[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]
MACRA AND ALTERNATIVE PAYMENT MODELS: DEVELOPING OPTIONS FOR VALUE-
BASED CARE
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON ENERGY AND COMMERCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED FIFTEENTH CONGRESS
FIRST SESSION
__________
NOVEMBER 8, 2017
__________
Serial No. 115-75
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Printed for the use of the Committee on Energy and Commerce
energycommerce.house.gov
_________
U.S. GOVERNMENT PUBLISHING OFFICE
28-263 PDF WASHINGTON : 2018
COMMITTEE ON ENERGY AND COMMERCE
GREG WALDEN, Oregon
Chairman
JOE BARTON, Texas FRANK PALLONE, Jr., New Jersey
Vice Chairman Ranking Member
FRED UPTON, Michigan BOBBY L. RUSH, Illinois
JOHN SHIMKUS, Illinois ANNA G. ESHOO, California
MICHAEL C. BURGESS, Texas ELIOT L. ENGEL, New York
MARSHA BLACKBURN, Tennessee GENE GREEN, Texas
STEVE SCALISE, Louisiana DIANA DeGETTE, Colorado
ROBERT E. LATTA, Ohio MICHAEL F. DOYLE, Pennsylvania
CATHY McMORRIS RODGERS, Washington JANICE D. SCHAKOWSKY, Illinois
GREGG HARPER, Mississippi G.K. BUTTERFIELD, North Carolina
LEONARD LANCE, New Jersey DORIS O. MATSUI, California
BRETT GUTHRIE, Kentucky KATHY CASTOR, Florida
PETE OLSON, Texas JOHN P. SARBANES, Maryland
DAVID B. McKINLEY, West Virginia JERRY McNERNEY, California
ADAM KINZINGER, Illinois PETER WELCH, Vermont
H. MORGAN GRIFFITH, Virginia BEN RAY LUJAN, New Mexico
GUS M. BILIRAKIS, Florida PAUL TONKO, New York
BILL JOHNSON, Ohio YVETTE D. CLARKE, New York
BILLY LONG, Missouri DAVID LOEBSACK, Iowa
LARRY BUCSHON, Indiana KURT SCHRADER, Oregon
BILL FLORES, Texas JOSEPH P. KENNEDY, III,
SUSAN W. BROOKS, Indiana Massachusetts
MARKWAYNE MULLIN, Oklahoma TONY CARDENAS, California
RICHARD HUDSON, North Carolina RAUL RUIZ, California
CHRIS COLLINS, New York SCOTT H. PETERS, California
KEVIN CRAMER, North Dakota DEBBIE DINGELL, Michigan
TIM WALBERG, Michigan
MIMI WALTERS, California
RYAN A. COSTELLO, Pennsylvania
EARL L. ``BUDDY'' CARTER, Georgia
JEFF DUNCAN, South Carolina
Subcommittee on Health
MICHAEL C. BURGESS, Texas
Chairman
BRETT GUTHRIE, Kentucky GENE GREEN, Texas
Vice Chairman Ranking Member
JOE BARTON, Texas ELIOT L. ENGEL, New York
FRED UPTON, Michigan JANICE D. SCHAKOWSKY, Illinois
JOHN SHIMKUS, Illinois G.K. BUTTERFIELD, North Carolina
MARSHA BLACKBURN, Tennessee DORIS O. MATSUI, California
ROBERT E. LATTA, Ohio KATHY CASTOR, Florida
CATHY McMORRIS RODGERS, Washington JOHN P. SARBANES, Maryland
LEONARD LANCE, New Jersey BEN RAY LUJAN, New Mexico
H. MORGAN GRIFFITH, Virginia KURT SCHRADER, Oregon
GUS M. BILIRAKIS, Florida JOSEPH P. KENNEDY, III,
BILLY LONG, Missouri Massachusetts
LARRY BUCSHON, Indiana TONY CARDENAS, California
SUSAN W. BROOKS, Indiana ANNA G. ESHOO, California
MARKWAYNE MULLIN, Oklahoma DIANA DeGETTE, Colorado
RICHARD HUDSON, North Carolina FRANK PALLONE, Jr., New Jersey (ex
CHRIS COLLINS, New York officio)
EARL L. ``BUDDY'' CARTER, Georgia
GREG WALDEN, Oregon (ex officio)
(ii)
C O N T E N T S
----------
Page
Hon. Michael C. Burgess, a Representative in Congress from the
State of Texas, opening statement.............................. 1
Prepared statement........................................... 3
Hon. Gene Green, a Representative in Congress from the State of
Texas, opening statement....................................... 4
Hon. Frank Pallone, Jr., a Representative in Congress from the
State of New Jersey, opening statement......................... 6
Prepared statement........................................... 7
Hon. Greg Walden, a Representative in Congress from the State of
Oregon, prepared statement..................................... 127
Witnesses
Jeffrey Bailet, M.D., Chair, Physician-Focused Payment Model
Technical Advisory Committee................................... 8
Prepared statement \1\
Elizabeth Mitchell, Vice Chair, Physician-Focused Payment Model
Technical Advisory Committee................................... 10
Joint prepared statement of Dr. Bailet and Ms. Mitchell...... 12
Louis A. Friedman, D.O., Fellow, American College of Physicians.. 54
Prepared statement........................................... 57
Daniel Varga, M.D., Chief Clinical Officer, Texas Health
Resources...................................................... 68
Prepared statement........................................... 70
J. William Wulf, M.D., Chief Executive Officer, Central Ohio
Primary Care Physicians, on Behalf of CAPG..................... 79
Prepared statement........................................... 81
Colin C. Edgerton, M.D., Alternate Delegate, American College of
Rheumatology................................................... 89
Prepared statement........................................... 91
Brian Kavanagh, M.D., Chairman, American Society for Radiation
Oncology....................................................... 94
Prepared statement........................................... 96
Frank Opelka, M.D., Medical Director, Quality and Health Policy,
American College of Surgeons................................... 107
Prepared statement........................................... 109
Submitted Material
Statement of the American Academy of Family Physicians, November
9, 2017, submitted by Mr. Green................................ 128
Statement of the American Association of Nurse Anesthetists by
Bruce A. Weiner, President, November 8, 2017, submitted by Mr.
Burgess........................................................ 132
Letter of November 8, 2017, from James D. Grant, President,
American Society of Anesthesiologists, to Mr. Walden and Mr.
Pallone, submitted by Mr. Burgess.............................. 140
Statement of the American Medical Association, November 8, 2017,
submitted by Mr. Burgess....................................... 145
Statement of the American Physical Therapy Association, November
8, 2017, submitted by Mr. Burgess.............................. 151
Letter of November 8, 2017, from Mary R. Grealy, President,
Healthcare Leadership Council, to Mr. Walden, submitted by Mr.
Burgess........................................................ 156
----------
\1\ Dr. Bailet and Ms. Mitchell submitted a joint prepared statement.
Statement of the American Society of Clinical Oncology by Bruce
Johnson, President, November 8, 2017, submitted by Mr. Burgess. 160
Statement of America's Health Insurance Plans, November 8, 2017,
submitted by Mr. Burgess....................................... 163
Statement of the Health Systems for Stark Reform Coalition,
November 8, 2017, submitted by Mr. Burgess..................... 184
Statement of the American Hospital Association, November 8, 2017,
submitted by Mr. Burgess....................................... 186
Letter of November 7, 2017, from David Hebert, Chief Executive
Officer, American Association of Nurse Practitioners, to Mr.
Burgess and Mr. Green, submitted by Mr. Burgess................ 191
Statement of the Society of Thoracic Surgeons, November 8, 2017,
submitted by Mr. Bucshon....................................... 193
Statement of the American Association of Orthopaedic Surgeons,
November 8, 2017, submitted by Mr. Burgess..................... 196
MACRA AND ALTERNATIVE PAYMENT MODELS: DEVELOPING OPTIONS FOR VALUE-
BASED CARE
----------
WEDNESDAY, NOVEMBER 8, 2017
House of Representatives,
Subcommittee on Health,
Committee on Energy and Commerce,
Washington, DC.
The subcommittee met, pursuant to call, at 10:02 a.m., in
room 2123, Rayburn House Office Building, Hon. Michael Burgess
(chairman of the subcommittee) presiding.
Members present: Representatives Burgess, Guthrie, Barton,
Shimkus, Blackburn, Lance, Griffith, Bilirakis, Long, Bucshon,
Brooks, Mullin, Hudson, Collins, Carter, Green, Engel,
Butterfield, Matsui, Castor, Sarbanes, Schrader, Kennedy,
Eshoo, DeGette, and Pallone (ex officio).
Also present: Representative Ruiz.
Staff present: Adam Buckalew, Professional Staff Member,
Health; Jordan Davis, Director of Policy and External Affairs;
Paul Edattel, Chief Counsel, Health; Adam Fromm, Director of
Outreach and Coalitions; Caleb Graff, Professional Staff
Member, Health; Jay Gulshen, Legislative Clerk, Health; Alex
Miller, Video Production Aide and Press Assistant; James
Paluskiewicz, Professional Staff Member, Health; Jennifer
Sherman, Press Secretary; Hamlin Wade, Special Advisor for
External Affairs; Jeff Carroll, Minority Staff Director;
Tiffany Guarascio, Minority Deputy Staff Director and Chief
Health Advisor; Una Lee, Minority Senior Health Counsel;
Samantha Satchell, Minority Policy Analyst; and C.J. Young,
Minority Press Secretary.
Mr. Burgess. The Subcommittee on Health will now come to
order, and I will recognize myself 5 minutes for the purpose of
an opening statement.
OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF TEXAS
Today marks the Health Subcommittee's third oversight
hearing to examine the implementation of the Medicare Access
and CHIP Reauthorization Act. Personally, for me, the Medicare
Access and CHIP Reauthorization Act was a significant milestone
because repealing the Sustainable Growth Rate formula was one
of my highest priorities coming to Congress.
The Medicare Access and CHIP Reauthorization Act represents
a fundamental change in a healthcare payment system that had
remained static for many years and had created uncertainty for
providers. Before the passage of this bill, Congress delayed
cuts to Medicare reimbursements for doctors a total of 17
times.
Through the hard work and steadfast leadership of the
Energy and Commerce Committee and the unwavering commitment
from the medical community, this bipartisan effort led to
policies that sought to put power back in the hands of those
who actually provide the care. That way, doctors will give
shape to the healthcare payment of the future.
So it is critically important that the Medicare Access and
CHIP Reauthorization Act succeeds and I am glad that the
committee remains dedicated to ensuring that we get payment
reform right. It does continue to be one of my top priorities.
Today, we will convene two panels of witnesses.
And I want to welcome Dr. Jeffrey Bailet, the chairperson
of the Physician-Focused Payment Model Technical Advisory
Committee--we will call it PTAC for short--and Ms. Elizabeth
Mitchell who is the vice chairperson of PTAC. I want to welcome
you to our subcommittee this morning.
The next panel, we will hear from physicians representing
key stakeholder groups that have either already had, have an
alternative payment model, or have one in the pipeline with the
PTAC or the Center for Medicare and Medicare information. With
that I want to take a moment also to welcome Dr. Daniel Varga
from the Texas Health Resources Presbyterian Hospital where I
did part of my residency, which provides care for many of my
constituents in the north Texas area. It is good to have you in
person today, Dr. Varga.
The focus of today's hearing will be on the Alternative
Payment Models which is one of two options that eligible
professionals can be reimbursed under MACRA. The other option
is a Merit-based Incentive Payment System which also deserves
our full attention and will be the subject of an additional
hearing in the very near future.
One of the many goals of the Medicare Access and CHIP
Reauthorization Act was to encourage and engage in care
delivery models that drive quality while reducing healthcare
costs. This movement towards alternative payment methods has
allowed providers greater flexibility to innovate and try a
delivery system that better aligns with their unique practice
needs and allows them to produce better patient outcomes and
offers an opportunity to share in the savings. I am encouraged
by figures that indicate an estimated 50 percent of Medicare
payments will be tied to these alternative payment methods next
year.
We may have heard of some of these models before. The
Medicare Shared Saving Program through Accountable Care
Organizations, the Next Generation ACO Model, the Comprehensive
Primary Care Plus model, and the Oncology Care Model. It is
safe to say we will likely hear of them and similar hybrids in
the near future. It is notable and important these efforts are
physician-directed and physician-led. This is not necessarily
the easiest path, but it is the correct one.
A recurring theme that we will hear this morning is that
physicians are best suited to provide the determinants of
quality. Patients are counting on us. Not congressmen, but
doctors. They are counting on us to get this right. It has been
2\1/2\ years since the Medicare Access and CHIP Reauthorization
Act became law.
I believe the true potential of this act has yet to be met,
but I believe the law has already begun proving a success of
delivering better care to beneficiaries, savings to the
Medicare program, certainty for our doctors. It is important to
hear the positive impact this law has had so far from everyone
here today. Finally, it is critical that what we accomplish
today follows the same open, transparent, and bipartisan
structure that helped us get this act signed into law.
I again want to welcome all of our witnesses. Thank you for
being here today. Thank you for giving us your time. I look
forward to your testimony. And I will yield the balance of my
time to Mrs. Blackburn from Tennessee for a statement.
[The prepared statement of Mr. Burgess follows:]
Prepared statement of Hon. Michael C. Burgess
Today marks the Health Subcommittee's third oversight
hearing to examine the implementation of the Medicare Access
and CHIP Reauthorization Act since its enactment. Personally,
MACRA was a significant milestone because repealing the
Sustainable Growth Rate was one of my driving forces soon after
I came to Congress. MACRA represents a fundamental change in a
health care payment system that had remained static for many
years and had created tremendous amount of uncertainty for
providers since 2003. Before MACRA, Congress delayed cuts to
Medicare reimbursements for physician services a total of 17
times! Through the hard work and steadfast leadership of the
Energy and Commerce Committee and unwavering commitment of the
medical community, this bipartisan effort led to policies that
sought to put power back in the hands of those who actually
provide care. That way, doctors will give shape to the health
care payment systems of the future. So, it is critically
important that MACRA succeeds, and I am glad that the committee
remains dedicated to ensuring we get payment reform right. This
continues to be one of my priorities.
Today we will convene two panels of witnesses. First, I
want to welcome Dr. Jeffrey Bailet, chairperson of the
Physician-Focused Payment Model Technical Advisory Committee
(PTAC), and Ms. Elizabeth Mitchell, vice chairperson of PTAC to
our subcommittee this morning. Later, we will hear from
physicians representing key stakeholder groups that either
already have an Alternative Payment Model (APM) or have one in
the pipeline with PTAC or the Center for Medicare and Medicaid
Innovation (CMMI). With that, I want to take a moment to also
welcome Dr. Daniel Varga from the Texas Health Resources, which
provides care for many of my constituents in the North Texas
area.
The focus of today's hearing will be on Alternative Payment
Models (APMs), which is one of two options eligible
professionals can be reimbursed under MACRA. The other option
is the Merit-based Incentive Payment System (MIPS), which also
deserves our full attention and will be the subject of an
additional hearing in the near future.
One of the many goals of MACRA was to encourage and engage
in care delivery models that drive quality while reducing
healthcare costs. This movement towards APMs has allowed
providers greater flexibility to innovate and try a delivery
system that better aligns with their unique practice needs,
produce better patient outcomes, and offer them an opportunity
to share in significant savings. I am encouraged by figures
that indicate an estimated 50 percent of Medicare payments will
be tied to APMs next year. We may have heard some of these
models before: the Medicare Shared Savings Program through
Accountable Care Organizations, the Next Generation ACO Model,
the Comprehensive Primary Care Plus Model, and the Oncology
Care Model. It is safe to say we will likely hear of them and
similar hybrids much more in the future.
It is notable and important that these efforts are
physician directed and physician led. This not necessarily the
easiest path, but it is the correct one. A recurring theme we
will hear this morning is that physicians are best suited to
provide the determinants of quality. Patients are counting on
us--the doctors--to get this right.
It has been 2\1/2\ years since MACRA became law. I believe
the true potential of MACRA has yet to be met, but I believe
the law has already been proven a success in delivering better
care to beneficiaries, savings to the Medicare program, and
certainty to doctors. It is important to hear the positive
impact this law has had so far from everyone here today.
Finally, it is critical that what we accomplish today follows
the same open, transparent, and bipartisan structure that
helped get MACRA signed into law.
I again want to welcome all of our witnesses and thank you
for being here. I look forward to your testimony.
I would like to yield the balance of my time to Ms.
Blackburn of Tennessee, for a statement.
Mrs. Blackburn. Thank you, Mr. Chairman. And I am so
pleased that we are doing this hearing today. And I was one of
those that joined you in being a vocal opponent of kicking the
can on the SGR. There were things that needed to be done and it
is our responsibility to address those issues and to find
solutions and of course getting MACRA to the President's desk
was a solution.
The old system of short-term fixes does not work, didn't
work, and I am looking forward to hearing how the law's
Alternative Payment Models are being designed and implemented
and improving patient treatment and outcomes in a variety of
settings. Being from the Nashville, Tennessee area, we have a
lot of health care that is headquartered there and the steps
that are being taken are important to them, to our
constituents. And I yield back.
Mr. Burgess. The Chair thanks the gentlelady. The
gentlelady yields back. The Chair recognizes the subcommittee
ranking member, Mr. Green of Texas, 5 minutes for an opening
statement, please.
OPENING STATEMENT OF HON. GENE GREEN, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF TEXAS
Mr. Green. Thank you, Mr. Chairman. And I want to thank you
for calling this hearing. I know we were both concerned over
those 17 years that how we were going to fix the SGR and we did
come to a bipartisan solution. And my concern and with this
hearing we don't want to recreate the SGR and have Congress go
through that so as nimble as Congress can be on our feet we
need to make sure we catch it before we have to deal with it
for 17 years.
The Sustainable Growth Rate was the scourge of Medicare and
doctors who treat Medicare patients for more than a decade and
acted as part of the Balanced Budget Act of 1997. The SGR
calculations led to a reduction of physician payments starting
in 2002 and had to be patched annually, as you said, for 17
years. In 2014, this committee along with other committees of
jurisdiction finally came together and introduced a bipartisan
bill to permanently repeal the SGR and replace it with a system
that rewards value over volume and incentives for quality care.
Finally, in 2015, an agreement on offsets was reached in
H.R. 2 that was Medicare Access and CHIP Reauthorization Act or
MACRA overwhelmingly passed both chambers and was signed into
law. MACRA did more than just repeal the flawed SGR formula. It
was designed to overhaul and realign payment incentives for
Medicare and transition of our health system to one that
rewards value instead of just volume of care. It provided
stability in Medicare payments for providers for immediately
following years and made it easy for providers to report on and
deliver high-quality care, streamlining Medicare's multiple
quality reporting systems, and over time consolidating them
into one.
Critically, MACRA encourages providers to move away from
fee-for-service and partake in a new delivery model that will
reduce costs while increasing quality. Under the law,
physicians who treat Medicare beneficiaries have a choice
between participating in the Merit-based Incentive Payment
System, MIPS, or the Advanced Alternative Payment Models, APMs,
to make the shift from fee-for-service and volume-based payment
system to a value-based payment system.
The focus of today's hearing is in the implementation of
these two tracks, the Alternative Payment Models. Alternative
Payment Models generally are an approach to provide provider
payment that offers incentive to quality, cost-effective care
in specific circumstances for specific patient populations or
episodes of treatment. Advanced APMs created under MACRA go a
step further and under these models physicians accept some
amount of financial risk for the quality of the care and
ultimate outcomes of their patients. Participants in Advanced
APMs accept this risk in exchange for greater rewards when they
succeed.
Starting next year, qualifying APM participants can receive
a 5 percent bonus in their reimbursement annually. Centers for
Medicare and Medicaid Innovation center has developed and
piloted APMs since its inception. Many of these now qualify as
Advanced APMs under MACRA including certain Accountable Care
Organizations, Patient-Centered Medical Homes and the
Comprehensive Primary Care Plus model.
I want to note that one of the most successful ACOs in the
country is Memorial Hermann Accountable Care organization
created and operated by leaders of the Memorial Hermann Health
System in Houston, a 16-hospital integrated health system based
in Houston. The Memorial Hermann ACO has been number one in
Shared Savings Program ACO in the country for several years
running, and by 2016 has generated nearly 200 million in
savings across 3 years of participation in the program. Today
we hear witnesses from these payment models, models that are
currently underway and physicians participating in them in
which are generating savings to Medicare and improved patient
outcomes.
