Posted in Accountable Care, Affordable Care Act, health insurance reform

CMS Quality Measure Development Plan: A DRAFT

by Gregg A. Masters, MPH

An inspirational leader and ‘disruptive‘ politician taken down well ahead of his time once opined:

“Ask not what your country can do for you, ask what you can do for your country…” John Fitzgerald Kennedy

Fast forward some 55+ years and season such an invitation with the relentless drone of 24/7/365 faux patriotism, hate mongering, intolerance, and emotive ‘hell no‘ sound-bytes proferred by those who self righteously claim title to the ‘take back our country’ narrative and you may ask yourself how did we get from there (the Peace Corps) to here (carpet bomb em)?

Yet, in our unique strain of American democracy even through studies empirically demonstrate a consistent disconnect between what Americans want and what their representatives codify via policy with a capital ‘P’, the bottom line is look in the mirror ‘we are the government’.

CMS_quality_development_planWhether it’s the creation and passage of what merged into the ‘Affordable Care Act‘ (ACA) or how the ‘public’ participates in both the legislative process and its implementation via the rule making process initiated aka the ‘notice of proposed rule making’ (NPRM), we are presented with both the opportunity and as it turns out obligation to engage in and thus granularly shape (via a dialectical bottoms up vs. top down exchange) the ground rules which in turn govern our economy and the conduct of its constituent industry stakeholders.

In the quest to advance the efficacy of quality initiatives (garbage in garbage out) one recent effort is the DRAFT release of the ‘CMS Quality Measure Development Plan: Supporting the Transition to the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models‘.  

As an industry we are process oriented sometimes to a fault. Moreover the ‘check the box’ or drop down nature of many of these measures lends itself to the argument that the state of the industry to actually measure, document and report healthcare quality is at best a crude representation of what is actually going on. Clearly there is more work to be done if this industry is to matter.

To help readers of this blog, the introduction of the executive summary is pasted below:

I. Executive Summary

Background

A transformation of the U.S. healthcare delivery system gained momentum in 2010 with the passage of the Patient Protection and Affordable Care Act (Affordable Care Act).1

The law established the Health Insurance Marketplace to extend consumer access to affordable care through private payers and provided strong incentives in publicly financed healthcare programs to connect provider payment to quality of care and efficiency. 

Building on the principles and foundation of the Affordable Care Act, the Administration announced a clear timeline for targeting 30 percent of Medicare payments tied to quality or value through alternative payment models by the end of 2016 and 50 percent by the end of 2018.
These are measurable goals to move the Medicare program and our healthcare system at large toward paying providers based on quality, rather than quantity, of care.2

The passage of the Medicare Access and Children’s Health Insurance Program (CHIP)
Reauthorization Act of 2015 (MACRA)3 supports the ongoing transformation of healthcare delivery by furthering the development of new Medicare payment and delivery models for physicians and other clinicians. Section 102 of MACRA4,i requires that the Secretary of Health and Human Services develop and post on the CMS.gov website “a draft plan for the development of quality measures” by January 1, 2016, for application under certain applicable provisions related to the new Medicare Merit-based Incentive Payment System (MIPS) and to certain Medicare alternative payment models (APMs).

The law provides both a mandate and an opportunity for the Centers for Medicare & Medicaid Services (CMS) to leverage quality measure development as a key driver to further the aims of the CMS Quality Strategy:

• Better Care,
• Smarter Spending, and
• Healthier People. 5

Measure Development Plan Purpose
The purpose of the CMS Quality Measure Development Plan (MDP) is to meet the requirements of the statute and serve as a strategic framework for the future of clinician quality measure development to support MIPS and APMs. CMS welcomes comments on this draft plan from the public, including healthcare providers, payers, consumers, and other stakeholders, through March 1, 2016.ii The final MDP, taking into account public comments on this draft plan, will be posted on the CMS.gov website by May 1, 2016, followed by updates annually or as otherwise appropriate.i

So here it is… have at it. Perhaps your input will in fact shape the substance and steward the glide-path of how the transformation from volume to value can be realized. Certainly it’s worth your consideration. Afterall, another attributed Kennedy quote with biblical DNA may apply here:

“We are not here to curse the darkness, but to light a candle that can guide us through the darkness to a safe and sure future. For the world is changing. The old era is ending. The old ways will not do.

