killed, 48 of whom were employees of the united states government. >> watch on american history tv this weekend on c-span3. > . what does it mean to be american? that's this year's student cam question. we're asking students to talk about a constitutional right, national characteristic or historical event and explain how it defines the american experience. we're awarding $100,000 in total cash prizes, including a grand prize of $5,000. this year's deadline is january 20, 2019. for more information, go to our website studentcam.org. health care analysts talk about medicare's merit-based physician payment system. the brookings institution and

the university of southern california organized this forum in july. this was part of the medical acts of 2015, or macra. to both physicians and many in congress, first thoughts about macra are the end of the sustainable growth rate, a policy enacted in 1997 that spun out of control a few years later. it occupied congress for over 10 years with short-term fixes to finally get a handle on it. but macra not only ended sgr but it also put in place reforms and physician payment for the medicare program.

most attention has been to the bonus for physicians participating in advanced alternative payment amounts. it's not so much the number of physicians getting a 5% bonus, but here is congress speaking, pointing the way to how it wanted medicare programs to evolve. and this was a very broad consensus in congress, and i think very much applauded throughout the health care system, but macra also included mips, which applies to physicians not participating in advanced alternative payment models. it streamlined some existing pay-for-performance programs in medicare. mips has had what you might call a rocky start. cna delayed part of it and exempted large parts of

physicians in smaller practices. physicians raised concerns about the burden and the cost required to do the reporting required in mips. and policy analysts examined the track record of the measures and raised concerns about their relationship to the quality and cost goals and whether they reliably identified good and bad performers. in january, medpac voters acknowledged that mips be demoted and they would recognize them on a voluntary basis. this brought ideas to mips and their shortcomings. our opening speaker had to drop

out because of a scheduling issue, so we decided just to proceed with our two panels. our first panel is going to describe how mips is working, it's going to focus on physician practices with mips, and the second panel will discuss ways to reform mips. the first panel will be moderated by cavita cottell who practices medicine and is a non-resident fellow at brookings. >> thank you, paul. i'm going to go ahead and -- i'm going to briefly introduce our panel. each panelist does have slides, and as a result, i couldn't help but put in -- i was able to get some slides myself. but as paul mentioned, and i know there are a lot of you watching on the webcast, we are going to talk about how mips is actually working on the ground, but we can't help but offer potential foray into some solutions or try to bridge to

our second panel which paul will be leading. so starting to my right, we have belinda rutledge, and they're in order of appearance as well. the vice president of public strategy of the core institute for the green health system of california, sharon with the american college of physicians, aaron litz, and tim gron nirnig. they can each talk about their respe respective roles during their presentations. i decided to put in a couple pragmatic slides around -- here we go. i just have to pull up the powerpoint myself? okay. that sounds like i'm being a little -- all right. every single one of you have to pull up the powerpoint and then

somebody is going to make it sync with the screen. what i decided to do while we're waiting for it to come up -- i mean, it's on full screen. it's on my full screen. ah. everybody has to do this? i was a chief resident so i'm ready for all the -- here we go. i wanted to just do this as a ground refresher because i think everybody on both these panels are extreme experts for the mips programs, but just wanted to kind of offer a little bit of level setting for the categories. by the way, last week the administration released a proposed rule around the physician fee schedule and the tpp program and other changes, so there's actually tweaks and adjustments to what you see here. needless to say, as paul mentioned, this was all an attempt to make something better than what was previously there

in various programs, and somebody might have talked about this. i want to bring up i practice a plurality of my time in a community-based primary care setting that is on fee for service. 98% of our residents is fee for service. 48% of my practice across eight primary care physicians and four specialists is actually medicare. so there were many of us, but we all roll up into one big tax i.d. number across many sites, so because of our performance, volume and thresholds, we are actually all contributing to mips. i did look up my mpi quickly to see if i could be out of mips, and fortunately, i wasn't. i'm just going to briefly show you how we do things internally. we're on epic. i've just been interacting with our i.t. team over the last several days to understand what our work flows are, what our

investments have been. it's best to qualify what our financial has been to stand up to mips requirements. basically i was told they are too large and scattered to put into one dollar amount, but needless to say, it's a lot less than what our bonus we received was which was approximately 2% to a mips adjustment. it's not even fair to call it a bonus, it was just kind of meeting these performance goals. i decided to take some of these things i had to do at the staff level and then what we had to do to record our electronic health record, and because of changes in requirements, we'll have to keep doing these continuous changes or builds. i'm not going to read the slides to you and i'm not expecting you to read. this is my own personal dashboard. you'll see that i have a lot of re reds in areas which tell you what a practical physician experiences. there are things that have deno,

ma'am narts th-- denominators tt apply but because of the entire system they're put on our dashboard. i want to drive home the point that as a practicing physician, i actually don't use this dashboard. it's completely meaningless to me, especially since so little of it applies to me personally. and one of the greatest opportunities, and tim gronniger and others at brookings have discussed this, i don't know what to do when i ne'm in red bi need to go into green which i feel is most electronic, but everything with johns hopkins is done over fax. so there are things that are very complicated. i don't want to go through each of these steps but i did want to show you very practical on a daily basis what our view as a

practicing physician might look like. i do have the ability to do a lot of things inside my health record to kind of look at patients and look at things. quite honestly, i don't have the time or the motivation to do it. i asked just to kind of put a little finer point on this some of the recent changes around the mips program that had been proposed last week which i think in general are causative changes. my question to our mips leadership is, what do we sacrifice? what do we do because we need to get the dashboards up, get the work flows right? something as simple as reporting blood pressure alone can take approximately 200 hours in time on the electronic side, and on the physician work flow side, can take even five to six times that, so we spend almost a thousand hours like an aggregate

across our practice and across different personnel to really understand how do we implement measuring and then controlling hypertension? so i bring that up because at the same time we are a level 1 accountable care corporation, and doing mips are coming at a cost of our health-based models. there is only so much time i can ask of fellow doctors and medical assistants and front desk schedulers, and there are only so many employees, primarily on our i.t. side, to help us with this. so i offer a pragmatic view from my perspective, but i think a lot of my colleagues would echo this and kind of say the same thing. i'll hand it over to belinda. each speaker will have a presentation and then we'll have a q & a period afterwards.

thank you. >> thank you, abby. i don't know if i could figure out how to pull the slides off. i'm belinda rutledge. i'm the vp of public strategy at brookings health system. greenville health system has come together with palmetto health. as you can see, we're one of the largest systems in south carolina. we have a total of close to 2800 physicians in our cin. and about half of them are employed and half of them are independent physicians, so that's pretty unique. a lot of cins either have a predominant of employed physicians or it may be much smaller with a large amount of independent physicians.

what also makes this unique is because south carolina is a little bit different than the northeast, we have a large amount of raw area. so we have 32% of our practices that's in our cin is in what you would classify as small practices in rural areas. so the ongoing rural challenge we've had in mips is that the mmmr vendors require significant upgrade fees and order to have upgrades in the product to be able to report mips requirement. so not only do you have the initial investment of putting the emr in, but you also have yearly upgrade fees that are pretty substantial for rural providers. second, in quality outcome measures, the absence of a risk

adjustment is not addressing the older and single populations that you currently see in the rural area. as you know, currently in mips, smaller practices have -- you can get a small practice bonus, but that still does not level the playing field in the competition between the rural and urban practices that you will see. also there are very few alternative payment models that urban providers can actually purchase a. there are systems that people have with other pay providers. many snips lack pay providers.

so that makes it difficult to have effective integration activities. also rural providers have been running lean for decades, and they simply don't have enough staff to be able to address all the mips complexity. many of them, as you know, may have one or two providers in the office, may have one mid-level provider and a part-time office staff. so that's a very lean operation that makes it very difficult for them. and final, the mips implementation costs far exceed the potential for positive adjustments. the number of billings that they have, the ones that do not qualify for exemption, the number of billings that they have are very, very small, and yet the cost of the

implementation in terms of implementing mips requirement far exceeds that. so i'm going to share with you a tale of two cities. so the first tale is our mips negative ri. so once upon a time, we had a very large and sophisticated, clinically integrated network that had 30 to 35% rural providers, which means they need an extra amount of time to be able to comply for mips. we recognized that we had to spend a lot of time in terms of helping our partners be able to comply with mips and able to deliver a high-quality care in the areas that we serve. so we spent a lot of energy in terms of giving them extra resources. we hired staff, we spent side by side with their practices.

