulties small clinics would face in creating an organization that would qualify as a MACRA APM. One of the criteria for an APM is that it must bear “two-sided risk” (the risk that the APM will lose money as well as make money). Can small practices be expected to do that? Commissioner David Nerenz noted that very few of the groups that have signed up for Medicare’s MSSP ACO program signed up for the “track” that requires they take both upside and downside risk, so why should anyone expect small clinics to expose themselves to two-sided risk? “We have no good working examples of people willing … to step into the two-sided risk models of the MSSP,” Nerenz warned. “It’s a tiny, tiny fraction of those that are accepting two-sided risk. You can force people in. You could declare everything else to be a felony punishable by law, but we don’t have examples of how to do it.” (p. 268)
Commissioner Jack Hoadley asked the staff if they could refer the commission to “any history” of successful “physician groups” the commission might learn from “so that we’re not in the business of just creating … organizations that aren’t really doing anything….” (p. 291)
The staff had no answers for Nerenz, Hoadley, Buto and other commissioners who asked how small clinics were supposed to meet the two-sided-risk requirement for a MACRA APM. Commissioner Paul Ginsburg summarized the prevailing evidence accurately when he said, “I think that the reality is that for the fairly large percentage of physicians, they probably don’t have very extensive APM activities now.” (p. 250)
So if smaller clinics don’t want to stay in MIPS where they’ll lose 1 to 2 percent of their Medicare reimbursement, and if they can’t flee to an APM because they can’t handle two-sided risk, maybe they could flee to one of the other two types of groups proposed by the staff – “virtual groups” that doctors might form, and geography-based groups CMS would define. The commission discussed that scenario next. But that discussion also led nowhere. The commission wound up agreeing that groups of any sort (APM, virtual, geographical, whatever) make sense only if the groups are built on a shared culture – a consensus among the participating doctors about how they want to practice. This shared culture cannot be fabricated top-down by CMS or hospital executives seeking to expand their empires. They must arise organically.
At this point MedPAC’s director, Mark Miller, could see that the commission was beginning to realize they had swapped one impossible mission (measuring at the individual level) for another (measuring at the group level). But rather than advise the commission that the problem they were having was the intractability of the obstacles to measurement at both the individual and group level, Miller blamed the commission members for being unable to complete either mission. “[M]easuring in the aggregate, measuring in the individual, you guys are the commissioners. I don’t care,” he began. Then he complained that advocates of measurement mania are damned if they try to measure at the individual level and damned if they try to measure at the group level (as if the measurement advocates were the victims here). “[B]ut at some point in time, somebody has got to decide how this is going to go.” Miller offered no way out of the rabbit hole he had led the commission down. He instead offered only his own frustration at finding himself in the hole. “What are we doing here?” he asked. (p. 274) 
As the January meeting drew to a close, both Crosson and Miller expressed their confusion about how to summarize the commission’s discussion, presumably for the purpose of setting the agenda for the March meeting and to begin writing a chapter in the June 2017 report to Congress. Crosson was reduced to saying “[W]e need to take, you know, a much more effective approach, and I couldn’t describe it right now.” (p. 303) Commissioner Buto gamely tried to help Crosson by asking, “Are we essentially saying that on MIPS that … we don’t think it potentially is going to work the way it’s structured? … I think we still need to fill in the blank as to what we think should happen.” (p. 304) No one could answer Buto’s question; no one filled in any blanks.
Crosson ended the meeting with this plaintive question to the commission as a whole: “So a paper with suggestions. Is that what you’re saying”? (p. 307)
Further adventures in the rabbit hole: The March meeting
Crosson and the staff apparently learned nothing from the January meeting. They returned to the March meeting with the identical proposal they had presented at the January meeting, with one addition: They proposed to change the way in which primary care physicians (PCPs) who participated in ACOs would be paid, but not the amount they would be paid. The staff’s refusal to alter its proposal, and their addition of a partial-capitation method of payment for PCPs, made no sense. Here is my guess at the staff’s rationale for adding the PCP bauble. They left the January meeting aware that the commission was worried that small clinics wouldn’t have any groups to flee to; many of these small clinics have PCPs in them; if the PCPs were given more upfront financial support, smaller clinics might be able to join or start an ACO and survive two-sided risk. I realize this doesn’t make sense, but that’s the only rationale I can imagine. 