The problems are not all solved and the battles are not all won and we stand today on the edge of a New Frontier – a frontier of unknown opportunities and perils, a frontier of unfulfilled hopes and threats.

It has been a long road to this crowded convention city. Now begins another long journey, taking me into your cities and towns and homes all over America.

Give me your help. Give me your hand, your voice and your vote.”

John Fitzgerald Kennedy

Posted in Accountable Care, Affordable Care Act, health insurance reform

12 Steps to the Triple Aim or Value Based Healthcare

by Gregg A. Masters, MPH

It has been challenging at times being in the ‘innovation conversation’ dating back to the 70s (who remembers ‘WIN’ [whip inflation now], PSROs or even HSAs (no, not the WIN \ Whip Inflation Nowprivatization funding mechanism, but the CON overlords) watching what get’s reported by industry press or online media as ‘innovation‘ or ‘bold new thinking‘ amidst a ‘cottage industry’s’ 3x trillion spend rate – including it’s culpable supply chain and many vendors (some may even say ‘pigs’) at the trough.

As indicia of the impending collapse of our aging house of cards healthcare delivery and financing industry (continued burnout rates driving physician exits to direct practice or concierge medicine, un-ending and nauseating opposition to the ACA, mega and no so mega hospital mergers, associated practice acquisitions and health plan consolidation, not to mention the codification of the cost shift charade via the lower metals designations of the ACA and including armies of dissatisfied patients suffering in a provider centric culture) continues to accumulate, it affirms what Esther Dyson once presciently characterized as the ‘calcified hairball‘ given it’s ‘resistance is futile’ [to change] nature.

Healthcare Inflation

Recent healthcare inflation moderation trends notwithstanding (see: ‘2014 National Health Spending; The Great Moderation Likely Not Over‘ by healthcare futurist Jeff Goldsmith) whether a function of ACA implementation in part of as a whole, the industry has essentially and collectively failed to deliver on the principles of the triple aim – which existed in spirit considerably before it’s labeling by the Institute for Healthcare Improvement (IHI). Providers continue to maximize their profits or ‘excess revenues over expenses’ for the ‘non-profit’ [aka tax exempt’ sector] often at the expense of community benefit.

Perhaps no other chart series in line item detail captures and evidences this slow burn of fail as the progressive and relentless growth of one man’s healthcare premiums in California. Take note of the persistent [cost] shift from the payer (health plan) to the patient or beneficiary.  If this is the best we can do via ‘wholesale purchasers’ (market savvy health plans) leveraging millions of members and ‘medical management’ and network contracting infrastructure, how can an army of independent and often clueless if not dis-empowered agents (patients, members sometimes at the point of service) do better?

[Editor’s note: one reason for an earlier post on the need for a ‘new IPA’ i.e., independent patient association]

This testimony was provided by Josh Libresco to the Department of Managed Care in California during their consideration of rate hikes by health plans.

Testimony1

Testimony2

 

 

 

Time for a New Manifesto?

With this history as both context and some may say ‘institutional memory’, I thought I might make sense to take heed of what’s become rather well known in the 12 step recovery community (from AA to Al-anon and many derivatives) which is to admit our ‘addiction’ to the arguably ‘easier softer path’, i.e., fee for services medicine.

Perhaps this can be a manifesto of sorts to embrace as we embark upon this journey for volume to value based healthcare?

Adapted from the 12 Steps of Alcoholics Anonymous

1. We admitted we were powerless over our addiction to fee for services medicine – that our healthcare delivery and financing model had become unmanageable.

2. We came to believe that power greater than ‘do more to earn more’ incentives (global capitation) could restore us to sanity and deliver on the triple aim.

3. Recognizing the finite nature of healthcare resources we made a decision to dedicate our will and our professional lives to the pursuit of the triple aim and the associated sustainable healthcare economy.

4. We made a searching and fearless moral inventory of our contributions to a seemingly ‘resistance is futile’ healthcare borg.

5. We admitted in our silo-ed huddles and to one another the aggregate nature of our collective wrongs.

6. We were entirely ready to have a calling to the ‘greater good’ transform a profit maximization – at any expense- operating culture.

7. We humbly asked our ‘higher power’ for faith in value based healthcare and for support to let go of the fee for services addiction.

8. We made a list of all patients, payers, or employers we had harmed, and became willing to make amends to them all.

9. We made direct amends to such stakeholders wherever possible, except when to do so would injure them, others or our ability to facilitate the journey from volume to value.

