#64: Stuff You Should Know About Health Policy

October 27, 2017 | By Matthew Watto, MD

Get schooled on medical homes, payer reform, and what the future might look like for primary care with Dr. Sue Bornstein, MD, FACP and Executive Director of the Texas Medical Home Initiative and Chair of the Health and Public Policy Committee at the ACP.

Dr Alex Lane of Cooper University Hospital joins Matt as cohost!

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Clinical Pearls:

1. Major interest groups in healthcare arena: Professional groups (e.g. physicians, nurses), hospitals, pharmaceutical and medical device industries, insurers and consumers/patients. Patient not always at the center due to conflicting interests.
2. Medical home: a primary care model that is patient-centered, comprehensive, team-based, provides care coordination with enhanced accessibility (e.g. extended hours, electronic visits, telemedicine), and rigorous quality and safety measures.
3. Caring for chronic illnesses longitudinally is a recent concept. Previously care was “transactional” with doctors caring for acute problems. The old fee-for-service based payment models aren’t well suited for longitudinal care.
4. Medical homes seem to provide cost savings/benefit for: ambulatory care sensitive conditions like diabetes, congestive heart failure, and asthma; complex patients with high care utilization; and decreased utilization of acute inpatient care
5. Top 5% of Medicaid users account for 48% of healthcare dollars spent in the program!
6. MACRA: the Medicare Access and CHIP Reauthorization Act, is legislation passed in 2015.  Replaces previous Medicare reimbursement schedule (fee-for-service) with new pay-for-performance program (aka Quality Payment Program) focused on quality, value, and accountability.
7. Sustainable growth rate formula: Previous method used by the Centers for Medicare and Medicaid Services (CMS) to control spending by Medicare on physician services (from Wikipedia).
8. Quality Payment Program: Pay-for-performance model with two tracks: Merit Based Incentive Payment System (MIPS), or Alternate Payment Models (APMs).
   “You’re a part of the Quality Payment Program in 2017 if you are in an Advanced APM or if you bill Medicare more than $30,000 in Part B allowed charges a year and provide care for more than 100 Medicare patients a year.” -qpp.cms.gov
9. Merit Based Incentive Payment System (MIPS): in 2017 reimbursement based on quality (60%), advancing care activities (25%), and improvement activities (15%). “Cost” will be added as a fourth category in 2018 to determine payment adjustment.
10. Alternate Payment Models (APMs):
    “gives added incentive payments to provide high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population. Advanced APMs are a subset of APMs, and let practices earn more for taking on some risk related to their patients’ outcomes. You may earn a 5% incentive payment by going further in improving patient care and taking on risk through an Advanced APM.” – qpp.cms.gov
11. The Affordable Care Act (ACA) attempted to expand Medicaid in all states, however, the Supreme Court threw out the mandate for Medicaid expansion. Payments for disproportionate share hospitals (DSH) were set to decrease under the ACA assuming that Medicaid would be expanded by all states. As of October 1, 2017 payments to DSH will decrease by $43 billion by fiscal year 2025.

Goal: Listeners will be able to discuss the basics players in healthcare and how certain policies will affect doctors, patients, insurers, hospitals, and pharmaceutical/medical device companies

Learning objectives:
After listening to this episode listeners will…

1. Identify the major players (interests) in the healthcare arena and some of their inherent biases
2. Define MACRA, MIPS, APMs and explain what they mean for physicians
3. Define Medical Home
4. Explain why payments to disproportionate share hospitals are in jeopardy
5. List resources that can help health professionals better understand health policy

Disclosures: Dr Forciea reports no relevant financial disclosures for this episode.

Time Stamps
00:00 Intro
02:42 Guest CV and background
04:42 Getting to know our guest
10:40 Helpful resources for learning health policy
12:10 Who are the major players/influencers in health care and how do their interests align
15:02 Defining “medical home”
18:45 Where did the idea for a “medical home” originate
22:33 How does medical home affect cost
29:45 Payer reform and the quality payment program (QPP)
33:06 Recap and defining terms
37:18 How will the QPP be implemented?
41:04 Repeal and replace
43:37 Cuts in funding for safety net hospitals that care for the poorest, sickest patients
46:59 Take home points
48:55 Outro

Links from the show:

1. Self (album) by Breakfast with Girls
2. Jon Krakauer Into Thin Air
3. Curiosity (essay) by Faith Fitzgerald
4. Commonwealth Fund for health policy info
5. Health Affairs Journal for Health Policy http://www.healthaffairs.org
6. Kaiser Family Foundation https://www.kff.org
7. Texas Medical Home Initiative
8. “Sue’s Blog” by Sue Bernstein  PCMH outcomes improve as model is around longer
9. The Myth of the Lone Physician AAFP article (Free)
10. Defining the PCMH from AHRQ.com
11. Peter Sullivan. 5 percent of Medicaid patients account for half of program’s costs. TheHill.com 2015
12. Maeng, D et al. Reduced Acute Inpatient Care Was Largest Savings Component Of Geisinger Health System’s Patient-Centered Medical Home. Health Affairs. April 2015