Friday, March 16, 2018

Gas up the DeLorean, We’re coming back for you APMs

My colleagues and I have not been shy about our belief that a functional consumer-driven marketplace is a viable solution to curbing health care spending and ramping up health care quality. While 2017 was a year riddled with flux on this front as the then-HHS secretary Price seemed to be moving away from policy changes that would make this marketplace feasible, 2018 and several recent remarks by new HHS secretary Alex Azar have given us reason to be cautiously optimistic.

In a March 8th speech to America’s Health Insurance Plans, Azar positioned himself as a champion of value based care, transparency, consumer engagement, and a complete shake-up of the existing system. He said, “There is no turning back to an unsustainable system that pays for procedures rather than value. In fact, the only option is to charge forward—for HHS to take bolder action, and for providers and payers to join with us. This administration and this President are not interested in incremental steps. We are unafraid of disrupting existing arrangements simply because they’re backed by powerful special interests.”

When I say we’re cautiously optimistic, the caution comes from the fact that this is just signaling; the optimism is because signaling is 90% of where the change comes from in health care. Moving our health care system away from fee-for-service requires creating enough momentum with existing players to overcome the inertia of simply maintaining the status quo. Azar’s remarks came at a pivotal time in that they preceded the March 12 deadline for potential users to submit intent to participate in BPCI-A.

Launched by the Center for Medicare and Medicaid Innovation, the Bundled Payment for Care Improvement Advanced (BPCI-A) is a voluntary bundled payment model that qualifies as an Advanced Alternative Payment Model under the Quality Payment Program. Though it still has some bumps that will need to be smoothed out, it’s quite an improvement over its predecessor. The overarching advance is that by introducing out-patient episodes and allowing physicians to initiate and own episodes it is moving towards being physician-centric rather than hospital-centric. This represents a significant shift towards the marketplace model given that if you want to create competition your best bet is to do it at the practice level rather than unintentionally encouraging systems to band together into large oligopolies and jack up prices.

At the Center for Value in Health Care we are all in when it comes to APMs. Building on the foundation of PROMETHEUS Payment over the last decade, and Bridges to Excellence prior to that, we’ve designed, implemented, and evaluated bundled based payment systems from the point of view of payers at every level including geographically localized payers like Community Health Choices in Harris County Texas, statewide initiatives like New York State Medicaid, and national insurers such as Cigna. We’ve also continued to improve the Bridges to Excellence program (BTE), an early pay for performance model that incentivizes physicians to provide high value care. In the most recent redesign effort we’ve given providers even more ownership over participating in the program by creating a direct access portal for them to upload their EMR data for certification.

As we continue to do our part, we’ll see if the current HHS secretary is going to back up his promises with actions. If he’s serious it shouldn’t be hard to shift into a higher gear given the 4 to 5 APMs that have already been recommended for CMS implementation by the PTAC. These APMs sat on Price’s desk gathering dust; an indication that he is doing more than talking the talk would be for Azar to brush the dust off and put the recommendations into action. We maintain our cautious optimism that a true health care marketplace is on the horizon. It is our sincere hope that Azar’s remarks at the outset of his tenure foreshadow the start of a virtuous cycle of change.


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