we would actually go into their practice and sit down with all members of their teams. we hired dozens of additional part-time staff that we calculated worked tens of thousands of hours that worked the resources that's needed to meet the mips requirement. we did so well that we ended up close to 95% when we got our mips score back, which made everyone, the 2400 physicians, very happy. until we realized that that 95% gave us 1.59% payment bonus. and that included the exceptional performance bonus in that. we calculated out what that was compared to the cost that we used, and it came out to 60%.

so for every dollar we spent in complying with mips, we only got 60 cents back on it. and as you can imagine, that's not a sustainable system going forward. so the second thing is we have to look ourselves in the mirror and say, what should be our next step? do we stay in mips in which we can hope we can do better than 60 cents on the dollar? or do we need to take a look at it from another perspective. so the perspective we chose to begin to look at it is that mips has to be a stepping stone in terms of looking at the competencies to move into advanced alternative payment model. without being able to get that 5% bonus in advanced alternative payment model, there is no way

we can survive in terms of getting 60 cents on every dollar that we put in compliance with mips. >> we'll have time with questions. i'm smarter now. i'm going to help sheri get the slides up while she comes up here. >> so i'm shari erickson. i'm in government affairs and medical practice vice president at american college of physicians. our membership is made up of about half primary internal medicine specialists as well as

subspecialists in all different types of internal medicine, oncology, rheumatology, pulmonology, lots of ologies. we do have kind of a unique view of this because of the makeup of our membership, and even within the membership our members are in academic centers, they are in track to acos, they are in pioneer acos, they are in small practices. i would say a large significant number of our members are in the mips program. and that was expected just as it was across all the eligible clinicians that are participating in mips. so i hear a lot about it from our members and wanted to reflect on some of the things that i've been hearing from our members and sort of give you some buckets of what those look like from their perspective and their experience within mips.

so i kind of grouped it into a few different areas, and measures is a biggie. this has come up. but i would say what i hear about most from our members is the fact that they really don't trust, they don't believe these measures that they're reporting on are ones that are meaningful to them, their practice and their patients. and i think that there is a lot underlying that, and that's not unique to mips, necessarily, or, really, to -- it cuts across, i guess, all the value-based payment programs. but it's something that i think we need to start to address, and i'll talk a little bit more about that as well. there are too many and yet too few measures. so when our committee looked at the measures included in the mips program, i think they found about a third of them are viewed as clinically valid that should

be used by clinicians in the field. yet, really when you look at it more broadly than that, there are measures that are sort of in those other sets that are, quite frankly, maybe more meaningful to patients or other stakeholder groups also involved in this process. so we need to be thoughtful about those measures included in the program. yet also there are too few. some of our subspecialists struggle with having enough good measures that they feel are meaningful enough to use when they're reporting for the program or any value-based program. then there are multiple alignment efforts, and i mentioned the work of our committee, but there's also work with qf to endorse the measures, there's the work with the map that provides the subregulatory-preregulatory guide. there is the core measurements

that are going to be up soon along the line, so different entities have had different approaches for very different, very good reasons because of the different stakeholders, perhaps, that are at the table and the different types of goals they have set for themselves. so we need to think about that and i'll talk more about that in a moment, too. another big bucket is the health i.t. overall. you know, our members are very frustrated with the health i.t., with the ehrs that they use daily. the useability is extreme measures and when you tie it into additional reporting, they feel it's unnecessary additional clicks, unnecessary reentering of information and they're working with vendors which is a real challenge. so the vendors have to upgrade

and then the practices need to pay for that and be sure that it's there in time for them with a fuel year of reporting required for quality. that's a real challenge if the health i.t. is not up to speed and ready to do that. and meaningful inoperability. i put meaningful in quotes, but what i mean by that is we do need to share all the data, right? we need the flows in place and we don't want blockage of that data, but when physicians are taking care of a patient and they have one in front of them, they don't need every piece of data about that patient in front of them. they need what they need to be able to pull at that time to help that patient in that episode of care. that is where we need to try to get to and that is not where i think we've gotten to yet and it needs to be a place where we

start to think of what we mean by inoperability. you may have physicians or clinicians in a "c" suite somewhere looking at all the data that's available, and the measures and what's the smartest way to go about this? what's the best thing we can do in this program? then you have the front line clinicians saying, they told me i had to report on this. i don't know why. it doesn't mean anything necessarily to this clinical encounter that i'm in or in the 20 of them that i did today. so we need to figure out how to engage those clinicians in this decision-making as well. then when you get into smaller practices, less integrated systems, there is a real lack of understanding and ability to make those decisions with the same level of data, and then, much less, know how to report it. because there are a lot of different options and different

timing around it. then clinician accountability in what is a very fragmented system. patients may be very tied in to their primary care clinician in terms of all of their chronic care for their multiple chronic conditions, yet they may have a need or a want for a different clinician, a different provider in another setting. maybe they're just sick in the middle of the night and they need to go somewhere, yet there's no good way for that information to necessarily get back to that primary care clinician in a consistent way for them to be able to -- you know, then they're accountable as the patients themselves. there are certainly some

parameters within the law that are required to be met, and then the scoring also doesn't need to be as complex as it is. the annual changes, i think, came up and will come up some more. you know, not only leads to a lot of additional cost, they lead to a lot of additional confusion and disorganization, a lot smaller need to plan ahead. mips does sort of require your feet in both boats. it requires you to be fully vested in fee for service. you still have to document every code, you still have to do all that work while, by the way, trying to ircnch your way into what's called value-based payment. it's not easy to transition there. is there still value? i've laid out all these challenges what i hear on a regular basis from our members, and i would argue there are still some value in the program. the intent of the program is really to streamline and tie

together some existing, very disparate programs that are out there. if you look at what's going on, acp does kuala lumpur programs across the country, and i tell you, those things work. when you implement them and implement them well, it may mean the clinicians or staff have to do some extra steps, document some extra stuff, even, for that quality improvement work, but they don't actually mind that. they're actually engaged, they see that it's about the patients and the access of those patients. how can we figure out how to accea translate what we're learning there into the mips program? i don't think it's out of reach but it will take real courage wrapped in compromise. all of us will have to think about that. we still need to fly this plane, but how can we actually make some changes to those measures?

how can we actually get rid of the ones that are really not good measures but also draerls those measures where some things just aren't enough. how can we get to a place where we use as many of those as we can while also getting to the measures that are more consistent and useful and helpful to the patient? so i think we have to really just think through how to do this and be a little courageous about it. i think mips can actually be simplified and streamlined? i could talk all day about that but i also want to get to our other panelists. there are more pathways and more on ramps that i think could be put in place to get to apms, freeing up some work that's being done to rebuild, do that

so krrgs cavita's organization rebuild instead of practicing mips. some actually do take very thoughtful approaches to the very thinking they're using on the measures and the approaches they're taking. we need to learn from them. they're not all looking at just the bottom line. some are really engaging the clinicians on the ground and making some very thoughtful decisions based on what they have to do this work. how can we actually reward those visits and groups. >> thank you, shari. we have a work flow. i'll get the slides up. you should be good. >> i'm aaron litz.

