CMS Admin Seema Verma speaking at the American Academy of Ophthalmology annual meeting on Nov. 12. Credit: Twitter
The American Hospital Association has taken up Centers for Medicare and Medicaid Services Administrator Seema Verma's invitation to suggest changes to the Center for Medicare and Medicaid Innovation, filing a 17-page response Monday that lays out its concerns about the value-based models administered by CMMI.
"Our members support the healthcare system moving toward the provision of more accountable, coordinated care and are redesigning delivery systems to increase value and better serve patients," said Thomas Nickels, executive vice president of government relations at AHA in the response.
CMMI payment models should support both providers ready to take on additional risk without penalizing those that don't, according to Nickels.
What needs to count as financial risk is the investment risk borne by providers who participate in alternative payment models, he said.
The advanced alternative payment model track under MACRA currently allows only those APMs with downside financial risk to "count" towards the advanced APM track.
In a Wall Street Journal op-ed piece on Sept. 19, Verma asked stakeholders how best to proceed with care and payment models from the CMMI, which was formed by Congress in 2010. Comment was due Monday.
According to the AHA, CMS should develop a method to quantify such risk, as there is strong interest among providers to participate in advanced APMs to qualify for the bonus payment and exemption from the merit-based incentive payment system, Nickels said.
Providers and clinicians, through many CMMI models, have already made a significant up-front investment to develop and implement APMs.
An AHA analysis estimated start-up costs of $11.6 million for a small ACO and $26.1 million for a medium ACO. These investments are not sufficiently recognized, Nickels said.
"Regardless of whether an APM entails downside risk, providers must acquire and deploy infrastructure and enhance their knowledge base in areas, such as data analytics, care management and care redesign," he said.
One metric for APM success – meeting financial targets – may require providers to reduce utilization of certain services, such as emergency department visits and hospitalizations, resulting in lower revenues. This represents downside risk.
There are currently few opportunities to access the advanced APM track, Nickels said. CMS estimates that only 10 percent of eligible clinicians will qualify for the advanced APM track in 2018.
The Medicare Shared Savings Program Track 1+ provides a more gradual glide path to downside financial risk for current Track 1 MSSP participants than either Track 2 or 3. CMS should consider a similar approach for models 2, 3 and 4 of the bundled payments for care improvement program, the AHA said.
The AHA also urges CMMI to consider modifying the existing ACO models to allow the programs to waive beneficiary cost-sharing for items and services that treat a chronic condition or prevent the progression of a chronic disease.
The AHA encourages CMMI to test new technology approaches currently embedded in Stage 3 of meaningful use and the advancing care information category of MIPS before making them regulatory requirements for all healthcare providers.
In particular, Stage 3 and the ACI category currently include significant use of patient-generated data and use of application programming interfaces to connect the app of a patient's choice to a healthcare provider's electronic medical record.
These technologies are still in a development stage and have not been widely tested. A CMMI model that specifically incorporated these items would allow the agency, providers, and consumers to better understand how these technologies are best used, and how they contribute to improved health outcomes, the AHA said.
An AHA's Regulatory Overload report found that an average-sized hospital of 161 beds spends nearly $760,000 annually to meet only the administrative requirements of meaningful use and invests $411,000 in related upgrades to systems during the year.
To help contain the increasing cost of drugs, the AHA supports the development of value-based payment models. Annual price increases for just four common drugs, which ranged between 479 and 1,261 percent, cost the same amount as the salaries of 55 full-time nurses.
An AHA task force in 2015 outlined strategies that are doable but currently not allowed by law or regulation.
These include allowing emergency medical centers to provide emergency and outpatient services without having inpatient acute care.
An EMC model should test three payment methodologies including a Medicare outpatient prospective payment system rate plus an additional facility payment cover standby costs, a new fee schedule for EMCs and rates of 110 percent of the reasonable cost for EMC services.
CMS should lift restrictions on reimbursement for virtual care or telehealth. Medicare coverage is currently restricted to coverage in certain geographic locations, sites of service and types of technology. A model should test changes to coverage and reimbursement for video conferencing, remote monitoring, electronic consults and wireless communications.
Urgent care centers should be able to treat urgent medical conditions on an outpatient basis, without having to maintain emergency medical services or inpatient acute care.
There should be a voluntary demonstration program for current hospitals to convert to urgent care centers in rural and urban areas. The model should test the Medicare physician fee schedule rate plus an additional facility fee, a new fee schedule for UCCs, and rates of 110 percent of costs for services.
Social determinants of health should allow providers to screen patients, offer navigation services to assist in locating and accessing community services and direct alignment with community stakeholders to provide local services to patients.
CMMI's accountable health communities model addresses the social needs of beneficiaries. CMS should increase the funding, the number of bridge organizations, the period for participation and remove fraud and abuse law barriers that do not clearly allow hospitals to provide certain resources to Medicaid or Medicaid beneficiaries because they are viewed as an "inducement" that is likely to influence the selection of particular providers, practitioners or suppliers.
The AHA urges CMMI to utilize the full scope of fraud and abuse waivers allowed under the Affordable Care Act.
A demonstration program for a frontier health system accountable care organization should be created to join medical providers for care and also transportation services. This would allow individuals to receive specialized medical care outside of their community and return to their hometown for followup care. It would includes swing bed, rural health clinic, ambulance, home-based care and expanded visiting nurse services.
CMMI is currently evaluating the effectiveness of global budgets in both Maryland and Pennsylvania as a way to ensure access to healthcare in rural and urban communities. The AHA urges CMMI to continue these evaluations and provide hospitals with the necessary tools to be successful under the program.
Currently, rural hospitals and health clinics are required to meet separate and distinct regulatory requirements. In addition, each is paid under its own reimbursement structure.