The Healthcare Policy Podcast ® Produced by David Introcaso

Listen NowThe 2015 Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) will sunset three current Medicare performance measurement and incentive payment programs in 2018.  (This year, 2016, will be the last year these programs will be measuring and rewarding Medicare physician performance.)  These are: the Physician Quality Reporting System (PQRS); the HIT Meaningful Use (MU) program; and, the Value-Based Modifier (VM) Program.  The VM Program, modified under the 2010 Affordable Care Act, is designed to incent Medicare physician performance by updating annual Part B physician payments based on their quality and cost (or spending) performance.  (The performance and payment years are two years apart, e.g., the 2016 payment year is based on 2014 performance.)     During this 23 minute conversation Ms. Cleary explains how the VM program is designed, how physicians have performed to date under the program, the extent to which physicians use VM data to inform or improve their practice, how the program will be translated, or continue, under the MACRA Merit-Based Incentive Payment System (MIPS) and quality and value performance expectations under MIPS beginning in 2017, the first MACRA performance year.   Ms. Kelly Cleary is a DC-based health care attorney with the firm Akin Gump.  Her work primarily concerns health care related legislative and regulatory initiatives, matters involving state and federal fraud and abuse laws and cybersecurity, privacy and data protection issues.  Prior to joining Akin Gump, Ms. Clearly clerked for the Honorable Claude M. Hilton in the US District Court for the Eastern District of Virginia.  She was graduated from Catholic University's School of Law.  While there she served as editor-in-chief of the Catholic University Law Review.   For more on the CMS VM program go to: https://www.cms.gov/medicare/medicare-fee-for-service-payment/physicianfeedbackprogram/valuebasedpaymentmodifier.html This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit www.thehealthcarepolicypodcast.com

Listen NowMeasuring health care quality and outcomes effectively and efficiently remains a daunting task.  Quality measures are largely seen as too process versus outcome focused, substantially irrelevant to patients and insufficiently aligned between and among payers.  Measuring care or care quality, ironically, can and does detract from actual care delivery, can have no relationship to spending efficiency and on its own is costly.  A recent article published in Health Affairs found physician practices spent over $15 billion in 2014 in reporting quality measures.  Concerning the Medicare program's quality measurement activities, MedPAC in a 2014 report to the Congress went so far as to state, "Medicare's current quality measurement approach as gone off the rails." During this 23 minute conversation Dr. Burstin briefly describes the work of the National Quality Forum (NQF), the work done by the CMS-led Core Measure Collaborative, quality measurement under the CMS proposed MACRA (Medicare Access and CHIP Reauthorization Act) rule, risk adjusting measures for socio-demographic factors, the role of PREMS and PROMS or patient reported experience and outcome measures and correlating care quality and spending or measuring for healthcare value.  Dr. Helen Burstin is the Chief Scientific Officer at the NQF.  Prior to serving in her current position, Dr. Burstin was NQF's Senior Vice President for Performance Measurement.  Prior to NQF Dr. Burstin was the Director of the Center for Primary Care at the DHHS Agency for Healthcare Research and Quality (AHRQ).  Prior to AHRQ, Dr. Burstin was an Assistant Professor at Harvard Medical School and the Director of Quality Measurement at the Brigham and Woman's Hospital in Boston.  Dr. Burstin has published more than 80 articles and book chapters on quality, safety and disparities.  She was recently selected as a 2015-2016 Baldridge Executive Fellow.  She currently is also is a Professorial Lecturer in the Department of Health and Policy and a Clinical Associate Professor of Medicine at George Washington University and serves as a preceptor in internal medicine.For information concerning NQF go to: http://www.qualityforum.org/Home.aspx This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit www.thehealthcarepolicypodcast.com

