SPEECH: Remarks by Administrator Seema Verma at the Health Care Payment Learning and
Action Network (LAN) Fall Summit (As prepared for delivery - October 30, 2017)
Thank you Mark for that kind introduction…and thank you for all you have done to support me as the new CMS Administrator. I am very grateful for your wisdom.
Thanks to all of you for joining us at the LAN Fall Summit to discuss how to best foster collaboration and engagement so that together we can tackle the challenges we’re facing.
The LAN offers a unique and important opportunity for payors, providers, and other stakeholders to work with CMS - in partnership - to develop innovative approaches to improving our health care system. Since 2015, the LAN has focused on working to shift away from a fee-for-service system that rewards volume instead of quality. We support this move. And, today I’d like to talk about what we’ll need to have an effective transition, and I’m here also to announce our new comprehensive initiative on quality measures to reduce the burden of reporting called “Meaningful Measures.”
Since assuming my role at CMS, we are moving the agency to focus on patients first. To do this, one of our top priorities is to ease regulatory burden that is destroying the doctor-patient relationship. We want doctors to be able to deliver the best quality care to their patients.
We often hear about this term – “regulatory burden” – but what does it actually mean? Regulations have their place and are important to ensuring quality, integrity, and safety in our health care system. But, if rules are misguided, outdated, or are too complex, they can have a suffocating effect on health care delivery by shifting the focus of providers away from the patient and toward unnecessary paperwork, and ultimately increase the cost of care.
I saw this during a recent trip to Hartford, Connecticut, where I met with providers.
- One told me she was going to close her practice after decades in medicine because spending so much time away from her patients doing paperwork just wasn’t worth it for her anymore.
In Cleveland, Ohio, I heard a story of a physician who was overwhelmed by having to personally fax patient records…in 2017 we are still faxing patient records. Just thinking about that frustrates me…having to do it, I’m sure is even worse.
Doctors are frustrated because they got into medicine to help their patients. But, paperwork has distracted them from caring for their patients, who often have waited weeks, if not months, for the brief opportunity to see them.
We have all felt this squeeze in the doctor’s office…we have all seen our doctors looking at a computer screen instead of us. I hear it from patients across the country. This must change. The primary focus of a patient visit must be the patient.
Just last week, CMS announced our new initiative “Patients Over Paperwork” to address regulatory burden. This is an effort to go through all of our regulations to reduce burden. Because when burdensome regulations no longer advance the goal of patients first, we must improve or eliminate them.
At CMS, our overall vision is to reinvent the agency to put patients first. We want to partner with patients, providers, payers, and others to achieve this goal. We aim to be responsive to the needs of those we serve. We can’t do that if we’re simply telling our partners what to do—instead of listening and—most importantly—having our policies be guided by those on the front lines serving patients.
Our door is open to your ideas and we invite a two-way discussion about how we can accomplish our shared mission of delivering the best possible care at the lowest cost.
As many of you are painfully aware, CMS is one of the leading agencies for promulgating regulations within the federal government. We publish nearly 11,000 pages of regulation every year. That’s a lot of paper…and it’s taking doctor’s away from what matters most – patients.
The American Hospital Association, last week, published a report showing that health systems, hospitals, and post-acute care providers must comply with 629 mandatory regulatory requirements…and these entities spend nearly $39 billion a year solely on the administrative activities. This report also showed that an average size hospital dedicates 59 full time employees to regulatory compliance, over one quarter of which are doctors and nurses.
That’s a lot of provider time, money, and resources focused on paperwork instead of patients.
I like to think of our initiative in terms of painting a house. Typically, repainting needs to occur every few years and before you repaint, you need to strip out the layers of paint from underneath. Otherwise it looks messy! Unfortunately, CMS has been applying new layers of paint without taking this essential step.
But this Administration is beginning to peel back the layers. We want to know the impact of current regulations, so we’re going through all of them and asking:
- What’s the purpose?
- Is this required by Congress?
- Does it make sense, does it help us prevent fraud and abuse?
- Is it duplicative?
- Does it meaningfully impact patient care and safety or improve outcomes?
- If not, then why do we have the regulation in the first place?
We’re asking these questions every day and in everything we do. We know that the current collection of regulations that govern health care is overwhelming, hurts patient care, and is driving up costs.
A case in point is the implementation of the Medicare Access and CHIP Reauthorization Act of 2015, or MACRA as you know it. As most of you are aware, MACRA is a complex new Medicare payment system for doctors. The good news is that MACRA ended the Sustainable Growth Rate – or SGR – formula, which put clinicians in Medicare at risk for draconian payment cuts.
But, in its place, our implementation of MACRA included extensive reporting requirements – more boxes for physicians to check. At this time, the only way to avoid MACRA’s extensive reporting requirements is for physicians to take on risk to be part of Advanced Alternative Payment Models – or APMs, which many practices are simply not ready for. Moreover, we have few Advanced APM models available – and hardly any for specialists.
We are hearing that doctors are overwhelmed by MACRA’s new requirements and confused about the steps that they need to take.
We all believe in quality and value and the move away from fee-for-service…we all believe in the need to ensure requirements aren’t burdensome…and we all believe that quality metrics need to be based on real outcomes instead of processes.
