The 2016 Health Policy Trifecta: Payment Reform, Quality Measures, and EHRs

Greetings, Palliative in Practice readers, and Happy Valentine’s Day!

Valentine’s Day is always a special time of year for me. Like other holidays grounded on the exchange of love, it marks the likelihood of a 2 for $5 M&M sale at the Rite Aid next to the CAPC offices. On days like this, when a deadline loomed, you could often find me there, standing in line, with 25.2 ounces of my closest multi-colored friends cradled in my arms.

But this year I will not be celebrating in the usual fashion; I am not there. As some of you know, I left my full time role with CAPC a few months ago. I continue to abuse my knowledge of the CAPC conference lines by randomly dialing in, annoy our Policy Manager with toddler-like lines of inquiry about MACRA, and enjoy certain social media privileges. But as I am told they are changing the passwords to Palliative in Practice next week, this will be my last post.

As the policy landscape fades in my rearview, individual news stories lose their detail and only the tallest behemoths remain visible. Accordingly, I’m organizing this post in their three hulking shapes.

  1. Payment reform. As anyone with a subscription to Healthcare Alliteration Today can tell you, the refrain on this topic for the last few years has been ‘paying for value, not for volume.’ This was jump started by the ACA and now continues with the Medicare Access and CHIP Reauthorization Act (MACRA). MACRA was passed last year as part of the repeal of the SGR, and includes strong incentives for providers to either participate in the Merit-Based Payment Incentive System (MIPS) or Alternative Payment Models (APMs). For a nice overview of the law, head over to this AAHPM winter feature.

CMS is tasked with defining all aspects of the MACRA, including the measures for MIPS and the standards for APMs. In addition to issuing requests for information in the last few months, it initiated the Health Care Payment Learning & Action Network (HCP-LAN) to create a space for stakeholder discussion and input. Last month, the HCP-LAN released this framework describing alternative payment models (summarized by Nussbaum, McClellan et al. over on the Health Affairs Blog).

Also worth noting for our field is the policy options paper released in December from the Senate Working Group on Chronic Care. The paper lists many options related to payment reform that would impact palliative care, including expanding the Independence at Home demonstration, new codes for high-severity chronic care management and changes to how HCC scores are assessed. The paper also proposes the long-discussed, if not long-awaited, hospice carve-in for Medical Advantage. Reactions to the paper have been mixed but, all in all, pretty positive.

  1. Yes, it’s related to payment reform but, like an adolescent with a mustache, it has obtained its own identity. Since my first days with CAPC, measurement has been a concern. Though many providers are understandably worried that being beholden to performance on measures could negatively impact patient care, I would like to submit a new alliterative healthcare phrase for your consideration: mo’ money, mo’ measures.

While it is true that measure development is costly (thus mo’ money, mo’ measures) it is key to remember that measures are how we define value. “Value” is what the health system will soon be paying for. If something is not measured, it will not be remunerated, so it is critical that palliative care measures be included in payment-related measure sets.

Unfortunately there aren’t that many palliative care measures, and the field has yet to devise a unified strategy for how to include palliative care in these new definitions of value. But at least there will be a committee. The National Quality Forum announced that it would be forming a Palliative Care and End-of-Life Care Project which will include a committee and a call for new measures. They are due February 29. Don’t all submit at once, now.

Which brings us back to mo’ money, mo’ measures. As part of MACRA, CMS will receive $15 million per year for five years to develop quality measures in patient and caregiver experience, among other things. We hope that some of this funding will be used to develop palliative care measures, but I have to tell you: $15 million isn’t very much, particularly considering how complicated patient-centered measures can be. You can read CMS’s draft Quality Measure Development Plan here, and comment on the plan through March 1 on this very official-looking Survey Monkey page.

  1. Rounding out my trinity is EHRs and the new era of team practice. Patient-centered care means, among other things, that disparate providers come together to form a team around the patient. This requires communication, and unless the entire extended care team travels together like ducklings, documentation. Unfortunately, communicating with other people is hard. It takes time. And doing so electronically—in a system that was, until only recently, still using hieroglyphics—requires a lot of technological R&D.

So it really wasn’t much of a surprise that we got a lot of things wrong with Meaningful Use. It’s hard to codify something that’s still developing. And in any case, it appears to be on its way out. CMS Acting Administrator Slavitt stated at a conference on January 11 that the Meaningful Use program “will now be effectively over and replaced with something better.” This sounds, you know, better, so I support it.

The Senate HELP committee is also doing its part to legislate the future of HIT with a new HIT bill passed this week. The bill summary is here, and includes sundry provisions that vaguely sound like good ideas. You can read some unbiased reporting about the bill over at EHR Intelligence, and with a lede like “The Senate Committee on Health, Labor, and Pensions unanimously passes this legislation that will enhance patient-centered care with EHRs,” you know you’re going to get some penetrating analysis.

And honorable mention goes to the thousand other policy issues that are now rushing into my mind. There is always so much going on. You know, there’s a lot more trial and error in life than I was led to believe in college, and, in policy, it sometimes seems like there is nothing but. This wouldn’t be that bothersome if we didn’t also have such short memories, but we do. I’m leaving policy for the time being, but perhaps the content knowledge I have now will once again be relevant, in 30 years or so, when Congress is considering tying value-based reimbursements to the growth of the economy…

I’ll close by saying that though I’m leaving CAPC, I will always be a palliative care advocate. It is a uniquely unimpeachable goal, to help reduce suffering when people need each other the most.

On the tall shelf of my questionably tasteful, but often-used quips is the statement that working in palliative care makes me a hit at dinner parties. I mean to imply one of several things with that, but the remark is founded on real experience. Whenever I have brought up my work at social gatherings, if someone in earshot has been the beneficiary of palliative care, the tone of the conversation abruptly changes. A conversation once cheerful, but trifling, turns to solemnity as they remember the care someone took of them and their loved one once, when things were so hard, and of the stark contrast of this bond against a world of such immense indifference. They are reverent as they observe the memory, and they are grateful for their palliative care providers. I have been very proud to be an advocate of something so wrapped up with what we consider the best of ourselves. And I can’t help but be afraid that when I need palliative care, it will not be there.

So, I will remain a palliative care advocate, and I look forward to following all of your work. I live in New York, District 7, if you need anything, and I’ll stay on your mailing lists. But, dear God, please don’t use any acronyms; I won’t know what you mean.

Post written by Emily Warner

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