In the past two decades, exploration of opportunities to improve efficiency and patient outcomes in health care delivery have become ever more important. This move towards efficiency and patient outcomes in health care delivery is necessary as half of all adults in the United States have at least one chronic health condition, with one in four individuals having two or more.[i] In fact, individuals with chronic conditions encompass 84% of national health care spending.[ii] The need to change from a fee-for-service model to a value-based system is substantial, as Medicare paid physicians approximately $130 billion, a fifth of the program spending, in 2015 alone.[iii] Under fee-for-service models, providers are incentivized to maximize their treatment of patients to compensate for a system they do not think provides sufficient reimbursement. Due to providers taking advantage of the fee-for-service model there is a shift towards value-based payment models underway. Under new leadership focused on provider concerns with payment reform, it is likely CMS will be careful to implement changes that may lower provider reimbursement and discourage provider participation in the program. As policymakers and the industry explore ways to address the sustainability issues this environment presents and incentivize change in provider behaviors, providers should explore reimbursement opportunities that will allow for advancement of infrastructure supportive of the complex populations they serve while moving towards value-based delivery models in the long-term.
An Enhanced Provider Focus at CMS
While bending the cost of care is a bipartisan concern underscored by the passage of MACRA in 2016, HHS Secretary Tom Price has been very outspoken in his stance against much of the regulations for value-based payment reforms under MACRA and the potential impacts they may have to the patient-provider relationship.[iv] Secretary Price’s specific concerns have focused on the doctor-patient relationship and whether a shift away from fee-for-service payment models could limit physician discretion in their management of patient care.[v] Without further engagement of impacted stakeholders in the design and implementation of quality based payment programs such as bundled-payments for hip and knee replacements and other quality and outcome-based models, Secretary Price and others from the Congressional Doctor’s Caucus question whether such programs may be successful or may cause undue harm through changing the clinical decision making process.[vi][vii]
It is inevitable that the health care system will over time shift away from the fee-for-service model overall as it encourages greater use of services, ultimately playing a major role in driving unsustainable costs in health care without delivering quality care. However, the resistance across the health care industry is likely to dramatically slow such a shift, especially under the leadership of Secretary Price and CMS Administrator Seema Verma. During her confirmation hearing, Administrator Verma underscored the need to ensure providers want to participate in Medicare, stating:
“We don’t want to see that our policies and our programs are actually preventing providers, that we’re losing providers and that they don’t want to see Medicaid or Medicare beneficiaries anymore. We’ll be very careful with policies so that we’re not pushing providers out of the system but that we’re actually attracting providers to the program.”
The implementation and logistical challenges that must be overcome to succeed in a value-based payment system lie with many stakeholders in the industry. As these challenges are explored, it could be anticipated that Secretary Price will seek to redirect the impacts of MACRA on the delivery of Medicare services and keep payment models advantageous to providers intact through programmatic changes allowed for in the law.[viii],[ix]
Incentivizing Adoption of Chronic Care Management
The enhanced provider focus at CMS presents substantial opportunity for providers and advancing health care delivery systems to at once benefit from adoption of existing incentives, like Chronic Care Management (CCM) reimbursements. Of the millions of Medicare beneficiaries with multiple chronic conditions eligible for services under the program, just over 500,000 beneficiaries had received services as of November 2016 under the program because of rigid billing requirements.[x] In response to industry feedback on the initial implementation of this program and sustained priority for investment in comprehensive care management, CMS-implemented changes to the CCM program for 2017 to incentivize greater provider adoption of the value-based program, including higher reimbursement for CCM services and simplified documentation requirements.[xi] Under MACRA, as part of comprehensive changes to the payment models across Medicare, the Secretary is required to draft recommendations by the end of 2017 for increasing the appropriate use of CCM, which likely indicates its continued inclusion in the physician fee schedule for the foreseeable future.
CCM incentivizes providers to implement care management practices that enhance focus on a patient’s outcomes. This is a natural precursor to pay-for-performance models that reward providers for various measures of quality or efficiency, a policy lever used to promote innovation in care delivery. The problem with value-based care as it’s been implemented to-date is that goals are not generally measurable or quantifiable, which ultimately makes it difficult to determine whether a program has been successful. To date, many value-based care models are a work in progress, with insufficient evidence of success and experimentation ongoing across the public and private sectors.[xii] However, care management as a part of a team-based, patient-centered approach has been shown to be a key component for successful value-based care implementations.[xiii] Progress may be made towards more successful, value-based infrastructure and provider behaviors where providers and health systems are able to pursue greater adoption of protocols that take advantage of CCM reimbursements.