Staunch oversight of MACRA is critical. We must avoid the
pitfalls of what we did since 1997, and I am pleased we are
having this hearing today and hope this committee engages in
more oversight and dialogue as the major reforms of MACRA are
fully implemented. And I yield back the balance of my time.
Oh, sorry. For the record, I would like to insert a letter
from the American Academy of Family Physicians.
Mr. Burgess. Without objection, so ordered.
[The information appears at the conclusion of the hearing.]
Mr. Burgess. The Chair thanks the gentleman. The gentleman
yields back. The chairman of the full committee has been
detained on a conference call. We will recognize him for an
opening statement upon his arrival. But pending that, I would
like to recognize the gentleman from New Jersey, Mr. Pallone,
the ranking member of the full committee, 5 minutes for an
opening statement, please.
OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF NEW JERSEY
Mr. Pallone. Thank you, Mr. Chairman, for holding this
important hearing and thank the witnesses for being here today.
We are meeting today to discuss one of the great bipartisan
success stories of this committee, the Medicare Access and CHIP
Reauthorization Act of 2015 or MACRA.
MACRA built upon the successes of the Affordable Care Act
to improve the quality and efficiency of the Medicare program
and of our healthcare system more broadly. Prior to the ACA,
healthcare services in the Medicare program were predominantly
reimbursed on a fee-for-service payment model which rewarded
providers for the number of tests or procedures they performed
instead of the quality of medical care provided. And the ACA
took major steps towards improving the quality of our
healthcare system by creating new models of healthcare delivery
within the Medicare program.
These new payment and delivery models focused on
transforming clinical care and shifting from a volume- to a
value-based care model such as Accountable Care Organizations
or ACOs and Patient-Centered Medical Homes. These models
prioritize the patient with the goal of improving care
coordination and patient outcomes by simultaneously lowering
costs and they have reduced hospitalizations, emergency
department visits, and have improved both the quality of care
and access to care. There are additional opportunities to
refine these models and increase savings, for example, by
better targeting the riskiest and costliest patients for
interventions.
But I want to take a moment to recognize that while we
continue to face challenges, the transformation to a value-
based healthcare system is well underway. With MACRA we are
entering the next phase of delivery system reform and further
shifting the paradigm away from a volume-based to a value-based
healthcare system.
MACRA builds on these healthcare delivery systems reform
efforts by offering opportunities and financial incentives for
physicians to transition to new payment models known as
Advanced Alternative Payment Models or AAPMs. And AAPMs must
meet a number of criteria and require clinicians to accept some
financial risk for the quality and cost outcomes of their
patients. Physicians can join existing and successful models
that qualify as AAPMs such as ACOs and the Comprehensive
Primary Care Plus or CPC+ model which we will hear about today.
They can also develop their own models known as Physician-
Focused Payment Models.
A number of physician organizations have already submitted
applications for approval by the Physician-Focused Payment
Model Technical Advisory Committee or PTAC, and PTAC has been
accepting and reviewing applications for Physician-Focused
Payment Models over the last year and has approved several for
testing, including the ACS-Brandeis Model which we will hear
about today from the American College of Surgeons.
I look forward to hearing from PTAC about the application
process, the way these efforts fit within the broader context
of delivery system reforms, how these submitted models have
been evaluated, and how models may be implemented going
forward.
Our second panel of witnesses practice in a variety of
settings across the country and represent diverse expertise and
training. They each have a unique perspective to share with us
regarding the implementation of MACRA and how it has encouraged
a focus on quality and efficient health care. And I want to
thank you all for your commitments to delivery system reform.
It is only through sustained commitment of the leading
physician organizations and clinicians such as yourselves that
we can hope to bend the cost curve.
So I look forward to discussing the tools and best
practices providers are already using, some of the challenges
and opportunities they have faced as well as future efforts
that can be employed to help make MACRA work effectively for
all, so I thank you.
I don't think anybody on my side wants the time, Mr.
Chairman, so I yield back.
[The prepared statement of Mr. Pallone follows:]
Prepared statement of Hon. Frank Pallone, Jr.
Good morning. Thank you Mr. Chairman for holding this
important hearing, and thank you to the witnesses for being
here today.
We're meeting today to discuss one of the great bipartisan
success stories of this committee, the Medicare Access and CHIP
Reauthorization Act of 2015, or MACRA. MACRA built upon the
successes of the Affordable Care Act to improve the quality and
efficiency of the Medicare program, and of our healthcare
system more broadly.
Prior to the ACA, healthcare services in the Medicare
program were predominantly reimbursed on a fee-for-service
payment model, which rewarded providers for the number of tests
or procedures they performed instead of the quality of medical
care provided. The ACA took major steps towards improving the
quality of our healthcare system by creating new models of
healthcare delivery within the Medicare program. These new
payment and delivery models focused on transforming clinical
care and shifting from a volume- to a value-based care model,
such as Accountable Care Organizations or ACOs and Patient
Centered Medical Homes.
These models prioritize the patient, with the goal of
improving care coordination and patient outcomes while
simultaneously lowering costs. They have reduced
hospitalizations, emergency department visits, and have
improved both the quality of care and access to care. There are
additional opportunities to refine these models and increase
savings, for example, by better targeting the riskiest and
costliest patients for interventions. But I want to take a
moment to recognize that while we continue to face challenges,
the transformation to a value-based healthcare system is well
underway.
With MACRA, we are entering the next phase of delivery
system reform and further shifting the paradigm away from a
volume-based to a value-based healthcare system. MACRA builds
on these healthcare delivery system reform efforts by offering
opportunities and financial incentives for physicians to
transition to new payment models known as Advanced Alternative
Payment Models, or AAPMs. AAPMs must meet a number of criteria,
and require clinicians to accept some financial risk for the
quality and cost outcomes of their patients. Physicians can
join existing and successful models that qualify as AAPMs, such
as ACOs and the Comprehensive Primary Care Plus (CPC+) model,
which we will hear about today. They can also develop their own
models, known as Physician-Focused Payment Models.
A number of physician organizations have already submitted
applications for approval by the Physician-Focused Payment
Model Technical Advisory Committee, or PTAC. PTAC has been
accepting and reviewing applications for Physician-Focused
Payment Models over the last year, and has approved several for
testing, including the ACS-Brandeis model we will hear about
today from the American College of Surgeons. I look forward to
hearing from PTAC about the application process, where these
efforts fit within the broader context of delivery system
reform, how these submitted models have been evaluated, and how
models may be implemented going forward.
Our second panel of witnesses practice in a variety of
settings across the country and represent diverse expertise and
training. They each have a unique perspective to share with us
regarding the implementation of MACRA and how it has encouraged
a focus on quality and efficient healthcare. I want to thank
you all for your commitment to delivery system reform-it is
only through the sustained commitment of the leading physician
organizations and clinicians such as yourselves that we can
hope to bend the cost curve.
I look forward to discussing the tools and best practices
providers are already using, some of the challenges and
opportunities they have faced, as well as future efforts that
can be employed to help make MACRA work effectively for all.
Thank you, I yield back the remainder of my time.
Mr. Burgess. The gentleman yields back. The Chair thanks
the gentleman. The Chair would remind Members that, pursuant to
committee rules, all Members' opening statements will be made
part of the record.
And we do want to thank our witnesses for being here today
on both panels. We thank them for taking their time to testify
before the subcommittee. Each witness will have the opportunity
to give an opening statement followed by questions from
Members.
Today we will hear from Dr. Jeffrey Bailet, the chairperson
of the Physician-Focused Payment Model Technical Advisory
Committee, and Ms. Elizabeth Mitchell, vice chairperson,
Physician-Focused Payment Model Technical Advisory Committee.
That is a mouthful.
We appreciate you being here today.
And, Dr. Bailet, you are now recognized for 5 minutes for
an opening statement, please.
STATEMENTS OF JEFFREY BAILET, M.D., CHAIR, AND ELIZABETH
MITCHELL, VICE CHAIR, PHYSICIAN-FOCUSED PAYMENT TECHNICAL MODEL
ADVISORY COMMITTEE
STATEMENT OF JEFFREY BAILET
Dr. Bailet. Thank you. Chairman Burgess, Ranking Member
Green, and distinguished members of the Energy and Commerce
Subcommittee on Health, thank you for the opportunity to
testify on behalf of the chair and vice chair of the Physician-
Focused Payment Model Technical Advisory Committee or PTAC. We
are Jeffrey Bailet, executive vice president of Health Care
Quality and Affordability at Blue Shield of California--we
insure 4.1 million members, we are nonprofit, and the third
largest health plan in California--and Elizabeth Mitchell, my
vice chair, CEO of the Network for Regional Health Improvement,
a national network of multi-stakeholder Regional Health
Improvement Collaboratives with over 30 members across the U.S.
As an otolaryngologist--head and neck surgeon--and as a
Blue Shield executive vice president, I am responsible for
leading all medically related activities for the health plan,
including quality medical management, provider contracting, and
our Accountable Care Organization strategy, and I also serve as
the chair of PTAC. Thank you for extending this opportunity for
us to speak on the important topic of Medicare payment reform
and PTAC's role supporting physicians and technicians as they
transition to value-based care delivery.
Even before the inception of MACRA there was considerable
agreement that the current fee-for-service model based on
paying for the volume and intensity of services is
unsustainable and needs to change to a model that is value-
based, patient-centered, and accountable. However, we need to
transform the care delivery system and change the trajectory of
spending in a way that maintains the vibrancy of the
institutions and professionals that have dedicated their lives
to preserving health and caring for the sick, injured, and
dying in the U.S.
MACRA and Alternative Payment Models have the potential to
address the fundamental drivers of cost and quality and ensure
that we have a high-value health system, the backbone of which
is providers who want to change care delivery and give better
care to patients.
As the largest purchaser of health care in the world,
Medicare has considerable influence on payment and, through the
development of Alternative Payment Models, drive market change,
and the PTAC plays an important role in accelerating model
development. The PTAC is an 11-member advisory committee
established to consider physicians and other clinical
stakeholders' proposals for new payment models that foster
high-quality, high-value health care.
PTAC members are a diverse, highly talented group that have
deep expertise in clinical care and technical expertise in the
areas of measurement, payment, and care delivery reform. The
committee includes a balance of physicians and non-physicians
who are highly committed to ensure that proposals are
critically, thoroughly, and expeditiously evaluated.
We have sought to establish high-integrity relationships
with the clinical and broader stakeholder communities across
the country, some of which you will hear today. We are inviting
comments, questions, or concerns prior to and during public
meetings when models are evaluated. Furthermore, PTAC is keenly
interested in all types of models including those emanating
from single specialty, primary care, small and rural practices,
sophisticated health systems, and multispecialty group
practices.
PTAC's disciplined and collaborative efforts have garnered
tremendous interest in creativity from stakeholders, receiving
33 letters of intent and 20 full proposals spanning many
specialties, payment types, and practice sizes. To date, the
PTAC has held 9 days of public meetings, we have deliberated on
six proposals, we have voted on five with submitted reports to
the secretary, and we have 14 proposals under active review. It
is our belief that the interest in and work of PTAC confirms
Congress' direction and intent for MACRA to transition U.S.
health care to a high-value system delivering better care at
lower cost.
Lastly, PTAC works collaboratively with CMS and CMMI to
garner input about specific proposals especially if they have
previously evaluated to any capacity by CMS or CMMI. To date,
the models PTAC has sent to the secretary for potential
limited-scale testing have not been approved.
In addition, we are unclear whether because of the
extensive review process already provided by the PTAC,
submitters can undergo a more expedited review and evaluation
process. Our concern is that if we are not able to support our
recommendations or work to fix any shortfalls in our analyses,
the value of PTAC's process will not be fully realized. We
believe that closer coordination between PTAC and CMS and CMMI
will enable greater efficiency, greater capacity to implement
more innovative models, and greater clarity for applicants
seeking to understand the process of submission and approval
and look forward to continued partnership with CMS and CMMI.
In closing, PTAC is an incredibly important forum to
identify innovative models from the field to expand Medicare's
payment model portfolio. Transforming care delivery, including
implementing innovative payment policy, is complicated;
therefore an open public process that includes the stakeholders
and also educates stakeholders and the public is likely the
best way forward. We believe the PTAC is well suited for this
purpose.
We commend Congress for its vision and we thank you for the
opportunity to be part of such important work. Thank you.
Mr. Burgess. The Chair thanks the gentleman.
Ms. Mitchell, you are recognized for 5 minutes, please.
STATEMENT OF ELIZABETH MITCHELL
Ms. Mitchell. Thank you Chairman Burgess, Ranking Member
Green, and distinguished members of the committee. Thank you
again for the opportunity to be here today and for your
leadership on these critically important issues.
As president and CEO of the Network for Regional Health
Improvement, my members and I work at the community level with
all stakeholders, employers, providers, health plans, patients,
and others, and I can assure you that healthcare quality and
affordability are of primary concern. The urgency to reduce
healthcare costs while improving quality cannot be overstated.
This is impacting families, employers, State governments, and
our overall economy.
MACRA addresses the fundamental drivers and by reforming
care and payment we have truly the opportunity to achieve
better care at lower cost and this is an incredible opportunity
for the U.S. Dr. Bailet has shared the innovation and
leadership that we have seen from the physician community and
their readiness to lead these changes. This is an opportunity
that we cannot squander.
Despite the exceptional interest in PTAC as evidenced by
the number of proposals and letters of intent, there are still
barriers that physicians face in transitioning to these new
models. Providers who are ready and willing to lead change
continue to face barriers and need additional support. The PTAC
took the time to think about some of the key barriers that we
have seen from the submitters over the first year and we have
identified three priority areas for your consideration. These
include the need for technical assistance to providers, greater
access to shared data, and the opportunity for limited-scale
testing of innovative models.
PTAC believes that there is a material need for technical
assistance for providers to develop and implement Physician-
Focused Payment Models and APMs. Most physicians, they have
experience changing care delivery but they have not been
trained in the development of incentives, payment models, or
risk management. Recent surveys of high-performing health
systems and medical groups demonstrate the growing willingness
to support and assume risk, but these organizations have made
considerable investments in the infrastructure to successfully
participate in APMs.
And while large health systems may have the resources and
expertise to develop and implement these models, such small and
rural practices are at greatest risk of not being able to
afford the technical support to design and implement the
payment and care changes needed to succeed under risk-based
models. This threatens to leave these small and rural practices
out of the transition to value-based care.
Congress should identify ways to enable the provision of
technical assistance to providers seeking to develop and
implement APMs in a way that does not exacerbate resource
differentials among providers and that helps move all providers
forward towards value-based care. Although MACRA does not
authorize PTAC to provide such technical assistance, many
members of our committee believe that PTAC should be able to do
so, or at a minimum PTAC can provide valuable insights related
to what types of technical assistance would be most helpful.
The PTAC supports deployment of HHS resources to provide
access to analytic, technical, and quality improvement support.
We also believe that there is a need for greater access to
shared data. This is a common barrier identified by submitters.
PTAC, too, has observed common weaknesses among some of the
submitted proposals. Specifically, applicants need
communitywide, all-payer claims and clinical data sharing
across communities to successfully implement models. Providers
cannot manage risk, care, or cost without timely, comprehensive
data.
Most of the proposals PTAC has received require
coordination of care across practices, providers, and
communities, but if data is not shared effectively participants
cannot coordinate patient care across episodes or populations.
Data blocking, lack of interoperability, and other limits on
data access continue to be a major barrier to care improvement
on behalf of patients. The move to APMs as required by MACRA
has made this an urgent issue. We ultimately must address the
barriers to communitywide data access in order to enable the
successful transition to APMs.
Finally, limited-scale testing of innovative models is
necessary before we scale models for national implementation.
This is the committee's third priority and we believe that
innovation in any industry requires the opportunity for small-
scale testing. PTAC has identified limited testing of models as
an important phase of development and implementation as it is
unknown how key elements of the model will clinically and
financially perform until the model functions in a testing
environment.
Given the diversity of markets across the United States,
regional testing will also identify aspects of the models that
may require flexibility and implementation. We do not expect a
one-size-fits-all approach to reform and we believe limited-
scale testing of these important innovations will allow
successful transitions to Alternative Payment Models.
In closing, I want to underscore what my chair has said. We
are seeing excitement and innovation and enthusiasm from the
field. We see clinicians who are ready to lead the
transformation in care and payment, and we think this is an
incredibly important opportunity to support the move to
alternative-based payment models for a high-value health
system. Thank you.
[The joint prepared statement of Dr. Bailet and Ms.
Mitchell follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Burgess. The Chair thanks both of our witnesses for
their testimony this morning. We will move to the question
portion of the hearing and I am going to recognize myself for 5
minutes for the first round of questions.
And Dr. Bailet, it is my understanding that during the
summer you communicated with the Department of Health and Human
Services identifying a number of opportunities where your group
can provide or improve payment model development and I think I
heard in Ms. Mitchell's testimony the answer to this question,
but I am going to ask you.
Does PTAC need authority to specifically authorize its
ability to provide technical assistance through the APM
development process?
Dr. Bailet. Under the statute, MACRA remains silent on
whether it gave the PTAC the authorization to provide technical
assistance. As we said in our testimony, there are significant
interests by PTAC members to provide technical assistance. As I
said earlier, there is some very skilled, highly talented folks
who really understand how to build these models both clinically
and also on the financial business side and the measurement
side to make them successful.
We also understand that the PTAC has a role to play
relative to evaluating models and providing technical
assistance does cause potential conflicts. If you think
downstream, supporting particular stakeholders and we then at
the same time evaluate their models, depending on how that
turns out you can see that there could be some downstream
complications. Despite those challenges, we still believe at a
minimum that we should because of our exposure and the insights
that we gain from working with clinical stakeholders, we think
we can be at a minimum a beacon to cast the light on particular
areas that submitters are struggling with or are challenged
that the global stakeholder community can learn from. And I
think that is at a minimum a role the PTAC should play.
I do think to answer your question directly that this
question of can the PTAC provide technical assistance that
needs to be answered definitively and so we would look to you
for clarity on that.
Mr. Burgess. And are you free to disclose your
communications with the Department of Health and Human Services
this summer? Were they positive in their comments toward you
or----
Dr. Bailet. Yes. Yes. We sent Secretary Price a letter. We
have had private conversations with him as well. Very
supportive, understands the importance of technical assistance.
Again we have spent a year before we accepted our first
proposal standing up the committee, building in a process. We
want these models to be successful, but stakeholders, depending
on their level of sophistication and experience and the
infrastructure investments, they come at it from different
places. This is new and we are all learning.
So I think it is absolutely paramount that technical
assistance be delivered. I believe the word we got back--and I
will let my colleague speak as well that the receptivity for
technical assistance exists. I think the mechanics of how it
would be distributed, how it would be identified, and how it
would go out to the stakeholders that remains an open question.
Mr. Burgess. Very well.
Ms. Mitchell, did you have something to add to that?
Ms. Mitchell. I would only underscore the demand we are
hearing from across the country. Again physicians understand
clinical care delivery, but a lot of this work in incentive
design risk management is new. PTAC has recognized the urgency
of this. We do not have clear authority to address it. We think
that somewhere HHS needs to find a way to meet the needs of
providers so that they will be successful.
Mr. Burgess. OK, thank you. Thank you for that observation
and the acknowledgment that it may require legislative activity
not just administrative activity.
So I am going to ask you a question. I mean it comes up all
the time, the hiring freeze that the administration has imposed
across all levels of the Federal Government. Is your PTAC, is
it currently subject to a hiring freeze?
Ms. Mitchell. It is our understanding that they are subject
to a hiring freeze. I think it is also important to note the
volume of activity which I think is an indicator of success of
PTAC, but it has also been more than we have anticipated in
terms of time demands. This is again also highly technical,
complex work, and I think having the right staff is critical.
We have had excellent staff support. We just think that given
the demand there is need for additional support.
Mr. Burgess. Very well. We previously asked the
administration to evaluate an exemption for PTAC and we will
continue to communicate with them.
Just to my last few seconds, I just want to make the
observation. I downloaded the application form and, man, it is
lengthy. I was actually going to provide a little technical
advice that there ought to be a worksheet or a checklist.
