Road to value-based payment bumpy in 2017

The shift to value-based payment stalled in 2017 largely because of decisions made by new CMS leadership and distractions caused by efforts to repeal the Affordable Care Act, health quality experts say.

Over the last year, new CMS Administrator Seema Verma touted an agenda that supported value-based payment but also focused on ways to reduce administrative burden for clinicians. As a result, the Trump administration slowed down the implementation of Obama-era mandates intended to move the dial on value-based payment. The CMS in November rescinded a rule requiring more providers to participate in Comprehensive Care for Joint Replacement Model and then tossed out the Episode Payment Models and the Cardiac Rehabilitation Incentive Payment Model, which were scheduled to begin on Jan. 1, 2018. The agency also exempted more physicians from participation in the Quality Payment Program. At the same time, the GOP made several — albeit unsuccessful — attempts to repeal the ACA. "(The CMS) didn't retract and didn't move forward" in the shift to value, said Dr. Ashish Jha, a professor of health policy at the Harvard School of Public Health. "The move towards value isn't a one time do it and done. It needs constant refreshing and re-tweaking, and I feel like that didn't happen this year because I think the administration was distracted by other issues." The moves by the CMS on bundles were particularly disappointing, Jha said. "I think the evidence on bundles is better than the evidence on anything else" regarding the impact of value-based payment arrangements to improve quality and reduce costs. The CMS' objection to mandatory models is a concern as well, said Dr. Karen Joynt, an assistant professor of medicine at Washington University School of Medicine. "I don't think voluntary programs incentivize the kind of transformational change we need because it doesn't bring all the stakeholders to the table and until we do that, there is going to be a lack of incentives to play together in the sandbox." Concerns about access to care for patients is distracting for quality improvement efforts as well and efforts to repeal and replace the ACA exacerbated those worries, argues Joynt. Providers still care for patients who hardly ever see the doctor or follow through with care plans because they lack coverage, which makes it hard for physicians to make great progress in quality And the value-based purchasing programs that did stay in place this year were subject to scrutiny. Several studies came out in 2017 that questioned the CMS' Hospital Readmissions Reduction Program including one that found the mortality rate rose for heart failure patients as readmissions declined. The Medicare Payment Advisory Commission called for the Merit-based Incentive Payment System created by MACRA to be repealed because they questioned if it would truly motivate providers to improve care. Multiple studies this year were in line with MedPAC's concerns, finding the CMS' Value-based Payment Modifier program, which MIPS is modeled after, didn't actually impact performance or costs. "This year there were a bunch of studies and data on the ways we have been measuring quality and incentivising pay-for-performance that shows it's not working," Jha said. "I think there is a reckoning that happened. In 2018, I think we are going to go back to the drawing board." A new approach to value-based purchasing models appears to be on the mind of the CMS as well. In September, the agency asked stakeholders to bring forward new ideas for the center to test. Verma said in an op-ed the CMMI's old policies stifled innovation and competition. "Providers need the freedom to design and offer new approaches to delivering care," she wrote. Francois de Brantes, vice president and director of the Center for Payment Innovation at the Altarum Institute, said there currently aren't many payment models for providers to try out. "(Right now) we have two different flavors of advanced APMs. The vanilla flavor is the total cost of care, or ACOs, and the chocolate flavor is bundles, and that is it," de Brantes said. "More flavors should be tried out. It is OK to innovate around payment because there all these different types of populations." de Brantes said he expects the CMMI to try out different kinds of APMs in the next few years. "Instead of having one or two models, we are going to have multiple models that are tested on a voluntary basis in different parts of the country." In its ROI, the CMS said it wants "to test new models for prescription drug payment." Value-based drug pricing, a concept in which the price of the drug is based on the patient outcomes they deliver, has been touted as a possible solution to skyrocketing drug prices. The CMS said it's open to testing such a model at CMMI.