CMS Acting Administrator Comments before the American Medical Association

Source: CMS
CMS Acting Administrator Comments before the American Medical Association

Below are the comments as prepared for delivery of CMS Acting Administrator Andy Slavitt at the American Medical Association’s National Advocacy Conference in Washington, D.C. on February 23, 2016.

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Thanks for the introduction and the opportunity to be here. You know, last year I began every speech talking about my first year on the job and our big plans for CMS in playing our part in moving the health system forward. All of the sudden, come January, I find myself thinking that it’s in all probability my last year, and focusing on what that means.

And my reflections aren’t that different than last year. We have a busy year and a lot to do. I think about our agenda not only in terms of how it impacts life for patients and their physicians and caregivers today, but also in how CMS can set a tone to work constructively with you for years to come.

Today, I’d like to lay out our 2016 agenda as it relates to our work with the physician community. And there are really three parts to that agenda that I want to discuss. The first sounds simple enough. It’s how we listen better to physicians, keep lines of communication open, and get a better and more direct feel for what is happening on the front lines of care delivery. The second, which I think follows fairly directly from there, is how we simplify things. And the third relates to our payment reform agenda of improving care outcomes and spending. Throughout the conversation this morning, I will touch on implementation the bi-partisan MACRA and MIPS programs.

We know that new programs bring changes to the real world of medicine. So I will talk a little bit about our philosophy towards payment reform generally and even more about our approach to this very complex implementation.

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I always start with our shared priority: your patients, the consumers of the Medicare, Medicaid, CHIP, and Marketplace programs. Our charge at CMS is clear, meeting the evolving needs of 140 million Americans, most with low- or fixed-incomes, whether they are living with a disability, trying to afford a prescription, or are in need of coverage as they look for a better job.

These are the people we serve every day and these are the people I wake up every day thinking about. Since my email address is available to the public, I now know many of them wake up every day thinking about me too.

As I read the many emails beneficiaries send me, I realize that even in a wide diversity of circumstances, everyone is hoping for the same basic things from the health care system: to get care they can afford, to keep their family well taken care of, and when they’re sick, they want nothing more than to get them home and to lead as productive and healthy life as possible.

As society ages with 10,000 people joining Medicare every day, the challenge to all of us increases. We need to invest in all the things that keep people healthy and at home like primary care, prevention, chronic disease management, medication management, care coordination and all the transitions where people get lost. We need to do all of this, while at the same time striving to find new ways to care for and interact with patients we don’t see every day in a world of more information and better technology.

While fostering a future of sharable and wearables and telemedicine is undoubtedly some part of the answer, at its most fundamental level, we cannot devalue the most important and precious element of health care: the time a patient has with their physician. The moments when a patient’s course can be most effectively changed for the better. Getting patients the care they need is why our agenda is so important.

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This is why our first priority for 2016 is opening the lines of communication and listening to the physicians and other clinicians who provide care to our beneficiaries. CMS has significant responsibility for implementing new laws which must intersect with an already complex system with many demands. I’m a believer in the maxim that it is almost always 90 percent about implementation.

And so good policy must be ultimately informed by the impact it has at the kitchen table of the American family and in the clinic or office where they seek care. The EHR Incentive Program, ICD-10, MIPS, ACOs and medical homes, bundled payments, 2 Midnights. These are just the recent crop of implementations CMS has been charged with. And it is clear from listening to physicians there is fatigue – with change, with measurement, with new requirements that come from the outside and aren’t simple to implement.

As we hear this feedback, it tells us we must provide more tools and support and be as flexible as possible to the needs of physician practices, even while we push for a health care system that is better connected, more coordinated and produces better outcomes.

Our working relationship with the AMA has been an important and very positive model for us in listening. One of the first rules of building a learning organization is to listen to people most directly impacted by, and sometimes most critical of, our work. In the case of ICD-10, we reached an important turning point when we heard and responded to the very reasonable fears of physicians on their readiness, on cash flows and on potential penalties, particularly for small practices.