Listen NowIn an extremely busy year for Medicare delivery and payment reform,  regulatory implementation of the 2015 Medicare Access and CHIP Reauthorization Act (MACRA) stands out.   This past April CMS published the agency's 960-page proposed rule to implement the law.  The proposed rule, that will go final this fall, will change the way Medicare physician payments (Medicare Part B) are annually updated beginning in payment year 2019.   Payment updates, either at the individual provider or at the group level, will be calculated either by the Merit-based Incentive Payment System (MIPS), a composite score based on four, differently weighted, component scores, or via provider participation in what CMS defines as an "advanced" Alternative Payment Model (APM) pathway, e.g., Track 2 and 3 ACOS and Patient Centered Medical Homes that meet certain financial risk criteria.During this 22-minute discussion Ms. Mara McDermott evaluates how CMS proposes to define APM nominal risk, how the agency has defined the MIPS composite score, the effect MACRA will have on small practices, how Medicare Advantage plans and physicians can be included in MACRA, and several inter-related issues.   (While the introduction to this discussion provides some brief explanatory information, our conversation assumes the listener has some familiarity with Title I of the MACRA law.)    Mara McDermott is the Vice President of CAPG (formerly the California Association of Physician Groups) where she leads the organization's federal legislative and regulatory activities in Washington, D.C.  Prior to joining CAPG, Mara was Counsel in the health industry practice of Akin Gump Strauss Hauer and Field.  Mara received her JD with high honors and her MPH from George Washington University School of Law in 2007.  She received her BA in 2003 from the University of California, Davis.The CMS MACRA proposed rule is at: https://www.federalregister.gov/articles/2016/05/09/2016-10032/medicare-program-merit-based-incentive-payment-system-mips-and-alternative-payment-model-apm Information concerning CAPG is at: http://www.capg.org/ This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit www.thehealthcarepolicypodcast.com

Listen NowWhat accounts for so called patient compliance or adherence or why is it the case physicians and other providers are frequently unable to successfully engage their patients.  Why is it the case, for example, that patients adhere to highly toxic regimens of such as chemo therapy and not to more tolerable drugs such as statins.  What explains adherence or non-adherence?         During this 22-minute conversation Dr. LaFountain explains why, using her phrase, the "epidemic of non-adherence" persists. She discusses the "importance of differentiation," the application of "cognitive profiling" or "cognitive restructuring," and provides examples using treatments for ADHD, breast cancer and diabetic patients at the Cleveland Clinic.Dr. Andrea LaFountain is CEO of Mind Field Solutions Corporation, a firm specializing in the application of cognitive neueroscience to health behavior and patient engagement.   Prior to establishing Mind Field, she worked for AstraZeneca Pharmaceuticals leading consumer research and analytics for their oncology portfolio.   Before moving to the US, Dr. LaFountain was a Lecturer at The University of Liverpool.   She is a fellow of the American Psychological Association and the British Psychological Society and a scientific reviewer for the International Society of Pharmaco-economic Outcomes Research.  Dr. LaFountain earned her Ph.D. in pre-frontal cortex executive functioning at Imperial College, London.  For information concerning Dr. LaFountain's work go to: http://www.amazon.com/How-Patients-Think-Science-Based-Engagement/dp/069266095X. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit www.thehealthcarepolicypodcast.com

Listen NowSince, in part, April is recognized by DHHS as National Minority Health Month (this year's theme is "Accelerating Health Equity in the Nation") it is thoroughly appropriate to discuss Professor Daniel Dawes's recent work, "150 Years of Obamacare."  Professor Dawes's work begins with a discussion of efforts since the Civil War to reform national health care policy beginning with the 1865 Freedmen's Bureau Act.  The work moreover provides an accounting of his and others efforts to lobby successfully for health equity provisions in passing the 2010 Affordable Care Act ( ACA).  During this 31-minute conversation, Professor Dawes discusses passage of the ACA, i.e., "Obamacare,", e.g., Republican opposition to the legislation and moreover the importance of the sixty plus health equity-related provisions in the legislation and what are his priorities for furthering health care equity or reducing disparities in health care delivery and outcomes - that sadly remain pronounced.   Attorney and Professor Daniel E. Dawes is the Executive Director of Health Policy and External Affairs at the Morehouse School of Medicine and a Lecturer within Morehouse's Satcher Health Leadership Institute and the Department of Community Health and Preventive Medicine.  He founded and chairs the Working Group on Health Disparities and Health Reform and is the co-founder of the Health Equity Leadership and Exchange Network (HELEN).  Previously, Professor Dawes held positions with the Premier Healthcare Alliance, the American Psychological Association and served on the Senate HELP (Health, Education, Labor and Pensions) Committee under Senator Edward Kennedy.   He is the recipient of numerous award including the Congressional Black Caucus Leadership and Advocacy Award.  He earned his JD from the University of Nebraska and his BS from Nova Southeastern University.For more information concerning Professor Dawes's work, go to: https://jhupbooks.press.jhu.edu/content/150-years-obamacare.   This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit www.thehealthcarepolicypodcast.com