Following the staff’s presentation, the commission took up where they left off at the January meeting – posing questions about how the staff’s proposals for measuring “merit” at the group level would work. Commissioner Jack Hoadley led off with a question about why doctors in “virtual groups” and geographically defined groups would have any influence over the cost and quality measures they would be subjected to. “[I]t certainly doesn’t feel like it has any potential for anything I do as a clinician to make those measures go up or down,” he said (p. 207, transcript of March meeting).
Commissioner Brian DeBusk asked whether the staff had “explored” whether groups in lower-income areas would be punished by the proposed “quality” measures because of factors outside physician control. (pp. 209-210) Commissioner Kathy Buto said, “I do not know what we are trying to do with primary care….” (p. 235) Commissioner Alice Coombs (a doctor) said she was struggling with the question of “finding a home for the primary care physician [within] MACRA.” She asked her fellow commissioners to “have a little mercy on the onesie-twosie groups.” She said the “whole notion of attribution [of patients to doctors] within a geographic region” is riddled with problems. (pp. 222-223) 
Again, the staff’s answers to these obvious questions and concerns were grossly inadequate. Staff director Mark Miller was especially unhelpful. He implied the commissioners were spoiled brats asking for the moon. He said they needed to remember how bad MIPS is now and that anything would be better than MIPS. For example, after a brief discussion about whether hospitals could serve as the staging ground for an ACO when few doctors follow their patients into hospitals anymore, Miller said:
In listening to you guys, you are absolutely right. Tons of physicians do not set foot in a hospital, but you could almost have the hospital-based physicians … say, “Okay, let’s reach out and get these sets of physicians so that we can all be measured together.” And then I will just say this again: Keep in your mind, what is the alternative?…. [E]ach time you guys say this I am going to … force you back to the status quo…. [Y]ou are right, this has a bunch of problems; so does the status quo…. And so if there is another idea, that is what we are searching for. (pp. 228-229) 
But no one offered another idea. The closest thing to “other ideas” were bromides like, “I really think that we need to give up on … repelling people from unorganized care and drawing them into organized care” (Ginsburg, p. 237), and, “I think it is time to put our thumb on the scale for ACOs” (DeBusk, p. 246).
At the end of the January meeting, Chairman Crosson made an attempt to summarize the commission’s confused and unproductive conversation. It was embarrassing; Crosson sounded incoherent (see pp. 301-303, transcript, January meeting). His attempt accomplished nothing other than to drive home how much time the commission had wasted discussing the staff’s proposal. But Crosson, whose term expires this month, made no attempt to summarize the commission’s discussion at the end of the March meeting. Instead he ended the meeting abruptly with this cryptic happy talk: “We will be returning to this issue probably early in the next MedPAC term…. We are going in the right direction.” (p. 247)
Crosson himself observed at the January meeting that the commission could not just sit on the sidelines “and watch a dysfunctional thing unravel.” (p. 305) But it appears now that’s exactly what MedPAC intends to do. For the foreseeable future, it appears MedPAC will do what MedPAC always does after they identify defects in a managed care nostrum they previously endorsed – they will dither.
 Here is a lengthier version of the statement MedPAC director Miller made at the January meeting expressing his frustration with the commission’s inability to figure out how to make measurement at both the individual and group level work:
[T]here has been a 15, 20-year discussion about this, where it’s like, okay, you can’t do anything but measure me at my individual level, and … you have to tell me precisely how you are measuring me. [T]he physicians groups argue this. Then they are upset that it is too burdensome, that the comparisons aren’t fair, … and nobody is happy. [This] exchange [about individual versus group measurement] … basically … just stopped the process because it’s too complicated. So then, as an analyst, you’re sort of like, “I don’t know what to do, except go to a more aggregated level and measure.” Then everybody says, “But this isn’t me, and that’s not fair.” So fine, but at some point in time, somebody has got to decide how this is going to go. And I’m going to throw just one last bomb into the middle of this. A few meetings back, [commissioner] Paul [Ginsburg] said, “Why are we measuring and paying for quality?” and I’ll just ask that question. I mean, as long as this is so complicated and nobody can come to any agreement on this – and any model you pick, you’re going to have a bunch of unhappy people and a bunch of logical or analytical failure. Then maybe Paul’s point should come into the conversation and say, “What are we doing here?”…. [W]hat the hell. (pp. 273-274)
 Here is how MedPAC staffer Ariel Winter explained the partial-capitation payment method at the March meeting: “[T]he … approach would allow primary care practitioners in two-sided ACOs to receive an upfront, lump sum payment…. PCPs in ACOs would not receive new money for this upfront payment; instead, they would be shifting some of their own revenue from fee-for-service payments to the upfront payment.” Why, you might ask, should doctors feel happier about being swallowed by an ACO and bearing two-sided risk if they receive no increase in revenues, only a change in the chronological distribution of those revenues (more in January and less over the remaining months of the year)? Winter offered this non-explanation: “The advantage of this upfront payment is that it would give providers more flexibility to invest in infrastructure and staff for care coordination activities.” (pp. 199-200).