Actually there is one, but it is way, way deep in the weeds
here. Maybe that ought to be advanced to right after the table
of contents.
Ms. Mitchell. Well, we appreciate the concern and we
recognize that it is lengthy. However, the committee really
felt that it was our job to make the instructions as clear as
possible and as complete as possible, so we are hopeful that
this is actually a helpful document. You will note that there
is even visuals in there to explain the process.
Mr. Burgess. Right.
Ms. Mitchell. Again this is meant as a tool for assistance
to submitters. Dr. Bailet?
Dr. Bailet. I think the only other comment is as we design
this we really put ourselves in the eyes of the stakeholders.
Mr. Burgess. Sure.
Dr. Bailet. And we were thinking this is new, our process
is new. We wanted to be entirely transparent. And if you look
at the document, it is constructed--there is a lot of
definitions. Every 10, all 10 of the criteria are spelled out
through the lens of the committee what is it that the criteria
is trying to accomplish, what is the committee looking for to
see in these proposals, because again I will go back to my
earlier comment. We want these proposals to be successful.
We also are taking feedback from the clinical stakeholders
about our process. They have provided input and we have revised
our process based on that input and we will continue to do so
and we will take this comment under advisement as well.
Mr. Burgess. I am sure we will have continued
conversations. My time has long since expired. I will recognize
Mr. Green 5 minutes for questions, please.
Mr. Green. Thank you, Mr. Chairman. I think we would be
happy to work with you to see what we can do. We don't want to
have this process fail because we don't have staff or quality
staff or that you can't provide assistance. That just seems
silly. But we will be glad to work with you on that to see how
we can do.
Dr. Bailet and Ms. Mitchell, thank you for being here today
and your insights. I would like to ask about PTAC's mission and
what you have set out to accomplish. From my perspective, PTAC
and the PTAC process, evaluating Physician-Focused Payment
Models is uniquely in the delivery system reform context
because it is driven primarily from the ground up by providers.
Now does PTAC fit within the broader delivery system reform
efforts?
Ms. Mitchell. Thank you. I think what one of the consistent
themes that we hear from submitters, and we have experienced in
our day jobs, is that there are many clinical improvements that
providers know could be made that would make care better for
patients, and the current payment system is actually a barrier
to making those changes. Many physicians will tell you they
will lose money trying to do the right thing in many cases. The
pay-for-service system often incents duplication, redundancy,
overuse.
So this is actually a forum, in my view, where clinicians
can bring models for better care and hopefully have a payment
system that supports those changes.
Mr. Green. Well, and that's what I hear from my physicians
that they are concerned about the end result so they want to
have the input. And the unique benefits and challenges does
have a model or, you know, challenge.
But from my understanding PTAC is comprised of 11 members
appointed by the Comptroller General. Each of these members are
nationally recognized for their expertise in payment and reform
and Alternative Payment Models. PTAC's members include both
physicians and non-physicians.
I know it has been official for having both physicians and
non-physicians there because they can get the process moving,
how does your review process engage stakeholders and the public
along each step of the way?
Dr. Bailet. So we have a multistep process and if you will
indulge me I will walk the committee through it as quickly and
efficiently as possible.
So working with the ASPI staff using our primer on how to
submit a model, the model is submitted to the committee
formally after a letter of intent is sent 30 days in advance.
And the only reason the letter of intent, it is non-binding,
but it just helps us staff appropriately. We need to know how
many models are out there and potentially coming in and that
was the purpose of that letter of intent.
When the proposal is submitted, the ASPI staff check it for
completeness to make sure that all of the appendices and the
references in the document is complete. At that point the model
is transitioned to a review committee which is comprised of at
least one physician and two other members of the committee to
review the contents of the proposal and then they go about
working with the stakeholders, the submitters directly. There
is a question and answer. Typically it is at least one pass, if
not two or more, in writing, an exchange for clarity on
particular points in the model and then we have, we host a call
with the submitters for additional clarity.
During this entire process the proposal is published for
the entire stakeholder community nationally to see. We get
comments from the stakeholder community globally either in
writing, we also have them come to our deliberative meetings in
public and make public statements about their concerns,
questions, or support for the models.
Following the exchange between the stakeholder submitter
and the PTAC review team, we then go to the national expert
clinician. We have, if it is on renal disease we will speak
with a qualified renal nephrologist to get their perspective on
the elements of the model and it helps sharpens our focus and
answer our questions that we still may have about the model and
the proposal and how does it work in the real clinical
environment, if you will.
All of this time, the full committee does not deliberate.
As a FACA committee all of our deliberations have to be done in
public. So the proposal review team creates a document after
all of their work on their recommendation based against the
criteria of the secretary. It is non-binding, but it is
directionally helpful for the full committee when we sit down
for the first time in our public session to then deliberate and
review.
And if I could, that particular session how it starts is
the review team reviews the model for the committee, we then
invite the stakeholders up to the table. They either, so far
they have been all coming in public. They have been coming to
the public meeting. They then have an exchange. That typically
can go on for an hour where we talk with them about questions
that we have or sharpen our focus on the model before we
deliberate because we want to make sure we understand the
nuances of these models.
We also have public comments come before we start to
deliberate, so then the public comes up, they provide their
input, and at that time the committee goes into the
deliberative mode. We discuss the model amongst ourselves and
then we vote against the 10 criteria on an individual basis. So
it is, we support it--well, we don't support it, it doesn't
meet the criteria, it meets the criteria, or it meets the
criteria with priority. We do that through all of the criteria
and then we vote on the model in general at making the
recommendation to the Secretary to support, to support with
high priority, or to support it with limited testing.
That is the process, and it is exhaustive. And we are
really happy to be part of it, but it takes a lot of energy to
get it done.
Mr. Green. Thank you, Mr. Chairman. I know I ran over, but
these are issues that again we don't want to come here 5 years
from now and have to see what we didn't do now.
Dr. Bailet. Right, thank you.
Mr. Green. So I appreciate your explaining the process.
Mr. Burgess. The Chair thanks the gentleman. The gentleman
yields back. The Chair now recognizes the gentlelady from
Tennessee, 5 minutes for questions, please.
Mrs. Blackburn. Thank you, Mr. Chairman. And I want to stay
kind of in that same vein where Mr. Green is, because one of
the things I think many times we will do is something gets
passed, it gets on the books, it takes forever to get it
straightened out. And when we are looking at the APMs and the
utilization of technology in this process, it changes so
quickly that there has to be a nimbleness that we have not seen
before. And I assume that each of you agree with that because
you are shaking your heads in the affirmative.
But let's stay right with you, Dr. Bailet, and let me have
you talk a little bit more about timeline, a little bit more
about process. And Ms. Mitchell, I want you to weigh in on how
we are, when you have this integration, if you will, the
physician, which is an incredibly important component of this,
and the other two stakeholders that are involved in this
process, talk to me about how that relates to our rural and
underserved areas.
Dr. Bailet. So I will start with the timeline and the
process. We are very sensitive and acutely aware of the need to
get these models in the field. Physicians are being measured as
we speak today for payment that will impact them a year and a
half, 2 years downstream, so we did not want to be a rate-
limiting step as these models came forward. We measure our, as
we move through that process that I described those
measurements are done in weeks. It typically takes about 2
weeks for us to get back to the stakeholders with a series of
questions.
Mrs. Blackburn. So basically you are doing an expedited
process in approving as you go?
Dr. Bailet. Yes. We don't--well, because of our public
schedule because we can't deliberate in private----
Mrs. Blackburn. OK.
Dr. Bailet [continuing]. The deliberation, we batch them.
So we have a meeting next month. We have seven proposals. We
are going to go through 3 days of public meetings.
Mrs. Blackburn. All right. And then let me stop you right
there.
Ms. Mitchell, talk about this as it relates to the rural
and underserved areas and how you are feeding in that data,
because data is essential to this.
Ms. Mitchell. Certainly I will try. I think it has been
very important that there is a balance on the committee of
physicians and non-physicians and I am one of the non-
physicians. My background is actually working with multi-
stakeholder groups at the community level for transforming care
and payment.
I am from Maine. I am highly sensitive to the small and
rural issues. I think what we are--because we are receiving
proposals from the field, we are receiving proposals from small
practices. I believe you will hear that on the next panel. We
are, I think, as a group we are a diverse group. We are
committed to ensuring that everyone can succeed under this
model and that is actually one of the reasons that we are
particularly urging technical assistance so that it isn't just
the well-resourced health systems that can afford these
changes.
Mrs. Blackburn. So you are deliberate and intentional in
having individuals from these rural and underserved areas?
Ms. Mitchell. We don't actually control who comes to the
committee, we respond to the proposals that we receive.
However, we are certainly trying to promote the opportunity and
we certainly welcome and weigh the issues of small and rural
practices to the extent possible.
Mrs. Blackburn. OK. And let's look at the high-performing
hospital or health systems and medical groups and just a couple
of comments quickly--I have a minute left--on how you
characterize those groups' interest in risk assumption.
Dr. Bailet. The larger, more sophisticated integrated
systems they have already made the infrastructure investments
whether it is electronic health record, they have the modeling,
they have the data analytics, the population health tools that
really help them be successful in an Alternative Payment Model
environment.
And so they are very much, they are ready and willing, and
some of them, many of them across the country, are already in
alternative or Advanced Alternative Payment Models, so they are
sort of leading the way, if you will. That said, I would be
remiss if I didn't mention that the smaller practices have a
high degree of nimbleness that the larger practices don't
necessarily have, and can move very quickly, but they also need
help with the infrastructure.
Ms. Mitchell. And if I might just add to that, the small
and rural practices may be providing exceptional care. We think
that this might provide greater flexibility to them so that it
isn't again the one-size-fits-all approach because we recognize
that care will be delivered differently in different
communities and in different sized practices.
Mrs. Blackburn. Right. And that is the nimbleness that I
think we are wanting to see and the flexibility that we want to
see on this. And we are not going to be hesitant to continue to
do oversight and to pull it back if we think it needs
adjustment.
I yield back, Mr. Chairman. Thank you.
Mr. Burgess. The Chair thanks the gentlelady. The
gentlelady yields back. The Chair will make the observation
that is the third time the word ``nimble'' has been used. I
don't recall that ever happening in a committee hearing before.
Mr. Green. It is tough for Members of Congress to be
nimble.
Mr. Burgess. The Chair recognizes the gentlelady from
California, Ms. Matsui, for 5 minutes, please.
Ms. Matsui. Thank you, Mr. Chairman, and I will try to be
nimble. So thank you very much for holding this hearing and
thank the witnesses for being here today. You know, as you know
we came together in a bipartisan way on this committee to fix
the broken SGR and replace it with a MACRA, and I am pleased
that you are making progress with the goals set forth by MACRA
to truly transition our Medicare payment system from value to
volume.
As you state in your testimony, Medicare has considerable
influence on payment and that can drive innovation. That is
what I would like to focus on today. Every witness here is
testifying to the hard work providers are putting in to update
their systems of care and develop payment models that
adequately reflect that. We are hearing about care
coordination, patient-centered care, and better management of
chronic diseases.
I believe that technology whether in the form of data
systems, measuring quality, interoperable electronic health
records, care delivered remotely, or conditions monitored
remotely will be integral to our success in achieving our goals
of higher quality and reduced costs. Thank you, Dr. Bailet and
Ms. Mitchell, for your leadership on PTAC and I appreciate the
dedication you bring to your work.
I would like to focus on this issue of telehealth and
health IT. The 10th criterion for judging APMs is to encourage
a use of health information technology. Either one of you or
both of you, can you expand upon that? How does the PTAC ensure
that models are encouraging the use of health IT?
Dr. Bailet. I will start. It absolutely is essential,
especially when you realize the diversity of the care that is
delivered across the country and the shortages in particular
areas where certain specialty services, for example, are not
available. So leveraging technology is absolutely essential.
You mentioned telehealth, making sure that patients,
members have access to high-quality specialists through
telehealth. There is a lot now with technology with your smart
phone and a lot of diagnoses can be made using your smart
phone, for example. So we need to leverage that technology and
we embrace the submitters who put technology in front, embed
that in the model.
There are some challenges with that and the Secretary has
commented about proprietary technology, because that obviously
limits the deployment and the implementation of these models,
but the notion of leveraging technology to drive care into the
communities is absolutely essential.
Ms. Matsui. OK.
Dr. Bailet. Getting everyone on a health information
platform and, as you know, being from California, my
organization with also Blue Cross----
Ms. Matsui. Sure.
Dr. Bailet [continuing]. We have built an HIT platform with
over 25 million records. So we----
Ms. Matsui. Can I ask you this, then? So I assume health
IT, electronic health records, devices that remotely monitor,
clinical decision support software, software that helps
clinicians on a team communicate securely and to allow
providers to deliver care remotely, it includes all of this. So
are there experts on the PTAC that specialize in health IT or
have extensive experience with it? Does PTAC consult with such
experts? Because I know you have a balance of people on there,
physicians and non-physicians.
Ms. Mitchell. I think to your point, there is a range of
expertise, users of EHRs and other health IT and some of us who
have been working around data sharing. I would like to
emphasize our deliberations on this criteria. Technology is
important but it is also insufficient. This is really about
sharing the data freely and effectively across sites and many
of the barriers to doing that are not technology barriers, they
are business or otherwise.
So I think it will be very important particularly as we
move to measures of population health and also to reduce the
burden on providers that this data be shared effectively
regardless of the technology.
Ms. Matsui. So you have, of the 20 or so models you have
under review can you provide some examples of those that are
leveraging technologies, and have the providers come up with
creative solutions?
Dr. Bailet. So there are several that have been highlighted
that we have reviewed already. There is one specifically around
looking at five different cancers and accuracy of diagnoses--
lung, colorectal, breast. It is a bundled payment model. It
comes from the Hackensack Meridian Health. They have a special
technology that looks at the biopsies themselves and is able to
do genetic analyses and helps tailor the treatments to the
specific characteristics of that particular tumor type. We
talked about the proprietary nature of that technology and they
have assured us that other systems can adopt either that
technology or a sister technology like that. But that is just
one example.
Ms. Matsui. Sure.
Dr. Bailet. There are several others.
Ms. Matsui. No.
Mr. Burgess. The gentlelady's time has expired.
Ms. Matsui. Thank you. I yield back.
Mr. Barton [presiding]. The gentlelady yields back. The
Chair recognizes himself for 5 minutes. I want to say at the
beginning of my question period that I am not an expert on
this, and I didn't hear the opening statements, so if this were
an energy hearing I would be in good shape. But talking about
MACRAs is, as I told Gene Green, a little out of my depth.
My first question is just a basic question. We wanted to
change the payment system because the old one was so
complicated. Are any of these new systems actually being used
right now, or are you just thinking about it? Either one of
you.
Ms. Mitchell. The models that we have received, several of
them we have recommended for further testing, but then it is up
to CMS and the Secretary when and if to implement those. So----
Mr. Barton. As we speak, all the payments are still being
made under the old system; is that correct?
Ms. Mitchell. Well, there are demonstration projects that
CMS has implemented over the last several years that do change
payment, but the Physician-Focused Payment Models that we have
evaluated have not yet been implemented at least through CMS.
Mr. Barton. All right. And Dr. Burgess told me that you
have actually voted on five alternative systems; is that
correct?
Dr. Bailet. Yes, five. We have deliberated on six, voted on
five, with recommendations to the Secretary.
Mr. Barton. OK. Now these five all passed, so to speak, so
they have been forwarded to the Secretary, or did you vote down
any of them?
Dr. Bailet. We voted two down. And then the reason we
deliberated on six, the sixth submitter retracted their
proposal after hearing the point of view of the committee. They
are--resubmitted it for after they have modified it, but the
others were either recommended for small-scale limited testing
or implementation.
Mr. Barton. So you forwarded five to the Secretary----
Dr. Bailet. Yes.
Mr. Barton [continuing]. Which we don't have right now.
Dr. Bailet. That is correct.
Mr. Barton. But there is somebody active, I guess. The
Secretary or his or her designee decides if these systems that
you voted on are acceptable for the marketplace; is that
correct? And then if he passes it then it comes back and
doctors pick which one they want to use. Is that how it works?
Dr. Bailet. Well, that is part of our challenge is we see
this, we want to be a value-add to the system. We are upstream
of CMS and CMMI. We want to make sure that the process and
evaluation and the analysis that we are providing sharpens
these models so that when they get downstream to CMS and CMMI
it helps them do the work they need to do relative to analysis
and figuring out how to actually stand up these models within
the current Medicare system.
Mr. Barton. Well, to me that seems overly complicated. Now
it may not be, but I want to try again. Somebody is going to--
your doctor groups have voted on systems that they want to use,
right?
Dr. Bailet. Right.
Mr. Barton. You have forwarded those to the Secretary of
Health and Human Services. The Secretary of Health and Human
Services and the bureaucracy decides which of those are
acceptable; isn't that right?
Dr. Bailet. That is right.
Mr. Barton. If they say, ``We have the HHS stamp of
approval,'' it comes back, and who decides which of those to
use once they are approved?
Ms. Mitchell. The only requirement is that the Secretary
post a public response to our recommendations. It is then up to
the Secretary and CMS if and when to implement.
Dr. Bailet. Our charge is to advise the Secretary, work
with the stakeholders, make a recommendation, provide that
advice.
Mr. Barton. I got that and you have done it.
Dr. Bailet. Yes, sir.
Mr. Barton. You are waiting on the Mt. Olympus approval,
right? Sooner or later some of these are going to be approved.
My question is once they are approved--I guess I will rephrase
it. How are they implemented once approved?
Dr. Bailet. And again, that is, we need more clarity on how
that is going to happen. That is not under our purview. We are
ready, willing, and able to partner with CMS and CMMI.
Mr. Barton. Well, who is the decision maker?
Dr. Bailet. The Secretary and HHS.
Mr. Barton. OK, I am saying they have approved it. I mean
at some point in time somebody in the system, a doctor who is
seeing patients----
Dr. Bailet. I get it. OK.
Mr. Barton [continuing]. Says OK, we are going to switch
from this old system to this new system A.
Dr. Bailet. Right.
Mr. Barton. And I am assuming since we are trying to be
inclusive that is a hospital, a region, a State, somebody says
yes, we are going to use alternative system A.
Dr. Bailet. Right. So that is where just like in CPC+ or
some of the other models, the Alternative Payment Models that
have already been deployed, the Oncology Care Model, for
example, that is what CMS will do. They will take our
recommendations. They will look at these proposals. They will
refine the model and figure out how do we build this model with
these concepts and be able to implement it within the Medicare
payment system. They will put it out there, I believe.
I don't want to speak for them, but my guess would be that
they will take these models, put them out there for the
physician----
Mr. Barton. They. They being----
Dr. Bailet. CMS and Medicare, put in Alternative Payment
Models saying----
Mr. Barton. So CMS is the one who chooses which model to
use?
Ms. Mitchell. We don't have the authority to direct CMS to
do that. We can make recommendations.
Mr. Barton. So they are going to tell you which model to
use.
Dr. Bailet. Or not.
Mr. Barton. See, I had it all wrong. I assumed the doctor
groups, the providers would choose which one they want, but you
are saying CMS is going to say, ``We like this one.''
Dr. Bailet. Well, CMS will make the models available for
the stakeholders to then sign up to deploy. So they will, just
like the Oncology Care Model, it is out there and practices
will sign up to participate.
Mr. Barton. And they can make more than one model
available?
Ms. Mitchell. Yes.
Dr. Bailet. Yes.
Mr. Barton. OK, because I thought the whole point of this
was to give doctors or--I keep saying doctors--to give
providers----
Mr. Bucshon. Will the gentleman yield?
Mr. Barton. I would be happy to yield.
Mr. Bucshon. I think what you are trying to get at, if you
don't--if there is an Alternative Payment Model that has been
approved and you don't participate in that, then you are in
MIPS.
Dr. Bailet. Right.
Mr. Bucshon. So you can at that point it seems to me you
are not necessarily forced to accept the Alternative Payment
Model, but if you don't you have to participate in MIPS. Is
that----
Mr. Barton. What is MIPS?
Mr. Bucshon. That is the overall reporting system that
assesses quality, value.
Mr. Barton. The current system?
Mr. Bucshon. Well, no. It was put in place under MACRA.
Mr. Barton. So it is a new one too.