i'm the director of strategy and business development at tennessee oncology. for those of you not familiar with tennessee oncology, we're one of the largest physician-owned oncology practices in the country. we have over 80 oncologists, including medical oncologists, radiation oncologists. we have our own specialty pharmacy as well as a phase 1 research program through our partnership with sarah cannon research institute. my role there, i have, in the four years or so that i've been there now, it's been primarily focused on finance related to value-based payment as well as reporting our operational initiatives in our value-based programs in which we're participating. so i would have referred myself as an expert on the aco program, but i think there were some

interesting lessons from that program that were relevant to the apm that we are participating in, residents oncology care program, relative to mips. one of the things is, you know, you see kind of -- you start to see a spike in groups who were successful in this program once you get about two years in, and then again at about the 3.5-year mark. i think that just sort of illustrates the complexity of these new payment models, whether that's mips or whether that's a new apm and how long it takes organizations to adapt without sort of multiple rounds of data and feedback loops, you know, in that experience. it's really hard to, you know,

sort of get to that point. and these are organizations that self-selected themselves for having a high propensity for organizational change. so, you know, in terms of the impact of mips so far, i think one model, one framework we can use for that is to focus on the quadruple aim for a second. i'm going to assume you all can concede that work force health is a severe issue. i'll talk more about that. i'm sure we're going to talk more about that on this panel. but in our analysis of the link between patient experience and these programs, we found that, you know, it's -- the gains we've made in patient experience in our analysis of internal surveys are made despite these programs, despite the attributes

of these programs and not as a result of those attributes. and i think that it's really sort of -- the responsibility is on proponents of these programs to justify the -- the cost to workforce health with the benefits to health outcomes and total costs of care that purported the we should see in these programs. so i think the high level intentions in terms of increasing consideration of costs of care and introducing performance based variation in reimbursement, that's not a really sufficient justification for continuing these programs in their current form because there's other more evidentive ways to accomplish those mundment the objectives.

the standard really should be higher order accomplishments. such is feeling that reimbursement is commensurate with influence over outcomes. that there are gains in health outcomes those can't be achieved some other way through some other type of program that dun have the level of burden on workforce health as well as patient satisfaction. these programs increase the perhaps satisfaction of public health researchers that will be available or people who sell hit systems at the expense of providers being able to look up from the screen.

and us think that in tempts of organizational economics, one of the interesting things about the apm in which we're participating is that we are required to report how we are investing in that program. and very quickly is becomes apparent in that analysis that the cost of time far exceeds any revenues that we garner from the apm or from mips that fte time is four times the cost of the fte resources or four times the

revenue from mips and the apm. i'll concede those are costs that we would take on to do something else for some other types of activities as mentioned, but they are real co costs that we have to allocate and realtime we have to allocate to these programs. so basically as we increase the multidimensional performance evaluation that are associated both with our apm and with mips, we raise the resource investment necessary to perform well in these programs and we reduce overall workforce health and i think so far those two things

are way out of balance. we can't measure everything. we shouldn't need to report everything. we really need to be more judicious in terms of focusing on what's really important and what's going to move public health outcomes and total costs of care. there was a really interesting article written by my co-panel ist that proposed focusing on apms as a potential remedy for some of these issues that we're seeing in mips and that type of solution has a hot of potential, but sort of similar to the gap between intentions and reality that we have seen in mips so far, you have to get the structure of the apms right in

order for them to sort of render those benefits. it's 15 times the small incentive we get from participating in an advanced apm. we're not going to be driving provider organizations to those options in a way we could if we balanced those issues appropriately. i think that's as much as i'm going to cover for now and we'll have time for questions. >> thank you.

>> really happy to be here today. a quick note about me and caravan health. we are a company that helps physicians create and operate accountable organizations as well as purchasing programs. before this job, i spent a numb of years at cms and on the hill working on physician payment policy, so i certainly am happy to shoulder my fair share us of the blame for the mips design and operations. so what i wanted to talk about today is summarize what i think people representing physicians and provider organizations that mips isn't work iing if we wereo define what we think congress was trying to accomplish for the program. but i want to get to mips can't be. made to work to accomplish the

objectiv objectives, which if you listen to how people spoke about it, if you look at the design of the program, it's intended to drive quality improvement, drive attention to total costs of care. it's sort of like creating a payment model for the fee for service. but it was designed to differentiate performance and measure at a clinic level the performance so patients could use that information to choose physicians. the high quality and reenforce quality improvement. it's also intended to create to join payment models, which offer a more direct and knnuanced way for total costs of care. and so just to summarize what i think we're hearing that the problems with the program today it's very administratively complex and difficult to manage program from the perspective of a clinic or practice

administrator that requires a lot of staff time and investment in i.t. resources. what we didn't hear was mips has mot motivated me to put in place the best industry standard cycle to identify needs of my patients. what we see often is it motivates the choice of the easiest measures. so that's really where i'm going to start of why mips can't be made to work. congress laid out in trying to maximize physician independence and autonomy while supporting quality improvement. a system where physicians and clinics would be able to choose measures on which they are judged. it set physicians in the position of having these single highest purchasing program in medicare. and these are the smallest actors of significance. plans effectively they are value based is 5 points. some cases it's 10. these are giant companies that

have the ability to manage that risk and to plan for it over a number of years spending hundreds of millions of dollars in the process. while physician offices the plus and minus for them when you get out to four years implementation is minus 9 to plus 30. so that's a huge spread. looking at the negative is the cleanest way, but even minus 9 is a big number for clinics in a context you ask them to turn around and do real quality improvement work. and as sherry described, the measure choices that physicians face, there's they feel they do not have enough measures to choose from. i want to pull up a table from a paper we wrote. what is the operations of mips likely to look like over the

program based on what we knew from physician quality reporting programs that proceeded mips and rolled into mips. so what we found is that if you look at this strong incentive to choose the easiest measures possible resulted even in a program where there was no attachment to your performance, it didn't matter how your score was. but even with that, clinicians gravitated towards the easiest measures and the number one in the program and still to this day is documentation of medications in the record. in many cases, you could argue that's effectively a state law requirement. we have a giant apparatus built up spending hundreds of millions at the federal level. to encourage measures that are easy or that are standard in practice. cms, i will note, is aware of this and is trying to rotate out top down measures.

but for reasons of political economy, i'm going to talk about more in a minute, that ends up being hard to do over time. so with this really strong incentive to choose the easiest measures, you end up with practices choosing the easiest measures, but not spending that time focusing on real quality improvement, but having the i.t. staff do quality improvement. the high stakes seems like if you're dealing with minus 9 to plus 30, that's a pretty strong

reason to do well on the program. the alternative is what is done in some contexts to define a list of measures. public/private cooperation, but in a context there are 30 measures that are reported. 15 of them are reported from clinical data. and they are known ahead of time and are cure rated and the organization can improve performance over time. some are easy, some are hard. but it's a back and forth. you've got this situation where congress in trying to put in place a high impact program wanted to give as much choice as possible and undercut their ability to do that with the choice. this is not something that can be fixed by tinkering because

you are always going to be looking to encourage that choice and also because we have in our minds if we put in place the right incentives for these organization, then they are going to figure it out. but paying physicians is like paying employees or paying small, very small businesses. not that physicians are employees of the federal government. that's not the case. but they are not in a position to put in place a business processes that a hospital is in the value based purchasing context where they are able to invest significant resources and quality improvement over time. this problem becomes more clear and our paper goes into in more detail. the cost measures that are a large part of the program, it started at zero percent in 2017.

