The Trump administration is putting the brakes on a key set of goals created by the Obama administration to dramatically reduce the cost of the clunky and overpriced U.S. health-care system.
The Centers for Medicare and Medicaid Services says it’s no longer operating on the aggressive timeline laid out by the Obama administration that increasingly seeks to tie more Medicare payments to the quality of care received by the program’s beneficiaries. The previous administration’s goal was revamping the way Medicare, the nation’s largest health program, pays doctors and hospitals so that providers were encouraged to reduce unnecessary or duplicative services and better coordinate patient care. That would be a major shift for the U.S. health-care system in which providers make more money the more treatments they offer, even if such services are unnecessary or even harmful.
Back in 2015, Obama’s Health and Human Services Secretary Sylvia Mathews Burwell announced an ambitious goal for Medicare: By the end of 2018, half of all its payments were to be tied to alternative payment methods with wonky-sounding titles — mechanisms such as “accountable care organizations,” “bundled payments” and “primary medical homes.” They all aim to help doctors improve the care they provide by basing payments on certain quality standards.
That’s no longer the goal, a CMS spokesman told me last week. Instead, the focus is on ramping up a review of how the Obama administration did or didn’t fail in these efforts. “The Trump administration’s focus has not been on a specific targeted number by the previous administration, but rather on evaluating the impact of new payment models on patients and providers,” said CMS spokesman Raymond Thor.
Health-care stakeholders told me they’re still not exactly sure how CMS plans to take on the task of improving Medicare payments. That’s partly because the agency is going through a time of transition: HHS Secretary Alex Azar has been on the job only a few weeks and CMS’s innovation center is soon expected to get a new leader, widely rumored to be Adam Boehler of Landmark Health.
It’s not exactly that the Trump administration is totally backing away from Medicare payment reforms — but it may not be chasing them as forcefully as under Obama. Seema Verma, Trump’s appointee leading CMS, publicly acknowledges there need to be changes to the way Medicare pays doctors and hospital — now primarily done through a “fee-for-service” model in which providers are compensated per test, procedure and clinic visit. But in recent months, Verma has been critical of some of the Obama administration’s tactics while also pulling back on some of her predecessor’s projects to pay health-care providers based on quality instead of quantity.
In a Wall Street Journal op-ed last fall — around the time CMS formally requested input into which payment models were and weren’t working — Verma suggested some of the Obama officials’ efforts erected high barriers for participation and may even have encouraged consolidation within the health-care industry.
“We are analyzing all innovation center models to determine what is working and should continue, and what isn’t and shouldn’t,” Verma wrote.
The following month, Verma spoke to a group of health-care payers and providers called the Health Care Payment and Learning Action Network, which Burwell formed in March 2015 to support CMS’s efforts and share ideas for spreading payment changes throughout the industry.
Verma didn’t try to undermine the value of innovative new Medicare payment reforms, which aim to lower overall spending by encouraging providers to deliver better, smarter care. But she did lob a criticism at the system, suggesting her predecessors forging ahead with new experiments without sufficiently evaluating their performance.
“I like to think of our initiative in terms of painting a house,” Verma told attendees. “Typically, repainting needs to occur every few years and before you repaint, you need to strip out the layers of pain from underneath … unfortunately, CMS has been applying new layers of paint without taking this essential step.”
In November, CMS did partially cancel two programs changing reimbursements for joint replacement and cardiac rehabilitation procedures by using what’s known as “bundled payments.” Under bundled payments, providers get a flat payment covering the duration of a procedure and recovery. If their costs come in under the fee, they can keep the difference — if their costs exceed the fee, they lose money.
But the agency is taking some steps forward on voluntary experiments with bundled payments for other types of health procedures. Patrick Conway, who headed CMS’s innovation center before departing last fall, pointed to a new program the agency rolled out in January, which allows doctors to participate in bundled payments for 32 different kinds of medical procedures, including major joint replacements and spinal fusion.
Conway acknowledged that even as the Trump administration has discarded the Obama-era goal of reforming 50 percent of Medicare payments by the end of this year, current top HHS officials have still expressed interest in the idea overall.
“It’s not like the White House has come out with a new number as a goal,” Conway said. “But Seema and others – Alex Azar – have stated their belief that the push for value-based payment needs to continue.”
