This is why value-based care is not going away this year

Last year’s uncertainty over the future of value-based care did not deter Marlyce Hill Ali, MD, from delivering healthcare in the way she thinks is best.

The internist at JenCare Senior Medical Center in Louisville, Kentucky, was aware of the questions about the new administration’s approach to value-based care, as well as turnover at the Centers for Medicare & Medicaid Services (CMS) and the U.S. Department of Health and Human Services (HHS). But she never had doubts about the value-based care model.

“We’re still operating with the status quo and still functioning the way we were founded to perform. It hasn’t affected operations at all,” she says.

By the end of 2017, much of the uncertainty had lifted. The shift toward value-based care is continuing, though this year is likely to see some adjustments that could ease the regulatory burden on physicians.

That’s good news to advocates like Ali. “I think everyone, regardless of political affiliation, likes the notion of value-based care, getting the most bang for your buck in healthcare,” she says.

An uncertain 2017

Last year was a tumultuous one for healthcare. For many physicians, 2017 was the first year of reporting quality measures under the Medicare Access and CHIP Reauthorization Act (MACRA). Meanwhile, the Trump
administration and GOP-controlled Congress failed to overturn the Affordable Care Act and Tom Price was named HHS secretary, but later resigned under pressure.

Some of the new administration’s moves, such as cutting bundled payment programs, prompted questions about its commitment to value-based care. 

“When they proposed cutting back the mandatory bundled payment program, there was a fear that they were going to hit the brakes on payment reform on everything, and we haven’t seen that,” says
Timothy Gronniger, MPH, former chief of staff at CMS and now senior vice president at the consulting firm Caravan Health. “Payment reform is so deeply entrenched across the industry right now that CMS doesn’t seem to want to stop that nor do they have an alternative vision for that.”

Value-based care has maintained broad support, even in the highly partisan atmosphere in Washington, says Jeff Micklos, executive director of the Health Care Transformation Task Force, a consortium of patients, payers, providers and purchasers. Policymakers have largely exempted it from the debate over the ACA, he says.

There is no appetite in Washington to revisit value-based care, agrees Shari Erickson, MPH, vice president of government
affairs and medical practice at the American College of Physicians (ACP).   

“The law was so recently passed and done in a bipartisan way that everyone thinks that it’s better to move forward,” she says.

CMS Administrator Seema Verma, a former healthcare consultant who made her reputation advising states on how to restrict Medicaid eligibility and roll back the ACA, has indicated that she supports value-based care and wants the pilot programs to accelerate. “I think while we are moving in that direction, we’re probably not moving fast enough,” she said in a speech in the fall of 2017.

A difficult journey

While the administration assessed value-based care, physicians such as Lerla Joseph, MD, simply implemented it.

The internist with Charles City Medical Group in Richmond, Virginia, formed an accountable care organization (ACO) in 2011, the Central Virginia Coalition of Healthcare Providers, because she thought value-based care was a better way to deliver care.

She has since recruited 21 small practices with 53 practitioners in Virginia and North Carolina into the group. The ACO met the minimum patient threshold to qualify for the Medicare Advantage program in 2015 and is now in its second year reporting quality measures under MACRA.  

“Everyone focuses on value-based care in the practice, from the front desk to me,” she says. “We can see the improvement in our patients and in our quality metrics.”

The ACO hasn’t yet seen the savings they’ve hoped for, but Joseph is confident it will. In the meantime, the group continues to invest in population health management tools and training staff to work to the top of their licensing, such as having medical assistants assess patients and do appointment follow-ups.  

“This is the direction everyone is moving, even with our commercial contracts,” she says. “It’s been a difficult journey, but I’m glad I persisted because it’s been good. I really do think ACOs are the best hope for the future of small, independent practices.”

Regulatory relief

While not abandoning value-based care, the new administration has taken steps to ease its regulatory burden on physicians like Joseph.

CMS Administrator Verma has made it clear she intends to streamline the reporting and quality measurement process. Her new approach to quality measurement is called Meaningful Measures and, according to a press statement, “will involve only assessing those core issues that are most vital to providing high-quality care and improving patient outcomes. The agency aims to focus on outcome-based measures going forward, as opposed to trying to micromanage processes.”

In addition, CMS has launched a “Patients Over Paperwork” initiative to evaluate and streamline regulations with the goals of increasing efficiencies and easing regulatory burdens.

Verma also has announced that the CMS Innovation Center, which was created as a part of the ACA to test new payment and delivery system models, will be reoriented to emphasize patient-centered care, market-driven reforms, price transparency, competition and choice. CMS invited stakeholders to submit ideas for reform. The comment period closed in November, but as of press time, changes have not yet been announced.

