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Has CMS gone overboard with the number of alternative payment models? Maybe yes, maybe no, but there is a problem overlapping programs and financial incentive.

A key provision of the bipartisan Value in Health Care Act of 2020 introduced in the House in late July would requires HHS to review the overlapping program and remove the statutory restrictions to allow CMS to distribute savings for each program, said 

 in Boston, in a video interview this week with Peter Wehrwein, senior editor of 

®, and Briana Contreras, the associate editor.

“How they address the overlap will depend on what they find in their analysis,” Macmillan said. “I would hope and expect that in doing this CMS would gather stakeholder input and input from actual participants in this model."

 will make adjustments to various MACRA (Medicaid Access and CHIP Reauthorization Act) programs and models launched by CMS. The legislation was introduced in the House two Democrats, Suzan Delbene of Washington State and Peter Welch of Vermont, and a Republican, Darin LaHood of Illinois.

Macmillan said she expects there to be a sponsor in the Senate soon.

“The provider community has been hit really hard by this national emergency and there is a strong need and desire to help providers continue to provide services,” she said.

High-profile, influential groups have come out in 

, including the American Medical Association, the American Hospital Association, and the American College of Physicians. The trade association for ACOs, the National Association of ACOs, is also supporting the bill.

Macmillan said the legislation is designed to make participation in the CMS Advanced Alternative Payment Models more attractive. One of the key provisions would keep the bonus for participating in the models at 5% of a provider’s Medicare B payments for an additional six years. It is currently scheduled to drop to .75%.

“A 5% bonus on all of your [Part B] Medicare fee for service revenue is significant and by extending that for six year — that is a real financial incentive,” Macmillan told Wehrwein and Contreras, nothing that the legislation would also lower the threshold for providers to become eligible for the bonus.

Videos

In this part two of two series, Senior Editor Peter Wehrwein and Associate Editor Briana Contreras chat with Keely Macmillan, senior vice president of policy and solutions management at Archway Health. The trio discusses the Value in Health Care Act of 2020, which would make some important changes to the Medicare Shared Savings Programs ACOs, the largest CMS ACO program.


Value in Health Act Would Tackle Alternative Payment Model Overlap

The COVID-19 pandemic has had many unintended consequences: Zoom calls, working from home, telehealth, 

 rise to fame and fortune. In healthcare, one of the most significant may have been to show providers the advantages of alternative payment models instead of relying on fee-for-service payment, according to 

, healthcare consulting firm in Boston that specializes on giving advice about value-based care

“Providers in capitated or semi-capitated arrangements that had predetermined amounts to care for their patients — they were actually faring much during the public health emergency and were financially better equipped to provide care for their patients and implement telehealth and weren’t forced to furlough their staff like many providers who were reliant on fee-for-service revenue,” said Macmillan in an video interview this week with Peter Wehrwein, senior editor of 

and Briana Contreras, the associate editor.

Macmillan noted that CMS has launched a group of several alternative payment models recently (models that include some degree of capitation)“COVID-19, in many ways, makes some of these alternative payment models more attractive.”

Because of COVID-19, many providers made technology and other investments to support telehealth and other services.

“In a way,” Macmillan said, “participating in these alternative payment models could be a way for them to cash in on some of that investment, so to speak, that they were forced to put in place because of Covid.”

, a bill introduced in the House in late July that would make various changes to MACRA (the Medicare Access and CHIP Reauthorization Act) and CMS’ alternative payment models.

Many provisions are designed to make participation in the payment models and the Medicare Shared Savings Programs (MSSP)ACOs more appealing— which is to say less risky for the providers and more rewarding if they achieve financial and quality benchmarks set by CMS,

Here are a few of key provisions of the Value in Health Care Act that Macmillan discussed:

Putting the sharing savings rates in the MSSP Basic track back to 50%.

Rising the risk adjustment cap for the ACOS from 3% to 5%

Extend the Advanced alternative payment model bonus of 5% on Medicare Part B payments another six years. Currently, it is scheduled to drop to 0.75% after 2024.