cms has gone through three batches of proposed measures in three years for that part of the program. and because you have to account for very small practices. that's going to be difficult to justify in terms of is that a good representation. it leads to huge disagreements with the medical community and it's not something that can be solved with statistics or simply trying harder. this is going to be a problem. you have conflicting incentives where hospitalizations are counted twice because they are counted in multiple episodes. so it's truly a mess on the cost episode piece of the program. but as i us said, this is something that can't actually be

fixed by simply tinkering the way we would try to improve some of the innovation center project can be modified every year. congress revisited the program multiple times and it's functioning more or less as intend ed. hospitals are tracking difficult in some cases measures and improving on them consistently. we have seen reductions in readmissions. but it's also bye-been tinkeredh by congress opinion the costs of the ongoing program are large in terms of wasted clinical time wherever we have physicians working on this program instead of focusing on patients' needs. also lost urgency around moving to better payment models that can be made to work better over time. so from my perspective, i still believe it's true. it's better for congress to get

involved now and to greatly system police if i the program and forget about trying to connect performance on a small list of measures to large payment adjustments for physicians and move to a simpler set of incentives to promote quality improvement processes and adoption of alternate payment models. i'm going to stop there. >> thank you. we'll go ahead and get started. i know we have about ten and we'll see where the conversation goes. maybe 15 minutes so we can have a discussion. i'm going to start -- i us wanted to ask aaron briefly because i don't know if everybody understands, but i'd like you to answer in a granular level. you're in both reporting on mips because you're only in advanced. just given everything that you

described, how hard is your organization going to work to try to get an aapm designation? or is that the goal? and you're speaking not on behalf of oncologists, but specialists looking at opportunities. very briefly. do you have a sense of whether or not as an organization the aapm looks more attractive if possible to get away with this that you described. >> i think the way the advanced apm sort of structure exists currently, i would hesitate to use the word non-starter, but it's just completely draconian in terms of the potential losses that a participant could occur on the downside compared to the

potential upside of participation. having said that, we took the step of participating in a mips apm for the reason that we are committed to moving towards value-based care and value-based payment programs. all of the practices that participate in the care model presumably a lot of those in the other models self-select themselves for their intention to innovate in that way. but you do kind of hit this road block when the numbers sort of add up the way they currently do in these two options. >> yes, and just very briefly, the mips apm because you're

reporting on mips and doing the apm requirements. >> we aren't able to select the easiest measures to hit. the measures that were measured against are dictated by the structure of the apm. and the improvement activities are the most complex of improvement tufts thactivities have to perform as part of the apm. we also have to do the advancing ca care, so we have much more stringent limitations in terms of options for participation in mips, but yet, despite all of the -- i should also mention that the clinical data reporting

associated with the oncology care model is incredibly robust. it's very couple can bettumbers. and then on top of that, we still have to do the aci portion of mips. so i think that's one of the things that could be rethought. >> great. you made several points. one around kind of the challenges of rural practices. and then you also kind of alluded to the desire to potentially find an advanced apm for the sake of getting out of some of these challenges. so can you speak -- number one, just to clarify, because a lot of people have misperception that you're automatically exempt from the mips requirements. do you mind clarify iing for th

audience and then number two, could you also speak a little bit. we can't -- tim described that mips can't just be tinkered with. it really does need to be replaced. and maybe describe a little bit about how operationally at a health system of kind of medium to large size how are you thinking about moving forward when you have to live in the current environment. are you as a system trying to get an aapm? and if so, what's your forecast on when that might occur? >> sure. so we have found that there's certainly significant number of rural providers that meet the exemption category. but we should not assume the vast majority of them are exempt from it. and so even the ones that are

exempt, particular ly if those providers are not near retirement, they really understand that they need to get into the game. they need to understand how to work within this new environment. so even if they may complain about it, when us yo go into their office and there goes the government again, you can imagine some of the conversations we have, the vast amount of them say i need to get an emr. i've got to figure out how to work within this. so one of the things that we have found is they are eager to join cins to help them. because they understand that they need assistance. but it's not at the level i us think that many of the rural providers are feeling comfortable with and not at the level of somebody in their own town and goes into their office

and drives to that rural city and sits there that they can provide. with that, many of the rural providers around us have been interested in being a part of the cin so we can assist them with that. with made the decision to go with advanced apm. you can imagine with 2800 providers we're really glad we made that decision after getting our 1.59% bonus. and i will tell you -- >> you made that decision without knowing. so you had to make that organizational decision. >> we were making it on the assumption we would get around 3%. we didn't think at a 2800 person

system we would probably reach the top at 4%. so we were anticipating we'd come in between 90 and 95 and spending millions and millions of dollars. we probably spent close to 7 to $8 million in helping the systems comply with it. and we as 60 cents on the dollar. >> so certainly 5% bonus will help offset that particularly from the employee at the independent providers will get that directly themselves. but that 5% bonus from the employee will help the system as a whole offset the investment.

>> sherri, you spoke about a number of activities. the acp sounds like you're supporting kind of quality improvement programs and more kind of collaboratives that are more meaningful. thinking about the struggle from a policy perspective including a lot of measures for the sake of political economy, how can we transition potentially? do you see an opportunity to take kind of the meaningful activities out of the ground level, which i have been using for the kind of clinical performance improvement activity bucket in terms of meeting requirements. is there something that should be translated into the quality measurement or some way forward because i know when we have spoken before, we have all said woor not in love with mips, but don't throw it out without anything about what you replace it with.

>> sure, so i think a lot of what's going on on the ground with the quality improvement activities or quality improvement programs that are going on are really tied in to clinical guidelines and measures that have been viewed as valid. and i think one of the things that i think we could do and i hear what tim is saying a about the issue we can't just tinker with the program. i think there's more flexibility than might be viewed, so to speak, by some in terms of what the law lays out. i think we need to be pretty open minded about that. so if one were to think about really taking a quality improvement activity, which includes the activity, that component of it. most of the times, those activities do include using health i.t. in a meaningful way

to do that work. they also include the measures. because you have to have measures to measure whether quality improvement activity or program is working. they also include looking at costs for the most part. so these programs are looking at those components. how can we have those types of efforts count across it all. that's really what's intended here. we had separate programs. we had value based program. we had whatever else. we had meaningful use. we had all these programs that were intended to be brought together. we had siloed programs within mips. and i don't think it has to be that way. it just doesn't. the law doesn't say that it has to be that way. so i think that's what we need to do.

be thoughtful about that. let's look at how we can actually have things that individuals and programs and practices are doing and give that credit across them. maybe it's things through safe harbors for those that test this out for the administration to give them ideas to be able to translate this into the policy that's needed to do it. i think that's one practical way to think about it. there are probably a number of others. >> tim, i'm going to give you a two-part question. we'll close with a rapid fire panelist question. our title of our program today is can mips be salvaged. it sounds like the probable answer is yes. let me ask a different question. were we better. off before with the separate programs? everyone is saying no. if i'll just get to that and if you say no, let me ask it a different way.

are we better off trying to do what tim suggested where we need to probably replace the program or do we think that we can do what schaar ri described with taking pieces of it and looking at how to make them work? i'm not going to load your answers. but two parts. the first thing you described kind of working pretty kritically with accountable care organizations of different types. i'm not sure if they are risk baring. this question of do you think that largely not hospital owned, i'm just going to venture just knowing what i know. do you see a trend where these organizations see their path forward kind of in an aapm, maybe a higher level aco taking risks and one way to keep moving along the continuum. the second part i can remind you

if we forget is around the backdrop and the trend towards consolidation. you can tell us whether some of the kind of aspects that we have been critical of of mips today might unintentionally drive consolidation in the provider market as well. >> i'll try to answer the first part. we work with different types of acos including hospital physician partnerships acos. many of them partly because they are annoying to deal with. many looking a at them making us take risks. see it as a more stable way to work on care improvement and total cost of care management. it's a little bit separable from mips in the sense of medicare

has to figure out what it wants to pay for, define what counts as high quality, define what counts as payment rates and pay that. i think medicare is in some cases looking at cite of care. there's a pretty strong argument that payment differentials led to consolidation. that's separate from mips. i think you need to get the definition of what you want the program to reward straight and then empower people in the private sector, firms, people at hospitals and physician networks and all across the system to figure out solutions that are going to be efficient for them and for their patients rather than microengineering it like we do in minneapolis. >> i have changed my lightning round question. so since we're talking about

solutions and strategies, each one of you mentioned several in your presentation. if you were sitting there today, you heard all the feedback. certainly there's the schedule rule. but what is kind of the one top priority in salvaging mips. it could be anything and even a repeat of what you said but the top thing. i'll go first. i'll say to expand the opportunities within advanced alternative payment models much more broadly including opportunities for primary care. one argued that acos offer that. expanding in a meaningful way and harmonizing that with the mips requirements. >> my comment would be don't try to tweak a program that's not working. that's always not a good time for us in this industry.