We’ve taken a hard look at MACRA and will continue to do so. We know that MACRA is a tremendous change, so we’re taking it slow to make the transition as smooth as possible. It’s great that some are ready to move faster, such as larger systems of care. But, we need a system that can work for all providers across the country – urban, rural, small, and large – so that the transition does not push providers out of the system and result in fewer patient choices.
2017 has been a transitional year for MACRA. We appreciate all of your thoughts and comments on the Year Two Proposed Rule, as we work to make this program less of a burden.
Related to our efforts to minimize burden in implementation of MACRA, we’re reexamining our process for conducting quality measurement across the board.
We want to move to a system that pays for value and quality – but how we define value and quality today is a problem. We all know it: Clinicians and hospitals have to report an array of measures to different payers. The measures are often different and there are many steps involved in submitting them, taking time away from patients. Moreover, it’s not clear whether all of these measures are actually improving patient outcomes.
For example, across the CMS hospital quality reporting programs, inpatient hospitals report up to 61 quality measures — 61. And 12 of these measures are “chart abstracted,” meaning that hospital staff must manually enter the values.
Some family practitioners have to report nearly 30 measures to 7 different payers, again which leads to less time focused on patients and is contributing to clinician burnout.
We have too many measures. We are measuring process and not outcomes.
We all agree that quality measures are a critical component of paying for value. But we also understand that there is a financial cost as well as an opportunity cost to reporting measures. Until we get to a smaller set of more impactful measures that assess outcomes rather than processes, the burden associated with reporting measures will run the risk of outweighing their intended purpose. We understand the problem…we understand the frustration…and we understand that something needs to be done.
That’s why we’re revising current quality measures across all programs to ensure that measure sets are streamlined, outcomes-based, and meaningful to doctors and patients. This includes a review of the Hospital Star Rating program. And, we’re announcing today our new comprehensive initiative, "Meaningful Measures.”
“Meaningful Measures” takes a new approach to quality measures to reduce the burden of reporting on all providers. It draws on advice and input from the LAN as well as the National Academies of Medicine, the Core Quality Measures Collaborative, and the National Quality Forum. Continued input from the LAN will be critical in this effort.
Meaningful Measures will involve only assessing those core issues that are the most vital to providing high-quality care and improving patient outcomes.
It’s better to focus on achieving results, as opposed to having CMS try to micromanage and measure processes. The ultimate goal of Meaningful Measures is to direct efforts on high-priority areas. This will help two things.
First, this will help address high impact measurement areas that safeguard public health. For example, the President last week directed the Department of Health and Human Services to declare the opioid crisis a public health emergency. So now, more than ever, we need to focus on measures around prevention and treatment for opioid addiction.
Second, Meaningful Measures will help promote more focused quality measure development towards outcomes that are meaningful to patients, families and their providers.
As we’re moving forward on Meaningful Measures, we’re also leading the Center for Medicare and Medicaid Innovation, or CMMI, in a new direction, one that will promote greater flexibility and patient engagement.
We recently issued a “Request for Information” to collect ideas on the best path forward for the Innovation Center. We’re moving away from the assumption that those in Washington, can engineer a more efficient health care system. Washington is unfamiliar with the nuances of local communities and is not at the center of private market innovation. Instead, we want to launch models that give people on the front lines the flexibility to be creative and transformative.
The system of market competition is the engine that drives innovation in other industries. No central planner gave Henry Ford a set of rules and instructions to manufacture the Model T. His ingenuity led to the product, and millions of consumers chose to buy it.
Our vision is to develop models that promote a patient centered system of care within a market driven health care system. Models should empower consumers to make decisions that are right for them and providers should compete around value and quality. We want patients to be activated shoppers and need to make sure they have the information and the incentives to make decisions that are right for them. We’re especially interested in exploring new demonstrations in the following areas:
- Direct Primary Care.
- Consumer driven health care.
- Addressing the cost of prescription drugs, looking at innovative payment methodologies for new high-cost therapies.
- Medicare Advantage plans including modernizing the bidding process.
- State-based and local innovation models, including those focused on managing costs for dual-eligibles.
- Behavioral health and treatment for opioid addiction.
- We want to see more models for specialists and models that qualify as Advanced APMs under MACRA. We are also in the final stages of developing new voluntary payment bundles. We intend for these to qualify as Advanced APMs.
As we are developing new demonstration projects, we’re also analyzing all current Innovation Center models to determine what’s working and what isn’t. We know that the complexity of certain models might have encouraged consolidation within the health care system, leading to fewer choices for patients. But strengthening the health care system will require health care providers to compete for patients in a free and dynamic market.
Our vision for models is to focus on outcomes and patient care. We’ll set the goals…and we’ll give innovators the freedom to get there.
Patients Over Paperwork, Meaningful Measures, and the new direction for the Innovation Center, are just three of our recent efforts to improve the health care system.
We can’t do this alone. And that’s why we need the LAN and appreciate your participation. I ask you for your ideas, your input, and your innovative solutions for new payment models as well as your ideas to help us reduce administrative burden and help us identify meaningful measures.
We are entering a period of high paced innovation and we need a sustainable system that moves with it.
If we truly want to put patients first, we need to all be part of a great partnership. At CMS, we’re working to do our part by leading the Agency in a new direction—to a better destination.
Ultimately, that’s what we want…what you want…and what patients want.
I wish you a very successful Fall Summit, and thank you.