Madam Speaker, Mr. President, Mr. Chairman, Members of the Board, Delegates, I’m honored to be invited to address this House and the physicians of America. Hello and good afternoon. Thank you for hosting me at the American Medical Association’s annual meeting. I want to give special thanks to:
- Doctor Steve Stack, the President of the AMA;
- Doctor Jim Madara, the CEO of AMA,
- Doctor Sue Bailey, the Speaker of the House of Delegates;
- Doctor Steve Permut, the Chairman of the Board,
- The Delegates and all members of the American Medical Association, and
- Perhaps most of all, the physicians who serve our beneficiaries and consumers everyday– whether you are in the room today or reading the speech on Twitter.
Thank you for the honor of allowing me to spend this day with you, and thank you also to Rich Deem for the straight talk, honesty, ideas, and conviction you have brought to our relationship.
In speaking to America’s physicians, you represent one of America’s most potent and proudest forces of talent and ability. When anyone across the world is in need of care, there is no one they would rather be cared for then by America’s doctors. I’m here to talk about the historic opportunity we have before us to change how Medicare pays for care, but I’m also here to talk about something bigger: reversing a pattern of regulations and frustration, and ultimately unleashing a new wave of collaboration between the people who spend their lives taking care of us and those of us whose job it is to support that cause.
Today’s discussion continues the conversation Jim and I began publicly last January in San Francisco. At CMS, the conversation has since continued every week with practicing physicians across the country in big practices and small, specialists and primary care, those in new payment models and in traditional ones. We have connected directly now with tens of thousands of physicians and other clinicians in some form and hundreds in more intensive discussions.
It has been a process of giving front line physicians a direct voice to us and of CMS, starting with me and the senior staff, learning how to listen. Most of you became physicians because of the desire to serve and heal people. Since I have been inside CMS, I have seen a similar drive where every day the staff wakes up thinking about the lives of the 140 million Americans, most on fixed or modest incomes, many in the most vulnerable stages of their lives, who depend on you through the Medicare, Medicaid, Children’s Health Insurance, and Marketplace programs.
Goals for the Quality Payment Program
It is because these patients depend on you, particularly at a time of great need and uncertainty, and often at a time when they need guidance through a complex, fragmented system that I stand here today to say: we can and must take this opportunity to do better. We must:
- Sharpen our focus on paying for what works;
- Reduce the time physicians and their offices spend on paperwork;
- Make health care technology a tool, not an industry; and
- Do this by carrying forward an open process that reduces the gulf between how policies are made in Washington and front-line patient care
This afternoon, I will tell you about the opportunity with MACRA, discuss our work to create the proposed rule, how we have been listening since then, and I will lay out the critical challenges we need your feedback on.
Let’s begin the discussion of MACRA by looking at what Congress did last April when it passed, and the President signed, the bipartisan Medicare Access and CHIP Reauthorization Act. This ended– permanently– the deeply flawed Sustainable Growth Rate (SGR) formula. This formula had created 17 potentially deep cuts for Medicare physicians over the last 13 years. Thanks to your hard work and advocacy, we now have bipartisan legislation that holds the potential to bring long-term stability and reliability to the Medicare program and to move the system in a direction that works better for patients. It also allows us to end the patchwork of measurement programs created over time and replace them with a new single framework, that while it has several components, can provide the basis for a more flexible, relevant and ultimately simpler to use system.
To be clear, with MACRA, we answered one question and opened up a set of others that are now ours to begin to address. To start with, Congress designed the SGR to control costs in Medicare, so that every American who pays into the system will have the care they need when they need it. Before Medicare, one in three seniors lived in poverty. Today that number is 1 in 10. Without a focused effort at delivering care while controlling costs, Medicare – upon which so many of us depend– risks becoming unaffordable.
As the Medicare program moves into its Golden Years, so does the reality of the job it must do in caring for our nation’s elderly and disabled.
- There are 10,000 new Medicare beneficiaries every day,
- A boom generation is turning 70, and
- The 85 and up generation is set to double over the next 10 years.
With the growth of Medicare beneficiaries outpacing the growth of working Americans, we need to find ways, like we do in other sectors, to deliver better care at lower costs.
Improving Medicare through the Quality Payment Program
Ensuring a stable and reliable Medicare program is a tough task. Through the ACA, we’ve extended the life of the Medicare Trust Fund from 2018 to 2030, which happens to be the year I turn 64. Together, Congress and stakeholders, designed a law that promotes ever-improving care at a reasonable cost. It replaces the blunt instrument of the SGR with a system that preserves the core structure of Medicare. The new program wraps around changes intended to promote coordinated care at reasonable costs through a uniform Merit Based system. This system is defined in the statute to focus on quality, cost, technology, and practice improvement. The system also allows physicians and other clinicians to define and advance new approaches to care for patients like medical homes, specialty models, and team-based models that improve quality, manage costs, and reward physicians in those models with additional bonuses.
