Internists offer recommendations to improve CMS's approach to testing new payment models

November 21, 2017

While the American College of Physicians (ACP) is supportive of the role that the Center for Medicare and Medicaid Innovation (CMMI) plays in the move toward value-based payment models, it has significant concerns about several elements of its plans to test new payment models. In a letter sent in response to the Centers for Medicare and Medicaid Services' (CMS) Innovation Center New Direction Request for Information (RFI), ACP expressed concern about the impact on disadvantaged patients of the agency's shift toward testing "consumer-directed and market-based" innovation models.

"There are a number of components of these principles that ACP supports; however, we also have significant concerns about some of the language used in terms of what it will mean for the implementation of the key concepts," wrote Jacqueline Fincher, MD, MACP, chair, ACP's Medical Practice and Quality Committee. "For instance, promoting patient choice and competition is a laudable goal but the current measurement systems and means of sharing the information with consumers are simply not ready to support a rapid implementation of that approach—and therefore we recommend that the Agency proceed with great care to ensure that patients and their families do not experience unintended negative consequences by relying on potentially flawed or unclear data to choose a clinician or type of payment structure."

The letter responded to each of the six guiding principles that CMS said they will use to approach new model design and outlined where ACP is supportive and where they have concerns.

1. Choice and competition in the market—ACP supports transparency of valid and reliable information, including quality, outcomes, and cost data. This has the potential of empowering consumers, physicians, payers, and other stakeholders to reduce and improve quality of care. However, ACP recommends caution in terms of moving too quickly toward systems that depend significantly on consumer choice based on quality, outcome, and cost data.

2. Provider choice and incentives—ACP agrees that physician participation in of their choice should be voluntary. ACP also understands the need to have defined control groups or comparison populations to allow proper analysis of the effectiveness of models in improving quality and decreasing costs. However, ACP recommends that CMS make every effort to minimize the amount of qualified (Alternative Payment Model) APM applicants who are randomized into control groups and therefore unable to benefit from enhanced payments or other potential incentive payments that participants in the model receive.

3. Patient-centered care—ACP strongly supports patient-centered care as it needs to be the critical underpinning of all delivery systems and payment models, whether they are APMs or not. However, ACP does have significant concerns with how the language in this principle may ultimately be operationalized. Current quality and cost measures and the system used to collect and share the data from these measures are simply not adequate at this time. ACP calls on CMS to move forward with caution in terms of developing and implementing programs that depend significantly on consumer choice based on quality, outcomes, and cost. Otherwise, there is a real risk of patients experiencing poor outcomes and even harm if they are making decisions based on potentially flawed or unclear information. Additionally, patient participation in such programs should be voluntary, and participants in models should not have financial penalties imposed simply for failing to achieve health goals and outcomes.

4. Benefit design and price transparency—ACP provides detailed recommendations related to this principle in the newly released position paper, "Improving Health Care Efficacy and Efficiency Through Increased Transparency." In this paper, ACP outlines its support for transparency of reliable and valid price information, expected out-of-pocket costs, and quality data that allows consum¬ers, physicians, payers, and other stakeholders to compare and assess medical services and products in a meaningful way. ACP emphasized that it is important to note that price should never be used as the sole criterion for choosing a physician, other health care professional or health care service.

Further, patient-targeted health care value decision-making tools must be developed that make easy-to-understand data avail¬able to consumers.

5. Transparent model design and evaluation—ACP supports the need for transparency in design and for CMS to collaborate with a broad range of stakeholders—and would strongly recommend that those stakeholders include specialty societies, frontline clinicians, and patients and families. Collaboration with stakeholders is a critical component of decreasing unnecessary administrative tasks that lead to clinician and patient burden.

6. Small scale testing—ACP supports testing smaller scale models and using 1115A(c) under Affordable Care Act authority to expand models that prove successful. However, ACP notes that testing on a more limited scale restricts the number of physicians who can participate in Advanced APMs. CMS should take steps to expedite reviews of models that are undergoing small-scale testing and take immediate steps to expand the models.

ACP's letter then goes on to describe specific recommendations concerning the models CMS sought comments about. Some of those recommendations include:

  • Expanded Opportunities for Participation in Advanced APMs—ACP strongly supports CMS seeking to expand options that are available for internal medicine physicians and subspecialists to participate in value-based models through the Advanced APM pathway because current opportunities are very limited.
  • Consumer-Directed Care & Market-Based Innovation Models—ACP cautioned that currently available performance measures, measurement systems, and means of sharing performance information with consumers, which would be the basis for and means of patients and families making their decisions under Consumer-Directed Care and Market-Based Innovation Models, are not adequate. In addition, ACP said it does not support models that would "incentivize them [patients] to achieve better health" if that means penalizing patients who are unable to achieve desired health outcomes. While ACP supports voluntary models that offer the support needed to help patients achieve better health, the models must not penalize patients that fall short of meeting desired health goals and outcomes. Social determinants of health such as socioeconomic status, inadequate housing and transportation, lack of access to healthy foods, and racial and ethnic health disparities are known to negatively impact patients' health. Accordingly, Consumer-Directed and Market-Based Innovation Models must not punish patients by withholding benefits or imposing financial penalties on them for behaviors or actions that may be associated with social determinants that are largely beyond their control.
  • Physician Specialty Models—ACP supports increasing the availability of models that are targeted to specialists and subspecialists. These groups currently have very few options. However, we encourage CMS to consider appropriate interaction between primary care and specialists in models. Specialty APMs that do not embrace the roles that primary care physicians and specialists play in managing the patient's overall care, in addition to any chronic and episodic treatment/care needs, will result in siloed, fragmented care to the detriment of the patient's needs.

"We hope that CMS carefully considers our recommendations on accelerating the development of new and expanded options for Advanced APM participation, while also considering the challenges that exist in moving too quickly toward consumer-driven care and market-based models involving price transparency," concluded Dr. Fincher. "The College looks forward to continuing to work with CMS to support the transition to innovative value-based care models and the development of performance measures that are truly meaningful to physicians and their patients. These new measures can better contribute to improved patient quality and outcomes and reduced costs, ultimately allowing enhanced price transparency for , physicians, and payers."

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