The first meeting of a panel convened by
Sen. Angus King (ME) to consider federal
regulatory barriers to provider risk payment models was held in Dirksen Senate
Office Building this morning. The panel was moderated by
Michael
Chernew of the Health Care Markets and Regulation Lab at Harvard Medical School,
which is guiding the process with Sen. King’s policy staff. I was joined on the
panel by Carrie Arsenault of
Beacon Health
in Brewer ME, one of the brave remaining 19 Pioneer ACOs of the original 32,
Eric Bieber of
University Hospitals
in Cleveland OH, and Janet Niles of
Ochsner Health
System in New Orleans. The discussion was thought-provoking and a little provocative
at times. After hearing all the challenges, I left wondering why any group
would consider becoming an ACO. Only one in four Medicare ACOs earned savings
payments last year, despite spending $2 million each on average to support the
model. It was clear that all the panelists are primarily motivated by improving
the quality of care they provide; financial interests are far less important.
Concerns included regulatory paperwork burdens, even if you get a commonsense
waiver, the difficulty of reaching the savings threshold, attribution, and the
need for a glide path for organizations wishing to develop ACO models
responsibly. Downside risk is a very heavy lift for these organizations;
reportedly many Medicare ACOs will leave the program if they are required to
accept downside risk, as the Pioneer ACOs are this year. We heard a lot about
the importance of engaging consumers in improving their health. In my remarks,
I focused on consumers’ perspectives and concerns – that shifting risk onto
providers holds great promise to build value and reduce overtreatment, but
great risk in that it significantly changes incentives in the patient-provider
relationship. Every regulation was a good idea and served a purpose at the time
it was proposed. Undoing those standards should be done carefully. I talked
about the importance of monitoring for underservice and how CT’s health
neighborhood pilots for dual eligibles is building such a monitoring system.
There was no argument that incentives in Medicaid are different than other
programs – when providers are underpaid, the incentives to overtreat are less,
but undertreatment is more of a concern. I talked about anti-competitive
concerns of consolidating providers, overlap and conflict with state regulatory
roles, and the importance of paying for quality, independent of and in addition
to shared savings. Relying only on shared savings to improve quality is not
realistic – if we want it, we have to pay for it.
It was a fascinating conversation. I can’t wait for the next
meeting.