The first question, of course, for many physicians is: What do you really need to know about the program? What new sets of requirements are there to participate?
So let me be clear, while it can be an understandable distraction, the goal of the program is to return the focus to patient care, not spend time learning a new program. Medicare will still pay for services as it always has, but every physician and other participating clinicians will have the opportunity to be paid more for better care and for making investments that support patients– like having a staff member follow up with patients at home.
We will, of course, provide information in as much or as little detail as is helpful. For those who like to read computer manuals end-to-end, there is of course the 900 page proposed rule complete with every detail about how the regulation and the law is proposed to work. But, for most people, who do not need to see every scenario and how each element of the formula works, there are webinars, in-person meetings, fact sheets, and web portals that will bring all the information to suit various needs.
There are several immediate features of the program that I want to start out with that are all designed as improvements over today’s payment system.
First, MACRA sunsets three disjointed programs. If you participate in the Physician Quality Reporting System, the Value Modifier, and the Meaningful Use program, your life just got simpler as they are replaced with a single, aligned Quality Payment Program, which will reduce reporting requirements, eliminate duplication, and reduce the number of measures. For those who participate in Alternative Payment Models, those requirements are reduced further or eliminated.
Second, it also reduces the combined possible downward adjustment of 9 percent that is occurring today from the three programs to a maximum of 4 percent in the first year of the Quality Payment Program. The program is designed to build up over the course of several years, with more modest financial impacts in the first year when the vast majority of physicians are expected to be in the MIPS part of the program.
Third, while the Merit-Based Incentive portion of the law is designed to be budget neutral in general, there are new opportunities for additional bonuses. In MIPS, in addition to the 4 percent positive payment adjustment, there is the potential for much higher payments through $500 million in funding over six years. Physicians earn a 5 percent lump sum bonus for participating in an Advanced Alternative Payment Model.
Under the current proposed timing, the first reporting isn’t due until early 2018 for the first performance period in 2017. Off the shelf tools like Certified EHRs and clinical data registries can provide complete capabilities, but other options exist as well, including most types of reporting that a physician is doing today. If CMS can get data automatically or through another source, we will do so.
Implementation Approach and Priorities
With this legislation, we now have the responsibility and opportunity to work together to fill in the details and do our best to avoid unintended consequences that can be so damaging. My first commitment is that we do this in as open, transparent, and iterative way possible.
I’m starting off talking about our process because I am convinced that adding new regulations to an already busy health care system without improving how the pieces fit together just will not work. I’ve always been a believer that good policy — like any plans — only usually get you 10 percent of the way there. It’s how we implement MACRA over the next 10 years that counts. We have adopted a new outside-in approach we label “user-driven policy design.” This approach calls on us to conduct an unprecedented effort of intensive listening and learning.
I will confess this is a new way of working for CMS. I know from my time outside, CMS can appear to be a black box with opaque regulations and limited back and forth about our policy reasoning or our implementation constraints. People won’t always agree with us and that’s okay. We also need to be convincible when we have something wrong or need to re-steer in a different direction as we recently did with Meaningful Use. And this world isn’t filled with perfect answers.
All of this means that policy cannot be written from behind our desks. Our career staff and our regions have been tasked with connecting us closer and closer to where care actually happens. We began this by reaching out and meeting with over 6,300 stakeholders all across the country before we published the proposed rule in April. Our particular focus on meeting with practicing physicians in their offices, in workshops, in focus groups and in weekly sessions to listen to policy options and to dig into the details of how the concepts in MACRA translate into the realities of a busy practice. Since proposing the rule at the end of April, we’ve held over 135 events centered on physicians and clinicians affected by the Quality Payment Program.
While it’s difficult for any organization to open themselves up to criticism, I can tell you that even in difficult conversations, the staff is incredibly energized by getting out from behind their desks and engaging directly with the many of you that care for our beneficiaries.
Most of all, these conversations are grounding our priorities and we are hearing some hard but important truths. Physicians are frustrated. We hear about the overwhelming sense that measures become exercise in compliance, instead of quality improvement; about how technology has often distracted instead of supported patient care; and how an accumulation of many small things imposed from afar add up to feeling that we just don’t get it. This gives us all a place to start thinking about this new Quality Payment Program framework and developing a roadmap that not only improves patient care but does it by beginning to address some of the very real causes of physician burnout. A few examples of what we’ve heard.