Keep the threshold for becoming an eligible “qualified provider” who can earn the alternative payment model bonus at the current level of 50% of their Part B payments coming through an advanced payment model. The threshold is scheduled to increase to 75% in 2021, and MacMillan said that is “essentially impossible” for the vast majority of providers to meet.

In this part one of two series, Senior Editor Peter Wehrwein and Associate Editor Briana Contreras chat with Keely Macmillan, senior vice president of policy and solutions management at Archway Health. The trio discusses the Value in Health Care Act of 2020, which would make some important changes to the Medicare Shared Savings Programs ACOs, the largest CMS ACO program. 

COVID-19 Makes Alternative Payment Models More Appealing

The excess mortality in New York City during the peak of the 1918 flu pandemic and the excess mortality during the early months of the COVID-19 pandemic were similar, according to a brief research report published in today’s 

During the peak months of the 1918 flu epidemic, there were 31,589 deaths from all causes among the city’s 5.5 million residents, according to Jeremy Samuel Faust, M.D., M.S., at Brigham and Women’s Hospital, and his colleagues, Zhenqiu Lin, Ph.D., at Yale-New Haven Hospital, and Carlos de Rio, M.D., at the Emory University School of Medicine.

That works out to 287.17 deaths per 100,000 person-months.

During the early phase of the COVID-19 outbreak in the city, between March 11 and May 11, there were 33,465 deaths from all causes among the 8.3 million residents, Faust and his colleagues calculated

That works out to 202.08 deaths per 100,000 person-months, so a lower proportion than the one for the 1918 flu epidemic peak period but still in the same ballpark.

“These findings suggest that the mortality associated with COVID-19 during the early phase of the New York City outbreak was comparable to the peak mortality observed during the 1918 H1N1 influence epidemic,” the researchers wrote.

But when Faust and his colleagues compared the peak periods of the two pandemics in New York City to baseline mortality rates in the preceding years, they found that the COVID-19 spike is higher relative to the 1918 spike. The peak mortality of the 1918 flu was about three times higher than the mortality in preceding years, whereas the peak COVID-19 mortality was four times higher than in the preceding years.

The research team used CDC data from 1914-18 to calculate the the figures for the 1918 flu pandemic. To developed the numbers for COVID-19, they sifted through data from the New York City Department of Health and Mental Hygiene and the U.S. Census Bureau.  

Faust, Lin and de Rio said their study can’t address the question whether the 1918 H1N1 flu virus was more or less “naturally” virulent — that is, more or less likely to cause death or harm — than SARS-CoV-2, the virus that causes COVID-19. To make that comparison, they said, you’d have to know how many COVID-19 deaths have been averted by 21st century treatment advances that didn’t exist in the early 20th century.

The estimates vary, but the CDC says that the 1918 flu pandemic caused at least 50 million deaths worldwide and 675,000 deaths in the U.S. Using those figures, about 1.3% of the 1918 flu pandemic deaths were American deaths.

 this morning was 750,371 deaths worldwide and 166,118 in the U.S. Using that tally, 22% of the COVID-19 deaths so far have been American deaths.

Articles

Excess deaths associated with the two pandemics are in the same ballpark during New York City peaks. 

NYC Mortality From 1918 Flu Pandemic, COVID-19 'Comparable,' Say Researchers

It’s fair to say — and to say it rather mildly — that healthcare was not a strong suit for Kamala Harris when she was running for the Democratic presidential nomination last year.

 video last August was titled “Kamala Harris keeps shifting her health care position.” And Paige Winfield Cunningham, the newspaper’s national reporter for healthcare and author of its 

healthare ewsletter characterized her as “making confusing statements about whether or not she’d eliminate commercial health insurance.”

 yesterday: “During her presidential bid, Ms. Harris got tangled up by the issue of health care. She was not the only candidate to suffer that fate, but her stumbles were memorable."

Like several other of the Democratic presidential candidates (Cory Booker, Elizabeth Warren, Kirsten Gillibrand), Harris was a co-sponsor of the Medicare for All legislation famously authored by Sen. Bernie Sanders.