and i think we need to look at where we want to end up at. and focus on modifying the program for that. if we feel the health risk based contracts do improve the health of the populations we all is sterve, that should be the end poi point. >> so i think you have to invest in making improvements in the current program because we have the current program. but at the same time, i like what she said about let's look at where our goal is. let's make those changes to it looking toward that goal. and i do think that what you and tim wrote about in that article is very important that there need to be more opportunities for clinicians and physicians to design and be part of advanced apm that's can offer them really much more meaningful chances for

making quality improvement and being reward forward that improvement. >> thank you. indiana? aaron? >> i think you have to mic the performance evaluation portion element of these programs fair for -- they have to be highly targeted, as we have discussed. and they have to be understandable at the point of care. the more understandable they are at the point of care, the more successful they are going to be. and i think we have to leverage some of the work that a lot of the professional society quality programs have done. and it's not a matter of getting rid of mips and replacing it with nothing, because we already

have things to replace it. we have quality programs. a lot of organizations across the country now are publishing case studies of their quality improvement efforts. we have done that in areas of pathways and appropriate biomarker testing and responsiveness to patients via value dauted sl management triage protocols. all these things that the folks who understand and see the value of them and will meaningfully improve care, when you take away some of the reporting burden of these programs, you leave more space for those types of initiatives. >> great, thank you. tim, final word. >> three things. although i would say mostly is

on congress to fix the structural problems, not cms. i think the cms needs to do what they are doing in terms of reducing the administrative costs of the program. it's got to be continuously made easier to deal with. they need to get rid of the easiest measures for patient care. there are too many measures not meaningful. they need to invest in payment models, but also incentives for joining wherever they have levers. >> i know we could go on and on. join me in thanking this current panel and we'll switch out quickly.

i'd like to begin our second panel. i'll begin by introducing the order in which panelists will speak. we'll start with jim matthews, who is exec fifth -- anything else he'd like to say. hear from matt fid letter, fellow economic studies at the brookings institution, who worked with tim to lead the analysis of the usc initiative for health policy work that tim put up in a slide. and we'll hear from sara levin, member of the democratic staff of the house ways and means

committee. and finally from robert horn, now with leavitt partners, but who served on the energy and commerce committee when macrowas developed. >> first, i'd like to thank paul and the staff of brookings for putting on this event and for inviting me. i'm privilege ed to be here and thankful for the opportunity. unlike the previous panel, i do not have slides, so you're just going to have to watch me talk for the next five to serve minute s, so i apologize for that. it's a very nice background slides. that should take the strain off. what i'd like to begin with, i prepared two presentations in response to the question of this forum. can mips be salvage d?

the first one went something like this. no, i'm happy to take any questions. but in the interest of developing that thought a little bit further, i do want to represent the current position with respect to mips and spend a few minutes talking about the evolution of our position. so we recommended eliminating mips in our march 2018 report to the congress. some of you may have heard about this. but i'm going to rewind a little bit and talk about the origin of that recommendation. it begins with recommendation we made seven years earlier to the congress that the sgr system be eliminated. this was something the commission had felt very strongly about over the years in terms of the impacts on physicians' willingness to treat

beneficiaries and fully engage in the medicare program. so in 2011, we made a recommendation that included some fairly draconian payment updates for the decade ahead and it was an indication of how strongly the commission felt that the sgr needed to be eliminated. congress did, indeed, eliminate the sgr in the macro legislation, and it was a tremendous accomplishment. we were completely on board with the notion that sgr was serving no useful purpose. we also were very supportive of the new path laid out in macro with respect to alternative payment models as a mechanism to help physicians engage in delivery system reform. so a very supportive of that effort. we're continuing to develop ways to improve the aapm process.

then we get to mips. and mips we were fully on board with the notion that there should be a value program available to nonorganized, non-aapm physicians. many of our commissioners over the last several years had expressed this sentiment in clear terms, so we are very much in agreement with the goal, but over the last two years, we have come to the conclusion that mips is simply not going to achieve those goals. and i'll spend the next couple minutes talking about why we believe that. when mips was first proposed on a regulatory basis in 2016, the commission's position was that we help cms try to improve mips. but even at that point, we were raising some concerns about how it had been articulated.

and we suggested focusing more on outcomes, measures, reducing burden by using claims measures and a number of other issues, but we still started to raise some doubts about the viability of the program for non-aapm physicians. over the following two years as the the agency continued to roll out regulations, refining the program, our concerns became even more pronounced. we ended up concluding that mips is simply not fixable as a broad value program for physicians. there are a few reasons for this. i want to emphasize here broad value incentive program for physicians. first of all, there are numerous statutory and regulatory exclusions to the mips program. by rough estimate, currently,

600,000 physicians are excluded as a result of regulatory decisions that the agency has made and another 300,000 or so are exempt by statute. so almost a million are exempt compared to little less than 600,000 who are subject to participating in mips. so in terms of a broad program to incentivize value, you have left two-thirds of your non-aapm physicians off the table right out of the gates. a second concern that we had is with respect to the small problem in statistical reliabili reliability. that given the fact that you're talking about measuring the performance of individual physicians, even individual physicians who are subject to mips and who are selecting their own measures may not have sufficient volume to have those

performance assessed in a statistical ly reliable way. you're starting to move et medicare dollars around on the basis of random variation. that's a point i'm going to get to in a minute. we also had concerned about the low performance thresholds that i think the minimum performance threshold now is 15%. and the exceptional performance threshold is currently 70%. and i don't know about anyone in the room, but if one of my kids came home with 70% average on their report cards, i would not call that exceptional performance. so we're talking about a very, very low bar for purposes of moving substantial quantities of medicare dollars around. we are also concerned about the fact that as currently constructed, physicians will select their own set of measu

measures. this creates a couple problems. one you cannot compare the performance of one physician to another. and again, this is a fundamentally unfair prospect, again, with respect to medicare identifying one physician as being better than another one and you're going to get more dollars than you'll ever hear. there's also the problem of slelkting their own measures and they will likely or this is what i would do, select measures where i would have the best chance of performing extremely well. this is just human nature. so what's going to happen is you're going to get measurement compression where you're going to see a lot of physicians performing at the 98th percent tile on their different measures and as a result, performance is going to be assessed on extremely fine grade dagss of

very high top of the spectrum in terms of their scores. and this is going to -- it might not make much of a difference now when the payment adjustments are entered in the 1 or 2%, but when you start getting into the negative nine to plus 30, this is going to make a real difference. as they have talked to physicians out in the community, one very compelling anecdote we heard was how do i explain to my family that i have taken a $20,000 pay cut do to random variation. big problem here. and then there's also the question of burden. so i think virtually everyone on the previous panel mentioned burden. no benefit relative to the cost, no return on investment and cms estimated a billion dollars in compliance costs in the first year of mips and we're projecting half a million dollars annually in compliance costs on an ongoing basis as

long as the program exists. and again this is for a program that is not going to really measure performance at the individual clinician level. the organizations will argue, we have spent a lot of dollars and made a lot of investments. we can't stop it now. how long do you want to keep throwing money into a program that's not going to achieve its goals. and at the same time that some of the advocacy organizations are making this argument, others are having campaigns their members that say one measure, one patient, one penalty, which does not sound like broad based quality improvement and incentivized value. on the basis of these concerns,

it was recommended in march of 2018 that mips be apobolished a replaced by the voluntary value program. i'm cognizant of the fact i'm running long on time, so i won't go into it in tremendous detail, but groups of physicians can volunteer to be measured on a small set of tolation based. that's an important point. and under this construct, it solves at least four major problems with respect to mips. one, it solves your small end problem. it can only be measured if you have a sufficient number of participants in your group. two, it solves the burden problem. there's zero burden to this approach. most of these measures are claims based, which would be calculated by cms or patient

satisfaction measures through surveys that could be used. it solves the equity problem. each group of physicians is going to be measured on the same set of measures. again, there's numerous questions and concerns about what they proposed and i can take on that question. but the last thing -- second to the last thing it does is solves the value program. the measures that we have in mind are not things like are you adequately assessing your patient's blood pressure on a regular basis, but they identify things that are important to the medicare program and its beneficiaries. lastly, this does provide an onramp or some set of training wheels for clinicians to come together as groups on an informal basis under our construct, but since they are going to be measured on the same kinds of things that in our vision would apply, this does