This “explanation” illustrates the free lunch syndrome . Winter is saying primary care doctors would now be “free” to spend money on something Medicare won’t currently pay for, for example, nurses stationed at nursing homes to reduce emergency visits, but new revenue to pay for the additional nurses would not be coming from CMS. Let’s see here, where might the extra revenue come from? Tinker Bell?
 Commissioner William Hall also commented on the attribution issue. “It seems to me that with MIPS … we are [telling] a group of physicians who call themselves primary care providers … ‘You are responsible for some kind of a catchment area…. And as we look at your area …, you have some problems – like maybe diabetes is not being cared for … very well, or there seems to be too much alcoholism in your community.’ And we are saying: ‘Why don’t you fix that?’ …. I think we have very muddy expectations what modern primary care should do.” (p. 238)
 The following conversation between Chairman Crosson and Commissioner Alice Coombs about whether hospitals could create “organized staff models,” taken from the transcript of the March 2017 meeting, illustrates one of the many dead ends the commission ran down in their search for the prototype of a physician group that would want to take on two-sided risk:
DR. CROSSON: So, Alice, … let’s just think about the organized medical staff model for a moment [Crosson was for many years an executive within Kaiser Permanente]. As you well know, … it’s kind of a group but not really a group…. Essentially, everybody is … nominally working in the same institution …. Historically, the organized medical staff has had a role … in trying to oversee and manage quality within that institution, right? Now, some are effective, and many have not been, and in fact, the enthusiasm for the value of the organized medical staff model has kind of waned over the last couple of decades. So at least one of the ways I’ve been thinking about this … is that … joining an A-APM would be an option, but then you would have the other option, which is to organize your organized medical staff to be the unit of measurement on these population-based measurements.
DR. COOMBS: So there’s an underlying assumption that you just made. … In our community [Dr. Coombs is from Massachusetts], 80 percent of docs don’t even come to the hospital. The hospital’s program has superseded … every single service. Pediatrics has an inpatient hospitalist. … [B]elieve it or not, the majority of care happens outside the hospital…. In the olden days, you’re right –
DR. CROSSON: Yeah. [pp. 226-228]
Categories: OIG Advisory Opinions
The Healthcare Blog - Sat, 04/15/2017 - 11:10
With all the machinations over ACA repeal and replace, the new law that makes big changes in the way the federal government pays doctors—the Medicare Access and CHIP Reauthorization Act, or MACRA—hasn’t garnered much attention lately.
But doctors nationwide are sure thinking about it. That includes many of the regular commentators on THCB. I think it’s accurate to say that most of them have been highly critical of MACRA since the law was enacted in April 2015, and even after it was significantly amended late last year to address physician complaints. (See, for example, Kip Sullivan’s most recent post here.)
The law’s main provisions kicked in on Jan. 1, 2017, with 2017 being the first performance-reporting year, affecting payment in 2019.
In a policy brief on MACRA for Health Affairs published late last month, I raised a host of questions about MACRA.
As Kip and many others have noted, some parts of MACRA are weakly designed and both the law and regulations implementing it make some big assumptions. Excerpts from one section of the policy brief are below. The whole brief can be had at the link above. If you are well versed in MACRA, you can skip to the section titled “What’s the Debate?
Is the overall design coherent and workable?
Major special-interest groups, including those representing physicians, industry, and consumers and patients, supported MACRA’s intent and the general framework of the regulations through three comment periods.
However, almost all groups sought changes and raised questions. CMS’s final revisions were most responsive to physician groups, which were insistent on an easier path and more flexibility for doctors in the initial years of the program.
Dissenting voices raised questions that are not easy to dismiss, however. These could gain credence and traction if implementation proves difficult or falters. For example, does the assessment of individual physicians’ performance with existing quality measures yield meaningful results?
Some critics say there’s no clear evidence that current measures, or the scoring framework proposed by CMS, will provide anything close to a full and accurate picture of how well an individual doctor does in treating his or her Medicare patients. Thus, basing payment to individual doctors on the MIPS scoring sys- tem—or any scoring system—is flawed and irresponsible.