- One comment summed up the feelings of many, “Let us practice medicine, and not practice documentation and bureaucracy. We don’t have it in us. We are caregivers. Let us do our job.”
- A rheumatologist, located in the Mid-Atlantic, said that we needed to, “Figure out how to get doctors noses out of computers and back to patient care.”
- A primary care doctor from Arkansas who was looking forward to joining a medical home commented, “There’s so much money in health care, but we need to direct it the right way.”
Through our listening sessions, a number of specific areas have been identified for us to work on that could really improve this program. They include:
- Providing reports and using quality measures that are more timely and helpful to practice improvement;
- Providing support specifically for smaller practices, which feel the burden of increased paperwork without the staff to handle it;
- Allowing physicians more participation in selecting measures and only focusing on what’s relevant to their specialty or practice;
- Putting more pressure on technology vendors and less burden on physicians, so physicians can do simple things like track referrals when a patient sees another specialist or visits a hospital;
- Making sure there are sufficient paths to participate in Alternative Payment Models; and
- Working to reduce the cost of reporting, so the juice is worth the squeeze.
Openly and honestly addressing these challenges and others we hear about give us a path to improving how the Medicare program works for you and will lead to getting better results for our beneficiaries. After listening to many sessions, personally visiting practices and hearing the concerns expressed by many, I have no illusions that frustrations and challenges that have built up over many years will be resolved overnight. While I know many of you support the MACRA legislation and the Quality Payment Program it introduces, I also know that no one likes all the details and new details create uncertainty. The unintended consequences of new laws and regulations, particularly on top of an already over-burdened physician practice, can make as many things worse as they do better. Complexity is not our friend.
We’ll be smart if we look at the Quality Payment Program as a framework we can work with that if implemented with care, can begin the process of turning things around towards a more sensible, simpler approach where physicians and other clinicians will feel supported by laws and regulations, the technology vendors, and the infrastructure that surrounds them. This is why we need to be so committed to a collaborative implementation, increased transparency, and a continual improvement process, so that over the next several years we allow feedback on the ground to inform the policies we implement.
Policy Implementing those Priorities
So let me get into a little of the policy red meat. Rather than go through each element of the program, I want to cover four of the crosscutting themes that have emerged to us through our listening sessions with many of you.
- Be patient-centered not only in the focus of the program, but in our approach to everything, so that we can promote the highest quality and most coordinated care for beneficiaries with the least disruption to the physicians and other clinicians who are treating them.
- Allow practices the flexibility to drive how they use the program as much as possible so that it supports the unique needs of their patients and allow adjustments as time goes on.
- Focus on the unique concerns of small practices– as well as rural practices and practices in underserved areas.
- Simplify wherever and whenever possible so that we can reduce the noise from the signal and give physicians time back to spend with patients.
I will spend a minute discussing some of our activity in each of these areas.
Priority #1: Keeping the patient at the center
The law builds on the evidence that care coordination and a focus on quality will improve patient outcomes. Last January, Secretary Burwell committed to moving the majority of Medicare payments to approaches that are linked to quality of care and smarter spending by 2018.
Payment systems are not intended to be finely calibrated models that we expect to be performed to the test. In all my years, I have never met, nor do I hope to meet, a physician who makes her decision on how to treat a patient based on how she gets paid. She does what she thinks is right for the patient and hopes that the system will support her. Physicians, and the patients they treat, deserve approaches that support them for doing the right thing, that encourage physicians to collaborate and reduce waste, and keep people at home and in comfortable settings so their lives continue as normally as possible.
We have been rapidly advancing models that put patients at the center. This includes over 9 million Medicare beneficiaries in Accountable Care Organizations; the recent introduction of largest primary care Medical Home model ever launched; a series of bundled payment initiatives and newer specialty models in Oncology and ESRD. The work in front of us is over time to develop a pipeline of Advanced APM models and work with physicians to generate more.
MIPS is intended to move the focus to patients, as well. There are a menu of more than 90 Clinical Practice Improvement Activities for physicians to choose from which support patient-friendly steps– such as expanding office hours, developing specific care plans, or using evidence-based aids that help support shared decision-making. And if not part of an Advanced Payment Model, the program encourages participation in a clinical registry which provides timely quality improvement feedback. If participating in an APM, no other quality reporting is required. Either way, we need these first steps to help us move away from a compliance program to something truly patient-centered.
It’s also time to ask a lot more of the technology and technology vendors. This is particularly true in the area of what many call interoperability– but which most physicians describe as allowing data to move back and forth between systems so they can follow the movement a the patient after they make a referral. A specialist here in Chicago told us, “I think that the one thing that this really could’ve added to patient care is the one thing that hasn’t happened, and that’s the systems don’t talk to each other. It’s actually the opposite. If one of the EMRs I used, I can’t even access it at the hospital because of the firewall. I can’t even get into the EMR at the hospital to look at patient records.”
