One obstacle to getting more physicians into APMs is the lack of options for specialists, the head of CMS said at a meeting.


Oct. 31—Among the payment models that the Centers for Medicare & Medicaid Services (CMS) plans to test is a direct primary care model, according to the agency’s leader.

Seema Verma, administrator of CMS, told a Washington, D.C., gathering of healthcare payment innovation leaders that her agency plans to pursue new demonstrations that focus on:

  • Direct primary care
  • Consumer-driven health care
  • Payment methodologies that address the cost of prescription drugs by excluding high-cost therapies
  • Approaches to modernizing the Medicare Advantage bidding process
  • State-based and local innovation models focused on managing the cost of dual-eligibles
  • Behavioral health and opioid addiction treatment models

Verma did not provide any specifics about what the new pilots would entail, but some policy watchers were confused about how CMS could implement a direct primary care pilot.

“I don’t know how you get direct primary care in Medicare,” said Bruce Landon, MD, professor of healthcare policy at Harvard Medical School. “The concept of direct primary care is that you don’t bill insurance.”

One possibility, Landon said in an interview, is that direct primary care in this case refers to an expansion of population-based payments that exceed fee-for-service payments in an effort to discourage overtreatment by “divorcing payments from visits.”

“Maybe she’s thinking along those lines,” Landon said.

MACRA Concerns

Verma said CMS is in the final stages of developing new voluntary payment models that are expected to qualify as advanced alternative payment models (APMs) under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

However, Verma said “many practices” are not ready for advanced APMs, which comprise one of two payments systems created by MACRA. CMS expects the vast majority of Medicare physicians to be paid under the other system, the Merit-based Incentive Payment System (MIPS), during the early years of MACRA, which took effect in 2017.

One obstacle to getting more physicians into APMs, Verma said, was the scarcity of options, including “hardly any” for specialists.

Meanwhile, in June, CMS proposed expanding the number of clinicians who are exempt from MACRA and MIPS requirements from about 700,000 in 2017 to about 830,000 in 2018. CMS is expected to soon release the final rules governing MACRA's year-two implementation.

“We know that MACRA is a tremendous change, so we’re taking it slow to make sure that the transition is as smooth as possible,” Verma said.    

“It does mean some rethinking of how MACRA will be implemented, but we’re at the stage where that’s needed,” said Mark McClellan, MD, PhD, co-chair of the Guiding Committee for the Health Care Payment Learning & Action Network.

To McClellan, those changes will mean finding ways to simplify quality reporting compared with the “burdensome” approach laid out in earlier CMS rules. McClellan said in an interview that he expects CMS to move from process-oriented measures to outcomes-based measures.

Such a shift is needed, said Landon, but he was skeptical that it is possible because consensus on outcomes-based measures has been elusive.

Measurement Changes

Verma also announced the launch of an initiative, called Meaningful Measures, to reduce the volume of quality measures and refocus them on outcomes.

“We’ll set the goals, and we’ll leave innovators the freedom to get there,” Verma said.

Such an overhaul is needed, Verma said, given that inpatient hospitals are required to report 61 quality measures, and family practitioners have described having to report as many as 30 quality measures from seven different payers. 

“We’re concerned about the burden because folks are spending so much time reporting,” Verma said.

Existing quality measure nonetheless have produced good results, noted Verma, who highlighted improvements in recent years in unneeded admissions and readmissions.

The new CMS initiative includes a review of the hospital quality star-rating system, Verma said.

A related initiative has sought public input on new directions for CMS’s Center for Medicare & Medicaid Innovation (CMMI). Verma said the goal of a planned overhaul is to “move away from the assumption that those in Washington can engineer a more efficient healthcare system.”

“Washington is unaware of the nuances and local needs and is not at the center of private healthcare innovation,” Verma said. “Instead, we want to launch pilots that give people on the front lines the flexibility to be creative and transformative.”

CMS seeks to develop models that promote a “patient-centered system of care within a market-driven healthcare system,” Verma said. “Models should encourage consumers to make decisions that are right for them, and providers should compete around value and quality.”

As part of her goal of making patients “activated shoppers,” Verma said she was “very open” to allowing patients to receive some of the shared savings traditionally offered as inducements to providers.


Rich Daly is a senior writer/editor in HFMA’s Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare

Publication Date: Tuesday, October 31, 2017