The practical effect these initiatives will have on physicians remains to be seen, but they’re a step in the right direction, says ACP’s Erickson. “I just really hope the administration puts some real meat on the bones of Patients Before Paperwork and Meaningful Measures in a way that is actionable in practice for clinicians,” she says.

The administration’s desire to cut red tape can be seen in the final guidelines for the 2018 Quality Payment Program (QPP) under MACRA, which were tweaked to help physicians, particularly those in small and rural practices. Among other changes the rules:

• Exempt more practitioners from the Merit-based Incentive Payment System (MIPS) and QPP
• Offer bonus points to small practices and groups that treat a large number of complex patients
• Maintain some 2017 performance year flexibilities for MIPS reporting, particularly on EHR requirements
• Allow physicians to form virtual groups to report for the first time, regardless of  location or clinical specialty
• Automatically exempt physicians from the quality, cost and improvement activity categories in 2017 if they were impacted by extreme weather or public health emergencies 

However, the rules include some additional requirements, such as adding cost containment as a MIPS performance category in 2018 and setting it at 10% of the final score.

Private sector push

While the government might have stutter-stepped on value-based care last year, the private sector had no such hesitation.

“[The government] might have lost a little momentum due to transition and departures, but the private sector continues to carry it forward,” says Micklos of the Healthcare Transformation Task Force. When that group formed in 2015, its insurer and provider members pledged to put 75% of their businesses in value-based payment arrangements by 2020.

Value-based care has been a successful model at ChenMed, a fast-growing Florida-based primary care practice for low-income seniors with more than 40 locations in six states. The company’s founders say their adoption of value-based care saves money and delivers superior care. It claims its rate of ED visits was 33.6% lower than the average among Medicare beneficiaries in the counties it serves and that ChenMed patients averaged 431 fewer in-patient days per thousand patients in 2015 than other Medicare beneficiaries-a reduction of 25.7%. 

Louisville physician Ali says the value-based care she delivers at JenCare, one of ChenMed’s locations, is superior to what she’s experienced in other models. She predicts value-based care will continue to grow. “I think we’re going to see more of that in 2018. It will be less and less fee for service - and that’s not going to make a lot of doctors happy,” she says.

This year could bring CMS and the rest of the healthcare industry into closer alignment on value-based care, says Erickson, particularly as commercial payers update their contracts with practices to reflect the core sets of quality measures announced by CMS and America’s Health Insurance Plans in 2016. The measures, which cover primary care and specialties such as cardiology and pediatrics, are meant to be used by both private and government payers.

A call for change

While changes to MACRA so far have been relatively minor, some are pushing for a major overhaul of the system.

Late last year, the Medicare Payment Advisory Commission recommended that HHS repeal MIPS and replace it with a voluntary value-based reimbursement program based on claims data rather than quality performance categories.

The commission, which includes physicians, healthcare executives and policy experts, blasted MIPS as unsustainable and unable to identify high- or low-value care or physicians. It also forecast that MIPS reporting would cost clinicians $1 billion in 2017.

“It’s time to get rid of MIPS. It’s almost surely going to do more harm than good,” says Ashish Jha, MD, MPH, an internist and professor at the Harvard T.H. Chan School of Public Health.

MIPS does a poor job of measuring or incentivizing value-based care, Jha says. True measuring of value-based care would require using a broader set of data that emphasizes patient quality of life, not just physician activity, he says.

He predicts a consensus for repealing MIPS will build this year, but thinks the emphasis on value-based care will remain. “This is an administration and a CMS that is committed to value-based care,” he says.

Additional incentive for change could come from the Office of the National Coordinator for Health Information Technology, which is working with CMS to develop a new concept for physician reimbursement.

A transitional year

Though 2018 likely will not be marked by the same level of uncertainty as 2017, value-based care will continue to evolve, experts say.

ACP will continue to lobby for further changes to MACRA that will reduce the regulatory burden on physicians and make reporting easier, Erickson says. MIPS scoring is too complex and needs additional  quality measures that apply in more than one category.

“The scoring system is no good if clinicians can’t understand how any of the things they do count. Right now, it’s almost like you do it all and wait to see what [scores] come back,” she says.

Gronniger expects further tweaks to MACRA rules, but no major changes. “The big picture stuff is still moving, the quality payment model is still happening and the Innovation Center is still trying to build new specialty models and trying to iterate on existing models,” he says, “MACRA is still moving forward.”