We doubled down on technical resources like the “Road to 10” and other support, provided more opportunities to test a practice’s readiness and we made adjustments to reduce needless penalties. And, to provide direct communications with front line physicians, we named an ICD-10 Ombudsman, set up a full-time command center and committed to 3 business day turnaround on any physician question and concern. We used a model for implementation first tested with the turnaround of healthcare.gov that we are now replicating in other implementations. It’s about responsiveness, collaboration, being publicly accountable and transparent, and being metric driven.

We’ve embraced this approach as we’ve implemented new payment models. Our newly launched Next Generation ACO model is a good example. It contains the features physician groups around the country have told us would best enable them to coordinate care, including innovative options like telemedicine, home visits, and direct patient incentive and engagement options. And as I will talk about in a moment, we are soliciting an unprecedented amount of direct physician input as we work to implement the MIPS payment models.

This will be a journey for all of us. One that requires a trusted partnership underpinned by honest, productive dialogue that helps each of us meet our common goal of better patient care.

I’m optimistic that our first objective of listening better to what happens in daily practice is not just a passing idea, but will make real lasting change to how we do things at CMS far beyond my tenure.

When I ask people at CMS to describe their best moments, they haven’t been spent behind a desk making policy in D.C. It is when they are out in communities across the country, helping beneficiaries, meeting with hospitals and physician practices, in nursing homes and PACE centers, talking to innovators, and working with many care providers who are on the front line of improving care for people.

Connecting to what happens in daily patient care is vital to our policy-making as we seek a better, smarter healthier system.

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The second agenda item is to simplify. I visited with a physician in suburban Massachusetts a month or so ago. Small busy practice, two docs. I asked the physician to take me through a typical day and his interactions with technology and measurement and how it helped and hindered his interactions with patients.

He was very pleased to have technology in his office, but it didn’t do the thing he needed most like give him feedback on referrals he made, and it required a fair amount of effort from him that took time but didn’t add a lot to patient care. He also discussed his interactions with various commercial health plans and with CMS and with payment model changes and administrative burden. The visit painted a vivid picture of the gulf that can exist between public policy, even good public policy, and what it feels like on the front line of practice.

We must reduce burden and give physicians back more time to spend with patients. Several years ago, we launched an initiative that is reducing regulatory burden and saving hospitals $3.2 billion over five years. But we are barely scratching the surface. We have a strategic effort this year designed to reduce burden and create efficiencies in the physician’s office.

Last week with AMA’s help, we announced the alignment of quality measures used by CMS and commercial payers so that everyone measures quality the same way across many areas of medicine.

Consistency is vital to simplicity. And we have also launched an initiative around the country to streamline how we provide data to physician practices so that CMS and commercial payers can provide it in a form that is practice ready and encompasses all patients the same way.

I visited with a physician practice in Denver where this has been fully implemented and heard first-hand how collaboration and simplicity were allowing them to deliver better care. Patient centered care means being practice centered as well. 

We are also pushing on administrative simplification and standards, and this year will launch a public framework for creating new standards and a tool for physicians to help us enforce health plan compliance with existing standards.

On the technology front, with the passage of the bi-partisan MACRA legislation, Congress has clearly recognized that technology is an important part of the solution. It obviously holds great promise to connect us to one another, to improve our productivity, and to create a platform for a next generation of innovations that we can’t imagine today.

As we move forward and implement MACRA, we must refocus on how to simplify the program so that technology can help get us where we need to go, not slow us down. We will be sharing details and inviting comment as we roll out our proposed regulations, but our work will be guided by several principles:

  • Rewarding providers for the outcomes technology helps them achieve with their patients, not for using technology alone.
  • Allowing providers the flexibility to customizegoals to their individual practice needs. This should cause technology vendors to become more user-centered and support physician needs.
  • Leveling the technology playing field to promote innovation, including for start-ups and new entrants, by unlocking electronic health information through open APIs, technology tools that underpin many consumer applications.  This way, new apps, analytic tools and plug-ins can be connected, and we can address the lock that early EHR decisions have created for some practices.
  • Prioritizing interoperability by implementing interoperability standards and focusing on real-world uses of technology, like ensuring continuity of care during referrals or finding ways for patients to engage in their own care. And we will not tolerate data blocking, business models that prevent or inhibit the data from flowing around the needs of the patient.

