The Robert Wood Johnson Foundation (RWJF) is pleased to have the opportunity to comment on the proposed regulations on Merit-Based Incentive Payment System (MIPS) for MIPS eligible clinicians or groups under the physician fee schedule (PFS) as provided in the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015.
Building a Culture of Health
RWJF is the nation’s largest philanthropy devoted to health. We believe that good health and health care are essential to the well-being and stability of our society, as well as to the vitality of families and communities. As the work of our grantees and countless others has demonstrated, moving toward a system that rewards health care quality and improves care coordination can help patients access better care and improve overall health system value. Over time, moving from a payment system based on reimbursing for the volume of services provided to one that is based on paying for value, can help reduce unnecessary spending and increase access to high quality care. To the extent savings can be achieved, this movement also can free up funding for longer term investments in communities and services that are essential to building and maintaining a Culture of Health1 across our country.
Movement from volume to value also affords us the ability to more squarely think about who we are delivering value to—not just payers and providers, but to patients, families, and caregivers—the ultimate recipients of care. MACRA represents an important step in that direction. Given the magnitude and pace of change the law is likely to engender, however, we need to make sure that we balance the technical challenges while never losing focus of the end goal of better outcomes for patients and better value for everyone. From RWJF’s perspective, it is important that as part of this transformation, CMS ensures that MACRA foster the conditions for meaningful change that moves us toward an integrated, patient-centered and truly high value health care system.
Over the past decade, RWJF has supported multiple projects related to promoting care coordination, promoting system value, improving patient care, and achieving a high performing health system. In fact, we are doing this hard work on the ground every day through our grantees. For purposes of developing our comments on this proposed regulation, RWJF collected input from many of our grantees including PatientsLikeMe; Network for Regional Healthcare Improvement; Professor Benjamin Miller at the University of Colorado School of Medicine; Consumer Purchaser Alliance; Eugene Nelson at Dartmouth College; Professor William Riley at the Arizona State University; National Partnership for Women and Families; Health Quality Advisors; Center for Health Care Strategies; and the University of Chicago’s Reducing Health Care Disparities Through Payment and Delivery System Program.
One of RWJF’s key focus areas relates to fostering an integrated health and health care system. Since 2005, RWJF has invested in better approaches to care in order to improve the value of integrated care for people with complex medical and social needs who account for a disproportionate share of health care costs. Key partners in this work include the Camden Coalition of Health Care Providers and the Center for Health Care Strategies. Last summer, RWJF sponsored a convening of leaders in the field of integrated behavioral health. As covered in the subsequent “Culture of Whole Health” recommendations report, a key impediment toward wider take-up of integrated practices is the payment system.2
CMS has also indicated its strong interest in integrated care approaches through funding opportunity announcements on Accountable Health Communities; efforts to improve population health through State Innovation Model funding; and other efforts. We urge CMS to continue this focus on ways to move the health care system toward a more integrated approach including through MACRA implementation. An integrated approach to care must consider the whole person by diagnosing and addressing the individual’s long term medical and social issues. This approach must be supported through integrated data systems that foster information sharing across multiple systems (e.g., housing, multiple health care settings, criminal justice, and social services) as well as through flexible payment systems that incentivize providers across systems to work together to ensure that patients get the coordinated care they need, even if it is outside the health care system. We are in the process of developing a body of work to better connect social services and health care systems, recognizing the challenges that need to be addressed, but also the great potential for care improvement and cost savings. We are also learning, through our program Data Across Sectors for Health (DASH), about the challenges and opportunities with collecting and sharing data across systems at the community level to support population health improvement. CMS might also look to align with other measure sets that may be outside the health care sector such as with other local health assessment and community or state health improvement activities.
The health care sector is experiencing increased pressure to address social needs in order to deliver value-based care and the social services system is grappling with how to partner with health care more effectively to meet this need. National model programs based in the clinical setting, such as the Medical-Legal Partnership and HealthLeads, have been implemented by a number of health care systems.3 There is a need to build the capacity of social services, and develop and spread new models, to coordinate with each other to offer a package of social services that seamlessly link to health care service.
Alternative payment methods should support and incentivize integrated care practice. One key design characteristic would be for incentive programs to allow for rewarding the care delivered by teams, not only individual providers, and to reward an approach that considers whole person needs. We are glad to see that CMS is looking to expand eligible clinicians and encourage the agency to consider ways to promote integrated care by expanding this list to not only include those mentioned but even more broadly to promote care integration.
RWJF also believes that we need to take steps to ensure that the health care system envisioned by MACRA is one that is truly patient and family-centered. That will require physicians and other providers to focus increasingly on delivering care that meets patients’ goals and needs. The Alternative Payment Models should ensure that the consumer perspective on value is taken into account. In February 2015, the Foundation, in partnership with AcademyHealth, released a call for proposals to better understand consumer perceptions of values in different health care settings, at various decision points and using different insurance benefit designs. This research will be completed in the next few years and we will look forward to sharing the findings publicly.