Along with relief from Meaningful Use, this is the number one ask of many physicians. As in the rest of our lives, the burden needs to be on the technology, not the user. EHR vendors and hospitals that use them will now be required to open their APIs so data can move in and out of an application safely and securely. This will also serve to help eliminate the “desktop lock” that occurred based on early EHR decisions by allowing technology to more easily plug and play. Today’s data silos are more a function of business practices than technology capability and we cannot tolerate it any longer.
Priority #2: Allow Practices to Drive How They Participate
We heard directly from many physicians, and specialists in particular, that a one-size-fits-all program won’t work. In fact, it may not surprise you that many of the physicians who have given us direct input, there are diverse opinions. We’ve heard we should reduce measures and add measures, that there’s too much complexity and not enough options. That’s why we are aiming to build a program that will be as flexible as possible so physicians can focus first, on what’s right for their patients or makes sense in their local community and choose from a number of ways to participate in the Quality Payment Program.
That means more options on choosing appropriate measures. Options on whether to participate in models like ACOs and Medical Homes and the flexibility to move between them without having to report multiple times. It also means using quality measures selected directly from work with specialty societies. We worked with front-line physicians, tech companies, and practice managers over an intensive session and through a Request for Information garner direct feedback on the right measures for each specialty and what could be automated.
For specialists, there are many different avenues to success within the Quality Payment Program. Already, nationally, specialists participate in Medicare ACOs at the same rate as primary care clinicians. And we are working on the development of more specialty-focused models, to go along with the oncology care model launching this year.
Priority #3: Focus on policies based on the needs of small practices or practices in rural or underserved areas.
We must make sure our policies fit with the realities of the local markets where you operate. To be blunt, we all need to acknowledge and work against the reality that many changes in health care today make it more difficult for solo and small practices to stay independent. To level the playing field against these things– more complexity, the fast pace of change, the call for more patient collaboration– we need to focus hard on the areas which increase the costs of operating a practice and look for other things we can do to offset these challenges.
We called direct attention to this by publishing a schedule that demonstrates the negative impact on solo and small practices when they don’t report. Under the Quality Payment Program, we know that physicians in small practices who report their performance can do equivalently well to mid-sized practices. While the results in the schedule we showed pertained to 2014, we expect reporting for small practices to be well above those levels of reporting. However, to be clear, solo and small group practices that don’t report will be negatively impacted.
In our implementation, we are committed to significantly reducing the financial cost and the burden of reporting so that it can be as easy for small physicians to report as for large practices. We are seeking input into how best to do this, but have already taken significant steps such as allowing reporting from multiple sources a physician may already use, increasing the number of items that can be reported through attestation, eliminating duplicate reporting and using data feeds such as claims whenever possible. We are also working with physician user groups to design a simpler portal that is intuitive and easy to use which I will discuss further in a moment.
There are other areas that are of importance to small practices we are focused on, including increased technical assistance, exemptions for small volume practices, and extra credit for participating in medical home models like CPC+, our largest Medical Home model, which was designed based on input from physicians and offers supplemental payments for investments in care coordination. This summer physicians can apply for CPC+ in regions across the country, and we’re mapping out other future opportunities to increase small practice participation in APMs. Small practice burden is an area we are soliciting direct feedback on specifically.
Finally, and perhaps more far reaching, through a network of learning collaboratives that are already on the ground educating physicians — including the associations in the room today — we are moving the Quality Payment Program from policy made in Washington, D.C. to medicine practiced across the country. We look forward to further targeting support to small, rural, and underserved providers through $20 million in funding each year over the next five years.
Priority #4: Simplifying wherever and wherever possible:
The law gives us a unique opportunity. Over the years, because physician performance programs proliferated as one-off programs, over time, regulations multiplied and the documentation burden increased. Even when CMS made improvements, they were piecemeal and the impacts modest as these programs by their nature couldn’t be coordinated or rationalized. Without a legislative change, we couldn’t address the larger problems.
One of the major opportunities is to use the rule making process to connect these programs together so they can be simplified in a single framework through the new Merit-Based Incentive Program. The good news is that the combined magnitude and reporting effort are far less than they are currently and set a framework for even further simplification over time. However, one reason we are hearing some concern from physicians is that it’s the first time the entirety of these programs can be seen end-to-end in one place.
I will call attention to three simplifications in the proposed rule.