As you may know, the MACRA legislation applies to physician office care, not hospital care, so we are also exploring ways to align hospital incentives with these principles as well.

All of these principles won’t change things overnight. It will take physicians and innovators time to build a better future, but this is the right place to start.

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The third priority area I will cover is the transformation of how we pay for care to reward for the delivery of high quality care. What we all want is a better system that spends money smarter, and keeps people healthier. How care is paid for is one element of that.

When we announced a year ago that more than 50 percent of our Medicare FFS payments will be linked to quality and value through alternative payment models by 2018, we were sending an important signal that we will soon reach a tipping point.

We know that to do this requires change from many parts of health care, and that actual change is hard. We know the challenge physicians and other clinicians face living in the fee-for-service world today while preparing for a payment system that rewards more coordinated, more value-oriented care that is emerging.

So, we committed to a $650 million-plus investment to over 140,000 physicians to support them in their aim to transform their practices to get paid for quality.  We are partnering with organizations and physician specialty societies across the country to help support these physicians to use data, technology, and quality measurement to improve care for their patients.

I’ve spoken about the implementation of the bipartisan MACRA legislation. It is a major priority for us this year and at its most fundamental level, is a program that brings pay for value into the mainstream through the Merit-based incentive program. The program compels us to measure physicians on four categories: quality, resource use, the use of technology, and practice improvement.

Over the next several months, we will be rolling out details for public comment, but I will say that the team is approaching the implementation by working with front-line physicians from the beginning. We started with a four day session with physicians and technology companies and through an RFI to garner direct feedback on the right measures for each specialty and how to implement the program most simply.

We are now conducting eight physician focus groups in four separate markets – none of them Washington, D.C.  Now everyone in CMS will a chance to hear directly from physicians. The AMA has provided significant input and we will be engaging closely with members of Congress who are also deeply committed to improving value-based care.

We are committed to building a program that is as flexible as possible and adapts around the goals of a provider’s individual practice and patient population. But even with all this work, I expect we will need to rely on significant input into how it works in reality, both positively and negatively so that, within the constraints of the law, we can improve it. If you commit to continually providing the input, we will commit to continually improving it.

I want to mention one other important element in how we are paying for care. Last year, with the active support from the AMA, we began paying for advanced care directive conversations.  While this was seen as big news and a step forward in dealing with an area with lots of strong views, there is other news I hope you take away as well. And that’s the value we place on conversations between the patient and their doctor.

Whether it’s this work, care coordination visits, or models like our oncology payment pilot, we believe we need to move back to a place where we are paying for doctors to talk to patients about their health, not just paying for new technology, devices, surgeries and prescriptions that have certainly been dominant drivers over the last number of years.

We have a ways to go here, but this is a direction that Patrick Conway, our Chief Medical Officer and a practicing physician, and I are passionate and excited about and are pushing to take root across the work coming out of CMS.

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Before I close, I want to thank those of you that are demonstrating your commitment to health equity, especially by treating Medicaid patients and the dually eligible. I recognize the challenge this can add to your practices and I want you to know that we have released several proposals both in Medicare and Medicaid intended to focus on improving reimbursement levels for lower socioeconomic status and higher need populations.

But I know, no matter what we do, that our lowest income and hardest to treat citizens won’t get the same high quality of care that others do without your commitment as part of your role in the medical community to provide high quality care for all patients. I thank you for it and I ask that you know our commitment to health equity is primary.

I want to close by repeating the theme I hope you’ve heard from me today: Success for us is helping build a better health care system for all Americans, with smarter spending, and resulting in healthier people.

We are at early stages. I know the challenge of this transformation as it plays out every day in practice creates challenges. All progress does. But the transformation to better care will only come from you and your patients. And as we move forward, we need to listen and stay close to the realities on the ground and work together with you to create new generations of solutions that work better and are simpler.

We thank you for all the constructive engagement and look forward to working with you in the coming months and years.

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CMS Acting Administrator Comments before the American Medical Association

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