Optimizing Diverse Approaches in Payment Reform
There is considerable need for solutions that address the growing necessity of care coordination for Medicare beneficiaries in a sustainable fashion. [xiv] As the future of value-based payments under Medicare is explored, the Administration will seek to address the demands of many physician groups who have sought changes to the MACRA program and raised concerns regarding whether sufficient evidence has been collected on the models proposed.[xv] Where the perspectives of providers are concerned, Secretary Price is likely to be supportive, with organizations like the American Academy of Family Physicians and American Medical Association encouraging providers to take advantage of revenue opportunities under the Chronic Care Management program.[xvi] The expansion of CCM in the 2017 fee-for-service schedule to encourage its adoption, as well as its acknowledgement under MACRA, is an opportunity to aid providers accustomed to fee-for-service move towards value-based coordination while continuing to address beneficiary utilization rates and health care needs. As CMS “doubles down” on their investment in CCM, providers would be prudent to explore this prospect as part of a larger strategy to improve the effectiveness and efficiency of services they provide to their Medicare patients.
[i] Centers for Medicare & Medicaid Services (2016). Chronic Care Management Services Webinar. Accessed April 6, 2017 from: https://www.cms.gov/About-CMS/Agency-Information/OMH/Downloads/CCM-Webinar-Presentation.pdf.
[iii] Centers for Medicare & Medicaid Services (2016). Medicare Provider Utilization and Payment Data: Physician and Other Supplier. Accessed March 31, 2017 from: https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/medicare-provider-charge-data/physician-and-other-supplier.html.
[v] Japsen, Bruce (2016). As Trump’s HHS Secretary, Tom Price Could Slow Shift To Value-Based Care. Accessed April 4, 2017 from: https://www.forbes.com/sites/brucejapsen/2016/11/29/as-trumps-hhs-secretary-tom-price-could-slow-shift-to-value-based-care/#5ebde18f636f.
[vi] Bruce (2016).
[vii] Findlay, Steve (2017). Implementing MACRA. Health Affairs: Health Policy Brief. Accessed March 31, 2017 from: http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=166.
[viii] Cragun, Eric (2017). 5 things providers should know about new HHS Secretary Tom Price. The Advisory Board Company. Accessed August 17, 2017 from: https://www.advisory.com/research/health-care-advisory-board/blogs/at-the-helm/2017/02/5-things-to-know-tom-price.
[ix] Finnegan, Joanne (2017). HHS’ Tom Price says the Trump administration won’t dictate payment model reforms to doctors. Fierce Health Care. Accessed August 17, 2017 from: http://www.fiercehealthcare.com/practices/price-says-trump-administration-won-t-dictate-to-doctors.
[x] Levin, Eric (2017). 3 Big Changes to CMS’ Chronic Care Management Program in 2017. McKesson. Accessed March 31, 2017 from: http://www.mckesson.com/bps/blog/3-changes-to-cms-ccm-program-in-2017/.
[xi] Centers for Medicare & Medicaid Services (2016). Chronic Care Management Services Webinar. Accessed April 6, 2017 from: https://www.cms.gov/About-CMS/Agency-Information/OMH/Downloads/CCM-Webinar-Presentation.pdf.
[xii] Damberg, C. et al (2014). Measuring Success in Health Care Value-Based Purchasing Programs. RAND. Accessed April 6, 2017 from: http://www.rand.org/content/dam/rand/pubs/research_reports/RR300/RR306/RAND_RR306.pdf.
[xiii] Agency for Healthcare Research & Quality (2016). Care Management: Implications for Medical Practice, Health Policy, and Health Services Research. Accessed April 6, 2017 from: https://www.ahrq.gov/professionals/prevention-chronic-care/improve/coordination/caremanagement/index.html.
[xiv] Neuman, T., Cubanski, J., Huang, J., & Damico, A. (2015). The Rising Cost of Living Longer: Analysis of Medicare Spending by Age for Beneficiaries in Traditional Medicare. Kaiser Family Foundation. Accessed March 31, 2017 from: http://kff.org/medicare/report/the-rising-cost-of-living-longer-analysis-of-medicare-spending-by-age-for-beneficiaries-in-traditional-medicare/.
[xv] Findlay (2017).
[xvi] American Academy of Family Physicians (2016). AAFP Chronic Care Management Toolkit. Accessed April 4, 2017 from: https://nf.aafp.org/Shop/coding-tools/aafp-ccm-toolkit.