- We reduced burden.We have reduced by one-third the number of quality metrics that need to be reported. We aligned the measures across the reporting categories to end repetitive reporting. We got rid of measures in the Advancing Care Information category that hindered usability, and in that category, we moved the focus from “clicking” to care provision and collaboration. Much of Advancing Care Information can be done through attestation, it’s no longer all or nothing and there are a variety of paths that can be selected by a physician practice.
- We simplified the process. Physicians may report as a group, and be assessed as a group across each of the performance categories. You pick how you want to report, and you can use it throughout the program. You don’t have to stop and switch because of differing requirements. We use the core quality measures, so that you can use the same measures across payers.
- We made it so the programs talked to each other. If you’re in an Alternative Payment Model like an Accountable Care Organization or through CPC+, then your job is half done from day one. You report your quality measures using the same process you have always used for your model, plus you automatically earn credit in the Clinical Practice Improvement Activities for being in an APM. If you see a substantial number of patients through an Advanced APM, then you’re qualified for a 5 percent bonus.
Even as we look to the development of the program over the first few years, we are committed to making the start as smooth as possible. I know there are specific concerns about whether there is sufficient time for physicians to get ready for the new system when the first performance period is due to begin this coming January. We are in active dialogue on this topic and seeking active input on the options. There are, of course, constraints and tradeoffs– reporting is due to be reduced when the program starts, for example, but we are working together and we are communicating openly about those tradeoffs as we solicit comments on the right approach.
We Need Input
We don’t profess to have all the answers. Right now, as we are talking through the details with physicians, patient groups and other clinicians and stakeholders, we are also in the process of collecting comments. Over the past month, I’ve probably asked people to submit their comments on the proposed rule over 100 times. We’re making this push because there’s no monopoly on some of these approaches and the more input the better. Final comments are due June 27.
All feedback is helpful and we continue to look for comments both on individual policy areas and on crosscutting topics such as:
- How to simplify further;
- How to align the performance categories;
- How to make sure we’re not encouraging “compliance” but rather rewarding care;
- How to simplify and provide transparency to the calculations; and
- How to encourage and promote participation in APMs and Advanced APMs.
Looking Ahead
Once the Quality Payment Program has been rolled out, I want to make it clear that this constant request for feedback and the need to improve will continue. Things won’t change overnight. The first year of this new program will hit bumps as new policies run into the realities of every day medicine. Systems will need to adapt to your needs. Long-time frustration won’t disappear right away. I’m asking for your ongoing collaboration over the next several years, so that we can implement, receive feedback, iterate, and progress. You may need to think about designing your own feedback report for CMS. Judging from my inbox some days, it’s already started.
We don’t win back hearts and minds with empty promises of quick fixes. We win them back by listening, by making progress even in small steps, and by calling attention to where the system remains dysfunctional. We don’t have the option of running from these challenges because it’s at the very heart of the care we get, that our family gets, that our country gets.
I understand the temptation for this program to become a lightning rod for all that’s wrong with the practice of medicine. I understand it. But I ask you that you not make it the case that until every element is perfect, physicians remain cynical and on the sidelines. I promise you that this process and this program will be better with your input and participation, as you help make sure it connect as closely as possible to supporting the realities of patient care. It is essential that physicians not only participate in but having a leading voice in the change that is ahead.
Conclusion
Seven years ago, President Obama came here to the AMA at the onset of his presidency and challenged us to participate in another change– not to accept the status quo and to move the country forward into an unknown path of health reform. It is thanks to your courage, and the hard work and passion of many of the people in this room, that preexisting conditions are a thing of the past. That preventive and comprehensive benefits are a minimum standard. That science, not insurance company policy, determines coverage guidelines. And that 20 million Americans now have access to coverage and care for their families.
We must do the same thing now. Use every opportunity to commit to the quadruple aim as the key to defining a new future for the health care system. I’ve given you several examples of visits I have had with physicians from across the country and have been sure to share the most critical. But I have also seen what happens when the tide turns and so have many of you.
A physician in New Jersey told me that as part of a Medical Home, he is setting up Skype Villages to connect his elderly patients to each other. Another in Oregon fulfilled her vision of being able to coordinate real-time mental health handoffs as a game changer for her community. A physician in Arkansas told me that, once ready to retire early, they were extending retirement to 70 because how he was getting paid caught up to how we wanted to practice.
When we all– policy makers, physicians, patients, hospitals, and innovators– focus with a unified purpose, we can make this infrequent but significant progress that I believe is ahead of us. We can do it. It’s our responsibility to do it. I look forward to taking on these challenges together. Thank you for your having me today. And thank you for bringing your gifts to heal our country when we need it most. I look forward to our continued work together.
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