Mr. Bucshon. It is a consolidation of three separate
evaluation systems that were previous MACRA.
Mr. Barton. I am glad I have clarified this situation.
Mr. Bucshon. So the point is I think, Chairman, is that a
physician if they don't participate in the Alternative Payment
Model they will have to be in the MIPS. And you might comment
on that. I yield back.
Mr. Barton. This is the last because our time has expired.
So answer Dr. Bucshon's question and then we will go to Ms.
Castor.
Mr. Green. I just want to say, Mr. Chairman, you and I
could talk energy all the time.
Mr. Barton. Yes. Energy policy is simple compared to this.
Would you like to comment on----
Ms. Mitchell. Yes. That is correct. PTAC is actually, I
think our role is to expand the options for participation so
that CMS has a broader portfolio that is representative of what
physicians think would be better models. So we can recommend
those for inclusion in the Medicare portfolio, but again it is
not up to us who participates or if they are implemented.
Mr. Barton. We thank and we yield to the gentlelady from
Florida for 5 minutes.
Ms. Castor. Well, thank you. And I want to thank you, Mr.
Chairman, for calling this much needed hearing. And thank Dr.
Bailet and Ms. Mitchell for your work on the Physician-Focused
Payment Model Technical Advisory panel and to all of the
doctors and medical professionals that have also been engaged
in this and taking this on.
I am very gratified to see the progress on transitioning to
value rather than volume, at the same time while we improve
patient care, allow doctors to practice medicine, and do
everything we can to help lower the cost. I hear you talking
about the difficulty now with submissions and approvals and you
need answers from CMS and CMMI. Would you say that the progress
has stalled on your work?
Dr. Bailet. I am not sure I would use the word stalled. I
think we are new. We are new at the game. And then I don't mean
game in a negative way, but I mean this is a new process. We
have only sent two sort of series of recommendations to the
Secretary and, as you know, we have an interim Secretary, so I
think that people are finding their way.
We are in dialogue with CMS and CMMI. It is a constant, you
know, it is a constant partnership. We are trying to work with
them. They are providing insight----
Ms. Castor. So they, really, it would be helpful if the
committee held a follow-on hearing with CMS and the folks that
are working on this to get some of the answers that Mr. Barton
asked and Mr. Green and others.
In order to most effectively review the proposals submitted
to PTAC, MACRA required the Secretary to establish a set of
Physician-Focused Payment Model criteria for evaluating the
proposals. MACRA also required PTAC to then review proposals
submitted based upon these criteria when making recommendations
to the Secretary.
So there are 10 criteria, including the extent to which
proposals provide value over volume, increase care
coordination, improve quality, all factors that PTAC considers
when evaluating a proposal. Ms. Mitchell, can you describe the
10 criteria established by the Secretary, particularly the
criteria designated by PTAC as high-priority criteria?
Ms. Mitchell. Certainly. And if I might just respond very
briefly to your last question, I think it is very important. We
are not seeing any sort of slowdown in number of submissions to
the committee. In fact, it is the opposite. We have more
proposals than we even had anticipated. I think the question
about what happens next is really the open one.
Ms. Castor. Thank you for clarifying that.
Ms. Mitchell. Yes. And in terms of the high-priority
criteria, we are evaluating each proposal against every
criteria, but there were certain criteria that the committee
thought carried, you know, particular weight. So as an example,
scope is a high-priority criteria. We don't think that it is
optimal to identify a model that only one or two or just a
handful of practices can participate in, we are really looking
for more transformative models. So scope, as an example, meant
that we would have greater participation if it was a high-value
payment model.
The high-priority criteria, quality and cost, obviously the
point of payment reform is not to change payment, it is to get
better care at lower cost. So how are we determining if these
changes are actually giving better patient care at a more
affordable rate? So that seemed extremely important in the
entire undertaking.
And then, finally, payment methodology, if Dr. Berenson was
here he would tell you we are not just looking for an addition
of a new code. We are talking about meaningful changes in the
methodology of payment, and that is what we are seeing. We have
had some proposals that do not meet that criteria. They could
be fixed differently, the barriers. We are really looking at
models of payment that are currently not supported and require
a new payment methodology.
Ms. Castor. So, Dr. Bailet, you talked about you have seen
some innovative proposals. Give us some hope here. What is
innovative that you have seen? What has been difficult? What
has been a little less challenging?
Dr. Bailet. So there was a lot of energy in our last public
meeting when we looked at hospital at home. So typically
patients today show up in the emergency room, they need
admission. They have criteria to meet admission. And this model
has the sophistication for select patients to actually treat
them as if they were hospitalized but to provide that care in
the home. That is tremendously innovative. It is also allowing
patients to----
Ms. Castor. Is that because the medical professionals go
there? I mean----
Dr. Bailet. There is a team that is deployed, there is
training. But the point is that hospitals are not places--you
don't, you know, I am a surgeon and I would tell my patients
you want to be in the hospital no more than 1 second longer
than you need to be. Bad things happen to you in the hospital.
And so this allows patients with the patient and the family
to make a decision to get that care, but get it at home,
safely. We think that model shows tremendous promise. There is
some economics obviously, but it also is very beneficial when
you match it against the criteria. It helps the patients
specifically and their family to be able to get that care at
home. That is just one example of several of the models that we
have looked at.
Ms. Castor. So out of these models what has been
particularly difficult?
Dr. Bailet. Physicians and stakeholders are very, they are
much clearer on the clinical side of the model. Where we are
challenged is on the payment side, getting the data to be able
to model for the committee to say, ``Here is what the data is
showing us, here is where the dollars are, and here is how the
model will impact the dollars.'' That is an area of technical
assistance that could help.
I think Elizabeth wanted to make a comment.
Ms. Mitchell. I would just add, several of the models we
have seen are communitywide. As an example, how do we bring in
hospice care, transportation, other services that patients
actually need? And there is a major barrier of sharing data and
information effectively in a timely way.
So that--and a provider has said that that is their primary
barrier to implementing the models that they are bringing--so
that continues to be just a priority area that we have got to
solve.
Ms. Castor. Great. Thank you again for your work.
Dr. Bailet. Thank you.
Mr. Burgess [presiding]. The Chair thanks the gentlelady.
The gentlelady yields back. The Chair recognizes the gentleman
from Illinois, Mr. Shimkus, 5 minutes for questions, please.
Mr. Shimkus. Thank you, Mr. Chairman. And I appreciate my
colleague from Florida, because that was one of the questions I
was going to ask and she picked it up, was highlighting a
specific example. And I think you outlined a pretty good
example of where you can be helpful. I am interested in this is
because, you know, I was here in '97 when we passed the SGR to
spend my career postponing it to the point where then we got to
MACRA and MIPS and all this other position where we are today.
Being a competitive market Republican and understanding
competition and how that improves, you always get a little--I
am concerned. The Government is such a big payer in the
healthcare arena, whether it is Medicare or Medicaid, that we
really do drive that reimbursement. And we drive the
reimbursement because I mean, actuarially, those two are
mandatory spending programs that are actuarially challenged.
So then we, how do we look at trying to save the money, but
we know docs want to get paid, right? We know docs want to get
paid well if they can, so I think this is an interesting debate
because doctors still want to be compensated for their
training, their loans, and the like while we are trying to
drive efficiency and lower costs.
And that is your challenge that and you are an advisory
committee or commission and you are advising the Federal
Government on how we might be able to do that. And you gave us
an example of one just in the last testimony, but I am
concerned about the--you talk about telemedicine, sharing data,
part of that is proprietary information. Part of it is going to
be patient records. Part of it is going to be specific care
models that practitioners may want to say, ``This is how I can
financially do it. This will drive patients to me, but it gives
me a competitive advantage,'' right?
So how are you doing this? I mean how are you, or just
let's do it in a big data framework, big data, and thank you
for helping me remember the word, an algorithm. I mean how do--
and we are going to have these big discussions on the
algorithms and transparent, how do you do transparency on
algorithms when someone feels that that is a proprietary nature
that they have come up with?
So those are the questions that I am interested in hearing
as you are trying to provide advice and counsel, because some
of this stuff might require either proposals from HHS or maybe
legislative changes. Can you guys--Ms. Mitchell, do you want to
say anything based upon my little diatribe?
Ms. Mitchell. I will try. We have actually had proposals
that do include proprietary elements, and I think we have been
clear with submitters that anything that is included in a
proposal for Medicare they won't have proprietary elements that
couldn't be shared more broadly. Again this is an entirely
voluntary process. They could do this without Medicare as well.
I think it would be helpful probably to ask the next panel
about some of their experience with that.
And I think it is going to be a balance of interests. I
think given the massive investment that we put into our
healthcare system and the value for patients we are trying to
achieve, I think there is just going to have to be a balance of
obviously preserving the interests of all. I also think that
there are success stories around the country--Oklahoma, Oregon,
others--where there are sharing data across the community in a
way that protects privacy. They are clearly effective stewards
of that data. But it also allows physicians and others to have
a full picture of population health and patient care and,
frankly, it helps with patient safety. If a patient is admitted
from one hospital to another and those records can be quickly
transferred, that actually helps patient safety as well.
So there are ways that this is being done around the
country now that could be emulated and scaled.
Mr. Shimkus. And I appreciate it. And I think also just in
the--and I am going to close with this brief statement is I
mean there is a national debate about how we pay for health
care and will it be a one-payer system or will it be a
competitive market model that helps bring clarity and
efficiencies?
So good luck, I am not sure how it is all going to turn
out. I yield back the balance of my time.
Mr. Burgess. The Chair thanks the gentleman. The gentleman
yields back. The Chair appreciates the gentleman's request for
good luck. The Chair recognizes the gentlelady from California,
Ms. Eshoo, 5 minutes for questions, please.
Ms. Eshoo. Thank you, Mr. Chairman.
Dr. Bailet, it is wonderful to see you. And thank you, Ms.
Mitchell. I have really enjoyed the questions of Members and
your responses because you keep deepening and broadening what
you are doing.
Several of my questions have already been posed, but I want
to pick up on what Congresswoman Castor said and recommend to
the chairman that we have another hearing both with the
stakeholders and with HHS, because I think it is important to
bring that--to strengthen the linkage.
Since you are dependent upon what, I mean you are doing so
much work and then it goes someplace else and it seems to me
that there is a question mark around it. So I am not
suggesting, I am not impuning the agency, it just seems to me
that I don't have a sense of how welcoming they are, especially
if the model that you are recommending to them is going to cost
more, because there is a constant push on the agencies not to
spend as much.
So which takes me to a question. You know the area that I
represent. It is known as the innovation capital of our
country. Most people think of it as just in terms of
technology, but we have many, many of biotechnology companies
that are creating really innovative technologies. Stanford
Medical Center, I think, is doing important and exciting work
around telehealth and telemedicine for the treatment of other
health conditions such as stroke.
Specifically, how are new and innovative technologies being
integrated into the APMs?
Dr. Bailet. We have had several proposals that have
proprietary technology that are embedded, and I gave one
example relative to the genetic ability to screen the tumor
types for personalized medicine, and I believe Stanford is
trying to do that work as well. There are other information
systems, population health systems, that are able to look at
the entire cohort. If you are in, for example, renal disease,
look at your patient population and find elements to help
sharpen the care and offer patients treatments before they
start dialysis to improve the outcomes and decrease the chances
for complications.
I am trying to remember, I have all of the 20 in front of
me.
Ms. Eshoo. Well, no. That gives me a flavor. Do you know
what the cost of a particular application is after you have
reviewed it?
Dr. Bailet. No, we don't. And that--no, we don't.
Ms. Eshoo. So that is up to the agency to cost it out.
Dr. Bailet. Right, yes.
Ms. Eshoo. And are providers--I mean money drives
everything in the world I am sorry to say, but it does. I don't
know what the incentive on the part of physicians would be--
well, maybe some that are highly idealistic, but people have to
live, to move away from fee-for-service. I think doctors would
say, and what do I get out of this? And I don't think that that
is a selfish question.
So do you see in the models that have been submitted to
your commission that--I don't know how to put it. Are they
based, if you put your fingers on the scales is it with
anticipation that there will be a better system with better
money? Maybe that is the best way to put it.
Dr. Bailet. Physicians they want to do the right things for
their patients. They want to get recognized appropriately for
the work they are doing. There are certain limitations in the
fee-for-service system that doesn't recognize those efforts,
and despite those challenges physicians continue to do it
anyways.
These models reframe the way care is delivered. It
recognizes their efforts. It pays for nurse coordinators. It
pays for home care. It pays for things that the traditional
system doesn't recognize that are incredibly valuable to drive
outcomes and lower cost. So that is why--that is certainly why
I am energized to be in this work, and I think my colleagues on
the committee would echo that, and you will hear that from the
stakeholders who are behind me.
Physicians, again, and clinicians, they want to do the
right thing for their patients. And yes, their economics have
to work, but there also has to be, you have to do the right
thing for your patients and it can't be completely driven by
the economics. But we also have to be realistic about that.
Ms. Eshoo. Thank you very much for important work.
Ms. Mitchell. May I just----
Ms. Eshoo. It is up to the chairman. You can answer. I
can't talk.
Mr. Burgess. Please answer.
Ms. Mitchell. I would just add that I think all the
research including recently from the National Academy of
Medicine show that about 30 percent of health spending do
nothing to improve patient outcomes, so there is waste in the
system that could be addressed through better, more effective
utilization that does not in any way create barriers for
physicians.
Physicians are trying to navigate those barriers right now.
I think there is huge opportunity. I think there was a recent
GAO report that showed we are spending about $40,000 per
physician per year on performance measurement. There are
opportunities for savings that actually enable physicians to
have more flexibility to give the right care at the right time.
Ms. Eshoo. Thank you very much.
Thank you, Mr. Chairman.
Mr. Burgess. The Chair thanks the gentlelady. The
gentlelady yields back. The Chair recognizes the gentleman from
Missouri, Mr. Billy Long, 5 minutes for questions, please.
Mr. Long. Thank you, Mr. Chairman.
And my questions are for both of you. And, Ms. Mitchell, I
will start with you. And this first one might sound like an
oxymoron, but can you each elaborate on why it is important
that physicians not overassume risk in models they may be
approaching for the first time while at the same time keep
pushing forward in their drive for physicians to assume risk?
Ms. Mitchell. Well, certainly, I think if Mr. Miller were
here again representing the committee--I don't think risk is
magic in any way. I don't think the assumption of risk will
suddenly change care delivery, but I think it is a move towards
greater accountability and ownership for outcomes. I think what
we are trying to do is find models that appropriately enable
risk and accountability certainly without putting a burden that
is not manageable or sustainable on physicians, so I think it
is a very important balance.
I don't know if that answers your question, but we think it
moves them towards value.
Mr. Long. OK, Dr. Bailet?
Dr. Bailet. So to follow on with Elizabeth's comments,
there are unintended consequences. These models have elements
that are new. Many of them have not been field-tested, if you
will, so the intent is good, but until you actually deploy the
model in the field, you are not exactly sure what are the
outcomes. Are you going to get the outcomes that the model is
established to accomplish, which is why the committee felt
strongly and continues to feel that some limited testing is
necessary for some models where the elements are uncertain or
unclear.
So we need to strike a balance between encouraging
physicians and clinicians to take risk and to be held
accountable and to be recognized for outcomes and paid
accordingly, but we also know that in the world of in the past
with managed care if you push too fast too far and you outstrip
the sophistication of the clinicians and their ability to
perform, those are also unintended consequences that we need to
be careful about making sure that we don't do anything that is
so disruptive that it impugns these organizations.
And I used the word ``vibrancy'' earlier, and I used that
specifically. I hear a lot of things about well, we want to
keep our practice viable. I used to run a practice of nearly
2,000 physicians in Wisconsin. I don't think viable is what is
top of mind for patients who are seeking care. We want
physicians and clinicians to have vibrant practices, to be able
to provide the highest quality care with the best outcomes.
And that is where if you outstrip your ability to do well
in risk you can have an economic consequence that could impugn
your practice. And when these small hospitals and rural
practices go out of business, your ability to repair them or
replace them are incredibly hindered. And so that is where I
want to make sure that as we go forward we are very thoughtful
about implementing at the right pace in the right way. And
there needs to be flexibility. Elizabeth said it is not a one-
size-fits-all solution that we are talking about here.
Mr. Long. OK. And since your microphone is still on I will
start with you on my next question and then we will move to Ms.
Mitchell. I would like for both of you to answer this one. But
do you believe CMS's approach in the short term should be more
focused on ensuring providers are ready to transition to
qualified Alternative Payment Models or in simply getting more
providers into value-based payment arrangements?
Dr. Bailet. You told me earlier that you were going to give
me a tough question.
Mr. Long. No, I didn't. You said I was, I just agreed with
you.
Dr. Bailet. Well, I think, and I am not being evasive, I
think it is both. I think physicians, as I said physicians are
in different--and clinicians--are in different states of
readiness, and so they need to get in. They need to move away
from fee-for-service. Whether they get in on the Merit-based
Incentive Program, which has value elements, or they are
sophisticated enough or willing to get into an Alternative
Payment Model, I think physicians have to get on the playing
field, clinicians have to get on the playing field and get in
the game. And the fee-for-service model is not sustainable and
so this, I think this legislation these efforts compel
physicians and clinicians to get on the field.
Elizabeth?
Ms. Mitchell. I would just add that what we are seeing in
PTAC is the early adopters, the leaders and the innovators who
are ready to go. And I think by creating that opportunity by
allowing them to go first with appropriate technical
assistance, flexibility, and small-scale testing, we will learn
a lot and that will enable some of the practices who are less
ready to actually, I think, succeed as they move forward.
Mr. Long. So do you agree with the doctor that both are
important?
Ms. Mitchell. Both are important, yes.
Mr. Long. OK, thank you. I have got a really, really tough
question for my next one, but you all are lucky I am out of
time so I am going to yield back.
Mr. Burgess. The gentleman's time has expired. The Chair
recognizes the gentleman from Maryland, Mr. Sarbanes.
Mr. Sarbanes. Thanks, Mr. Chairman. Thank you to the panel
for being here. A lot of the motivation for the Affordable Care
Act was to begin to kind of turn our healthcare system towards
prevention, primary care, shift the kind of caregiver world to
the prevention side of the spectrum, et cetera.
MACRA was passed separately from the Affordable Care Act,
but I am curious if you perceive that there is alignment there
between the goals of the Affordable Care Act and the goals of
the new kinds of payment methodologies that MACRA is pursuing.
Ms. Mitchell. Well, I guess I would say that to the extent
that the goals of both legislation were affordable care, I
think there is alignment in the intent. Obviously the
Affordable Care Act focuses more on insurance and I think MACRA
focuses more, and appropriately so, on the fundamentals of care
and payment. I don't think you will have affordable insurance
until you have affordable care and it is going to be these
payment and care delivery reforms that actually enable that.
Mr. Sarbanes. Thank you. The other question I had is, it
gets to sort of how--and a number of Members have spoken to
this--but how the physician community in particular is
receiving these new models. And I don't know if you are the
right witnesses to describe this, but I am interested in
whether kind of the next generation of physicians coming along
whether you are seeing that there is, first of all, more
facility with the concepts, maybe more eagerness to try them.
Are medical schools beginning to assimilate some of these
models into the conversations they are having with the next
generation of providers? Is there a symmetry with how certain
cohorts within the physician community are responding to these
things?
Dr. Bailet. I think it is highly variable. I mean, I am
hoping that my colleagues, when they come up and testify, that
you will hear some specific answers to those questions relative
to training and the receptivity for the next generation of
physicians and clinicians to embrace these models in care
delivery.
I think--and I don't want to speak for the committee, but
from my own personal experience--I think there is an appetite
for new medical trainees who are coming and entering into the
clinical practice, I think there is an appetite for them to
provide the value which is the high quality and affordable
care. I think they understand the economics that these folks
are coming out of school, for example, with hundreds of
thousands of dollars of loans.
So I think that they understand that there is an economic
consequence if their current employer or their practice is not
successful. So I believe that the economic piece is there. I
think the clinical piece is there as well relative to
innovation and training and I think there is a willingness to
try. I think one of our biggest challenges is there is still
the unknown. We don't know how some of these models are going
to impact outcomes. And so I guess I would leave it at that.