allow them to kind of try it out before deciding to go that next step and take on risk for the cost and quality of care for their aligned population. so with that, i will stop talking and turn it over to our next panelist. >> so given that as tim alluded to, he and i along with paul and a couple other folks here at brookings co-authored work on this topic. it probably won't surprise folks i'm on team let's abandon mips. i think there are three basic points that drive me to that conclusion. i think the first is that the empirical evidence on value-based purchasing programs that measure clinicians on a range of different quality measures and then adjust fee for service rates on that basis is

just very weak. i plr ly like the recent work b roberts on the volume modifier, which was a predecessor program that looked to see whether there were changes in performance at practice sites, thresholds where practices became eligible for bonuses or bonuses and penalties under the value modifier. they found there was no evidence of changes in performance at these practice thresholds, which strongly suggests that these types of incentives were not changing behavior. and that's not a unique finding to the value modifier. lots of research on these programs, including the value-based purchasing program and others finds these programs to be fairly ineffective tools for changing behavior. so that leads me to believe that mips is likely to go down a similar road. now perhaps you thought that these reflect fixable design

flaws in these programs. i think for a variety of reasons that people have touched on, i'm not optimistic on that front. i think the sml numbers program that tim and jim alluded to is just sort of fundamental here. when you're trying to do clinician or practice level quality measurement, you'll have noisy measures and that's going to mean the amount of incentive kick you're getting for the amount of risk you're exposing providers to is just not an i tractive trade off. i also think in a worlgd of practice level payment adjustments, it's very difficult to create a coherence of financial incentives that way. we have a great example of that. we have a need to measure lots of different clinicians and so the approach is do a bunch of different cost measure, throw them together and that's your score. but because each dollars is going to depend on who meets

sample size criteria and which measure you're using, each dollar is going to be counted multiple times or not at all. the overall set of incentives we're creating to think about the overall cost of care is pretty. hap hd. the scatter shots makes it harder to figure out how to respond to them. it may also mean if they figured out who to respond, we wouldn't be thrilled with the types of responses we saw. and then i think if we have a structure that we think is unlikely to work that we can't fix, other people have alluded to the fact it's not possible to operate this program. those costs might well be worth paying if we thought we were causing real changes.

in a world where we're operating a program that seems to be pretty inert, they are very difficult to justify paying. so for those reasons, my views that the evidence justifies abandoning mips. but if we were in a world where congress were taking action to repeal mips, which may not be the nerm we're living in, i think this would be a good opportunity to implement other changes that might reduce the cost or improve the quality of the care. i think that probably will take a lot of different forms. as we move forward, there's been a focus on silver bullets and wo we're looking at approaches to deal with these programs. but i want to focus on steps policymakers could take to make alternative payment models more effective.

these can be effective tools. early evaluations of the voluntary bundle payments program main voluntary seems to adjust that the models can generate modest savings without impairing quality. there seems to be some variation from episode type. having stronger evidence of the fact. i think the best work is probably by michael mcwilliams looking at performance in the shared savings program that seems to find modest but what i would call meaningful reductions in spending alongside modest quality improvements. for a variety of reasons, the suspicion is gained experience with the models. savings will grow and there's

also some reason to believe that as these types of models scale, there might be changes in how medical practice and technology involve. that means long running could be larger than we're able to measure in the short-term. so that's why i think this is a valuable road to go down. what do i think this sort of useful role for policy is beyond what we're doing now to make that possible. this is where i get a little more radical. i think one of the major barriers over the median term to realizing the full potential is they are right now for the most part pure ri voluntary. that creates a numb of challenges, but the biggest one is how to set provider spending targets. so benchmarks in aco models or the target prices in payment models initially they have solved this problem by setting the spending targets based on

own historical cost experience. that's a great place to start, but not a viable strategy. if you're recognizing that if i save a dollar today when they reset in a couple years, they are going to look back they reduced costs before. so my target is going to drop by a dollar. that's not a sustainable financial model or creates strong incentives. this approach tends to lock in cost differences, which is going to reduce the incentives for providers to expand and serve more patients for providers to contract. the problem is that the natural alternatives to that approach in the context of volunteering models have real challenges associated with them. the most natural place and others in the context have suggested going is to set spending benchmarks based on regional average spending. the problem with that is in a

voluntary model are likely to drop out of the model. providers with below average spending stay in the model and realize big wind fallss. so i think that does mean that over the medium run if we want apms to be our key strategy, we have to major these models less voluntary. that can be through a combination of carrots and sticks and depending on the model, the right approach is likely to differ. i think the right approach is going to be where we have models that we think work actually making them mandatory. on the acl side, it's not clear what it means or how you do it. so they are building on the bonuses for advanced apm participation that is really the right path forward. so step one is to make sure the bonus doesn't go away in a few years, but beyond that, we should be thinking about making

the financial incentive to participate larger. i would envision through a budget neutral combination of bonuses for participation and ultimately penalties for non-pargs. it's also a question whether they should be limited as there is question whether those should be limited to physicians or whether those should be expanding to additional types of providers in order to expand the set of providers in the stake to make sure these type of models have an opportunity in any type of community. look forward to the conversation. >> hi, thank you very much for having me here. i need to start with a disclaimer. the views that i am about to speak are my own. they are not necessarily those of the ranking member of the committee on ways and means or are they necessarily the views of the members of the committee. on to that. i think that paul and jim

touched on this. it bares repeating and stepping back a little bit and remembering where we were a couple of years ago with the near constant conversation with the sustain stainable growth rate. sgr was started as just discussed in 1997. since the early 2000s, there were repeated and regular cuts that were going to hit physicians that congress had to stave off. this would bring physician communities to congress saying, please don't have these cuts and beneficiary groups saying please don't cut these payments. i want to still be able to see my physician and my doctors. the conversation in health care was largely -- in the medicare space was largely about how to get rid of the sgr and what we can do next. and so, over the course of that

period of time, congress spent about $170 billion on short-term patches. in 2015, the physician community was facing a 21% rate cut. and so in comes macra and the affordable care act, here is this bipartisan work looking to talk about value of care and drive and the whole point of macra and mips and the advanced apms was to think about how to move towards a system that awards value of care instead of volume of care. that is a change of conversation from how do we stop these cuts to how do we move to value. it is reflective in this community where we are talking about how do we make sure we are improving care for beneficiaries

and doing it in a meaningful and efficient way for the physician community. congress established macra which created the two-pronged approach. the advanced alternative payment model for those willing to take on risk for their payments and those large section of the physician community that was maybe not ready to take on full risk but maybe interested in value. we heard loud and clear from the providers that not every doctor is the same. there is variation in the readiness to move to value. there is variation in size of practice and shops and location and what a physician practiced in iowa or tennessee looks differently than maybe one in

new york city or houston. and so, there is also the physicians would come and say, you know, i am different from another physician. you aren't going to measure my quality. i'm in pathology. i don't see patients. or i'm a family practice physician and these flu shot measures are relevant to me but surgical things are not relevant to me. how are you going to make thur these relate to me? so these are diverse in both size, scope, geography and what types of services they furnish and trying to make a program that encompasses them all. you want to make sure there is opportunities for everyone to succeed an push towards that value. so mips is an important part

thof that package to lead towards the janua onramp and giving them the opportunity to do so. this is a marriage on strategy, really. there are those that started in a more integrated practice doing this and baring risk for quite some time. started at mile 26 and only had .2 to go. and really to understand the systems and capabilities in place to move towards those values in a more advanced way and there are those that are not even at mile one. we need to set up the system, so they end up keeling over before they get to mile ten or four. there are those who talked earlier here on the panels that mips can be used as an

insensitive to move towards the vansed apm. that is the goal to get movement towards the advanced apms. they are continued to talk about here and in congress. how do you measure performance in a meaningful way? so they are important for physicians and for patients? that is an ongoing process and something that needs to continue to be developed and moved on. i will say that right now in congress, that is the conversation. how can we make these improvements and move towards more value and the conversation has not yet been how to dismantle mips. i think it is just remembering that this was the macra and mips

