Secy. Price: HHS Won't Dictate to Docs

— Promises flexibility in pushing value-based payment; fee-for-service may remain for some situations

MedpageToday

SAN DIEGO -- The Trump administration won't impose a one-size-fits-all strategy on doctors in their transition from volume to value, U.S. Health and Human Services (HHS) Secretary Tom Price, MD, told a Saturday conference of physicians in accountable care practices.

And while payment reform efforts under MACRA, the Medicare Access and CHIP Reauthorization Act of 2015, are "truly laudable," many challenges remain in standardizing measures of value "when every patient is unique," and doctors practice in widely varying settings and circumstances, he said.

Price stressed that for certain settings and procedures, maintaining "fee for service may not be the end of the world." Traditional payment systems could work for some solo and rural practices, in concert with capitated systems, in certain specialties such plastic surgery, dermatology and ophthalmology.

The former Georgia lawmaker and orthopedic surgeon was the keynote speaker at a conference subtitled "Now What?" attended by 1,900 clinicians in accountable care models. It was sponsored by CAPG, a Los Angeles-based national risk-bearing model trade group. Some 80%-85% of the organization's 300 multispecialty group members are opposed to the reforms being discussed in Congress today, said CAPG president and CEO Don Crane, who worried that Price would be booed.

In fact, he urged those assembled for Price's talk to "be polite to our guest," given "discussions about heckling ... I certainly hope that doesn't happen."

Though there was clearly anger toward Washington, audience members seemed at least temporarily appeased as Price flattered them and urged them to give his administration as many new options for payment model reform as they can think of.

The administration's job "isn't to dictate to docs and others providing care what kind of payment models to use or must use," Price said. "Our job is to make it easier for physicians to use the payment models that work for them, and to put in place a system that incentivizes and accommodates innovation."

During his 30-minute talk, which included a 15-minute question and answer session with Crane on stage, Price mainly asked more than a dozen rhetorical questions that conveyed his administration's willingness to be flexible in administering payment systems change.

"How do we standardize measures of value and efficiency when every patient is unique?" Price said. "One patient has the same diagnosis as another patient, yet that same diagnosis may be treated differently. It's tough for us to put that in an equation."

Price also asked CAPG members for ideas on how "we collect data on physician performance without inundating doctors and nurses and administrators with costly, time-consuming paperwork." He added, "That's kind of where we are right now. We've turned a lot of folks in the healthcare professions into data entry clerks."

And, "what kind of data should we collect? How do we ensure its relevance in a dynamic world of medicine?... How do we encourage the development of innovative and alternative payment and delivery models without being clunky?"

Price made it clear that he was not going to answer those questions that day.

"You might think that because HHS is responsible for implementing MACRA -- that, as secretary, I'm the one who needs to answer the question, 'What now?' That's why you're all seated. What are you going to do?"

Price said he prefers to ask another question, "who decides?" adding that he believes "physician payment innovation should be in the hands of physicians and healthcare providers across the country. It shouldn't be in the hands of Washington, D.C. We need to facilitate it, yes. But you're the ones with all the good ideas of how we can make our system work better for patients."

During the Q&A, Crane posed the question whether "efforts to repeal and replace the Affordable Care Act will speed or slow the value movement to which we're so committed."

"In the big picture, [the bills under discussion] likely won't affect a whole lot," Price replied. "If it does at all, it incents it, because the goal again is to try to make it so that it's physicians and physician groups, those in the industry, who are the ones providing the greatest amount of input into the systems."

Besides, he said, the Senate bill under discussion now, the Better Care Reconciliation Act, "is primarily looking at that individual small group market, the exchange market -- that's 18 million, 20 million folks, 7% of the population."

Price mentioned Medicaid, which covers 74 million low-income adults and children, only once as one of the nation's six healthcare systems, along with the VA, Medicare, employer-based coverage, Indian Health and the individual small group market. He did not address the current proposals to cut projected Medicaid spending by nearly $1 trillion over the next decade. Many CAPG members provide Medicaid managed care plan services and would be affected by those cuts.

Following Price's talk, Crane told MedPage Today that one problematic administration policy for CAPG members is the Centers for Medicare & Medicaid Services' recently proposed loosening of requirements under the Medicare Merit-Based Incentive Payment System or MIPS.

Under the current rule, low-volume clinicians exempted from MIPS are those with $30,000 or less in allowed Part B charges annually, or 100 or fewer beneficiaries. That's 32.5% of clinicians. The latest proposal expands the exemption threshold to $90,000 in Part B charges and 200 beneficiaries, "the effect of which is that now, I think, 64% of physicians in this country are exempted," Crane said.

The idea behind MIPS and MACRA was to move more doctors into value-based models but the latest proposal slows that down, Crane said. It likewise slows opportunities for better care and inhibits efforts to reduce waste in the healthcare system.

"Our argument is that if you have the right model scaled across the country, you would achieve so much in savings that coverage would become a much easier matter," he said.

By deploying best practices everywhere, "you probably would knock out most of the 30% waste right now, you would achieve enormous savings, which could be transferred into benefits and coverage for the uninsured."

MACRA is "a good soft tailwind pushing the nation. But what we need a hurricane pushing the nation."