Listen NowAs a follow up to my April 1st conversation with Jim Gera concerning bundled payments, during this podcast Dr. Richard Morel discusses Medicare's other major payment reform program, Accountable Care Organizations (ACOs), or WESTMED Medical Group's three year experience as a Track 1 ACO.   The Medicare ACO program is a creation of the 2010 Accountable Care Act and participation in the program began in 2012.   Currently, there are 434 ACOs (over 90 percent participating in the "no risk" Track 1) caring for approximately 7.5 million Medicare beneficiaries.  The program to date has been a mixed success.  After two performance years (2013 and 2014) only 25 percent of participants have been successful, i.e., have earned shared savings.  (Performance year three or 2015 performance will be made known this September.)  CMS is currently in the process of revising how the agency calculates an ACO's reset financial benchmark.  It is anticipated these changes will improve program performance, or improve both provider interest in participating (or continuing to participate) in the program and participant success in earning shared savings.   During this 21-minute conversation Dr. Morel provides an overview of WESTMED, explains the organization's interest in becoming a Medicare Shared Savings Program or ACO participant in 2013, WESTMED's experience under their first three year agreement, what explained their success, challenges they've found with the program, how the program could be improved and their expectations now as a second agreement period Track 1 ACO.Dr. Richard Morel is the Co-Medical Director of WESTMED Medical Group in Yonkers, New York.  Prior to joining WESTMED in 2008 Dr. Morel was in private practice affiliated with Columbia-Presbyterian Riverdale Hospital for 12 years.  Dr. Morel is board certified in internal medicine.  He received his medical degree from Columbia University College of Physicians and Surgeons, did his postgraduate training at Columbia-Presbyterian Medical Center and  received his masters of medical management from Carnegie Mellon.  He is a fellow of the American College of Physicians and a member of the American College of Physician Executives.  For information regarding WESTMED go to: http://www.westmedgroup.com/. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit www.thehealthcarepolicypodcast.com

Listen NowToday, CMS launched the agency's second bundled payment demonstration, a mandatory five-year initiative in approximately 800 hospitals nation-wide.  It's titled, the Comprehensive Care for Joint Replacement (CJR).  The CJR essentially reimburses hospitals a predetermined amount for a 90-day hip or knee surgical and rehab episode of care.  CMS is emphasizing hip and knee replacement surgeries because they account for the single largest Medicare dollar amount and highest percent of annual 30 day episode spending.  This demonstration follows CMS's voluntary Bundled Payment for Care Improvement (BPCI) demonstration that provides bundled payments for 48 care episodes (including hip and knee replacements) via four care model designs.  How successfully hospitals, orthopedic surgeons and various post acute providers manage these care episodes will be important if CMS is to better control Medicare spending growth.   (Listeners will recall I discussed moreover the theory of bundled payment arrangements with Harold Miller this past September 23rd.)  During this 29 minute conversation Mr. Gera provides and overview of Signature Medical Group and their orthopedic bundled payment work under both CMS's BPCI and CJR demos.  More specifically, he discusses how hip and knee replacement surgical patients are identified, how the bundled payment care team is assembled, how the care episode is manged, how quality is measured, profit sharing conducted and moreover principles his organization has developed to succeed under these capitated payment arrangements.  Mr. Jim Gera is the Senior Vice President of Business Development for Signature Medical Group, Inc., a multi-specialty group of physicians located in St. Louis and rural Missouri.   Among other related activities Mr. Gera co-authored an Advanced Payment Medical Accountable Care Organization application and a successful CMS Strong Start for Mothers and Newborns grant award.   Recently he has also served as a Chair for several CMS innovation grant reviews.  Mr. Gera's previous experience includes working with other physician group practices, in outpatient facilities and in managed care both in Medicare Advantage and Special Needs Plans.  Mr. Gera received his MBA from Southern Illinois University at Edwardsville.For more on CMS's CJR demonstration see:  https://innovation.cms.gov/initiatives/cjrFor more on Signature Medical Group see: http://www.signatremedicalgroup.com/  This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit www.thehealthcarepolicypodcast.com

