By Cornelia Hall, Master of Public Policy Candidate, Harvard Kennedy School, Class of 2017
This is the first entry in a three-part series on the AcademyHealth National Health Policy Conference, held in Washington, DC, on February 1-2, 2016.
At AcademyHealth’s 2016 National Health Policy Conference earlier this month, payment reform was a pervasive theme. Its prominence was not surprising. Indeed, in early 2015, HHS Secretary Sylvia Burwell announced the agency’s goal to have 30% of traditional, fee-for-service Medicare payments tied to quality or value through alternative payment models by the end of 2016, and 50% by the end of 2018. As the current sea change in health care moves the system towards these goals, the conference’s panelists explored various aspects of the transition to value-based payment. Speakers who discussed the issue included leaders in government, clinical practice, and private insurance. They sent an overarching message that payment reform efforts will continue to take a variety of forms — on parallel tracks with cross-cutting themes — rather than a single approach. Representatives from provider organizations particularly stressed the necessary groundwork for these efforts to be effective.
The Center for Medicare and Medicaid Innovation (CMMI) under the federal Centers for Medicare & Medicaid Services (CMS) is operating dozens of payment- and quality-focused models and demonstrations across the country. The breadth of payment models and their varying degrees of success represent different approaches to health care reform, such as population- and episode-based payment. On his panel, CMMI Deputy Director Dr. Rahul Rajkumar noted that this breadth is designed to appeal to diverse providers that differ in type and readiness for payment reform. Indeed, a health care system that has operated for decades with multiple payers, little care coordination, fragmented use of technology, and inconsistent definitions of quality care is undergoing monumental transformation. The transition from fee-for-service to value-based payment thus involves some experimentation to identify the most effective approach.
In this context, CMS panelists noted that various payment demonstrations and pilots have led to a certain level of understanding as to what constitutes an effective program. Dr. Rajkumar indicated that the agency’s demonstrations have shown strong evidence for the Pioneer ACO model, as well as for two-sided risk. CMMI Deputy Administrator for Innovation & Quality Dr. Patrick Conway echoed Dr. Rajkumar in noting that the Pioneer ACO program was the first demonstration to be expanded. He emphasized that CMS is prepared to expand a program or require participation if it shows sufficient success. For example, the Comprehensive Care for Joint Replacement (CCJR) Model grew out of the success of episode-based payment for joint episodes in the Bundled Payments for Care Improvement (BPCI) Initiative and is now mandatory in several regions. Above all, Dr. Conway indicated that the government intends to make participation in these programs more flexible for providers, including ease of entry, exit, and transition to different tracks within a demonstration.
It was clear from the panels, however, that this multifaceted transition to value-based payment requires some uniformity. For example, Dr. Conway discussed the importance of robust primary care, while panelists representing provider groups stressed the need for collaboration and consistency across health care provider systems. In particular, they highlighted alignment of quality measures as one of the most pressing challenges for providers. Several representatives from physician groups and insurance companies underscored this point. Elizabeth Mitchell of the Network for Regional Healthcare Improvement, Lois Nora of the American Board of Medical Specialties, Jill Yegian of the Integrated Healthcare Association, and Lewis Sandy of UnitedHealth Group all stressed the importance of clinical engagement and leadership in the development of quality measures and the definition of “value” for related health policy. Indeed, Dr. Nora cited a recent RAND study that highlighted quality of care as a driver of physician satisfaction. Ms. Mitchell also emphasized the need for wide access to all-payer data, community partnerships, interoperability of systems, and a neutral convener of information in the insurance market in the transition to value-based payment.
Ultimately, the panelists expressed a near-consensus on the idea that, for the foreseeable future, payment models will continue to work differently across the health care system and in different spheres. Dr. Conway noted that “health care change happens at the state, local, and community levels,” citing State Innovation Model work and other pioneering Medicaid initiatives. He expressed confidence that payment reform efforts are on track to meet Secretary Burwell’s goals. And as Dr. Rajkumar summarized, “The way in which we pay for health care does matter,” calling payment reform “a generational effort.”