These critics would scrap MIPS and, over time, prod doctors to join APMs. But other critics take aim at the whole notion of changing or incentivizing physician behavior through performance measurement and financial incentives. They assert that this has not conclusively yielded improvements in care or in the health status of the US population.
Still other critics say there’s only weak evidence indicating that ACOs and APMs
(including bundled care payment) improve care and lower cost growth enough to justify the administrative costs they incur—which would extend to the administrative costs that physician groups, APMs, and the federal government will now incur as MACRA gets implemented.
CMS officials and other health policy experts don’t reject these critiques completely. But they do argue that some early evidence suggests that financial incentives, performance measurement, and ratings can and do propel individual clinicians and groups of physicians to improve care.
Moreover, they assert, the government has a moral duty to prevent unnecessary and wasteful care, and a powerful fiduciary duty to spend tax dollars wisely, in part by restraining excessive growth in health care spending, which makes up a substantial part of the federal budget as well as business and consumer spending.
Is the program good or bad for solo doctors and small or rural practices?
MACRA is designed to push doctors who practice on their own or in small groups into larger groups and into APMs. A vocal group of such doctors don’t want to do this. They prefer their current arrangement.
The government recognized this dilemma and increased the number of physicians who would be exempt. It also gave clinicians more flexibility, primarily to accommodate those in small practices who had not to date been participating in any pay-for-reporting or pay- for-performance programs.
CMS officials and other experts acknowledge that the evidence is not strong that solo or small practices deliver poorer-quality care than larger practices. Even so, debate continues about the pros and cons of larger versus small physician groups or solo doctors.
That debate will continue and is likely to trigger changes to MACRA rules in the years ahead as evidence mounts one way or the other.
In comments accompanying its final rules, CMS said: “Although small and solo practices have historically been less likely to engage in [the existing physician quality reporting system] and quality reporting, we believe that small and solo practices will respond to MIPS by participating at a rate close to that of other practice sizes.” The agency also estimates that “at least 80 percent of clinicians in practices with 1–9 clinicians will receive a positive or neutral MIPS payment adjustment [in 2017 and 2018].”
Does MACRA constitute government intrusion in the practice of medicine?
Federal law dating back to the 1930s discourages, and in some cases prohibits, the government from dictating how doctors practice medicine, collectively or individually. Some, mostly conservative, commentators and physician organizations say that recent history has eroded that principle.
In keeping with that emerging debate, doctors and groups allied with conservative and libertarian interests believe that MACRA is intrusive and that, by definition, it pushes doctors to practice in certain ways that could be inimical to good patient care. The same argument was brought to bear against managed care, as wielded by both government and private insurers, in the 1990s and early 2000s.
Mainstream medical groups disagree that MACRA dictates to doctors how to treat individual patients. However, recent surveys indicate that a majority of physicians have low morale and are concerned about excessive paperwork, the time they have with patients, and the future of medicine. In one large-scale 2016 survey that garnered responses from 17,236 physicians, only 14 percent said they had the time they needed to provide the highest standards of care.
“Volume to value”—slogan or sound policy?
Critics allege that the volume-to-value movement is, for now, based more on faith than strong or conclusive evidence. For example, they cite the experience of countries in Europe that control spending primarily through regulated prices and fees in fee-for-service systems, instead of relying on performance measurement and payment incentives.
Critics also argue that “value” in medicine is an elusive concept and not one likely to be pinned down through a single composite score—especially for an individual physician. As yet, these critics further allege, value has not been clearly pegged or produced by ACOs, patient-centered medical homes, or integrated health care systems.
Such criticisms are countered by researchers who point to published studies as well as hundreds of initiatives and innovations in care delivery over the past twenty years that claim to have improved care delivery through enhanced accountability, quality measurement, and incentive payments.
The magnitude, depth, and significance of the improvements certainly can be disputed, and MACRA’s impact will almost certainly trigger continued debate on this issue.
MIPS versus alternative payment entities
It’s clear that in designing MACRA, Congress wanted the majority of physicians, over time, to join APMs. Larger potential bonuses (compared to MIPS) and fee increases are inducements to physicians to take the alternative model path. MIPS is designed as a bridge to that end, although it is unclear when and if MIPS would be terminated.