Listen NowCalifornia has been long known for health care delivery and payment reform (think, for example, Kaiser Permanente).   With efforts nation-wide to better align health care quality and patient outcomes with reimbursement or savings efficiency, related efforts in California are carefully watched and studied.     During this 23 minute conversation Dr. Jill Yegian briefly outlines the work if the California Integrated Healthcare Association (IHA), provides an overview of the California healthcare payment reform landscape, discusses specifically IHA's value-based pay for performance work involving 10 health plans, 200 physician organizations and nine million Californians, discusses quality measurement including "resource use" and "total cost of care" and identifies lessons learned from IHA's activities.     Dr. Jill Yegian, is the Senior VP for Programs and Policy at the California Integrated Healthcare Association where she oversees IHA's work regarding care integration, performance measurement and reporting and payment innovation.   Previously, she co-directed the American Institutes for Research Health Policy and Research Group, a team of over 70 health services research professionals.   Prior still Dr. Yegian worked with the California Healthcare Foundation where her focus was on improving the state's healthcare financing and delivery system.  Dr. Yegian is the author of numerous peer-reviewed articles and is a frequent conference speaker.  She was graduated from the University of California at Berkeley with a Ph.D. in health services and she earned her undergraduate degree in human biology at Stanford. For more on IHA's work go to: www.iha.org This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit www.thehealthcarepolicypodcast.com

Listen NowThe Medicare program, now in its 51st year, still does not cover oral/dental health care such as exams, X-rays, cleanings, fillings, tooth extractions and dentures.   (Medicare will cover an oral health procedure if it is incent to a serious accident or disease, for example, for surgery to treat fractures of the jaw or face or if you have oral cancer and need dental services necessary for radiation treatments.)  This is unfortunate when you consider for example: poor oral/dental health worsens overall health; less than five percent of older Americans have dental insurance of any kind; one-third of adults over 65 have untreated dental caries and over 40 percent have periodontal disease; the Affordable Care Act did not name adult oral/dental benefits as an "essential health benefit"; an overwhelming majority of adults believe dental coverage should be part of overall health coverage; for all of CMS's "innovation" demonstrations (now numbering well over 50) there are none that address improving oral/dental health for seniors; and, oral/dental health disparities are, according to the CDC, "profound."  During this 20-minute conversation Dr. Vujicic provides his assessment of the oral/dental health of American seniors, his understanding of why the Medicare program still does not cover routine oral health care and what can be done to improve access and (insurance) coverage of oral health for seniors or Medicare eligible individuals.Dr. Marko Vujicic is the Chief Economist and Vice President of the Health Policy Institute at the American Dental Association (ADA).  Prior to joining the ADA Dr. Vujicic was a Senior Economist at The World Bank and also a Health Economist with the World Health Organization in Geneva, Switzerland.  Dr. Vujicic is the lead author of the book, "Working in Health" and has authored additional essays and book chapters on various health policies.  He is published in the New England Journal of Medicine, Health Services Research, Health Affairs and other policy and scholarly journals.  Dr. Vujicic is also a visiting professor at Tufts University in Boston.   Dr. Vujicic earned his Ph.D. in Economics from the University of British Columbia and his undergraduate degree at McGill University in Montreal.For more on the work of the ADA's Health Policy Institute go to: http://www.ada.org/en/science-research/health-policy-institute This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit www.thehealthcarepolicypodcast.com

Listen NowMuch of the health care industry's effort to improve health care payment and delivery centers around improving primary care. This is largely because Americans suffer more disease/disease burden throughout their life spans compared to individuals in other industrialized countries.   This therefore makes obvious sense since primary care is the foundation upon which an effective and efficient health care/medical care program is built.  When done well primary care promotes wellness, prevents disease onset, progression, exacerbation and prevents premature death.  Primary care also moderates the need for higher cost specialty care and improves population health.  For numerous reasons, not least of which is inadequate reimbursement, primary care delivery has been sub-optimal.   New models of primary care are emerging, one termed direct primary care (noted in the ACA under Section 1301 (A) (3) and now recognized in 13 states) is showing promise in improving quality, improving patient satisfaction and lowering cost growth.      During this 21 minute conversation Dr. Judge discusses moreover the impetus for the creation of Iora Healh, how Iora's primary care delivery model works or how it is different from traditional primary care delivery, how Iora's model is staffed, IT supported and reimbursed, with whom and how it contracts and what Iora's performance data demonstrates to date. Dr. David Judge serves as Iora Health's Chief Medical Officer.  Dr. Judge joined Iora in 2014 to continue his work in improving and redesigning of primary care.  Priorto , he helped found and was the Medical Director of the Ambulatory Practice of the Future at Mass. General Hospital.  David received his undergraduate degree in biomedical engineering and public health studies at Brown University and attended University of  Mass. Medical School.  He completed his residency training in internal medicine at Columbia Presbyterian Medical Center in New York City. For more on Iora Health go to: http://www.iorahealth.com/ This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit www.thehealthcarepolicypodcast.com