Mr. Sarbanes. Do you feel as though the provider community
gets that they are living in a new world, if you think they are
living in a new world or not yet?
Dr. Bailet. I think there is probably some vestiges of
remnants of folks in the provider community that still harken
back for the fee-for-service environment. And I am not saying
that fee-for-service there is not a place for that model in the
new world, but I think that also there is a high degree of
recognition that the value, paying for outcomes, being able to
track it, and being able to actually deliver on the commitment
to provide outcomes is one of the things that is in front of us
that actually can bend the cost curve.
So I do think that that is where the collective thinking
around the provider community is today. As I go around the
country I don't hear a lot of debates about, well, we need to
go back to just pure fee-for-service. I am not hearing that. I
think people are now focused on what does it look like, how do
we get there, and at what pace do we move from fee-for-service
to value and how do we do it while we are basically practicing
in both worlds. How do we navigate risk in one and fee-for-
service in the other, for example.
Mr. Sarbanes. OK, thank you. I yield back.
Mr. Burgess. The gentleman's time has expired. The
gentleman yields back. And speaking for the vestige, the Chair
recognizes the gentleman from Indiana, Dr. Bucshon.
Mr. Bucshon. Thank you, Mr. Chairman.
I would first like to, I would like to comment on what Ms.
Mitchell said about the cost of care coming down as the key to
affordable insurance. I completely agree on that. That is a big
issue. And to do that more transparency in the healthcare
marketplace as well as more active consumer participation in
their healthcare decisions, including the cost of what they are
being provided, is really key.
As a former cardiothoracic surgeon I know my organization
that I participate in, the Society of Thoracic Surgeons, they
have been really pioneers in quality measurement for the last
25 years with the STS database. And, Mr. Chairman, I would like
to ask unanimous consent to submit their comments on this
hearing to the record.
Mr. Burgess. Without objection, so ordered.
[The information appears at the conclusion of the hearing.]
Mr. Bucshon. I would like to highlight the STS has designed
a quality-based payment program specifically related to
cardiothoracic disease including coronary bypass, grafting,
valve repair, replacement procedures, and as well as treatments
for lung cancer, relying on this database and I would encourage
CMS and Congress to take a look at that, as they already have.
And they are actively pursuing partnerships, looking forward to
bringing, you know, fruition of payment model that could help
provide quality incentives and efficiencies to really one of
the largest cost centers that we have in the Medicare program.
Ms. Mitchell, according to CMS, only, currently, 5 percent
of physicians are in Alternative Payment Models. And I have
heard from a number of physician specialty organizations that
there are some Stark Law barriers potentially to participating
and succeeding in an APM because it prohibits practices from
financially incentivizing their physicians to follow treatment
pathways that are related to value that might improve the
system.
Do you think there is any problems there legally in that
that are preventing some people from participating in APMs?
Ms. Mitchell. I am not an attorney and would not want to
pretend to be, so I would not be able to answer that question
with any authority. Perhaps Dr. Bailet has insights.
Dr. Bailet. No.
Mr. Bucshon. Maybe I will ask that for----
Dr. Bailet. Played one on TV, right?
Mr. Bucshon [continuing]. The next panel. Just there are
some barriers out there. I am not a lawyer either. I don't, but
we are going to be working on trying to decrease the barriers
for physician participation in APMs.
Maybe any one of you can discuss the importance of engaging
in the specialty community in developing APMs. That can be some
of the more difficult APMs to work to get together. And can you
elaborate on where you see growth potential in the future for
specialists playing a bigger role in these new care delivery
models? Dr. Bailet?
Dr. Bailet. Well, we have garnered a lot of interest from
the specialists, single specialty societies. You are going to
hear from my colleague Dr. Opelka about his ACS model. So there
is tremendous interest and we have a number of specialty-
specific models that we are evaluating right now. So I think
that our interaction with the specialty community actually is
pretty robust, but again I think you will hear that as you get
to the next panel.
Mr. Bucshon. I suspect that is true. Do you think it is
more difficult to put together APMs as it relates to the
specialists versus primary care or no?
Dr. Bailet. I haven't seen that.
Ms. Mitchell. I haven't seen that, either.
Mr. Bucshon. Not really?
Dr. Bailet. No.
Mr. Bucshon. OK, good. The other area, and I have a minute
and 30 seconds to address MACRA, is it will require
significance guidance by CMS's physician participation in
multiple APMs. Obviously we want physicians to be able to
experiment with different approaches to improving their
practices while also recognizing that many APMs being developed
by stakeholders are somewhat narrow, centered around a specific
disease or condition.
Can each of you speak to why it is important to allow
physicians to experiment with different quality-based payments
and have you thought about this facet of the program as you
review the proposals?
Ms. Mitchell. So I will try to answer that. I actually
think it could be very important to participate in more than
one model. I think at the community level you are trying to
align models and incentives and not carve out certain groups
over here and others over there.
So I think the ability to, as an example, have episodes
within a capitated payment or an ACO, I think, is an important
innovation to test. I think there are regulatory barriers right
now to doing that and I think that is something that warrants
further exploration.
Dr. Bailet. I agree.
Mr. Bucshon. Do you have any comments?
Dr. Bailet. No, no.
Mr. Bucshon. I yield back.
Mr. Burgess. The Chair thanks the gentleman. The gentleman
yields back. The Chair recognizes the gentleman from
Massachusetts, Mr. Kennedy, 5 minutes for questions, please.
Mr. Kennedy. Thank you to the chairman. Thank you to the
witnesses. Thank you for answering the questions and educating
the discussion.
I wanted to get your opinion on a couple of things and
build off a little bit of the conversation from our colleagues.
There are different, I guess, excuse me, a variety of
Alternative Payment Models that have now been put forth and
authorized by CMMI. In your assessment if you had any ideas or
suggestions for us, how does CMMI evaluate those different
models?
Are there factors there that should be taken into account
differently or aspects there that perhaps Congress should be
looking at that should be accentuated that aren't fully
contemplated there? Do you have any suggestions as to how those
models or other models might be put together to address the
themes that you have talked about so far today?
Ms. Mitchell. I hope this answers your question. I think
that there are a lot of lessons from the demonstrations to
date. I will point to sort of CPC and CPC+, initially, because
we have seen, I think, real success in some communities because
you have aligned payers so you have alignment of incentives and
measures. So it is not just noise, it is everyone is going in
the same direction. It is a primary care-based model and it
requires data sharing across the community.
I think those examples point to successes that could be
replicated. I think there are some elements of the CMS
evaluation approach that I don't know that we get information
soon enough so that we can apply it and sort of rapidly learn
and improve and I think there are ways to really take lessons
earlier and share them more effectively to benefit all of the
new models and implementers.
Jeff, would you add anything?
Dr. Bailet. No, I think that is well said.
Mr. Kennedy. Building on that for a second, and one of the
areas that I have focused on here is the--well, mental
behavioral health and the integration thereof in primary care.
So particularly for that model then we have seen issues around
the absorption of electronic medical records for the mental
health practitioners, the sharing of that information between
primary care and mental health practitioners and obviously
concerns about some of the dissemination around mental health
records.
What if there is some things that CMS might be able to do
there, there is some issues there that might actually require a
legal change. I don't know if you have any suggestions for us
to look at given at least in my concerns about the lack of
adequacy on a comprehensive care system set up to address those
patients that are suffering from medical illness across the
country particularly with regards to Medicaid. And so I don't
know if you have any comments on that but would welcome them.
Ms. Mitchell. I would personally just state for the record
I think that is one of the highest priority areas in the
country. I think that if we don't address mental behavioral
health we are missing just a huge need, and integrating that
into primary care is a very important strategy.
I think there are very real limits and barriers, some
regulatory and legal, that keep us from sharing information
adequately and I think there are also examples around the
country where we have done that effectively, responsibly, and
protecting patient privacy but actually getting the information
to people who need it for better care.
I am happy to follow up with you on some of those models--
--
Mr. Kennedy. I appreciate that.
Ms. Mitchell [continuing]. Because you are exactly right.
We have to address that.
Mr. Kennedy. Doctor, anything else?
Dr. Bailet. No. I agree.
Mr. Kennedy. So one of the great things about representing
Massachusetts is, I am kind of preaching to the converted here,
but being able to visit particularly those community health
centers that are on the front lines of some of these issues
from, you know, partnering with farmer's markets in doctors
writing scrips to farmer's markets to make sure that their
patients are getting access to fresh fruits and vegetables to
the absorption of medical and adoption of medical-legal
partnerships, so that when a patient potentially comes in with
an asthma issue that if there is mold in an apartment, yes, you
can give them an inhaler, but you are not going to address the
concern because there is mold and an inhaler doesn't cure mold.
Are there other systemic, you are talking about alignment
incentives, what should we be focused on when we start to look
at issues? You mentioned transportation before which is
obviously critical. Are there other kind of one-offs here that
you think we should keep in mind as we try to think of the
opportunities and challenges of actually trying to reach out to
patients and then wrap them in this continuum of care so you
can get to them and reduce the cost of delivery?
Dr. Bailet. I think there are lots of opportunities,
palliative care, for example. I mean I think that the data
where, you know, you follow the economics. So we consume a
tremendous amount of resource relative to folks who are at
their end of life. We have been able to, I have seen models out
there where we have been able to get the uptick, the average
length of stay, for example, in hospice which is, I think,
nationally, somewhere between 16 and 18 days. There needs to be
a more concerted effort that should be measured in months, not
days, if we are doing the good work and want the outcomes we
would want for that cohort of patients.
So I think there is tremendous opportunity and, again, I
used palliative care as an example, but there are others that
you also raised.
Ms. Mitchell. And you are exactly right. That is where the
opportunity is to really improve health and reduce costs. We
have examples by members around the country. There are
partnerships with the criminal justice system and hospitals to
actually identify much more effective interventions than, you
know, another ER visit.
And by doing that coordination, finding out what people's
real needs are, typically--housing, transportation, the real
upstream social determinants--that is where you are going to
really impact health. And connecting those services, the
providers and that information, I think, is a very big
opportunity.
Mr. Kennedy. Thank you. I appreciate it.
Mr. Guthrie [presiding]. Thank you. The gentleman yields
back, and I will now recognize myself for 5 minutes for
questions.
Dr. Bailet, in your testimony you mentioned how Medicare is
driving market change through the development of APMs. What are
these trends and what are you seeing the impact is on other
players, or payers? I am sorry.
Dr. Bailet. Well, I can speak for my organization that I
currently work with, the Blue Shield. We are moving the
commercial side of the business to value-based pay-for-value.
It is one of our top priorities in the organization and MACRA
actually allows--in 2019--allows the commercial payers to
partner with Medicare and put these models in the field.
So, again, the economics going from fee-for-service to
value, paying for outcomes, it not only is the right thing to
do clinically, but it is also the right thing economically. And
as one of the largest payers in the State of California
contracted with over 50,000 physicians and over 400 hospitals,
we are very activated to get these practices of the future, if
you will, out in the field and we want to do it with the
stakeholder community, not to them.
And that is one of the things that that is a tenet of the
PTAC, which is why we are so transparent. We want to make sure
that we are right there, lock arms with our stakeholders, and I
hope you hear that from the folks who are going to come behind
us. But it is driving market change.
Mr. Guthrie. Do you believe our patients are being affected
in a positive way with this?
Dr. Bailet. I do. Again, yes. I do.
Mr. Guthrie. Thanks. I have another question. So it appears
that many are already responding to practice transformation
efforts in commercial markets. Can you speak to the ideal way
Medicare can both learn from these private sector efforts and
harmonize with them to smooth practice modernization?
Ms. Mitchell. So I guess I would just say I don't think
providers think about their patients based on who pays their
care, so to the extent that private and public payers can align
that will enable providers to actually give optimal care across
their patient population. To the extent that there are
innovations in the commercial sector, I would hope that they
would share those.
Often it is very hard to get information on the outcomes of
those changes. I think they could inform Medicare, and I think
Medicare coming to the table and joining multi-payer efforts is
really an optimal way to accelerate change.
Mr. Guthrie. OK, thank you. And can you comment to the
interests of PTAC in the diversity of models, but also those
who have reached out to you? Do they include large and small
rural and urban as well as primary and specialty interests?
Dr. Bailet. Yes.
Mr. Guthrie. Specialty interests, not special interests.
Dr. Bailet. Yes. And so I think you will hear we have a
small rheumatology practice that has submitted a model before
us that we have not evaluated it, it is under evaluation. So we
have a broad array of medical stakeholders again from the range
of small and rural practice to sophisticated systems and
specialty societies like American College of Surgeons, for
example.
Mr. Guthrie. OK, thank you.
I will yield back and recognize Dr. Ruiz for 5 minutes for
questions.
Mr. Ruiz. Thank you very much, Mr. Chairman. And thank you
for allowing me to waive on to this subcommittee.
When we passed MACRA in 2015, one of the goals was to
increase quality of care and stabilize payments, moving towards
payment models that reward high-quality care. One of the
options under MACRA is for providers to participate in an
Advanced Alternative Payment Model under which the physicians
accept some of the financial risk. However, in just over a year
since its creation, the Physician-Focused Payment Model
Technical Advisory Panel which reviews the proposed APMs has
received only 19 proposals that we have discussed earlier for
consideration and deliberated on just five of those. So I am
concerned we are not seeing enough to really make a smart
decision on what is going to be the best model.
And speaking to different physician specialty
organizations, I have learned that one of the greatest barriers
to developing APMs are laws that prohibit many of these
physician practices from coordinating, collaborating with other
specialties while they are trying to develop an APM, much like
what Dr. Bucshon mentioned, so this means that the groups are
not able to test out their model to see if it will work in
practice. And while these laws are important and serve an
important purpose, in this instance they are restricting the
development of these payment models, stunting movement towards
fully achieving the goals of MACRA.
What are some of these barriers in general that have
inhibited different practices and organizations from developing
APMs? If you can name me the top two barriers and then I want
you to name the--if you were to recommend us, how would we
resolve those top two barriers?
I will start with Mr. Bailet and then I will go to Ms.
Mitchell.
Dr. Bailet. I guess what I would say, I would turn to the
second row of testimony behind us, the folks who are actually
out there trying to create these models for our consideration,
to answer your question relative to those two barriers.
Mr. Ruiz. OK.
Ms. Mitchell, do you have an answer or an idea? Because I
will ask them and I have been speaking with them.
Dr. Bailet. Yes.
Mr. Ruiz. But, you know, I wanted to get your perspective
in being involved as well.
Ms. Mitchell. Absolutely. In my testimony I shared that the
barriers that we have heard most frequently in our first year
are access to data and technical assistance to design the
models and opportunity for small-scale testing. So I think
those are three issues and we have actually asked for
congressional consideration on each of those.
So I do think that there are barriers, but I do also think
that the panel, the next panel will be able to share how they
have overcome them.
Mr. Ruiz. So the MACRA required the Secretary to establish
a set of Physician-Focused Payment Model criteria for
evaluating proposals. MACRA also required PTAC to then review
the proposals submitted based on these criteria when making
recommendations to the Secretary. These 10 criterion including
the extent to which proposals provide value over volume,
increase care coordination, improve quality, et cetera, can you
describe the 10 criteria established by the Secretary,
particularly the criteria designed by the PTAC as, quote, high-
priority criteria?
Dr. Bailet. Yes, we reviewed that earlier but we can go
back again.
Mr. Ruiz. Give me the top two, please.
Dr. Bailet. There is three.
Mr. Ruiz. Give me the top two.
Dr. Bailet. Scope, cost, and quality.
Mr. Ruiz. Scope, cost, and quality. And in the proposals
that you have reviewed in scope, cost, and quality, what are
the easiest criteria for most proposals to attain?
Ms. Mitchell. Well, I think all of the proposals that we
have seen have recognized that we are looking for models that
improve quality without increasing cost and they have all
brought forward models that will----
Mr. Ruiz. So everybody has been able to meet all 10
criteria easily?
Dr. Bailet. No.
Ms. Mitchell. No.
Mr. Ruiz. All right, so which are the difficult criteria
for the organizations to meet?
Ms. Mitchell. Well, I think one of the challenges is
sometimes that it is not a payment methodology that is actually
different enough to require an Alternative Payment Model. As an
example they may just need a tweak in codes or something, a
much more minor intervention, so it might not qualify as an
Alternative Payment Model. That is one example.
Dr. Bailet. I would say another example that we have found
as a committee is the care coordination, the ability for
physicians and clinicians to work with each other across
communities, across disciplines, sharing data that we talked
about. Those are all contributors to make----
Mr. Ruiz. Is it more of a technical difficulty with the
electronic medical records issues or is it a cultural, a
difficulty within different institutions?
Ms. Mitchell. I don't believe it is a technical barrier. I
think it is more often a business or a cultural barrier. I
think that it is certainly possible to share data across
platforms and----
Mr. Ruiz. What would you recommend we do to improve
collaboration across the different institutions and specialties
so that we can get better models?
Ms. Mitchell. I think that we are seeing that. I think that
the proposals that are coming forward are actually laying out
ways to collaborate more effectively. I think that there can be
incentives for data sharing. You can have data standards so
that it is possible to share data across platforms, and you
could actually ask the vendors to ensure that there is no data
blocking so that data can effectively be shared.
Mr. Ruiz. OK. If the barrier is a business model then I
think we have to look at what are the business incentives for
them to work together during these APMs, because they also have
business needs in the short term as well.
Ms. Mitchell. Absolutely. And I think that by changing some
of the incentives that we are actually helping them to find
viable business models for the right care.
Mr. Burgess [presiding]. The gentleman's time has expired.
The Chair recognizes the gentleman from Oklahoma, Mr. Mullin, 5
minutes for questions, please.
Mr. Mullin. Thank you, Mr. Chairman. Thank you for both of
you all being here. As you guys have, you know, been sharing
the same questions, my question line will be the same too. And
I really appreciate you all's patience. As you can tell, the
committee is really looking into this. This isn't something
that we are looking to stand in the way, we are looking to help
to improve and so we appreciate you all being here.
I represent a very rural district, very, very rural
district, and our constituents obviously receive care, many of
them, from critical access hospitals. Do you think it is time
that we explore, target value-based payment models for critical
access hospitals that recognize the unique needs of rural
areas?
Dr. Bailet. I think, yes, I would agree with that.
Mr. Mullin. Ma'am?
Ms. Mitchell. Yes, I think so. I think there can be some
very innovative practices in rural areas, and in many cases
some of these models may actually allow small rural practices
to succeed by creating more flexibility and really evaluate----
Mr. Mullin. Which models specifically would you think?
Ms. Mitchell. In terms of the models that we have received?
Mr. Mullin. Well, and if you are talking about ways to look
at the value-based payment structure how would that look like?
What would we be needed to push from this point of view to make
it?
Dr. Bailet. Well, my experience with critical access
hospitals in small rural communities, my former practice was in
Wisconsin, getting specialty care to these small hospitals,
allowing patients to get the care they need at home or in their
local community rather than have to travel great distances. So
using technology, telehealth, telepsych, for example,
psychiatry, behavioral health at the bedside, neurology, it is
often difficult to get those services, the actual practitioner,
on the campus of these smaller hospitals.
Mr. Mullin. Right.
Dr. Bailet. But if you can leverage technology like
teleneurology where they can actually be at the bedside with
cameras and do the analysis that they need for patients who are
having a stroke whether they are going to administer treatment
there or transfer the patient, those are the kinds of things
that these models will support, will stand up and recognize and
pay for.
Mr. Mullin. Have you looked at what Alaska is doing within
the IHS? You know, they are extremely, obviously, rural and IHS
has their own issues, their own problems, which, you know, we
are working through that on a task force. Being Cherokee
myself, I understand, you know, very well. But Alaska has
seemed to be ahead of telemedicine, where, I mean, they just
don't have that access to the care, that it is not reasonably
for them to be able to get into and a lot of dynamics play
into, factors play into this when you start talking about
having to fly people in and out.
And so they don't have a choice. They have been forced to
do it, but they have been successful at it. Are you familiar
with it? Have you looked at it at all?
Ms. Mitchell. Not in any detail.
Dr. Bailet. No. No.
Mr. Mullin. Maybe we--I suggest you maybe taking a look at
that. Another question, what is PTAC doing to encourage
applications in rural and underserved areas?