This approach is consistent with the Obama administration’s approach under the ACA and with other recent bipartisan laws, as well as marketplace dynamics, over the past fifteen years. All promote larger group practices, integrated systems, a shift away from fee-for-service, and enhancement of the Medicare Advantage program as an alternative to traditional Medicare.
How much financial risk should physicians take on in alternative payment models?
An APM will qualify as an advanced APM in performance years 2017 and 2018 if it is at risk of either losing 8 percent of its revenues when Medicare expenditures are higher than expected or repaying CMS up to 3 percent of total Medicare expenditures, whichever is lower.
However, it’s not yet clear how much financial risk will flow down to individual physicians in APMs. CMS uses the phrase “more than nominal risk” to define its approach, but physician interest groups want limited physician exposure to losses from taking on insurance or financial risk.
“Physicians will be much more willing to take on accountability for costs that they can affect through their own performance, such as the costs of preventable complications, than they are to take on risk for the total cost of care for a large patient population,” the AMA said in its initial comments on the MACRA proposed rules.
Measures that matter
A majority of the comments on the proposed regulations urged CMS to adopt a common core set of measures focused on population health, clinical outcomes, and assessments of patient experience for both MIPS and the alternative payment entities.
Most also urged CMS to eliminate overlapping, duplicative measures and “topped out” process measures that no longer provide meaningful barometers of quality of care or performance.
CMS in its final rule concurred on these points and said it was undertaking efforts to focus on “measures that matter.”
Notably, in February 2016 CMS and the insurance industry jointly released an initial set of core physician performance measures intended to replace existing overly complex measure sets.
In its initial MACRA comments, the AMA expressed concern about a too-rapid shift to claims-based cost and outcome measures. “We would view proposals to dictate the percentage of measures that must be based on outcomes rather than process as highly premature,” the group said.
For their part, employer and consumer groups want CMS to put more emphasis on the results of patient experience surveys such as those developed by the Agency for Healthcare Research and Quality’s Consumer Assessment of Healthcare Providers and Systems (CAHPS) program.
Employer and consumer groups also have urged CMS to aggressively explore the use of patient-reported outcomes—information and data that patients themselves document about their care. But physician interest groups such as the AMA are divided on the utility of CAHPS and patient-reported outcomes. The American College of Physicians, for example, requests that CAHPS surveys not be used at all under MIPS.
Other comments reflect near-universal agreement that CMS should make more use of the data contained in patient registries, as CMS proposes. But how such registries can be standardized is an open question.
Physician groups urged CMS to concentrate on assessing performance and quality at the group-practice level and avoid grading individual physicians in MIPs and APMs.
Employer and consumer groups, in contrast, want CMS to push toward performance measures at the level of the individual physician, where appropriate, since, they argue, that is what consumers want.
Under the ACA and now MACRA, CMS is mandated to assess performance and quality at the individual physician level. But this intense debate is unlikely to go away anytime soon. It reflects a fundamental disagreement—as mentioned above—about whether current methods and tools allow accurate assessments of individual physician quality of care or outcomes.
MACRA mandates that performance results be made available to Medicare beneficiaries and consumers broadly, to aid their choice of individual physicians and physician groups.
CMS says it is finalizing how it will fulfill this public reporting requirement, of MIPS information, through the Physician Compare website. The agency says it remains committed to reporting performance results for both individual physicians and groups, in “an easily understandable format” for consumers.
Debate over the reliability of performance results for individual physicians, versus groups, could undermine this intent, however. Some observers say they expect the Trump administration to take a fresh and close look at what will be posted on Physician Compare, and when.
Electronic health records
CMS concurred with commenters that the previous EHR “meaningful-use” program was in need of reengineering under MACRA. To that end, there will be far less emphasis on data entry and “check the box” use of EHRs and more emphasis on the secure exchange of patient information; promoting patient engagement; and reporting to state and federal public health agencies and clinical data registries.
Steven Findlay is an independent journalist, health policy analyst, researcher and consumer advocate.
Categories: OIG Advisory Opinions
Medical Coding News - Wed, 04/12/2017 - 08:54
There has been a wide array of discussion through published articles, forums, webinars, and meetings about the topic of outpatient clinical documentation improvement (CDI) programs. Outpatient CDI is receiving much attention and experiencing traction in the healthcare industry due to providers coming to terms with the fact that documentation truly matters from a financial perspective, […]
The post Outpatient CDI: Is it an Offshoot of Traditional CDI Programs? appeared first on MedicalCodingNews.Org.
Categories: Healthcare News