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CHQPR Testimony to the House Energy and Commerce Committee

House Energy and Commerce Committee

On February 14, 2013, Harold Miller, Executive Director of CHQPR, gave invited testimony at a hearing of the Subcommittee on Health of the House Energy and Commerce Committee of the U.S. Congress. Key points in the testimony include:

  • The Sustainable Growth Rate formula should be repealed.
  • Fundamental changes in the fee-for-service system are necessary in order to control the growth of Medicare spending and to improve the way care is delivered to Medicare beneficiaries. Congress will have limited success in controlling Medicare spending and providing truly high-quality care to Medicare beneficiaries if it merely uses quality-based pay-for-performance or shared savings programs built on top of the dysfunctional fee-for-service system. Fortunately, there are better ways of paying physicians that can enable them to make more significant improvements in patient care and achieve greater savings for Medicare.
  • Accountable payment models need to be designed and implemented as quickly as possible in ways that will work for every specialty and every part of the country. To do this, Congress should establish a new, bottom-up approach to payment reform, whereby physicians, provider organizations, medical specialty societies, and regional multi-stakeholder collaboratives are invited to develop payment models that will work well for individual physician specialties in the realities of their own communities.
  • New payment models should be able to be proposed to CMS at any time, with no limit on how many different proposals can be approved as long as they will improve care and reduce costs. Proposals must be reviewed quickly and CMS should have the obligation to approve a proposal if it is specifically designed to improve patient care and save Medicare money.
  • There should be frequent opportunities for physicians to apply to participate in already-approved payment models. Every physician should be permitted to participate in an accountable payment model whenever they are ready to do so. If a physician is participating in such a model, they shouldn't be subject to threats of SGR-type payment reductions.
  • Physicians need to be given access to Medicare claims data so they can determine where the opportunities for saving are, how care will need to be redesigned to achieve those savings, and how payment will need to change to support better care at a lower cost.
  • Once a physician is participating in an accountable payment model, they should have the ability to continue participating as long as they wish to do so if the data show that the quality of care is high and Medicare spending is being controlled.
  • Funding should be made available to medical specialty societies and multi-stakeholder Regional Health Improvement Collaboratives to provide technical assistance to physicians.
  • To help new payment models be as successful as possible, Congress should ask Medicare beneficiaries to designate which physician(s) they want to be in charge of care for each of their conditions, so that there is no need to use complicated, inaccurate statistical attribution methodologies to determine which physicians are accountable for which patients.

CHQPR Testimony to Congress, 2011

On May 5, 2011, CHQPR Executive Director Harold D. Miller gave invited testimony to the U.S. House of Representatives' Committee on Energy and Commerce at its hearing on how to replace the Sustainable Growth Rate formula.

House Energy and Commerce Committee

Miller urged that Congress focus on three major ways to control costs in the Medicare and Medicaid programs without having to deny care that patients need:

  • by preventing diseases from occurring in the first place;
  • by helping patients manage chronic diseases and other conditions so they don't have to be hospitalized as often; and
  • by reducing the high rate of infections, complications, and readmissions that occur today when patients do have to be hospitalized.

Miller noted that all of those things not only save money but improve outcomes for patients. But he said that current payment systems drive the healthcare system in exactly the opposite direction. Doctors and hospitals lose money when they reduce infections and readmissions; doctors and hospitals lose money when they help patients avoid unnecessary hospitalizations; and nobody in health care gets paid at all when patients stay well. He emphasized that those things can't be fixed by changing fee levels or by adding regulations; the payment system itself is broken and has to be fundamentally changed.

He called for two major kinds of payment reforms:

  • One is episode-of-care payment, where physicians and hospitals are jointly paid a single price for all of the services associated with a hospitalization or procedure, including a warranty stating that they will treat any related infections and complications at no extra charge. This is the same approach that every industry uses for selling products and services and it can be done in healthcare, too.
  • The other is comprehensive care payment, where a physician practice receives a single payment for all of the care a patient needs for their chronic diseases or other conditions.

Miller said that paying in these ways provides the flexibility that physicians need to deliver better care as well as accountability for costs. He noted that where these payment systems have been used, they have improved quality and lowered costs. He said that a myth that has developed is that only large, integrated delivery systems can manage such payments and deliver higher-value care, but he said that small, independent physician practices can also do so. Indeed, he emphasized that just like in every other industry, small healthcare providers can often be more efficient and innovative than large systems can, if they are given the opportunity to do so without imposing unnecessary and expensive regulatory requirements.

Miller noted that he had talked to physicians all over the country about these payment reform concepts, and had found that once physicians understand them, they were willing to embrace them. But he said that physicians need assistance to implement new payment models successfully, and they need a reasonable transition period. He said physicians need four kinds of help:

  • First, physicians need data on utilization and costs, and they need useful analysis of those data. Physicians today typically can't find out how often their patients are being hospitalized, going to the ER, being readmitted, or getting duplicate tests. Electronic Health Records alone won't solve this, nor will typical published measures of quality and cost.
  • Second, physicians need training and coaching to help them restructure their practices so they can deliver more efficient and higher quality care. Not only is this kind of re-engineering not taught in medical school, it is hard for physicians to do it and still keep up with the demands of ongoing patient care.
  • Third, physicians need transitional payment reforms that will enable them to restructure the way they deliver care without risking bankruptcy. These transitional payment reforms can be designed in ways that can improve quality for patients and still save Medicare and other payers money.
  • Fourth, physicians need to have all payers - Medicare, Medicaid, and commercial health plans - make these payment changes and do so in similar ways.

Miller said he felt the best way to organize this help was not through a one-size-fits-all federal program, but through community-level efforts, because healthcare is delivered in very different ways in different parts of the country. He noted that in a growing number of communities around the country, there are non-profit, multi-stakeholder organizations called Regional Health Improvement Collaboratives that are working to provide the data and technical assistance that physicians, hospitals, employers, health plans, and consumers need to design and implement better payment and delivery systems that are customized to the needs of their communities. He said that Congress could help these Regional Health Improvement Collaboratives and other community efforts to support payment reforms for physicians in several ways:

  • by giving Collaboratives access to Medicare data so they can help physicians identify the best opportunities to improve quality and reduce costs;
  • by giving them some modest federal funding so they can provide the hands-on help that physician practices need to reduce costs elsewhere in the system.
  • by encouraging or requiring Medicare to participate in the multi-payer payment and delivery reforms their communities design.

CHQPR in the News

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