10. We continued to take personal inventory and when we felt the temptation to default to legacy inertia promptly admitted it.

11. We sought through mindfulness, meditation and collaboration to improve our vision and practice of value based healthcare, sharing openly for the knowledge, capacity and willingness to deliver this historically elusive goal.

12. Having had a professional if not spiritual awakening as the result of these steps, we tried to carry this message to one another and practice these principles in all our affairs.

 

Posted in Accountable Care, ACO, Affordable Care Act, health insurance reform

Health Insurance Industry Consolidation: Any ‘Qui Tam’ Exposure?

by Gregg A. Masters, MPH

If you’re a health policy junkie like me, then the best show in town (or anywhere for that matter) was in the Dirksen Senate Office Building in Washington, D.C., where HMO industry veteran and Chairman, President and CEO of Aetna Mark T. Bertolini and Anthem President and CEO Joseph R. Swedish among other industry stakeholders testified before the Senate Judiciary Subcommittee on Antitrust, Competition Policy and Consumer Rights on health insurance industry consolidation, for video replay click here or watch below:senate hearing health insurance industry

As most of you reading this blog know, subject to the Department of Justice review Aetna will acquire Humana, and Anthem will acquire CIGNA. Thus, the submitted testimonies and ad hoc answers to sitting Senators on the Subcommittee were potentially a high stakes exchange.

Moreover, the hearing today was nothing short of a tutorial into the dynamics of the managed competition marketplace (both theory and practice since absent complete transparency assuming the salutary benefits of such competition may be more ‘wishful thinking‘ than reality as noted by Senator Blumenthal – CT, the home of the insurance industry) and whether this unique American strain of public/private collaboration can deliver on the oft repeated promises of such integration, i.e., that scale via consolidation drives operating efficiencies, improves quality and lowers costs to end users. We shall see…

As I heard the pitches from the various representatives assembled to offer perspective to the sitting Senators (see list here), I began to wonder if any of their testimony would be subject to the ‘false claims Act‘ if post consolidation the promised benefits do not accrue to the intended benefactors.

For those of you not familiar with the ‘False Claims Act‘ or otherwise known as Qui Tam filings, here a summary including its recent expanded scope via the Affordable Care Act:

The False Claims Act, expanded by the Fraud Enforcement and Recovery Act of 2009, P.L. 111-21 (S. 386), 123 Stat. 1617 (2009), now proscribes: (1) presenting a false claim; (2) making or using a false record or statement material to a false claim; (3) possessing property or money of the U.S. and delivering less than all of it; (4) delivering a certified receipt with intent to defraud the U.S.; (5) buying public property from a federal officer or employee, who may not lawfully sell it; (6) using a false record or statement material to an obligation to pay or transmit money or property to the U.S., or concealing or improperly avoiding or decreasing an obligation to pay or transmit money or property to the U.S.; (7) conspiring to commit any such offense. Additional liability may also flow from any retaliatory action taken against whistleblowers under the False Claims Act. Offenders may be sued for triple damages, costs, expenses, and attorneys fees in a civil action brought either by the United States or by a relator (whistleblower or other private party) in the name of the United States.
If the government initiates the suit, others may not join. If the government has not brought suit, a relator may do so, but must give the government notice and afford it 60 days to decide whether to take over the litigation. If the government declines to intervene, a prevailing relator’s share of any recovery is capped at 30%; if the government intervenes, the caps are lower and depend upon the circumstances. Relators in patent and Indian protection qui tam cases are entitled to half of the recovery.

Not sure if qui tam consideration can or even remotely applies to the upside representations proffered in favor of the acquisitions, since as noted by one or more witnesses today much of the empirical (public) record is incomplete and inconsistent with respect to supporting or discounting the arguments that will or have been made to DOJ as they conduct their anti-trust investigation into the proposed acquisitions or mergers.

[Editor’s Note: Two examples of previous health insurance industry consolidations were noted, including Aetna’s 1999 acquisition of PruCare, and United Health Group’s acquisition of Sierra Health Services. I will post the submitted witness testimony once it becomes available online, including any current discussion ‘tea leaves’ of what and where the DOJ investigation may be headed in both transactions. If you have anything, please feel free to add in comments section.]

This Subcommittee hearing is rich with both fundamentals and nuance considerations of the Affordable Care Act and whether it’s many moving parts can indeed align to meet the legislative intent of its authors.

Stay tuned!