was a baipartisan solution that came after a long-broken system -- and we don't even have the results from the first year. payment consequences haven't started. they don't start until 2019. we don't know how the program is working. we are very interested in how the program is working. we've had several hearings on the implementation of macra. energy and congress is having one next year. congress is interested in that it works and can be useful. we've made changes earlier this year in the bipartisan budget act specifically with providing more flexibility with physicians and a clearer onramp to clarify terms that are confusing and

additionally, there were clarifications relating to the development of new advanced alternative payment models and making sure physicians have the assistance to get to developing those value-based models that physicians and beneficiaries want to see. the whole idea of this is to lower costs and improve quality. and so, you know, i think it's very important to hear all of the perspectives on the different challenges. i would say that the statute is pretty -- there's been a lot of regulatory issues that have been discussed here. i appreciate the discussion that shari talked about. there is a lot of flexibility in the law. when we talk to the physician community and beneficiary community, they are not coming in banging down the doors to

repeal mips right now. they are coming down talking about how can we -- i need an advanced alternative payment model. how can i get one? and that is a good conversation to have. how can we make the measures more relevant or allow more people to have the ability to bear risk and do more advanced alternative payment models and hopefully lead down the road to those advanced alternative payment models. this delivery system focus is important. so we can bring everyone down the road. mips using that onramp to bring those to the baring those discussions. that small rural practice or urban practice is very different than the large integrated

medical practices that have all the data. so moving everyone along is really difficult. i'll stop there. >> first and foremost, happy friday, everybody. look, i had talkers, i've completelity rated around those now. let me go back. i'll note, i'm a chicago optimist. it is a tough value proposition living in an area. that was a bad joke, by the way. i want to talk about how mips and physician reporting can be used as a tool to drive value and i want to answer whether mips can be saved or not. two things to note and one to build off sara.

they are still very bipartisan. as we think about macra and the role of physician reporting, it was created to get away from the sgr budget tool that was utilized around the updates and around the physician fee schedule and to help drive value in the medicare program. before, some might have thought of it was solely the program. it is something that is still a very bright proposition. number two, it could be finding ways to measure those value propositions. finding ways to measure that

value proposition. knowing that reporting is going on in an apm as much as it is mips. my humble pin, mips is not just a measurement tool but the effective deployment of data to support identification and adoption of value propositions. my dad basically bought a new car, first year model when i was six years old. he was so excited. he brought it home and was so excited. six months later, it was no longer in our driveway. it had problems and got fixed. funny thing, it was back in the driveway three weeks later. it worked well. it did. to sarah's point, there are a lot of things that can be

utilized to improve physician reporting and see what measurement looks like but to give cmf and cmi the data it needs. we may not necessarily be utilizing those tools as effectively as we can but what sarah spoke to. one example, the combination of cpias and rewaiting of the measurement categories within the law can help define what new value propositions are from a value standpoint and possibly an atm standpoint. there is a lot of flexibilities. if you look at the flexibilities that cmi affords, you can almost double. congress is not a passive part parent in this. if someone walked forward with a

way to make macra more meaningful, that wouldn't be a subject they would shut down. in thinking about basically mips. let's think about physician reporting beyond mips. physician reporting really can be a way to identify what new value reporting propositions are. one area of improvement to focus on or opportunities to tie the mips path way closer with the apm path way. it is a policy i am working on with a broad stake holder community. i do believe mips can be improved on and not in the statement that it should be gotten rid of. if somebody talks about throwing it away, they should look at a solution. mips and the statue are not an

sgr budget tool. one example of how physician reporting can be utilized better to drive our identification, adoption and use of value propositions in the medicare program is to allow physician reporting to report more on what we call prototypes of what measures look like and what apms might be. apm is largely a behavior change, other stuff wrapped around the middle and a payment change. proposition is based on, if you accept morris being, we can allow you to do things in a different way that bring value to us all. cms, largely right now, they need information. they need data. they want to figure out what works and what doesn't. one of the areas under the statute right now was designed to deliver data to cms, cmi was

ptac. it was envisioned much different than it ended up. it ended up where it was because staffers had visionary ideas of what different pathways could look like. we ran into the scoring and right fully so, i think. pointed out some of the flaws in what we had considered. the point is, there could be a second reporting option. the flexibilities that would allow physician organizations to put forward prototypes of what an outcome measure could look like. what an episode could look like or what an apm could be. identify ways to report on those prototypes that facilitates data gathering to help them better

understand the reporting. if you use the physician fee schedule and reporting, you don't have to apply payment consequences to it, which means largely every physician in this country could be reporting on a prototype. the information that they are reporting would help inform cm&i with the problems being more accurate. in areas where the proposition fails, we have also largely succeeded because cms and cmmi now know what might work in the future and then put it forward again. lastly, you have increased provid provider kns confidence in identifying what the future looks like.

the reason of the bad analogy on my dad's car is because macra was my dad's first-year car. it didn't work. self-edit. but it was in my family for 12 years after it got back from the shop and didn't have problems. i won't mention the maker. but model year two and three and four didn't have the problems year one did. to sarah's point, the opportunity is a huge opportunity to utilize the entire medicare program as a driver of value instead of just containing the area. my hope is we can all engage in a conversation of how to improve the law to make it a more effective driver of value. i'll stop there. thank you very much. happy to answer questions.

>> thank you, robert. i came into this panel with a couple of questions. i think they've been answered pretty well by the panalists. let me not have them repeat it. i will ask the panelists if they have anything they'd like to say inspired by what others said. then i'll go to the audience, which did not have a chance to answer questions after the first panel. i'll make sure you do after this one. any comments? okay. there is a woman there with her hand up. please introduce yourself. >> good morning. can you hear me? >> yes. >> my name is jennifer with the medical group management association. to build on comments made in the last panel, we've done a lot of work with the physician community, cardiology, ama around the idea of mult eye

category credit. i would be interested in your thoughts in some of the push back we've gotten from officials that this would be the equivalent of double dipping because this lays out four different categories, you have to report within each of them. if cms did want to innocent advise reporting around really important issues like take the opioid epidemic absolutely a certain component. if they wanted to bundle that and allow the community to report once on the prescription management, drug program, report that information to the public health regular industry, document that through reporting

activities, our response was, you recognition that as a sort of bundle, if you will, within mips and don't require group practices to put in all of the burdenen some requirements to meet those three buckets but allow them to say, we are doing this important work. can we get credit across the mips program. that could be perceived as double dipping. what are your thoughts on that? >> so, i'll answer this but understanding i haven't seen all the details of the proposal. just to go back to shari's point. there is a lot of flexibility in the law to think about those four categories not as separate

categories but as areas, let's say of measurement and activity that could be relied upon for the purposes of measurement. the reweighting flexibilities within the law, if you look closely at the language around the reweighting, do allow for areas of condensing those four categories into smaller amounts of categories. it's largely wrapped around cpia. the intent of congress was we don't want to think about these four categories as simply four categories. i will say this. i think the add miministration others are still feeling their way around something that is very complex and very dynamic law. opportunities to engage the administration and congress and what the opportunity is but also

maybe how to support it could be an opportunity for exploring new ways. >> another question. yes. and then the next one is this gentleman back there. >> i would just add that i think the idea of macra in general was to stream line and to think about different ways to make reporting easier while also making it more useful and value based. i don't know the specifics of your proposal or cms's challenges but even the different activities within those four buckets. even if you you are doing them within the four buckets, they could be aligned towards the same goal, which is really what the intention is to drive value whether in the opioids fear and reducing unnecessarily

precipitations or others. >> let's hear from aaron lyss. >> i think matthew brought up a critical issue that i think has been understated throughout the morning, which is the importance of benchmark setting and target price setting and getting that right and having that be -- having those target prices and benchmarks be equitable. there was one element i didn't hear that i think is a very significant concern. i was wondering how the panel would propose addressing this. that is the degree of innovation in therapies and in diagnostics that we've seen over the past several years is fundamentally different than a lot of the data on which these models were based.

