CMS Initiatives

Spring 2019 Conference Cliff Notes from CMS Administrator Seema Verma

In a way it was refreshing to read what Ms. Seema Verma, CMS Administrator, had to say regarding CMS initiatives moving forward.

The basic facts presented by Ms. Verma included:

  • 2027 Estimate healthcare spending to reach 20% of earnings
  • Affordable Care Act failed to control costs and increased premiums nationwide

I’m not surprised about either one of these statements. In fact, I agree with the conclusion that our current healthcare system is not sustainable. I also agree with some of the basic challenges presented by Ms. Verma. For example:

  • Stark Law. This law is obsolete and prevent cooperation between Providers and Organizations.
  • Data. Access to data in a timely fashion is critical to the success of any future healthcare system.
  • Over regulation and paperwork. At times it seems that we expend more time completing paperwork and doing tasks that have nothing to do with patient care.

With the above information as a framework Ms. Verma turned to Value-based care. In fact, during the National Association of Accountable Care Organizations (NAACOS) Spring 2019 Conference she explained:

 “Value-based care means upending the current paradigm, and in my view it’s not happening fast enough. It means tracking and rewarding improvements in quality, instead of paying for services regardless of outcomes. It means holding clinicians accountable for cost and quality, and then providing the flexibility they need to innovate. It means getting unnecessary government regulations out of the way, so clinicians have more time to spend with their patients and so they can provide efficient, innovative, and coordinated care without bureaucratic requirements getting in the way. It means coordinating a patient’s care across the system, instead of having patients feel like they have to navigate through a maze of fragmentation to get the care they need.”

In short, rather than been reactive and wait for the patient to be sick before we deliver care, we need to be proactive. In other words, do not wait for the patient to develop a chronic condition to start treating them. Instead, help them get a better quality of life by using a preventive care approach. This answer is simple as the same signifies better outcomes and lower expenses.

As a matter of fact, CMS already has several new payment models where Providers share risk in exchange for increase payment. However, the number of payment models do not fit every situation and adoption has not been as high as CMS expected. CMS is aware of this and is currently developing new payment models. Some of these models may actually include a mandatory participation component.

Moving forward I foresee a change from the fee for service model to a capitation model with some kind of adjustment based on expenses. Ms. Verma suggested as much when she explained a program where: “participants will receive a fixed monthly payment that can range from a portion of anticipated primary care costs to the total cost of care – therefore, participants can bear full risk or share risk with CMS.”

Of particular interest should be CMS interest in “synchronizing CMS models with those in private plans”. My interpretation of that statement is that traditional Medicare patients could become part of a Managed Care Medicare type model. Also keep in mind that one of CMS Direct Contract Options looks into contracting with organizations that have experience taking risk and serve larger patient populations. In other words, Accountable Care Organizations could become your next Medicare Advantage Plan.

There was a lot of useful information presented By Ms. Seema Verma in her speech and I personally will recommend all healthcare professionals to take time to read the same. However, I have some takeaways for you:

  • Stark law will change.
  • We need to track outcomes and be more aggressive in handling chronic conditions.
  • Preventive programs are the key to success.
  • Capitation (payment on a per patient per month) may be a reality in our future.