Dr. Bailet. So we are again reliant on the proposals that
are submitted, but I will say, in the first year before the
Secretary's criteria were finalized, we had several public
meetings with stakeholders across the country and we were very
clear and we continue to be very clear that we are encouraging
small and rural practices to submit proposals, that we are
receptive to receiving proposals.
We see that as a significant area of need and we are trying
to foster everything that we can do relative to our process to
make sure that we are open and willing and we make it as
seamless as possible for these smaller practices to compete and
build these models for our evaluation.
Mr. Mullin. So what are some of the barriers? And once
again we are looking to work with you.
Dr. Bailet. Right.
Mr. Mullin. So what are some barriers that is standing in
your way from this side? I mean because I am assuming if there
were barriers that you could already take care of you would
have already done that so there must be something that we are
keeping that from happening.
Ms. Mitchell. Well, again one of the barriers that again
keeps coming up is the need for technical assistance
particularly among small and rural practices who might not have
the resources. I think we do need to find a way to offer that.
I think some of the measurement systems in some of these models
could actually be beneficial for small and rural practices or
critical access hospitals which often have higher patient
experience scores.
They are actually, they might be recognized for the things
that they are already doing well. So I think looking at
measures and technical assistance and again the data needs for
these practices. They can't necessarily build analytic teams
nor should they need to. So how can we make it easier, reduce
provider burden to actually just have the information they need
to give the care that they are giving.
Mr. Mullin. And just to make a point on when you said a
patient's experience which we put, you know, high value on that
which I agree is about customer service, but it is also about
care too. A lot of times the reason why you see that, in my
opinion, is these rural providers they are personally connected
to the individual.
Ms. Mitchell. Absolutely.
Mr. Mullin. When my father had a major heart attack and
actually coded he was right at the hospital. And the guy that
was working there who is a good friend of ours knew my dad well
and when he couldn't speak, he couldn't say anything, knowing
the personality that my dad typically had, immediately
recognized it and it saved his life. But I think that we take
it more personal, but we are getting farther and farther
behind.
And we as a committee really want to help with that and as
personally as a Member I want to work with you. If you have
ideas, if there is something that we can do, if you recognize
areas that we can push on this committee, please use our
office. Use me as a resource because I am going to be using you
as a resource. Thank you. And I yield back.
Mr. Burgess. The Chair thanks the gentleman. The gentleman
yields back. The Chair recognizes the gentleman from North
Carolina, Mr. Butterfield, 5 minutes for questions, please.
Mr. Butterfield. Thank you very much, Mr. Chairman. Thank
you for convening this hearing today.
Dr. Bailet, let me just direct one or two questions to you
and then we will see how much time we have left after that.
Dr. Bailet. All right.
Mr. Butterfield. But first of all, thank you so very much
for your testimony. Like the gentleman from Oklahoma, I
represent a small rural community in eastern North Carolina and
so I am very interested in your comments to him and to others
about the challenges facing small rural providers in taking
advantage of the APMs. And so, I guess, question one would be
what proportion, what proportion of the 32 letters of intent
and the 20 full proposals are from small and rural practices?
Dr. Bailet. I don't have the number available. It is more
than one.
Mr. Butterfield. You just don't have it with you?
Dr. Bailet. I don't have it with me.
Mr. Butterfield. But you do collect the data?
Dr. Bailet. Yes, we do. Absolutely.
Mr. Butterfield. All right. Number two, has PTAC observed
differences in applications from large practices and small and
rural practices? Do you discern any differences between the
applications?
Dr. Bailet. Well, the applications are highly variable from
application to application. And I think----
Mr. Butterfield. In terms of quality?
Dr. Bailet. Right.
Mr. Butterfield. Quality?
Dr. Bailet. In terms of sophistication and how they are
built. So there is clinical sophistication and then there is
the policy, payment policy sophistication, and both components
need to be present for our recommendation to carry weight and
to garner our support. The area of technical assistance, I
don't want to--I think I would be--I don't want to say that the
smaller practices are the ones that are needing more technical
assistance compared to the larger, more sophisticated
practices. I am not saying that.
But we have found in both arenas, in both practice cohorts
that there have been challenges with their model. More so on
the payment side and the data side, not so much on the clinical
side.
Mr. Butterfield. But you do acknowledge that there is room
for improvement in many of the applications?
Dr. Bailet. Absolutely, yes.
Mr. Butterfield. From the large practices to the small
practices?
Dr. Bailet. That is correct.
Mr. Butterfield. But wouldn't you acknowledge at least that
the weight of those, the majority of those are more toward the
rural practices because of the lack of expertise? I mean we
hear that every day up here where disadvantaged groups just
don't have the expertise to present the quality of proposals
that you would want.
Do you communicate directly with the small and rural
practices about the benefits of technical assistance? Do you
let them know that it is there for the asking?
Ms. Mitchell. Actually one of our key challenges is that we
are not at this point allowed to offer technical assistance. We
have made available the resources that we do have, so to the
extent that the committee can organize data for applicants we
are doing that. But so far we are limited from what----
Mr. Butterfield. You can't proactively go out and advertise
that it is available?
Ms. Mitchell. Currently not.
Mr. Butterfield. I didn't know that.
Dr. Bailet. We are charged to evaluate the models as they
stand. We cannot provide guidance. We cannot make
recommendations on how the models should be reconstructed. That
is not in the purview of the PTAC and we are careful not to go
into the area at this point.
Mr. Butterfield. All right. Let me try it this way then.
Have you worked with Health and Human Services to share your
experiences with applications and make recommendations about
how to deploy resources and technical assistance, at least has
HHS been made aware of this?
Ms. Mitchell. Yes. And the committee sent a letter to
Secretary Price naming technical assistance as a key need for
applicants. So we certainly weighed in on that need.
Mr. Butterfield. Right. I am about to run out of time, let
me move to a different subject.
Dr. Bailet, I am acutely aware of many of the health
disparities that affect African American citizens today.
Several of the approved APMs deal with chronic disease
management like ESRD that disproportionately affects
minorities. Can you discuss with me some of the APMs that are
being considered that would disproportionately affect African
American and other minorities?
Dr. Bailet. We are currently evaluating a model for
hepatitis C, which I would think, I believe, I don't have the
numbers specifically in front of me, the demographics, but I
believe that that is another health challenge that just like
end-stage renal disease with the African American community. So
those are two that come to mind.
Mr. Butterfield. We are out of time.
Mr. Burgess. The gentleman's time has expired. The Chair
would inform the gentleman that I am getting a copy of the
letter that the Physician Technical Advisory Committee sent to
the Secretary in August and I will make that available to you
so that you will know the communication that occurred from this
group back to the agency.
The Chair now recognizes the gentleman from Florida, Mr.
Bilirakis, 5 minutes for questions, please.
Mr. Bilirakis. Thank you, Mr. Chairman, I appreciate it so
very much and I thank the panel as well.
I have a few questions for both of you. Can both of you
discuss your experiences in transitioning to value-based care
outside of your work on the Physician-Focused Technical
Advisory Committee and how that has influenced your view on
what Advanced Alternative Payments Models can deliver? Now I
know that some of these things have been covered, but if you
could respond I would appreciate it.
Ms. Mitchell. Sure. Well, I will speak to my experience
which is quite different from Jeff's, but I actually used to
work in a very large health system so I had some experience
there as they were trying to transition their practices. But
more recently I have worked in multi-stakeholder groups in
various communities from Hawaii to Maine where they are
bringing together employers, health plans, providers, patients,
State governments, others, to try to come up with payment
changes that actually meet all the stakeholders' needs.
So is it getting value for the money, is it improving
patient outcomes, and are clinicians actually happier providing
this care and is it better suited, are the barriers being
removed, it is actually that multi-stakeholder alignment that
enables the transition. So that is, and we have tried various
models, ACOs, bundles, Patient-Centered Medical Homes, and
implemented those in different communities.
Mr. Bilirakis. Thank you.
Dr. Bailet. In my experience supporting large physician
practices, multispecialty group practices, there is a
tremendous amount of inertia to work with the physicians and
the clinicians to get them to change their practice styles and
move away from fee-for-service, volume-driven practices to
focus more on outcomes. The models I have deployed in my former
leadership roles relative to supporting physicians and
clinicians, paying them for quality outcomes, paying them for
collaboration with their colleagues, paying for their
utilization of electronic health record. There has been and I
think there continues to be some challenges with galvanizing
the level of interest.
There is challenges with the data that typically we hear
from the physicians that as they move away from volume, you
know, does the data that you are sharing with me that you are
now going to pay me for accurately reflect the work that I am
doing? So there is--I think it is washing out--but there was
obviously on the front end of moving from volume to value a
healthy dose of skepticism from the physicians. Well, you are
going to pay me differently, but am I actually going to get
paid for the work I am doing?
So it is very challenging, but I think right now what I am
seeing is that the mindset of the physician and the clinician
is they know they need to do it. They know they need to move
away from the fee-for-service environment and pure fee-for-
service, and the question is how do we do it, and at what pace
do we do it, and what tools are you going to provide me so that
you are not overburdening my practice?
Elizabeth talked about the $40,000 per physician just to
monitor and track quality, but I would also argue there is
another 750 hours I believe that was in that same study that
each physician has to devote to monitoring and managing and
measuring and reporting quality. I am here to say that as a
health plan we had 188 quality metrics that we were holding our
physician community accountable for. I don't want to get into
the weeds, but I am sure you think that that is not optimal.
Yesterday, the board of Blue Shield approved moving to an
integrated healthcare association set of metrics, 34, and we
are going to lead the way in the State and try and get a
standardized set of metrics, 34 metrics--it is not boiling the
ocean--to actually have and change outcomes and drive this
value and try and take the burden away from the practitioners.
Ms. Mitchell. And could I just add, I think that that is
absolutely essential to not only reducing burden and cost, but
allowing physicians to accelerate improvement. And the other
element of that report is that there was only 5 percent overlap
in commercial plans for using the same measures. If they could
do what Blue Shield of California did and agree to use a common
set, that makes life easier for physicians and it can lead to
better care at lower cost. I think it is just an exemplary move
and one that could easily be replicated around the country if
folks were willing to do that.
Mr. Bilirakis. Very good. We will take a hard look at that
and I will submit my questions for the record because I don't
have time. Thank you, Mr. Chairman, appreciate it.
Mr. Burgess. The Chair thanks the gentleman. The gentleman
yields back. The Chair recognizes Mr. Green of Texas for any
concluding thoughts that he might have.
Mr. Green. Mr. Chairman, my concluding thoughts, I want to
thank you for the work you are doing and I think we just see we
have a long way to go and we will do what we can to get you
some resources so we can move it. Again my biggest fear is we
are going to end up 17 years from now doing what we did with
the SGR and medical practice is more important than that. So we
will hopefully get some stability there. And thank you for your
work and keep in touch with us and let us know what we may be
able to do.
Dr. Bailet. Thank you for your support. Thank you.
Ms. Mitchell. Thank you.
Mr. Burgess. And I will just recognize myself briefly.
Dr. Bailet, I do want to, I think it is important to note
that you all were chartered January of 2016. It took some time
to organize and staff up, so it has really just been a little
over a year that you have been at work on this and as someone
else pointed out you do have day jobs as well.
So it is, I mean I picked up perhaps on some criticism that
you weren't active enough or doing enough. I am actually
pleased with the work product that is coming through the PTAC
right now and I believe that we--and then I think I heard your
testimony that there is more, it appears there is more activity
in submissions and I think that is good and I think that is
important. I think we all recognize that there is a tremendous
amount of work ahead of us on this.
One of the things that I do feel obligated to mention, when
this concept for the Physician's Technical Advisory Committee
came up, when the legislation to repeal the Sustainable Growth
Rate formula was being contemplated, some of us are less
enthusiastic about all aspects of the Affordable Care Act and
there are portions of the Affordable Care Act that to me are
disagreeable because of the coercive nature of the Affordable
Care Act. So the individual mandate would be one of those
things and I am well on the record about that in this
committee.
But the Center for Medicare and Medicare Innovation, CMMI,
which had the ability late on a Thursday or Friday afternoon to
simply roll out a demonstration product that was going to be
pushed out to the entire country with no cost-benefit analysis,
with no randomized clinical trial, I mean this was a problem
that I saw that we were careening towards. And the Physician's
Technical Advisory Committee in part was created to help us
offset what I saw was an impending disaster with CMMI.
Now I think it is very helpful that Ms. Mitchell has
pointed out the small-scale testing. It might be reasonable to
find out if something works before we require every practice in
the country to behave that way. CMMI was set up differently.
Your model is, I think, the correct one because, yes, I was
integral in setting it up, but still I think your model is the
correct one.
And we acknowledge there are elements of the unknown. This
is new territory. There are going to be things that we
encounter that we did not expect. And unlike the Affordable
Care Act that it was perfect when it was passed and has
required no adjustments, this I recognize may require
adjustments going forward and this committee is going to be
nimble about accepting those and providing you with the
legislative backdrop that you need to do your jobs and we thank
you for doing your jobs.
Thank you for being here today. It has been a very
informative panel, and you are now excused and we will
transition to our second panel.
Again we will thank our second panel of witnesses in
advance for being here today and taking the time to testify
before the subcommittee. Each will have an opportunity to give
an opening statement followed by questions from Members. And
let me give you a moment to get seated, and we will proceed
with the introductions.
Mr. Green. Mr. Chairman, before our witnesses leave, I
would offer again if you want to sit down and work on how we
can agree to, 7 years later, on the Affordable Care Act, we
would be glad to do that.
Mr. Burgess. I have always been available to you.
Very good. Again we are going to have each of you after
your introductions an opportunity to give an opening statements
followed by questions from Members.
So today we are going to hear from Dr. Louis Friedman, the
American College of Physicians; Dr. Daniel Varga, chief
clinical officer, Texas Health Resources; Dr. Bill Wulf, CEO of
Central Ohio Primary Care Physicians; Colin Edgerton, American
College of Rheumatology; Dr. Brian Kavanagh, chair for the
American Society of Radiation Oncology; and, Dr. Frank Opelka,
medical director of Quality Health Policy for the American
College of Surgeons. We appreciate each of you being here
today.
And Dr. Friedman, you are now recognized for 5 minutes for
an opening statement, please.
STATEMENTS OF LOUIS A. FRIEDMAN, D.O., FELLOW, AMERICAN COLLEGE
OF PHYSICIANS; DANIEL VARGA, M.D., CHIEF CLINICAL OFFICER,
TEXAS HEALTH RESOURCES; J. WILLIAM WULF, M.D., CHIEF EXECUTIVE
OFFICER, CENTRAL OHIO PRIMARY CARE PHYSICIANS, ON BEHALF OF
CAPG; COLIN C. EDGERTON, M.D., ALTERNATE DELEGATE, AMERICAN
COLLEGE OF RHEUMATOLOGY; BRIAN KAVANAGH, M.D., CHAIRMAN,
AMERICAN SOCIETY FOR RADIATION ONCOLOGY; AND FRANK OPELKA,
M.D., MEDICAL DIRECTOR, QUALITY AND HEALTH POLICY, AMERICAN
COLLEGE OF SURGEONS
STATEMENT OF LOUIS A. FRIEDMAN
Dr. Friedman. My name is Louis Friedman. I am pleased to
share with this committee my perspective and that of my
national organization, the American College of Physicians, on
Alternative Payment Models under MACRA, specifically a
Comprehensive Primary Care Plus program. On behalf of the
college, I wish to express our appreciation to Chairman Burgess
and Ranking Member Green for convening this hearing, for
allowing us on the front lines of patient care to share our
experiences in the transition to value-based care.
ACP is the Nation's largest medical specialty organization,
representing 152,000 internal medicine physicians who
specialize in primary care and comprehensive care of
adolescents and adults, internal medicine subspecialists, and
medical students who are considering a career in internal
medicine. I am board certified in internal medicine and am a
fellow of the American College of Physicians. Since 2001, I
have been in private practice at Woodbridge Medical Associates
in New Jersey which has been NCQA-certified as a Patient-
Centered Medical Home Level 3 since 2008.
Our practice is small with just four physicians and one
physician assistant. In the 3 years since our practice started
participating in the CPCI program and now 1 year into the CPC+
program Track 2, we have gained significant knowledge with the
benefits and challenges of the program. I would like to share
my experiences with all of you today. Under CPC+ we have
expanded our ability to analyze and deliver care and our
patients have benefited in many ways.
With the added financial support that the CPC+ program
provides, we have been able to offer self-management programs
such as nutrition classes and dietician visits. These are
available free of charge to patients and have been well
received by many who need them. For example, I have had one
patient who was six-feet three inches tall, weighed 442 pounds,
he had a high blood pressure and terrible venous insufficiency
of the legs, which causes massive chronic swelling. He enrolled
in our 8-week class and by the end had lost 31 pounds. He
dropped another 10 pounds in the next 2 months and his swelling
has improved.
Now this is an extreme example but shows that we can induce
positive lifestyle changes which in turn can help prevent
disease. Feedback data from CMS is another tool that we did not
have access to previously, but now do as a result of our
participation in CPC+. Often, patients simply are not aware
that many medical issues such as upper respiratory infections,
rashes, minor cuts and bruises, can be easily treated in less
expensive urgent care settings or office setting often for a
shorter wait time for the patient.
Now we can review the number of patients, our patients per
quarter who are admitted to the hospital, seen in the emergency
room, or seen in urgent care centers. Once identified, we hope
to better educate these patients as to when and when not to
seek emergency room care. Prior to CPC+ we didn't have this
ability and thus had no idea how many unnecessary emergency
room visits there were.
Pre-visit planning by ancillary staff and effective
monitoring within the EHR have helped us to improve our rates
of vaccination, screening procedures for mammograms, and
diabetic eye exams. Screening tools for early detection of
dementia have helped us and at-risk families better prepare to
care for their loved ones, and the CPC+ reimbursement for
managing these patients with this diagnosis has been helpful
for targeting this effort.
On a practice management level, regulations issued by CMS
requiring EHR vendors to obtain health information technology
certification made it possible to track patient parameters more
effectively. Prior to enacting these regulations, EHR vendors
had no incentive to create effective dashboards with which we
can track patient measures such as blood pressure, blood sugar
measurements, et cetera. Without this ability there would be no
way that a practice could hope to report the necessary measures
to the program.
If this committee and Federal agencies look to improve upon
this program in the future, I would like to offer some
suggestions. First, there is a need to simplify the reporting
requirements under CPC+. As more private payers enter the APM
market, one option would be to streamline specific metrics
across the proposed CMS and private payer models. This would be
in line with ACP's Patients Before Paperwork initiative and the
ideas that the college has laid out for how to address
excessive administrative tasks as well as with the
administration's new Patients over Paperwork and Meaningful
Measures initiatives.
Another suggestion would be efforts should be made to
encourage interoperability among EHR software vendors which
would lead to better electronic communication between medical
offices and hospitals. And I would be remiss if I did not
acknowledge that there is a financial incentive as well to
participation. This is needed for the practice to maintain the
appropriate staff and computer systems. However, I believe we
must continue to move forward with value-based coordinated care
such as been found in programs like CPC+, the Medical Home, and
other APMs away from fee-for-service system.
Given the time and effort our practice has invested over
the past few years to this end as well as the significant and
incremental improvements we have experienced, we plan to
continue with this model and not return to a purely fee-for-
service structure.
In closing, I would like to note that since 2016, practice
participation among ACP members and advanced payment delivery
models is increasing, and many more have noted that they are
making changes to prepare for successful participation in the
QPP overall. This is the case for both the ACP primary care and
subspecialist members. Therefore, we in the physician community
appreciate the opportunity to offer our input on how these
models are impacting our practices and both in patient care,
both now and throughout transition. We very much want to be
part of this process and provide feedback whenever needed.
[The prepared statement of Dr. Friedman follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Burgess. The Chair thanks the gentleman.
Dr. Varga, you are recognized for 5 minutes, please, for an
opening statement.
STATEMENT OF DANIEL VARGA
Dr. Varga. Thank you, Mr. Chairman. Thank you to the
members of the committee. My name is Dan Varga. I am the chief
clinical officer and senior executive vice president for Texas
Health Resources and the senior executive officer of the
Southwestern Health Resources ACO, also speaking as a
participant in Premier's Population Health Collaborative.