During the last few years of Obama’s tenure, Burwell made it a top priority to change Medicare payments and sought to draw more public attention to the issue. She and her staff rolled out a specific timeline, including a goal of tying 30 percent of Medicare payments to quality-based payment models by the end of 2016, an aim it achieved a full year early.
While private insurers are increasingly adopting value-based payments – including Blue Cross Blue Shield North Carolina, which Conway heads – it’s still Medicare that largely sets the tone for the rest of the industry.
The government’s ability to successfully adopt these new approaches to payments is a crucial factor in determining the future of the U.S. health-care system. By 2026, federal, state and local governments will sponsor 47 percent of national health spending, up from 45 percent last year, according to a projection released last week by CMS.
“Medicare is really the critical player in this,” said Sue Sherry, deputy director for the advocacy group Community Catalyst and a member of HCPLAN.
Sherry and others feel that for progress to continue, CMS needs to give clear direction to doctors, hospitals and other medical providers on the types of payments they should expect in the near future. A lack of strong signals makes it harder for providers to get fully on board with payment changes.
“You try to run a system with these conflicting incentives, and you have your feet in two different canoes,” Sherry said. “Momentum is so important.”
Medicare spending has grown more slowly in recent years, increasing an average of just 1.3 percent per person annually since 2010 compared to 7.4 percent in the decade prior. Conway credits much of that decrease to payment innovations. There are now more than 1,000 accountable care organizations in the public and private sectors caring for millions of patients around the country. These “ACOs” are groups of doctors, hospitals and other providers that unite to deliver coordinated, high-quality care for their patients.
It’s a shift in the way doctors and hospitals think, Conway explained. Under the old system, for example, a hospital would be paid for filling every one of its beds. These new payment models instead reward hospitals if they prevent hospital re-admissions, meaning, advocates hope, they got better care to begin with.
“If you were a CEO in a hospital in the older world, you wanted as many heads in your beds as possible,” Conway said. “In the new world, you want to prevent as many people from being admitted as possible, because the finances have shifted.”
There have been some fair criticisms that quality-over-quantity approach hasn’t achieved the savings many hoped for. Former staff admit this, but still argue that even a small margin of savings could have a big effect on Medicare spending, which totaled $672 billion in 2016.
In one experiment CMS has been conducting, 428 accountable care organizations reduced spending by $1 billion over three years compared to their benchmarks, and 82 percent improved the quality of care they provided.
There are some signs that Azar appears more interested in Medicare innovations than his predecessor Tom Price, who famously opposed the idea of requiring doctors to participate in any of the pilot programs.
In a congressional hearing last week, Sen. Sheldon Whitehouse (D-R.I.) told Azar he’s concerned about the possibility the secretary may not prioritize the “strongly bipartisan” goal of payment reforms. “I think this is a safe, bipartisan place where real progress can be made,” Whitehouse told Azar.
“I totally agree about the need for value-based transformation,” Azar said. “I think it’s a bipartisan issue that we can improve quality, decrease cost and make our programs more sustainable.”
Under Price, HHS began pursuing new rules lifting the mandate that providers participate in bundled payment models for hip fractures and cardiac care, which the agency finalized in November. It also significantly eased requirements for doctors in a 2015 bill passed by Congress, stressing in an October rule that physicians could pick their own pace to satisfy those measures.
All this has worried advocates for improvements to the current system, some of whom view the Trump administration’s approach as a retreat from progress made in the Obama era.
“Clearly under Secretary Price, there had been some pullback around not just the goals, but some regulations,” Sherry said. “All of which for people who were supportive of this shift from volume to value raised concerns.”
AHH: Researchers announced yesterday that by looking at the human eye, Google’s algorithms were able to predict whether someone had high blood pressure or was at risk of a heart attack or stroke, opening a new opportunity for artificial intelligence in the vast and lucrative global health industry. The algorithms didn’t outperform existing medical approaches such as blood tests, but the new approach could build on doctors’ current abilities by providing a tool people could one day use to quickly and easily screen themselves for health risks that can contribute to heart disease, The Post’s Drew Harwell and Carolyn Y. Johnson report.
It works like this: Google researchers fed images scanned from the retinas of more than 280,000 patients across the United States and United Kingdom into its intricate pattern-recognizing algorithms known as neural networks. Those scans helped train the networks on which telltale signs tended to indicate long-term health dangers.
