Part 2 - Early Indicators Suggest Reason + Logic May Be Expected From HHS & CMS


The Opportunity

When the Affordable Care Act (ACA) was originally published, I was dumbstruck by the unprecedented, unilateral authority delegated to the Secretary of Health and Human Services by Congress. It was a massive transfer of power from the Legislature (the people) to the Executive Branch. The result we have all seen in the ACA has been a massive promulgation of regulations and rules which have placed unprecedented cost burdens on all healthcare providers, including radiologists. I was alarmed by this precedent - especially when one-sixth of the entire economy was at stake. I had seen something like this before, in another life, and it was not at all pretty.

Today, I am thrilled that this HHS Secretary and CMS Administrator are taking that authority and making effective use of it by incrementally reversing onerous, ill-conceived, costly rule-making and policy implemented by their predecessors. As indicated in Part 1 of this series, watching what has already been done at HHS and CMS, I am hopeful they will use these powers for good - and to the benefit of medical professionals and 'we the people' whom they serve.

Speaking at a conference recently, HHS Secretary, Dr. Price, told the audience: "You might think that because HHS is responsible for implementing MACRA, that, as secretary, I'm the one who needs to answer the question 'What now?' That's why you're all seated. What are you going to do?"

Price said he prefers to ask another question - "Who decides?" - adding that he believes "physician payment innovation should be in the hands of physicians and healthcare providers across the country. It shouldn't be in the hands of Washington, D.C. We need to facilitate it, yes. But you're the ones with all the good ideas of how we can make our system work better for patients."

In a letter to the editor of the Wall Street Journal, Dr. Jason Acevedo, speaking to a WSJ article titled 'The Smart Medicine Solution' (the role technology can play to reduce costs), Dr. Acevedo wrote: "We physicians are already drowning in a sea of data that we cannot interpret or use. Thanks to PQRS, MIPS, MACRA, and the alphabet soup of government quality programs doctors must comply with, I now generate a four-page, single-spaced document for a patient with an ear infection."

Think what our healthcare system would look like if it was designed by the professionals who actually deliver care -- those who know what it takes to do the clinical work, those who know what gets in the way of excellence, those who can ensure access to care, ensure quality outcomes are achieved, make sure unnecessary services are not provided, and are willing to take manageable risks in a competitive environment. What if 'the professionals' could get a seat at the table and respond to the challenge from Secretary Price and Administrator Verna by saying 'Tell us what you want - don't tell us how to do it'. I would add, 'This is the help we, the private sector, need from you, the government'.

So far, all evidence indicates the new Secretary of HHS and CMS Administrator are actively seeking such solutions from providers (hospitals and health systems) and suppliers (physicians, manufacturers, and the service sector).

On May 17, 2017, CMS published its "Blueprint for the CMS Measures Management System" Version 13.0. (https://www.cms.gov/Medicare/Quality-initiatives-Patient-Assessment-Instruments/MMS/Downloads/Blueprint-130.pdf). In the section titled 'Stakeholder Engagement', CMS describes the "Technical Expert Panel (TEP)" (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/TechnicalExpertPanels.html): "A TEP is a group of stakeholders and experts who contribute direction and thoughtful input to the measure developer in every phase of the measure development process, from conceptualization through maintenance. While panel members may be involved at any time during the development process, CMS requires the panel to be asked for input at specific times, including but not limited to: when developing the business case (why the measure makes sense and is important), when reviewing testing results, and when deciding which measures should be recommended to CMS.

"The TEP process involves three postings to the dedicated MMS page on the CMS website. These three postings include:

  • Technical Expert Panel (Call for TEP) nominations

  • The TEP Composition Documentation with meeting dates

  • The TEP Summary Report.

Measure developers will communicate and collaborate with the Measures Manager for these postings.

"The table below describes the process:

"It is often appropriate to obtain stakeholder inputs at several points during the testing process. This includes obtaining face validity inputs at alpha testing, feasibility and burden inputs at beta testing, and other inputs based on a review of overall results. These inputs can take many forms, including but not limited to formal TEP's, consultation with subject matter experts (SMEs), outreach to professional associations or patient advocacy groups, and public comments. Once obtained at a given step, it is important to follow-up those communications by providing additional opportunities for stake holders to comment on the results of their inputs at future stages."