To this end, we believe that the metrics that form the basis of payment must be truly patient-centered. RWJF is developing a body of work to better understand and identify true patient-centered measures because in order for people to engage in decisions and receive high value care, they need measures that are useful and relevant to them. We strongly encourage CMS to prioritize patient-reported outcome measures, clinical outcomes, appropriate use, and patient experience in order to ensure that the care that is delivered is responsive to what patients want and need.
Much of our work looking at patient goals and needs focuses on the most vulnerable. Through work with our grantees at the Altarum Institute and Oliver Wyman, we are learning the importance to vulnerable patients of being able to trust their provider and to be treated with respect when they walk in the door.4 We strongly urge CMS to pay attention to this issue and the cues that patients are often looking for as meaningful indicators of quality rooted in a dignified experience. At the end of the day, relationships are personal and come down to human interaction and it is our responsibility to ensure our health care system is a humane and respectful one. This notion should not be viewed as distinct from our notion of what “quality” is.
Affordability is a key part of both access and patient-centeredness, and patients need a voice in making decisions about trade-offs that affect them with full, reliable information in front of them. However, patients cannot have a role in making those difficult decisions if they don’t have full information. We know from our work that conversations between patients and clinicians are an integral part of delivering high value care by helping patients find lower cost options; evaluating possible medical and financial trade- offs; and ultimately making better care choices. A growing body of evidence shows that conversations about costs can lead to better health care outcomes by, for example, improving patient adherence to treatment plans and engagement in the management of care. The Foundation has just released a call for proposals focused on supporting clinicians and patients in having conversations about the cost and value of health care and will be sharing research findings from these studies when they are available.5
We also would encourage the use of health information technology to strengthen patient engagement and care coordination. Requirements should be strengthened to encourage real, meaningful prioritization of patient engagement and make sure that it is meaningful and useful to patients and caregivers. Requirements should ensure that patients are receiving, using, and contributing information that improves their care and activation and, by paying particular attention to disparities, this should be assured across all patient populations. A key element of this strategy is to encourage and provide guidance to enable safe data sharing across patient-centered care providers and human service providers as a part of care coordination.
We also note one helpful change that would further the goal of patient-centeredness would be to include representation of diverse members of the care team, include patient representatives, not just physicians, on the Physician-Focused Practice Model Technical Advisory Committee (PTAC). We have extensive experience in ensuring multi-stakeholder participation in governance of health care organizations through our work with Aligning Forces for Quality and would be happy to share these lessons with you if you are interested.6
High Value for All
More action is needed to help providers identify opportunities for health equity and then, more support needs to be given to providers in achieving those opportunities. Too often, payers and providers employ a “rising tide lifts all boats” philosophy, hoping that efforts to improve quality of care generally will reduce disparities. To help address this issue, RWJF is investing in efforts to build disparities-reduction goals into new payment and delivery transformation models. We hope that CMS will also consider ways to develop and utilize explicit equity accountability measures that are sensitive to capturing disparities as part of their different value-based purchasing programs.
CMS should ensure that data and reporting requirements are efficient, strong, and actionable for all of the different ways that measures can be useful. This includes quality improvement and consumer decision-making as well as payment. This means, with total cost measures for example, primary care providers are aware of resource implications of their decisions. Through our Total Cost of Care initiative, we are learning about the level of interest and action that providers undertake when they have actionable information at the local level and strategies on ways to curb overutilization and reduce spending.7
2 Miller, Benjamin F, Gilchrist, Emma C, Ross, Kaile M, Wong, Shale L, et al. Creating a Culture of Whole Health Recommendations for Integrating Behavioral Health and Primary Care. February 2016. farleyhealthpolicycenter.org/cultureofwholehealth/
3 medical-legalpartnership.org/ and healthleadsusa.org/
4 Chris C. Duke and Christine Stanik. Health Affairs Blog. Knowledge Is Power: Improving Health Care Information For The Most Vulnerable. May 2016. healthaffairs.org/blog/2016/05/25/knowledge-is-power-improving-health-care-information-for-the-most-vulnerable/
5 www.rwjf.org/en/library/funding-opportunities/2016/integrating-cost-of-care-conversation-resources-into-the-clinical-workflow.html and www.rwjf.org/en/library/funding-opportunities/2016/optimizing-cost-of-care-conversations-between-clinicians-and-vulnerable-patient.html
6 Aligning Forces for Quality forces4quality.org
7 Total Cost of Care Project www.nrhi.org/work/multi-region-innovation-pilots/tcoc/