Your New Dilemma: Prepare for current CMS policies or wait to see if they change?

Thursday, December 29, 2016 | Larry Sobal

 

Call it what you will—confused, chaotic, concerned or uncertain—there are many ways to describe the current state of hospitals and physician groups related to the Affordable Care Act (ACA) and recently announced Center for Medicare and Medicaid Services (CMS) programs, and the potential that the new administration will alter or eliminate them in the near future. It seems like a classic “damned if you do and damned if you don’t” scenario.

Here’s the challenge. First, there’s the possibility that the Republican-led Congress may try to repeal the ACA as soon as it reconvenes in January. Second, in the past 60 days, CMS and the current administration have released waves of new programs that have significant implications for how hospitals and physicians will be paid in the future, and require weighty efforts for compliance. On that list are the following:

• Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
• Acute Myocardial Infarction (AMI) Model
• Coronary Artery Bypass Graft (CABG) Model
• Surgical Hip and Femur Fracture Treatment (SHFFT) Model
• Cardiac Rehabilitation (CR) Incentive Payment Model
• New Advanced Alternative Payment Models (APM)
• 21^st Century Cures Act

You can add the Comprehensive Primary Care Plus (CPC+) program, the 2017 Outpatient Prospective Payment System (OPPS), and the 2017 Physician Fee Schedule final rule to that list if you really want a complete inventory of all that is happening or slated to happen in the near future. And, you could make a good argument that, collectively, these are the most significant changes to how hospitals and physicians will be paid since Medicare was passed into law on July 30, 1965.

As you know, President-elect Donald Trump has selected Dr. Tom Price (R-GA) to serve as his Secretary of Health and Human Services (HHS). Representative Price is a board certified orthopedic surgeon who has served in the U.S. House of Representatives since 2004, as the House Budget Committee Chairman since last year, and he also serves on the Ways & Means Subcommittee on Health. He’s very familiar with Washington D.C. politics and public health policy, particularly HHS/CMS health policy. I’ve met him personally and can attest to that. It’s no secret that he has been among the fiercest congressional critics of the Center for Medicare and Medicaid Innovation (CMMI) and argues that the agency “has exceeded its authority, failed to engage stakeholders, and has upset the balance of power between the legislative and executive branches.”

In September, Price and fellow House members Charles Boustany, R-LA, and Erik Paulsen, R-MN, led an effort calling on CMS to abandon mandatory payment programs including CJR and the new (at the time proposed) cardiac-care bundles. In a September letter signed by 178 GOP House members (and one House Democrat) to CMS acting Administrator Andy Slavitt and Deputy Administrator Patrick Conway, Price and other House lawmakers not only accused the agency of overreach, but declared: "What makes these proposals even more disconcerting is their potentially negative effects on patients, especially our vulnerable seniors." 

As a physician himself, Price is especially sympathetic to physicians and complaints focused on the burdensome aspects of these recent CMS programs; it is likely he will want to simplify and reduce those burdens.

With a new administration coming in, there is a lot of uncertainty about the future of current health care policies and programs. What’s the best way to prepare? Larry Sobal offers some sound advice.

Some Washington experts predict that Price’s nomination as HHS Secretary may be confirmed as early as February 1^st. And since many of the recent CMS mandates, such as the bundled payment models for AMI, CABG and SHFFT are CMS policy decisions, he could instantly undo them on his first day. That’s what some people expect he will do given that the September letter also stated: “Until recently, the tests and models developed by CMMI were implemented as intended, on a voluntary, limited-scale basis where no state, healthcare provider, or health insurer had any obligation to participate…These mandatory models overhaul major payment systems, commandeer clinical decision making and dramatically alter the delivery of care.”  

So, do you bet on Congress trying to immediately undo the ACA and Price undoing MACRA, bundled payments and other CMS-announced policies? Or do you bet on the status quo and prepare as if nothing will change? That’s your dilemma. Here are some important points to consider:

1. Depending on the extent of a “repeal” of the ACA, the Congressional Budget office estimated that it would reduce federal tax income by $1 trillion in the next 10 years. That, along with some Republican leaders (such as Paul Ryan) committing to maintain some form of coverage for those in exchanges, suggests that repeal without replacement will take some time.
2. MACRA, bundles and other CMS initiatives were created with strong bi-partisan support. There’s no guarantee that there would be enough Republican support behind wholesale elimination of many of the recent programs.
3. Furthermore, both Republicans and Democrats recognize that we are in an unsustainable trend of increasing costs in health care. Most everyone agrees that we need to find ways to improve care and transition away from fee-for-service reimbursement, and whatever reimbursement-related programs exist in the future that involve rewards, and likely penalties, for performance.
4. Unless QRUR reports and the like are also undone, physicians are still going to be measured on cost and quality. As more of this data becomes transparent to the public, organizations will be held more accountable for their performance.
5. There is still wide and indefensible variation in care throughout the country. The leading and innovating organizations are taking it upon themselves to drive higher quality and lower costs. I think health care has a moral responsibility to “heal itself” by taking steps to get better.

My conclusion: whether the current CMS programs stay as they are, or are repealed or modified, physician practices and hospitals need to assess their current status in terms of quality, cost, and levels of service, and take steps to put themselves in the most competitive position possible.

As I appealed to you in my December 8^th blog post, A Proven Health Care Strategy for Uncertain Times, there are likely many aspects to your current operations that need improvement, and there should be no excuses for not fixing the problems you already know you have. At this time of health industry uncertainty, addressing your known opportunities will always serve as a winning strategy. You can’t control what Dr. Price will or won’t do, but you do control what you can (and should) do. Make a commitment in 2017 to do the right thing!

 

Illustration: Lee Sauer

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Larry Sobal is Executive Vice President of Business Development at MedAxiom. He has a 35-year background as a senior executive in medical group leadership, hospital leadership and insurance. Larry consults, writes and presents on topics relevant to transforming physician practices and health systems.

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