The CMS principal deputy administrator tries to reassure House members concerned with proposed budget cuts.
This article first appeared March 22, 2018 on Medpage Today.
By Joyce Frieden
WASHINGTON -- Pay no attention to that funding cut behind the curtain -- physician payment reform and patient empowerment are alive and well, Demetrios Kouzoukas told House members at a hearing on Medicare's physician reimbursement system.
"I think we share the goal of making sure patients have access to care in a way that makes sense for them," Kozoukas, who is Director of Medicare at the Centers for Medicare & Medicaid Services (CMS), said Wednesday at a House Ways and Means Health Subcommittee hearing on the implementation of the Medicare Access and CHIP Reauthorization Act (MACRA). "As we embark on this journey, we will do it in a way that makes sense for each community."
But committee Democrats did not seem convinced. "I'm more than a little troubled looking at contrasting what you're talking about here in encouraging tones, but [then there is] the budget from the administration that's a third-of-a-trillion-dollar cut, and their efforts to undermine attempts to pay for value over volume," such as making some Medicare programs in this area voluntary rather than mandatory, said Rep. Earl Blumenauer (D-Ore.). "I think we all ought to be troubled by this schizophrenia on the part of the administration."
Variety of Issues Raised
Rep. Terri Sewell (D-Ala.) was also concerned. "The president's proposal to cut Medicare ... would send shock waves throughout the healthcare system," she said. "A disproportionate amount of folks in my district live in remote rural areas; I can't tell you how many hospitals closings I have attended ... We have to make sure we look for creative ways to have access."
"So often, many of my constituents can't make primary care appointments because of the long distance, and they don't have anyone to help them get there," she said. "I know we'd save lots and lots of money if we could figure out a way to help people make [it to their] appointments."
Kouzoukas tried to reassure her. "We are working to make sure the programs we undertake and the way we implement them won't [harm] rural providers," he said of the possible cuts.
As for transportation, "I couldn't share your concern more," he said. "There are some really bright [steps] in transportation; Medicare Advantage plans can offer transportation benefits, and there is also recent guidance by the Inspector General's office that opened up rules and limitations around transportation. We have also focused on innovative models that might include transportation and care in the home."
Committee members expressed a variety of concerns about the MACRA program itself. Rep. Judy Chu (D-Calif.) noted that rates for psychotherapy services had dropped by an average of 17% in the last decade. "What is Medicare doing to increase the number of mental health providers in the system at a time when demand is increasing above beneficiaries due to conditions like Alzheimer's and dementia?" she asked.
Kouzoukas agreed that mental health providers were critical, especially in the wake of the opioid crisis. "We made changes last year to recognize that it's important for practices who don't have capital-intensive needs -- who operate with [just] a desk, a chair, and an office -- to [increase] their reimbursement," he said. "We set that out in the fee schedule last year; we look forward to hearing about the improvement it's hopefully made in addressing the issues you raise."
The Pain of Paperwork
Rep. Adrian Smith (R-Neb.) said the most common grievance he heard from rural healthcare providers in his district was about "the amount of administrative burdens imposed on them by the government." Again, Kouzoukas agreed.
"The notion of [administrative] burden isn't just an abstract idea -- it's very real," he said. To address this problem, Medicare has raised the claims threshold required for providers to have to participate in collection of healthcare quality data, and also allowed for providers to join "virtual groups" with doctors outside their own practice, in order to be measured on quality criteria as part of a larger group.
Kate Goodrich, MD, CMS's chief medical officer, also chimed in on the issue. "I'm a practicing physician; I know firsthand what administrative burdens are," said Goodrich, who was there to assist Kouzoukas with his testimony. "So we also provided a hardship exemption ... for small practices unable to procure an electronic health record" as required for Medicare reimbursement. In addition, CMS is making technical assistance available to smaller physician practices who need help with their EHR.
Besides helping smaller practices adjust to the new payment systems, Rep. Diane Black (R-Tenn.) asked Kouzoukas what the agency was doing to make MIPS [Medicare's Merit-Based Incentive Payment System] more feasible for physicians to take "downside risk" and move into advanced alternative payment models (APMs).
"We're working to create more APMs," he responded. "The more APMs we have, the more variation there will be for physicians to find the one that's right for them." For example, Kouzoukas said, CMS will be implementing an "all-payer" combination APM, in which physicians will be able to count their participation with a private plan or in a Medicare Advantage APM toward a "threshold" that qualifies them for an APM bonus.
"And we haven't stopped there," he continued. "We're working on ... a really exciting demonstration project that would create an opportunity for physicians to count their Medicare panel size toward APM participation in a two-sided risk arrangement. That's just to give a flavor of the breadth and scope we're looking at to make this fit right for each physician practice."
Self-Referral Laws a Concern
The big complaint in Rep. Kenny Marchant's (R-Texas) district is how the Stark self-referral laws -- which bar physicians from referring patients to facilities in which they have a financial interest -- "are creating barriers to the coordination necessary to get them to succeed in the new value-based programs," the congressman told Kouzoukas, adding that a bill sponsored by Marchant, the Medicare Care Coordination Improvement Act, would help physicians who are unable to participate in APMs due to self-referral laws. "What is CMS doing to relieve the Stark burden?"
"I think a discussion of Stark is really important," said Kouzoukas. "It has a really big impact on how relationships are structured in the healthcare space ... We acknowledge that MACRA is a piece of this [issue] ... and in the president's budget, we have a proposal similar to the concept you described."
Rep. Erik Paulsen (R-Minn.) asked what steps the administration was taking to include specialty-specific measures under the MIPS quality reporting requirements, as well as what efforts were being made to include rehabilitation providers.
"We're working with specialty societies and other stakeholders to develop the right kinds of outcomes measures," Goodrich responded. "Physical therapists and occupational therapists have long been enthusiastic participants [in similar reimbursement programs]. MACRA allows us to include those types of clinicians beginning in the third year of the program, so we'll be making proposals [on that]."
Rep. Tom Reed (R-N.Y.) had what seemed to be a more difficult question: how to explain to Medicare beneficiaries what the "volume to value" movement and empowering consumers was all about. "Tell me how to talk to a 65-year-old to say, 'This is how you participate in the program now'; translate that," he said.
"Tell her it's like choosing home or auto insurance ... so she [can know] she's got confidence and comfort in the person she's dealing with ... and feels like she's got a choice," Kouzoukas said.
"That [idea] is not getting to the people back home," Reed replied. "They don't get it ... We have to do a better job."