“Medical professionals today can look for similar signs by using a device to inspect the retina, drawing the patient’s blood or assessing risk factors such as their age, gender, weight and whether they smoke,” Drew and Carolyn write. “But no one taught the algorithms what to look for: Instead, the systems taught themselves, by reviewing enough data to learn the patterns often found in the eyes of people at risk…The true power of this kind of technological solution is that it could flag risk with a fast, cheap and noninvasive test that could be administered in a range of settings, letting people know if they should come in for follow-up.”
OOF: Even as the Trump administration seeks an ambitious military buildup, there’s a dwindling pool of Americans who can even join the Armed Forces, Politico’s Bryan Bender reportsin a fascinating look at how obesity, other health problems, criminal backgrounds or lack of education make nearly three-quarters of Americans ages 17 to 24 ineligible to serve.
“That’s a harsh reality check for the Pentagon’s plan to recruit tens of thousands of new soldiers, sailors, pilots and cyber specialists over the next five years,” Bryan writes. “The Army plans to add 4,000 troops to reach a total of 487,500; the Navy will add 7,500 sailors for a total of 335,400; and the Air Force is seeking an additional 4,000 volunteers to reach 329,100 active-duty personnel…But the military is struggling to reach its current recruiting goals.”
“The bleak demographic trends among the military-age population could make filling the ranks with qualified recruits exceedingly difficult for years to come,” Bryan says. “The government estimates that 24 million out of the 34 million people in the 17-through-24 age group are not qualified to serve….health problems are the clearest impediment to military service — especially the alarming number of youngsters who are overweight.”
OUCH: HHS’s top communications official Charmaine Yoest is leaving the agency for the Office of National Drug Control Policy, according to sources at the agency and several news reports late last week. She’s headed for the White House’s drug policy office, which has seen a turbulent year amid leadership changes and the withdrawal of Rep. Tom Marino (R-Pa.) from the confirmation process to lead it after a Post investigation showed his involvement in passing a bill limiting the CDC’s opioid oversight.
Over the months Yoest served as HHS’s secretary of public affairs, there was a marked shift in the access reporters were given to top HHS officials compared to under the previous administration. Then-secretary Price didn’t hold briefings or phone calls with national press, a pattern mostly followed by CMS Administrator Verma. At times, the agency has invited only select reporters to participate in calls about major initiatives, including its rollout of a new religious freedom division.
–In the wake of the Parkland, Fla. school shooting last week — which killed 17 people and prompted students to gather in front of the White House to call for change — Trump has focused mostly on the need for better mental-health treatment instead of talking about stricter gun control. That bought him some criticism from the medical community, the Associated Press’s Lindsey Tanner reports.
“Mental health professionals welcome more resources and attention, but they say the administration is ignoring the real problem — easy access to guns, particularly the kind of high-powered highly lethal assault weapons used in many of the most recent mass shootings,” Lindsey writes.
The American Psychiatric Association and the American Academy of Pediatrics were among several leading medical groups that penned a statement calling on the administration and lawmakers to declare gun violence a national public health epidemic. And in a column, American Medical Association President David Barbe wrote “even for those who manage to survive gun violence involving these weapons, the severity and lasting impact of their wounds, disabilities and treatment leads to devastating consequences.”
–However, Trump has signaled support for one piece of gun control legislation aimed at improving the background-check system used to purchase guns. Our colleague Josh Dawsey reports the president met with friends at Mar-a-Lago on Friday and discussed possible gun-control measures, telling them he was truly affected by visiting with shooting victims. The bill, co-sponsored by Sen. John Cornyn (R-Tex.) and Chris Murphy (D-Conn.), would reinforce the requirement that federal agencies report all criminal infractions to the National Instant Criminal Background Check System and create financial incentives for states to do so too.
“Federal agencies are required to report various felonies, indictments and other crimes — including domestic assaults — into the federal database, but Congress has no power to compel states to do the same,” Josh writes. “The Murphy-Cornyn legislation would offer direct financial incentives, as well as favorable future access to other federal assistance programs, to states that report infractions into the system.”
White House press secretary Sarah Huckabee Sanders said over the weekend Trump is working with senators on the measure. She said “while discussions are ongoing and revisions are being considered, the president is supportive of efforts to improve the check system.”