I would like to make three points to the committee. First,
our decision to move to a two-sided risk, Next Generation ACO
was a direct result of the incentives included in MACRA and the
fact that these Alternative Payment Models, in our opinion, are
working. We believe in a value-based healthcare system where
incentives for all providers can be aligned and where
healthcare providers are able to collaborate using an
integrated infrastructure and transparent data on quality and
utilization to deliver better outcomes for our patients.
This is even more critical in North Texas. Because of North
Texas' strong economic and population growth, more than 40
percent of practicing physicians do not participate in the
Medicare fee-for-service program or severely limit their
availability to fee-for-service beneficiaries. Thus, by
participating in the Next Gen ACO, Southwestern Health
Resources ACO has been able to keep almost 3,000 physicians in
the fee-for-service model. And this includes faculty, employed,
independent PCPs, specialists, urban and rural physicians.
Moreover, because of our participation in a Next Gen ACO we
have waivers that allow us to partner with doctors to reduce
the CMS reporting burden for our clinicians by reporting those
measures for them as a group, earn bonuses by participating in
the ACO which creates important incentives to physicians to
move to this new care model, have access to comprehensive data
on utilization for our 67,000 beneficiaries, allowing us to
better direct our care management activity to areas where it
can create the most value.
I can't point out enough that this data transparency for
integrated providers is priceless and also allows us to
clinically integrate within a set of safe harbors. In our
experience, these models are working. In our experience with
our 67,000 beneficiaries, we are among the top 10 Medicare ACOs
in 2015 and 2016, saving 30 million in '15 and 37 million in
2016.
We have been able to garner and retain top talent including
600 primary care physicians--40 percent employed, 60 percent
independent--as well as another 2,300 participating providers;
budget in 2017 and '18 to distribute over $22 million in
incentives and gain sharing to independent PCPs alone, make
investments in infrastructure to support coordinated patient-
centered care with a budget of 70 million in 2018 to go along
with over $100 million in investments since the institution of
our ACO program; to tighten our network of providers to create
better outcomes for our patients based on objective clinical
and efficiency metrics; and to better manage our ED and acute
care utilization.
We additionally have the benefit of participating in
Premier's Population Health Collaborative. Since 2012, about 50
percent of the Premier ACOs have achieved shared savings,
better than the approximately 31 percent experienced by the
rest, while also outperforming on quality metrics. In 2016, a
hundred percent of the Collaborative's Pioneer and Next Gen
ACOs achieved savings versus 50 percent otherwise.
And we also have the advantage, again referencing data, of
sharing data, not just on our beneficiaries but on hundreds of
thousands of Medicare beneficiaries and the ability to learn
from our peers on how their markets are performing and how
tactics in those markets can be deployed in ours. Share these
results to demonstrate that while there has been concerns that
APMs are not delivering real savings, it is clear that with a
balanced and planned approach and effective execution, these
models can work.
The second point is that these value-based care and payment
models are a significant departure from the past, changing 50
years of culture and habit. There is a number of implications
to that. First, the changes are obviously long overdue as we
move from a fragmented fee-for-service system where providers
are incented to do more services to one where competition will
be driven by high-value networks that deliver differentiated
outcomes.
This work to better organize the healthcare market into
high-value networks is necessary and desirable and we would
urge that folks make a differentiation between consolidation to
create excessive market power and integration of providers in
the market to create a high-value network. Policymakers should
also be careful not to tilt the playing field to the advantage
of one provider group over another and maintain a level playing
field.
And finally, while significant progress has been made to
move to a value-based payment and delivery model, this Congress
and administration should continue to build on these positive
steps as have already been mentioned with needed change as we
believe more organizations will move to and succeed in APMs,
and I encourage you to review the listed areas' reform in my
written testimony and those in Premier's Delivery System
Transformation Roadmap.
Thank you again for the opportunity to testify before this
committee. You have made a vital and lasting impact on our
Nation's healthcare system with the design and enactment of
MACRA and I urge you to continue to build on this successful
work. Thank you.
[The prepared statement of Dr. Varga follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Burgess. The Chair thanks you for your testimony. The
Chair would make an observation that it has been long a goal of
mine to have a panel with five or six physicians before this
subcommittee. This may be one of the first times this has
happened in my experience. I wasn't really planning on talking
about this aspect. I wanted to get five or six doctors in here
to tell us how much economists should be paid.
Dr. Wulf, you are recognized for 5 minutes.
STATEMENT OF J. WILLIAM WULF
Dr. Wulf. Thank you, Chairman Burgess, Ranking Member
Green, and members of the Health Subcommittee for inviting me
to testify today. I am pleased to be here to share with you how
the move to Alternative Payment Models is working to transform
the delivery of health care.
I am testifying today on behalf of CAPG. CAPG is the
largest association in the country representing capitated
physician organizations participating in coordinated care. CAPG
members include over 300 medical groups and independent
practices in 44 States, Washington, DC, and Puerto Rico. CAPG
members have proven that APM-type models of payment and care
delivery can lead to lower cost and higher quality.
I also address you today as a physician and the CEO of
Central Ohio Primary Care Physicians. Our group consists of 370
physicians, 200 adult primary care physicians, 60
pediatricians, 75 hospitalists, and 25 specialists. COPC is the
largest physician-owned primary care group in the country.
Let me begin by emphasizing a single point: The value
movement is working. To underscore that point I will share with
you our organization's journey into value-based payments and
why being in an APM matters to primary care. We were formed in
1996 when 33 of us got together from 11 practices. Beginning in
2006 through 2014, we reported for PQRS when it was still PQRI,
we deployed an EHR and we are now on our second generation EHR.
All of our eligible providers met meaningful use. We too became
Level 3 Patient-Centered Medical Homes.
All of these initiatives, every one of them, made being a
PCP less satisfying in a fee-for-service world. In 2014, we
entered into shared savings contracts with both commercial and
Medicare Advantage payers. We sought contracting structures
that reward PCPs for things that do not happen. If you are a
primary care physician taking care of 1,500 patients and no one
has colon cancer because they have all had their colonoscopies,
you have created value. Value heretofore unrecognized by the
primary care physician, but recognized by the employer or the
payer.
We developed programs to improve care. This meant expanding
our hospitalists program, developing transition of care
nursing, hiring care coordinators, having visiting physicians
who see only two patients in crisis a day, and having an ER
intervention program where our nurses intercept our patients in
the emergency room. In 2016, we earned $12 million in shared
savings for our primary care physicians that was returned to
them. Our Medicare readmission rate on 4,000 Medicare
admissions in 2016 was 7 percent. The national average is over
18 percent.
The ability to reward primary care physicians for high
quality and lower cost is crucial to the preservation of
primary care. In 2017, we desire to be in a Medicare APM. We
qualified for CPC+ Track 2. CPC+ payment model allowed us with
prepayment to expand our existing care coordination, move
towards capitated payment because of the hybrid model, and
receive quality payments. In 2018, we will move to prepaid
contracts with downside risk on 25,000 Medicare Advantage
lives.
Clearly, MACRA's incentives for advanced APM participation
is the latest program driving us into new models of payment.
Past programs have discouraged fee-for-service volume and APMs
are now rewarding value and creating value. We are thrilled to
see that last week CMS announced its intention to create an
advanced APM demonstration in Medicare Advantage. With one-
third of all Medicare lives in Medicare Advantage, it is
crucial that it be rewarded like fee-for-service Medicare. In
the MACRA final rule the agency states that participants in
such demo will qualify as an APM. This is a crucial step
forward and we thank the Members of Congress including those
present at today's hearing and we encourage CMS to move
forward.
Thank you for the opportunity to testify. I hope it has
been helpful and I am pleased to answer questions.
[The prepared statement of Dr. Wulf follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Burgess. The Chair thanks the gentleman.
The Chair recognizes Dr. Edgerton 5 minutes for your
opening statement, please.
STATEMENT OF COLIN C. EDGERTON
Dr. Edgerton. Chairman Burgess, Ranking Member Green,
Chairman Walden, Ranking Member Pallone, and distinguished
members of the Health Subcommittee, thank you for the
opportunity to speak before you today.
My name is Dr. Colin Edgerton and I am rheumatologist in a
small private practice at Low Country Rheumatology in
Charleston, South Carolina. I am one of seven rheumatologists
in a single specialty group. Our practice is a typical
rheumatology practice with around 50 percent of our patients
being in Medicare along with a significant number of TRICARE
patients and a smaller group of Medicaid patients. The
remaining group of patients are in the commercial segment.
Because South Carolina, like most areas of the country,
suffers from a shortage of rheumatologists, our patients may
travel long distances, commonly 1\1/2\ to 2 hours, to see us
and receive treatment. As a result, we see a mix of urban,
suburban, and rural populations. In addition to my work as a
rheumatologist, I am also privileged to be involved with the
American College of Rheumatology, where I currently chair the
committee on rheumatologic care. The ACR represents
approximately 9,500 rheumatologists and rheumatology health
professionals.
Community physicians including rheumatologists are keenly
aware of the opportunities created by MACRA for developing
models to promote value-based care. Before MACRA there really
was no meaningful way for small specialties and small practices
to participate in Alternative Payment Models. As
rheumatologists, we did not have the opportunity to engage in
APMs. Our specialty simply did not fit into the previously
existing value-based products.
Coming from a community practice setting, even just a few
years ago I would not have considered myself someone who could
get involved in an APM. But with the repeal of the SGR formula,
an institution of MACRA, rheumatologists saw for the first time
a structured opportunity to participate in value-based
medicine.
There are several reasons that I and also the ACR have been
excited to get involved in creating APMs under MACRA. Most
notably, we immediately saw the benefits of APMs, recognizing
that certain aspects of care provided by rheumatologists as
cognitive specialists are undervalued in the current system. In
many instances, the value of training and expertise provided by
rheumatologists is not recognized in payment outside of
innovative models. Additionally, non-face-to-face care and
chronic disease care coordination with other providers are
critically important but not reimbursed services provided by
rheumatologists every day. And like other specialists that are
developing APMs, rheumatologists know that these valuable
services prevent costly or unnecessary procedures and lower
overall costs.
My early foray into value-based medicine involved reaching
out to leaders in the AMA initially who had experience with
value-based projects through CMS. This finally led me to the
Physician-Focused Payment Model Technical Advisory Committee,
PTAC, whose members have been generous with their time,
listening to my ideas, and guiding my progress. The ACR
simultaneously has begun developing an APM and I have been
fortunate to participate as a representative of the community
of rheumatologists.
The ACR's APM is approaching its testing phase and my
partners and I are eager to be a pilot site. The ACR's APM
addresses the treatment of rheumatoid arthritis, a lifelong
condition whose care depends on the stage of the disease. The
APM reflects the varied involvement of the rheumatologist
during these distinct stages of care, splitting payment into an
initial stage for diagnosis, including, for example,
communication with primary care physicians followed by ongoing
care stratified by the disease severity and other illnesses
that complicate disease treatment. This model aligns payment
with physician work and reimburses services that have
traditionally been undervalued.
Quality measures are built into the APM to ensure treatment
adheres to best practices. Rheumatologists as a specialty are
energized by the opportunity to provide our patients value-
based care through this framework. We look forward to
participating with more physician participation in APMs.
Specifically, smaller practices are eager to participate in
APMs as well, and allowing some of the downside risk to be
covered could help those practices get involved.
Regarding timelines, as soon as MACRA was codified many
specialties began to look at APMs, and I am hearing that a
reduction in the qualification thresholds could allow these
eager physicians to utilize the APM framework.
We appreciate the committee's work to get us to this point
and we look forward to continuing to develop and implement
innovative new payment models that offer the opportunity to
provide better patient care aligning payment with highly valued
services. Thank you again for inviting me and I am happy to
address any questions the committee may have.
[The prepared statement of Dr. Edgerton follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Burgess. The Chair thanks the gentleman.
Dr. Kavanagh, you are now recognized for 5 minutes, please,
for an opening statement.
STATEMENT OF BRIAN KAVANAGH
Dr. Kavanagh. Thank you, Chairman Burgess, Ranking Member
Green, and members of the Health Subcommittee. I am a radiation
oncologist at the University of Colorado. I treat cancer
patients there. I serve as the chair of the board of directors
for the American Society for Radiation Oncology, also known as
ASTRO.
ASTRO represents more than 10,000 individuals striving to
give cancer patients the best possible care. ASTRO's membership
includes radiation oncologists, nurses, cancer biologists,
medical physicists, and other healthcare professionals. Close
to 60 percent of all cancer patients will receive radiation
therapy and ASTRO's members treat more than one million cancer
patients each year.
Radiation therapy is a safe and effective treatment for
cancer. It works by damaging a cancer cell's genetic material
thus stopping its growth. When the injured cancer cells die the
body's natural healing processes remove them. Most treatments
are given as outpatient procedures and so patients can maintain
a high quality of life while receiving treatment. Of the
million patients treated annually with radiation therapy, about
60 percent receive care in hospital outpatient departments and
the other 40 percent receive care in freestanding community-
based centers.
Radiation oncology centers have extremely high fixed costs.
The minimum capital to build one is approximately 5\1/2\
million dollars. Radiation oncology reimbursement rates have
had cumulative payment cuts totaling approximately 20 percent
for freestanding community-based centers in recent years. These
payment cuts created instability throughout the profession,
jeopardizing the viability of these centers and patient access
to care.
ASTRO very much appreciates Congress' longstanding support
of radiation oncology, perhaps best exemplified by the
bipartisan passage of the Patient Access and Medicare
Protection Act of 2015 or PAMPA. However, PAMPA is not a
permanent solution and it only stabilizes radiation oncology
payments temporarily through the end of 2018. We believe it is
critical that radiation oncologists have an Advanced
Alternative Payment Model before PAMPA expires.
The Medicare Access and CHIP Reauthorization Act, MACRA,
has provided ASTRO with an opportunity to pursue an APM that
promotes high-quality care and moves us beyond the prior era of
uncertainty. Recently, the Center for Medicare and Medicaid
Innovation, CMMI, released a report to Congress which outlined
design considerations for implementing an advanced APM in
radiation oncology. ASTRO has proposed a Radiation Oncology
Alternative Payment Model, the ROAPM, and we are pleased to see
that our proposal is concordant with the concepts for an
advanced APM in the CMMI report.
Currently, there is only one oncology-focused advanced APM,
the Oncology Care Model, the OCM. However, ASTRO is concerned
that this model does not adequately address the needs of
patients who need radiation therapy and ROAPM is needed to
fully realize the benefit of multidisciplinary care for
patients. And we believe that the ROAPM would complement and
build upon the foundation set forth by the OCM.
The ROAPM is designed to incentivize the appropriate use of
cancer treatments that result in the highest quality of care
and best patient outcomes. The model applies to a comprehensive
list of cancer disease sites that account for more than 90
percent of Medicare spending on radiation therapy and include
breast, lung, prostate, colorectal, and head and neck cancers.
The ROAPM uses care episodes that are clearly defined by
billing codes that punctuate the beginning and end of a
treatment course and the 90-day period thereafter. An episodic
payment rate will enable practitioners to focus on high-value
patient care. The model features a two-sided risk corridor with
an opportunity for shared savings but also accountability for
excess resource utilization. Throughout the episode, physicians
must adhere to strict clinical practice guidelines.
These guidelines help to ensure that patient care is
appropriate and of the highest quality without over or
undertreating patients. In addition, the model rewards
participation in a robust practice accreditation program and
measures performance on accepted quality measures to promote
safe, high-quality care. The ROAPM also rewards shared decision
making with patients, efficient communication with other
providers caring for the patient, and survivorship planning.
In summary, ASTRO would like to thank Congress very much
once more for repealing the SGR with the MACRA legislation.
MACRA has ended the significant instability associated with the
SGR and created a forward-looking framework for the advancement
of value-based care. ASTRO fully embraces the spirit and goals
of MACRA and is committed to ensuring that radiation oncology
can fully participate in advanced APMs to drive higher quality,
cost effective cancer care.
The proposed ROAPM incentivizes the use of appropriate
cancer treatments that produce the best possible outcomes for
patients, helps rein in Medicare spending, can stand on its own
or dovetail with other APMs, uses well-established guidelines,
and contains key patient engagement components. After
experiencing significant payment cuts under Medicare fee-for-
service in recent years, the field of radiation oncology needs
long-term payment stability and predictability to secure
patient access to care. ASTRO is committed to moving full speed
ahead to ensure that radiation oncology can participate in
advanced APMs under MACRA that drive greater value in cancer
care. The next step is implementation of the ROAPM before
December 31st, 2018.
Thank you for the chance to speak with the committee.
[The prepared statement of Dr. Kavanagh follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Burgess. The Chair thanks the gentleman.
And Dr. Opelka, you are recognized for 5 minutes for an
opening statement, please.
STATEMENT OF FRANK OPELKA
Dr. Opelka. Mr. Chairman, Ranking Member Green,
distinguished members of the committee, we thank you for the
opportunity, the privilege to come before you today on behalf
of the 84,000 members of the fellows who are members of the
American College of Surgeons.
MACRA, to us, created a unique opportunity for physicians
to lead in the development of APMs. When you think about it,
since the inception of fee-for-service over a half a century
ago, clinical care has become increasingly more complex. We
have many more medications and technologies upon which to treat
patients. And the only way to succeed has been for us to form
teams, teams of care around patients for which these patients
suffer.
So we have come together in thinking about Alternative
Payment Models in team-based episodes of care to add to the
library of Alternative Payment Models to be considered. We
lacked the opportunity to build business models or payment
models around team-based care until MACRA came along with the
advanced APM opportunity. When you consider what has to go
forth in building that APM model there are five general
principles that I think that would be helpful to think about as
you do this.
First is the clinical care model, something we as
clinicians are all expert at, and those are those complex
models of team-based care that have changed today. Second are
the quality measures that assure that those models are
effective. Third, what are the payment models the insurer has?
That is that technical component that makes it difficult to
build the APM. We as clinicians are not those who have the
technical skills of building the payment model aspects.
Fourth is changing our business operations from fee-for-
service into these alternative risk-based models. And fifth,
the actual structure of risk, what is involved? There are all
sorts of aspects to risk. There is insurance risk. There is
clinical risk. There is operational risk of having the right
team ready to meet those clinical risks.
The PTAC has been a wonderful experience for us. We learned
with them. They were hypercritical of our model and helped us
in framing the model and making necessary adjustments and
corrections to the model. There was an enormous back and forth
between our team, the American College of Surgeons, and our
partner Brandeis University in building the APM model. We
partnered with Brandeis because of their knowledge in the
Medicare cost measurement system and their role in developing
the CMS Episode Grouper that is used by Medicare to frame the
actual cost structure of different episodes.
The Episode Grouper allowed us to provide risk-adjusted,
patient-individualized, significant target prices. Not a
bundle, but a patient episode price, extremely granular
information that allowed us to create an operational model for
national scaling of an implementation of an APM. When we come
about the quality aspect of this, the ACS has a centurylong
experience in multiple registries that we use worldwide in
defining, measuring, and improving quality of care.
Our ACS optimal resource for surgical quality and care and
safety division runs things like the National Surgery Quality
Improvement Program. These gave us a framework upon which to
build an episode-based measure framework. Stop measuring
physicians and measure patients. How did the patient do? If the
patient did well, reward the team. If the patient didn't do
well, it is time to penalize the team.
So let's measure patients and what they do and not the
individual physicians and make us all have shared
accountability because that is what patients expect us to do.
We have added to this the ability to put in the phases of care
across the episode. For example, in surgery there is a preop
phase, an intraop phase, a postop phase, post-discharge phase.
We have also put in patient-reported outcomes which we think
create meaningful measures. So instead of measuring here and
there across a surgeon's experience, we are measuring the
episode for the patient. We think that is critically important.
The episode-based measure framework coupled with the EGM allows
us to create quality cost measures with teams of providers to
influence the patient experience and outcome.
Assigning risk--this is the difficult part. Asymmetric
risk, we don't think symmetric risk, same upside-downside risk
really draws in what we need. We think you need asymmetric
risk, more upside to bring people out of fee-for-service into
the model and significant enough downside to protect the
patients and the payer as well.
So that is the nuts and bolts of what we put forward. The
PTAC process has given us considerable experience and input.