“Medicare for all stands for the proposition that all Americans from the day of their birth throughout their lives will have access to healthcare,” Harris said at a rousing 

 about the legislation with Sanders lookin on. Harris also spoke of the ROI on broad-based healthcare coverage, referencing blood pressure control and reduced emergency room visits in particular. She has spoken consistently since about health care being a right not a privilege and on the benefits — including the financial benefits — of prevention and early. When Sanders re-introduced the legislation in 2019, Harris remained one of the co-sponsors.

Harris started to run into trouble navigating healthcare last January during a townhall-style session with Jake Tapper of CNN. When Tapper asked her about eliminating private insurance, which turned out to be the most controversial part of Sanders's plan, Harris talked about insurance company approvals and paperwork. “Let’s eliminate all of that. Let’s move on,” she said, according to excerpt of the exchange posted by Chris Cillizza, an editor-at-large for the network. 

But her campaign subsequently put out statements that she was open to more moderate plans that wouldn’t eliminate the industry.

The notion started to stick that Harris was, at the very least, fuzzy on her healthcare plans and wavering on Medicare for all.

It got stickier still. In June of last year, Harris raised her hand when the debate host, Lester Holt, asked the candidates whether they would abolish private insurance in favor of a government-run plan.” On a television show the next day, Harris said she misunderstood the question and qualified her answer. 

Then, a month later, Harris put her own plan, which was generally characterized as being a good deal less moderate than what Sanders and the progressive wing of the Democratic Party envisioned.

For one thing, Harris’s plan called for expanding Medicare over a 10-year period, not four as Sanders proposed.

But more importantly, rather than abolish private insurance, Harris proposed allowing companies to sell and operate Medicare Advantage-like plans but for the general population once Medicare was expandd.

“Kamala Harris Unveils ‘Medicare for All Plan that Preserves Private Insurance,” was a Bloomberg headline, and the “preservation of private insurance” became the chief takeaway about it. 

Harris defended her shift by saying that the plans would be tightly regulated. “Medicare will set the rules of the road for these plans, including price and quality, not the other way around,” she wrote in 

Her other selling point was choice: “This preserves the options that seniors have today and expands options to all Americans, while also telling insurance companies they don’t run the show.”

Harris’s got some props for putting out a plan that was feasible and had centerish political appeal. For example, 

quoted former CMS Administrator Andy Slavitt as saying that Harris had balanced idealism and pragmatism. But proponents of the Sanders version of Medicare of all were critical of the role that Harris left for private insurers.

As the campaign went on, Harris gamely defended her plans as accomplishing Medicare for all but leaving people a choice about who, in effect, manages their coverage. She invoked the choice that seniors have now between sticking with traditional Medicare or signing up for a Medicare Advantage plan. But she was also put on the defensive a good deal as she fielded questions about whether she had folded to the interests of the health insurance industry and flip-flopped from her early support and sponsorship of Sanders’s Medicare for all legislation.

Harris dropped out of the race in December last year before any caucuses and primaries. The early departrue surprised some reporters and commenters. A 

piece about why her campaign faltered mentioned her lack of command of healthcare issues. 

 story about what the end of her campaign meant for Harris and the Democrats was spot-on prescient.

“On the more immediate horizon is the possibility of being chosen as someone’s vice presidential running mate,” wrote Mark Z. Barabak last December. “One of the main job descriptions, leading the attack on the opposition, is a role for which the pugnacious ex-prosecutor seems particularly well suited.”

Harris ended up proposing a moderate Medicare for all plan modeled on the Medicare Advantage choice that seniors now have.

Author | Peter Wehrwein

Articles

Value in Health Act Would Tackle Alternative Payment Model Overlap

COVID-19 Makes Alternative Payment Models More Appealing

NYC Mortality From 1918 Flu Pandemic, COVID-19 'Comparable,' Say Researchers

As a Presidential Candidate, Kamala Harris Had Difficulty Navigating Healthcare Issues