I hope we, the stakeholders in imaging services, are willing to get together and take them up on the offer. Doing so will require unprecedented collaboration by physician groups, hospitals and health systems, as well as the payor community and the patients we serve - but, clearly, the opportunity is upon us. If not now...when? If not us...then who? At the risk of once again beating the drum I have been beating for years, the radiology profession needs to take the opportunities and invitations offered by HHS and CMS and, once and for all, quit merely commenting on policy and begin to get a 'seat at the table' where policy is being crafted. Doing so sure beats being a victim of what others may design regarding the role of diagnostic and interventional radiology as we transition from volume to value.

In late June, William Thorwarth, Jr., MD, American College of Radiology (ACR) CEO, spoke with HHS Secretary Tom Price, MD, to discuss 'unnecessary federal regulations and administrative requirements'. (See the interview of Dr. Thorwarth by ACR here.)

In a July 5th article in Radiology Today:

The ACR published a brief Q&A with Thorwarth about the meeting. "Secretary Price has opened the doors at HHS," he said. "He is looking for input from physicians and other health care providers to guide his leadership. Hopefully, we will see some impact from the way he and Administrator Verma listened and took copious notes during our presentations." The article went on to say: "Point-of-care appropriate use criteria and EHR interoperability were also discussed at length," Thorwarth explained, and he walked away from the meeting 'impressed' by Price and Verma's attentiveness. "Because of his background as a practicing physician, Secretary Price was especially attuned to the need to get rid of unreasonable regulations and administrative requirements," Thorwarth said.

Of note, among other matters discussed in the interview with Dr. Thorwarth (pre-authorization, AUC & EHR) was this exchange:

Q) Did the meeting give you reasons to be encouraged about future relations between the ACR, HHS and CMS?

A) Absolutely so. First, I was impressed that they invited us to share our opinions. Dr. Price and Administrator Verma were very attentive and asked appropriate questions.

It is readily apparent Dr. Price says what he means and means what he says. The ACR took him up on the invitation to come to the table -- a great start for radiology. More opportunities to engage will be important, to say the least.

The Broader Challenge/Opportunity Ahead

Payment Models and Mechanisms

In my view and experience, there is a place for 'national symmetry' in certain policy initiatives, but the reality of the marketplace reminds me of the old adage 'All healthcare is delivered locally'. Patient populations behave differently from region to region. Healthcare Integrated Delivery Systems (IDS) penetration vary significantly from region to region, as well as, in many cases, county to county across the United States. One-size-fits-all solutions have a higher probability of failure than success in achieving both the strategic and tactical objectives of much needed healthcare reform from community to community.

RBMA, ACR, AHA, AMIC, RSNA, MGMA, MBMA, and other imaging-centric professional associations, have matured 'advocacy efforts' and interventions with CMS in recent years on various rule-making policies. They should all be applauded and recognized for their efforts to date.

However . . .

What the various professional associations and other stakeholders have not yet discovered is a way for all of these constituents to be able to come together - to collaborate in the development and presentation of innovative solutions to the healthcare system policy and rule-making leaders in the government. Being able to speak with one voice. Being able to demonstrate the ability of this outstanding profession to achieve the objectives and goals required. Being able to transform healthcare delivery and contribute innovations directed at high-quality outcomes and pathways to bending the cost curve and affordability of diagnostic and interventional services throughout the continuum of care for 'we the people'. These are the imperatives. The profession is up to the challenge and ready for the opportunity.

As we can see, the invitation to get a seat at the table has been sent. It is time for the profession to RSVP: Tell us what you want -- don't tell us how to do it. We agree with the Secretary. Physician payment innovation should be in the hands of physicians and healthcare providers across the country. It should not be in the hands of Washington, D.C.

* * * * *

Many ask, "What can we really do to make a difference? After all, we're just doctors?"

Check back soon for Part 3 of this series

'Taking Action'

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