And moving forward now, we have gone through PTAC in December
all the way through March with approval in April. That went to
the Secretary, and within a couple months we heard back from
the Secretary giving us further direction, further
clarification, testing and piloting with CMS and CMMI. We have
been working with them almost on a weekly basis since then in
walking forward in workgroups to deal with intellectual
property, refinement of validity and reliability of the
modeling, further questions about how the EGM grouper is used
in the model, and the quality and the risk adjustment aspects
of the overall model.
Once again, Mr. Chairman, we thank you and your committee
for all your efforts in this regard, and we look forward to
your questions.
[The prepared statement of Dr. Opelka follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Mr. Burgess. The Chair thanks the gentleman and thanks to
all of our witnesses for participating today. We will move to
the question and answer portion of the second panel and I will
recognize Dr. Bucshon from Indiana for 5 minutes, please.
Mr. Bucshon. Thank you, Mr. Chairman. Thanks, everybody,
for being here. I was a cardiothoracic surgeon before I was in
Congress so I also reiterate what the chairman said about how
great it is to have an entire panel of physicians here at the
Health Subcommittee.
A couple of quick things. The American College of Surgeons,
Dr. Opelka and others, proper risk, and this is a little off
the beaten path, but proper risk stratification of patients and
assessing patient outcome and how important that is, I
mentioned in the previous panel the STS database and other, you
mentioned some databases.
I mean one of the things I have always been concerned about
as a physician when we are trying to design what is quality of
care, how important is, I think, individual specialties
assessing the risk stratification in the patient group that is
in their area. How important do you think that is?
Dr. Opelka. So if we are rewarding based on outcomes, there
is nothing more important than actually having accurate risk
adjustment and that comes ideally from clinical data. So we
have worked on this modeling with folks like STS. How do we use
the STS database to validate the current risk adjustment and
how do we use future versions of STS in this modeling to make
enhancements? We think that is the kind of work that needs to
be done so that you get proper risk-adjusted pricing as well as
proper risk-adjusted quality measurement.
Mr. Bucshon. Anyone else? Dr. Wulf?
Dr. Wulf. Two comments. I think data is useful, not only
for risk adjustment to identify your high-risk patients, but we
as primary care need accurate data to identify value in our
specialists. Historically, a primary care physician refers to a
specialist based on either knowing them and their kids play
soccer together, they trained together. We think of specialists
as quality, but data is so important as we in primary care seek
value for our patients and we can identify that through data.
Mr. Bucshon. Dr. Varga?
Dr. Varga. Yes, sir. And we would agree. Further, probably
the biggest issue for us is having adequate data as mentioned
to be able to do risk stratification. But it is not just simply
to get the right pricing, it is actually to understand the
level of care that the patient requires at any point in the
continuum and then understand how to match resources to that
level of risk stratification. It is critical whether you are
talking about a primary care scenario or whether you are
talking about a complex cardiovascular surgery case.
Mr. Bucshon. Anybody else have a----
Dr. Edgerton. I would agree. From the rheumatology
perspective we know that our patients with rheumatoid arthritis
suffer from other comorbidities that have a massive impact on
their outcomes, but that is also important when we are looking
at the cost of their care. We have struggled to extract that
data from our EHRs despite the fact that we spend large amounts
of time entering data into the EHRs. We have designed a
clinical data registry called a RISE Registry as a college to
help us do that, to extract some of that data, but it continues
to be a struggle.
Mr. Bucshon. Yes. I agree with everything everybody said
because I think Government agencies tend to maybe think if you
give a couple of little, a couple data points in health care
like overall morbidity or overall mortality without getting a
bigger, deeper dive, especially specific deeper dive, you can,
these things don't work out that well because it is just not
specific enough.
Dr. Wulf, you probably know I read, I co-led the letter to
CMS about certain payment arrangements between Medicare
Advantage plans and physicians as advanced APMs under MACRA.
And I understand, you mentioned CMS has come out and said that
a new MACRA rule that they would be initiating a demonstration
project to test the approach, and I know CAPG has been a
leading voice in pushing this.
So can you talk about the importance of APMs in a little
more depth than you did in your testimony as it relates to
Medicare Advantage and why CMS should move quickly along with
this demo?
Dr. Wulf. Yes, and thank you for that effort, Dr. Bucshon.
Just like as we entered into shared savings and now risk with
Medicare Advantage, we were able to provide for that subgroup
of our seniors certain benefits that we were able to pay for
with a per-member, per-month payment. Through CPC+ we were able
to expand those benefits to all of our seniors.
So just as we are now with APMs recognizing and providing
programs for Medicare, it would be unfair to exclude the one-
third of patients in Medicare Advantage from those type of
fundings that all medical groups use to create coordinated
care. So I think it is important that all programs are for all
seniors, fee-for-service Medicare and Medicare Advantage and I
think this is a step in that direction.
Mr. Bucshon. OK, thank you.
I yield back, Mr. Chairman.
Mr. Burgess. The Chair thanks the gentleman. The gentleman
yields back. The Chair recognizes the gentleman from Texas, Mr.
Green, ranking member of the subcommittee, 5 minutes for
questions, please.
Mr. Green. Thank you, Mr. Chairman. I want to thank our
whole panel for joining us today.
Dr. Varga, I understand that transitioning from a
healthcare organization to an Alternative Payment Model can be
challenging and there are a lot of moving parts to consider. In
your testimony you discuss how MACRA encouraged Texas Health
Resources to participate in the Next Gen ACO model. Can you
speak a little more about what it is like at Texas Health
Resources before implementing the Next Gen ACO model and why
this model was the best fit for your organization as opposed to
an APM?
Dr. Varga. Yes, sir, happy to respond. As I pointed out in
my oral testimony, first and foremost for Texas Health
Resources and for the Southwestern Health Resources ACO, this
was an issue of access to care. With a large percentage of the
doctors in North Texas not participating in fee-for-service
Medicare program there is a very difficult scenario for folks
who are aging out of commercial insurance and aging into
Medicare actually finding a primary care doctor and in some
situations a specialist who actually accepts patients in the
fee-for-service model.
A bit of workforce constraint as well in the Medicare
Advantage program there as well, one of the things we really
wanted to make sure we did with this is by offering the
incentive programs that come through the Next Gen Alternative
Payment Model, we are able to actually incent physicians to
participate and continue to see Medicare fee-for-service
patients.
I think the other thing that we are experiencing in this is
the ability to really coordinate care across the full continuum
with our physicians, whether it is specialists or primary care.
We have already shown that we can generate savings in the
model. We already started to demonstrate that we can actually,
in very targeted areas with adequate data, start to decrease,
which in North Texas is a big issue which is overutilization of
post-acute services whether it be rehab, skilled nursing
facilities, or home health.
So the program has made an incredible impact on us, and we,
like Dr. Wulf's group, believe that we can extend that into the
Medicare Advantage program as well as move forward.
Mr. Green. How did MACRA and the opportunities it created
hasten this decision to engage in a delivery system reform and
participate in the Next Gen ACO model?
Dr. Varga. I think probably the reason that MACRA
accelerated this is in the MSSP Track 1 program that we have
historically participated in, the cap on upsides really created
a model that, in terms of looking at what sort of benefits we
could return to physicians in that model, was relatively
limited. The other piece of the Track 1 model that was very
different from Next Gen is some of the waivers we get in Next
Gen to be able to more aggressively coordinate care across the
full continuum and actually take in different sorts or adopt
different payment models like advanced care coordination fees,
sub-capitation, actually full cap, really creates a model where
we can actually get our group of folks to manage these patients
across the full continuum.
The ability to create value, both for the patients and for
the physicians in the network, is far superior to the model we
had in Track 1.
Mr. Green. What was the challenge to get your providers to
get comfortable with the level of financial risk posed by the
Next Gen's ACO model?
Dr. Varga. Well, that is one of the reasons we believe in
this integrated model is that as it was mentioned earlier, the
concept of asymmetric risk is one that is tolerated in this. So
given that the health system and the Part A expense of the
model is usually the most expensive piece of this, the health
system provider can absorb upfront the bulk of the risk, both
the risk incurred by building infrastructure, but also the
potential for downside risk and the ability to help physicians
manage that piece as they went forward.
So we really had very little resistance to the providers
stepping in to a two-way risk model.
Mr. Green. And what type of infrastructure changes in
provider education did Health Resources require to implement
that Next Generation ACO?
Dr. Varga. The biggest change above the MSSP Track 1, which
we had been in for the last 3 years, was really a far more
aggressive care coordination model for mostly the post-acute
world. That is really in our ACO where the data points us. We
had already undertaken a fairly significant investment that
allowed us to help our doctors get onto a common electronic
health record platform with us, a common disease registry
platform to point out gaps in care, and a common analytics
platform for reporting. The biggest issue was actually in
putting the technology and bodies in place to be able to do the
post-acute care coordination model.
Mr. Green. Mr. Chairman, normally as a lawyer I have plenty
of lawyers in the room, today we have plenty of physicians. And
I think that is what is important, to make sure you are
comfortable with what we are doing and again not recreating an
SGR that goes 17 years and really hurts medical practice and
your patients. So thank you for having the hearing.
Mr. Burgess. The gentleman yields back. The Chair thanks
the gentleman.
And Dr. Friedman, Ranking Member Green brings up an
excellent point. And as I was talking to you before the hearing
convened, I can remember a morning probably 2005 or 2006 when I
had to face a roomful of your participants all sitting around
little round tables down in a room in the basement of this
building, and it was significantly stressful. I thought
everyone was going to be eager to hear what my thoughts were on
repealing the SGR, but nobody wanted to hear what they were.
They just wanted it done, and they wanted it done last week.
So I felt the anxiety. It only took us 13, 14 years to get
to this point, but it was largely your group, that group of
doctors that morning, that really provided the, you know, the
lift and the thrust to get this thing done. Do your doctors
ever talk about that now? Are they grateful the SGR is gone or
have we just moved on and now we are at the next thing?
Dr. Friedman. Sorry. So just repeat that last part of the
question.
Mr. Burgess. Well, are your doctors, do they talk about
things like that now? Are they grateful the SGR is gone or are
they just worried about the next phase?
Dr. Friedman. I think it is a mix. You know, I think, you
know, I spent a fair amount of time polling my colleagues in
the office before I came to do this and I get mixed remarks.
From the standpoint of patient care we have seen some big
benefits. Care coordination has improved and outreach to
patient has improved. We don't go to the hospital anymore. We
are just strictly outpatient doctors, so we are in the office.
And from that standpoint we have gotten very good at retrieving
the information and getting the patients into the office so
there is continuity of care.
So things have been great. And I have to say that, you
know, the fee-for-service model was not working for us. I mean
we, had we not embraced this model, had we not embraced CPCI
and Patient-Centered Medical Home early on and now CPC+, we
would have sold our practice to a larger system. So I think
they would all acknowledge that.
That being said, I think the administrative burden that we
see in the office, the physicians' administrative burden, and
also my administrator's, the amount of work that she has to do
has increased, and that is a bone of contention.
Mr. Burgess. Very good.
Dr. Varga, you in your testimony talking about that Premier
doesn't simply want to employ physicians, you want to create
those high-value networks so you have doctors who are basically
private practice doctors who are working within your network;
is that correct?
Dr. Varga. We do.
Mr. Burgess. And kind of a 60/40 split on that between
employed physicians and independent physicians?
Dr. Varga. With the 60 being the independent PCPs.
Mr. Burgess. How do you allow them to maintain their own
independent practices and at the same time conforming to the
measures that you are requiring to improve outcomes?
Dr. Varga. It is a good question. I think the biggest issue
for us as we started was actually getting everyone to commit to
a pluralistic physician model where in large part we are
largely agnostic to the physician economic relationship with
the health system.
So as we said we have faculty, we have employed, and we
have independent PCPs. We also have independent specialists who
participate with our ACO in a nonexclusive fashion through a
series of structures that we have built inside the ACO. I think
the common thread, Mr. Chairman, is simply that, independent of
the economic relationship folks have with this, we all have
aligned incentives, we all work off of a common infrastructure,
and we are all held accountable to the same clinical
performance metrics.
And we really believe that it is highly valuable to have
that pluralistic model in play because an employed-only model
really tends to drive you to one sort of structure. It can
work, but you don't really learn from the independent practice
proposition. You also don't learn from folks who are
nonexclusive to your network as well.
Mr. Burgess. So you also talk about the anxiety and
complaints. How is that part of it going?
Dr. Varga. You know, it has actually gone fairly well. You
know, we are fortunate in North Texas that the economics of the
two-way risk ACOs are actually a little bit better than they
are in some other areas of the country, so we have been able to
produce shared savings at a fairly hefty rate for the last 2 or
3 years. We still have complaints, and I think one of the
things that we will start to really encounter as we go forward
is we have not yet had to really, really drive the narrowness
of the network in terms of----
Mr. Burgess. Have not.
Dr. Varga. We have not, in large part because the
physicians have largely performed to the set of standards that
we have set in predominantly a one-way risk model. As you get
into a much more aggressive two-way risk model, as you get into
Medicare Advantage, the importance of really, really high-
performing physicians becomes absolutely critical.
Mr. Burgess. And Dr. Edgerton, your practice would, you
know, of all of the different types of practices that I worried
about as we were doing this, your highly specialized, small
office, I mean that was the one that I thought was going to
have the most difficult time with any sort of adjustment along
these lines, but you have done it. Is that right?
Dr. Edgerton. That is correct. And we are approaching now
that pilot phase. One of the real benefits has been the
interaction with PTAC. Interestingly enough, because they can't
reach out to us directly, it was largely looking at the PTAC
Web site and the way that they are so transparent. In studying
the feedback they had given to different models that were
similar to what we were thinking about and being able to learn,
it is sort of like a university of APMs if you spend enough
time on their Web site and see the comments that come both from
PTAC and from other stakeholders.
So that has really been useful in moving us along, not only
as a small office but also as a small specialty.
Mr. Burgess. Very good. And I do need to observe that we
have a vote on and I do want to recognize Mr. Guthrie for his
questions.
Dr. Bucshon, we probably won't have time to go to a second
round if that is OK with you.
Mr. Guthrie. Do you want me to yield to you? Do you have
any more questions?
Mr. Burgess. No. I will yield to you and please go ahead
with your questions.
Mr. Guthrie. Hey, Larry, I will ask one quick one if you
want to go into--OK.
Dr. Varga, since joining an APM what have you been able to
accomplish and what do you hope to accomplish in the future
with regard to patient outcomes?
Dr. Varga. So I think the first thing we have been able to
accomplish--and I can't emphasize this enough to the
committee--is, number one, we have for the first time I think
in history had comprehensive data on the population of Medicare
beneficiaries that we are managing, which opens up a world of
opportunity. As folks who are physicians would tell you, if you
give doctors useful, reliable, timely data, 99 times out of 100
they will make the right decisions off of that data. And so it
starts with that.
I think the second piece is we have been able to align
incentives with our physicians, our hospital providers and our
post-acute providers to really take a patient-centric, patient-
oriented approach around quality and efficiency and be able to
really drive that care model. I think we are excited about the
savings we have generated. We are also very proud of the
quality metrics we have generated within the program as well.
And I think the last thing that I would say in that is it
has really turned the culture. We think far more in an ACO-
centric way than we do in a hospital-centric way now, because
our lives live in the ACO and we coordinate care in the ACO.
The hospital is one very small----
Mr. Guthrie. Thanks. I want to--now I have a couple of
physician friends here that have practiced under this and they
may have a different perspective. I want to make sure they have
a chance to ask what they want to ask.
So Dr. Bucshon, I will yield.
Mr. Bucshon. Thank you, I appreciate that.
I mean this is more on a personal level. I mean, I think
for those of you who are in an APM, do you think participation
in an APM has affected positively the quality of life of
physicians in all of your practices and do you in the job
satisfaction amongst physicians, because I think all of us know
that there has been a decreasing job satisfaction amongst
physicians in all specialties over maybe the last 20 or 30
years, and our ability to recruit quality people to go into all
of our specialties maybe has become a little more difficult. So
do you think participating in these APMs and the way we are
redoing the system maybe will improve those circumstances?
Anyone want to comment?
Mr. Guthrie. I am noticing my time. We probably just have
time for one answer and then we are going to have to go vote.
So go ahead, Dr. Wulf.
Dr. Wulf. I would comment from a primary care standpoint,
absolutely. That we are able to get to a payment model that
rewards quality instead of volume, and this does that, makes
all the difference. And I have been asked before what is the
tipping point for this and it actually is not financial. The
tipping point is physicians understanding that you can get them
into a contract model that will pay for quality and pay for
value. And so absolutely it is these type of payer contracting
relationships have changed our physicians' lives and made a
very difficult clinical life much more palatable.
Mr. Guthrie. Thanks. I wish I had more time for everyone
else, but we are called to the floor. So I will yield back my
time to the Chair.
Mr. Burgess. And the gentleman yields back. The Chair
appreciates that. We have a series of votes on the floor that
is going to consume some time, so I think we can conclude the
hearing and dismiss you all and not have to reconvene after
votes. But I do want to thank all of you for being here today.
We have received outside feedback from a number of
organizations and I would like to submit their statements for
the record: The American Association of Nurse Anesthetists, the
American Society of Anesthesiologists, the American Medical
Association, the American Physical Therapy Association,
Healthcare Leadership Council, American Society of Clinical
Oncology, AHIP, the HSSR Coalition, American Hospital
Association, American Association of Nurse Practitioners, the
Society of Thoracic Surgeons, the American Academy of
Orthopaedic Surgeons, and without objection, so ordered. Those
will be made part of the record.
Pursuant to committee rules, I remind Members they have 10
business days to submit additional questions for the record. I
ask witnesses to submit their response within 10 business days
upon receipt of the questions. And without objection, thanks
again. The subcommittee is adjourned.
[Whereupon, at 1:09 p.m., the subcommittee is adjourned.]
[Material submitted for inclusion in the record follows:]
Prepared statement of Hon. Greg Walden
I thank Chairman Burgess for his continued leadership on
MACRA, as well as Ranking Member Pallone, for the bipartisan
slate of witnesses we have before us today.
Today marks our third hearing since the passage of MACRA.
Just as this committee led the effort to find a solution to SGR
and other issues then, we continue our oversight over the
bipartisan law and remain committed to its successful
implementation.
As my colleagues know well, we worked over many years to
address the problems associated with the SGR and impending
yearly payment cuts to doctors that inevitably were avoided
thanks to short-term, temporary patches--17 in all. It seems
like this was so long ago, but we must not lose perspective of
what we have accomplished. Particularly now as we continue to
move forward on the implementation of this important law.
MACRA is up and running and today we will hear about the
most forward looking aspect of the law--Alternative Payment
Models (APMs). Today, they are already delivering better
outcomes for Medicare beneficiaries and returning savings to
the Medicare program. This is not a hypothetical--the
transition to value is real, and very much underway and
delivering results.
MACRA has already proved to be a success. It has acted as
an accelerant on doctors being able to enter into new team
based arrangements, to think about their patient populations
through payments that reward outcomes, and to take what they
knew worked in the private sector and carry it over to the
Medicare program.
Most importantly, APMs finally reward providers for all the
things they have always wanted to engage with patients on, but
instead were forced to simply ``do more'' to be able to afford
to stay in the Medicare program. MACRA delivered that change.
Physicians in qualified APMs will receive a 5 percent bonus
from 2019-2024. Technical support is provided for smaller
practices to help them participate in APMs. We will hear from
the Physician Technical Advisory Committee (PTAC), another
successfully implemented element of MACRA, that is further
helping physicians create models that are data driven with
physicians in the driver's seat.
We are still in the early stages of moving away from
traditional fee for service, but these efforts continue to be
embraced by the physician community who are eager to assume the
risk if it means being put back in the charge within an APM to
best direct care for their patients and to be judged on
outcomes.
We expect to hear today from our witnesses who come from
diverse backgrounds. They train and practice across the
country, in rural and urban settings. Each are practicing
physicians, in different arrangements and all have worked with
their organizations to provide tools and best practices that
other physicians can utilize and learn from to be better
positioned to succeed under MACRA.
This committee stands with the physician community in our
united goal of a successfully implemented MACRA and we will
continue to work with you in a bipartisan fashion to see that
the law delivers on its promises.
That said, I think we should all be very excited by the
work already underway by our witnesses to make tangible
differences to the care delivered to the country's Medicare
beneficiaries. I look forward to hearing more about their
efforts and continuing to work toward a successful
implementation of MACRA.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]