and i think -- i'd be interested in hearing your perspectives on how to account for that. to me, it just seems like that is -- it requires a degree of technical expertise in various specialties provided by these that is hard to get and hard to account for in the design of these models. >> i'll share a couple of thoughts but to some extent, this is just a hard technical problem we don't have answers to. but i think there are two broad approaches you can try to take. one is in terms of growth rates over time instead of doing more pure benchmarking in growth rates. everyone is being affected by the same technology changes. that can capture those sorts of

trends. the challenge is, you have got to make sure the peer groups are being met with the same challenges. the other approach, and i think this becomes a bigger problem on some of the narrower models you are talking about. if you've got a broader patient population, hopefully some of this averages out a little more. where more technology care will average out but in the long run, i tend to think it is one of the advantages of total cost of cares models over episode case models because they are more robust but i think there is no perfect solution. >> there is a gentleman back

there. >> hi, david mcnew with national health advisors. i appreciate the points about where we were with sgr and where we are going. the physician groups i work with are very appreciative of the change and what congress did to pull us out of the constant sgr changes. we appreciate what mips is trying to do but we look at it as sort of a value purge torry as we wait for the more advanced options to come on line. they don't just want one apm but they want multiple onramps. you made some comments about the mandatory nature of apms. i wonder where should those lines be drawn? you are on the mips track and you have that one onramp or do

you wait for multiple options to be ready and say okay, this clinical space has enough options for most of you to be in the apm track. i think we are seeing it sort of play out with cjr being the first bundle. for those physicians that are in cjr msa but are successful under the bci model. they do not have the option to continue on into the bpci model. they are being forced into cjr. that is sort of another wrinkle to the mandatory aspect. how do you see that playing out? >> so, i think there are two broad philosophies here in terms of whether we want broad choice of apms or whether we want to

focus around a small set of models. i tend to be the focus on a small set of models camp. there are three reasons for that. just being a very complex environment for providers to navigate and policymakers to manage. the second, in many of those cases, i worry about vul canization where we have very narrow focus models because different clincians and providers are focussed on the measures in their particular models that prohibit cross-cloe lab operation we want to foster. the third is a major arbatrage concern. some of those will be more attractive than others.

that may be very good for the providers involved but costly for the medicare program. so i think that tends to lead me towards a place of what we want is a fairly restricted movement of models that we can find ways for a broad array for clinishians to find a way to enter into. >> i have a slightly different take. not to disagree at all. i tend to think more options are better. how you get to more options is a better question. there should be integrity in that. to suggest right now apms largely, the cost savings potential is undetermined at this point. i think the data supports that. i think we all see the potential and agree with the proposition that a new value proposition can save money. i think one of the down sides of

focusing on a sub set are that you limit your chances of success and actually finding what that savings is. in part two, what i'd love to see is is a focus on some areas or a small set there. but the strategy is to find components that can be rep indicated and provide more reply indication. to the specialty focus, geographic location and ability. sub specialty right now, they may never get to an apm the way they are going right now. you are almost creating a second class of citizen in the physician community where the focus is on value and they have no ability to drive it. number two, i would suggest that if we focus on small sub sets and utilize cmmi as the only approach, we run the risk of

when we identify a model down the line, it's already outdated. this allows us to look to the future and again ways that physician reporting can help inform what next generation models look like 10, 15 years down the line. i'll end with this. i agree that mips today can be improved upon, i really do. i would suggest that providers that are waiting under the current system for their place, could be waiting 20 or more years. i don't know if that is a sustainable place either. >> with final thoughts on this particular discussion. it seems as though the big choice in apms is whether to emphasize population models. you know, versus other models.

that's the weakness to the approach. the population approach could include the flexibility for those taking the population risk to actually inovate in the payment for particular episodes that are important to them and figure out how to do it their way rather than doing it through the regulatory channels which takes so much longer. i was going to close the meeting but you seem egger enough to say something. >> i'm a fourth year resident physician at georgetown. i did my mba on value-based care. i work very close with my medical society. the aapmr medical society.

one of the things i really think we should expand on is building regular industries and making that more points on the score card. if we have registries, it makes it more meaningful. we can build episodes of care. once we have that, we can really build apms. what are your thoughts about expanding upon registries for each physician society? >> i would say there are pathways built into the law recognizing the usefulness of the data that is infooted into the registry and developed and created to the specific type of work that the specific medical

profession engages in. so i think that, you know, congress found the value in them and included them as a result of that. there are basically implementation questions and changes even being considered in last week's new regulation but the use of the information that is put in there can provide some information and some answers to some questions that are useful that you discussed. >> if i can add to that a little bit too. it is funny, registries is probably the most used word. it became a joke at one point. there was a reason for that too. it is some what more of a hope for ways that registries can be

utilized. to answer your question, it is how they are recognition and not so much the recognition themselves. cms has a computer and capability problem in that cms doesn't have the modern analytic capabilities that private businesses and organizations do. somebody once told me it has a 1980s computer system that is still on apple 2e. not to den great cms at all but the ability to evaluate the value is limited. it could be one potential to improve the ability to opine on whether a valuation works or not. recognizing registries as a con duity to gathering information to cms might serve to not only have the data but also

understand what the data is telling us and it comes down to how the recognition happens but if done in the right way, it could be pretty powerful. i agree with you. >> one thing i would add here, they enable a lot of types of learning that have systemic benefits that are beyond the level of the individual clincian. even if you were in a world where i got my wish and mips went away. maintaining some incentive for reporting would have a strong rational for it. >> if i could weigh in on this. speaking for the commission staff, not the commission as a whole. we are contemplating the role of

registries in the overall value. some of the things we would become concerned about, again, moving substantial amounts of medicare dollars around would be what kind of efforts occur on the front end? how open are these? how accessible is the data to the search maker and policymakers? what do the owners or managers do to push that information out in some aggregated form to make sure it is indeed being used for purposes of quality and practice improvement as opposed to just sitting as a black box to allow the submitter to say, yes, i participated. we think there is some potential there. we want to see how that information is actually used to

drive change before we would buy into this as a vehicle for moving medicare dollars around. >> thank you. one final thing on registries, it has been exciting as the academy has a successful registry and has an advanced knowledge of what works and what doesn't work in giving feedback to physicians as to how they are doing. i'd like to thank this panel. they've done a marvelous job as well as the earlier panel. i want to thank lauren and abby the staff for planning this conference and supporting it. and finally to the usc brookings shaffer initiative for providing

the funds to pursue it. thank you all very much. here is a look at what's coming upped to on c-span 3. at 5:00, nuclear weapons specialists talk about trust between countries that have nuclear weapons and those that don't. and at 6:30, u.s. policy towards southeast asia. american history tv is in prime time this week on c-span 3. tonight on oral histories, thursday, historians look at the roles of u.s. conflicts over the

last century and a half. and on sunday, the world war ii series, why we fight. the out break of world war ii and the rise of authoritarianism. watch history tv on c-span 3. this weekend on american history tv on c-span 3, saturday at 10:00 p.m. eastern on real america. >> we are privileged to witness tonight significant achievement in the cause of peace. an achievement nonthought possible a year ago or even a month ago, an achievement that reflect the courage and wisdom of these two leaders. >> the 1978 film "framework for

peace." and sunday at 6:00 p.m. on american artifacts, i look back at the 1998 documentings of the u.s. embassies in kenya and tanzania. >> we were meeting with the minister of commerce. we heard an explosion. most of us went to the window. ten seconds later, a freight train sounding impact of high energy hit all of us. 213 people were instantly killed. 48 of whom were employees of the united states government. >> watch on american history tv, this weekend on c-span 3. the senate judiciary committee has postponed the schedule vote on judge kavanaugh's nomination.

a hearing called on monday to give judge kavanaugh long with the woman who accused the judge of schl you'lly assaulting her in high school a chance to tf. it's unclear if ford will attend. watch live coverage on c-span starting at 10:00 a.m. eastern also on c-span.org or on the free c-span radio app. up next, a hearing on resent developments in ethiopia and especial efforts of the country's new prime minister and community leaders testify before a subcommittee. this hearing is about two and a half hours. the committee will come to order. good afternoon to everyone. our first order of