tv American Enterprise Institute Discussion of Medicare Payment Rule - CMS... CSPAN November 28, 2018 7:49am-8:33am EST
considered citizens. that changes over time. over time, more people are brought into the american family. >> sunday night at 8:00 eastern and c-span's q and a. >> best-selling thriller author brad meltzer will be our guest on in-depth fiction addition. are alive call in program sunday at noon eastern. his most recent book the escape artist debut at number one on the new york times bestsellers list. 's other books include the inner circle, the book of fate and the first council plus eight other best-selling thrillers. join us for in-depth fiction addition with author brad meltzer live sunday from noon to 3:00 eastern on booktv on c-span2. >> next, centers for medicare
and medicaid services on medicare payment rules and potential changes to the system, she spoke at the american enterprise institute where she presented the administration's goals for efficiently maintaining medicare while trying to improve experiences for providers and patients. this is 40 minutes. >> i am with the american enterprise institute and i am pleased to welcome all of you here today for what i think will be a vigorous discussion of medicare physician payment. the center for medicare and medicaid services recently released a final regulation that made a lot of changes but the key changes we will focus on most, have to do with the
ways your doctor gets paid when you have a normal office visit. that is a big change for a program, medicare physician schedule program that has been very slow moving. it is 30 years old now and is pretty much the same payment system it was 30 years ago with some modifications. the reason regulation is one of the larger changes that has occurred over the past few decades and intended to reduce paperwork burden and improve the relationship between the physician and patient, more time for the physician to look you in the eye and ask you how do you feel and what do you think we should do now?
we are honored to have the administrator to lead us off with a keynote speech. the administrators will known to anyone, has been administrator of cms since early last year and has a great deal of experience with medicare and medicaid and private insurance, she comes from the great state of indiana where she had something to do with their medicaid program as well but the topic is medicare physician payment and the new changes, welcome. [applause] >> good morning and thank you for the introduction. before i get to the policy we will be discussing today i wanted to take a minute to
applaud aei. before i started i was honored to participate in aei's leadership network and i want to thank you for sending some great leaders, privilege to work with your former colleagues. we are proud to have him at hhs. think tanks cervical role in the policy development process and your work informs our thinking it helps us develop policies. there is the analysis that our host joanne shows last year on the health of the blog that looked at cms's own data on national health expenditures and cleaned key insights, it is clear that attempts from the prior administration to control costs under the affordable care act has not meaningfully changed the rate of spending growth so reports like this are
critical in drawing attention to the unsustainable trajectory of our nation's healthcare spending and that is something i worry about every single day. i appreciate aei inviting us to this discussion on a very important topic. a wonderful opportunity for cms to unpack a policies that we recently issued but before i delve into the actual policy i would like to take this time to put that policy into the broader context. i am often asked in my role as cms administrator what keeps me up at night and the answer is simple. by 2026, one in every $5 spent in america is projected to be spent on healthcare. to those of you in the room i shouldn't have to explain how this will lead to a crisis that we are not prepared to face. healthcare spending will crowd out funding for other national priorities like defense, public safety, education and infrastructure and the reality
is that small businesses will face barriers to investing in jobs and growing their businesses and americans household budgets will be stretched thin because they pay for higher premiums and co-pays. as administrator the programs we are in charge of, medicare, medicaid and the exchanges make up the largest fraction of the nation's healthcare system serving over 130 million americans and at cms we are constantly aware that due to the size of our footprint our policies have a spillover effect on the entire healthcare market as many private payers face their payments on medicare policies. many only see government solutions to this problem. since i have been at the helm at cms it has been clear to me that many times government is the problem. donald trump has directed all
federal agencies to cut the red tape, to get government out of the way and unleash the ingenuity and creativity of the american people. as we know there's plenty of this to be done in healthcare. regulatory burden is a major driver of healthcare costs. the american hospital association found health systems, hospitals, providers collectively spend nearly $39 billion a year on regulatory compliance, average hospital dedicates 59 full-time employees to compliance. over one quarter of which are doctors and nurses. in my time as administrator i met with clinicians and other stakeholders on the front lines and i have seen that not only are regulations increasing costs but contributing to
physician and provider burn out. in recent survey by 15,000 physicians from 29 specialties found a striking 42% of physicians report burnout, 42%. the most common driver of burnout is having to handle too many bureaucratic tasks including charting and paperwork. and this is a very big problem as our nation must have a workforce ready to serve our aging baby boomers. take a moment to consider this. we are at an age of amazing technological innovation that allows us to cure illnesses that would have been impossible to treat a generation ago but even with all of these evil advances our healthcare system relies on the doctors and
nurses that serve our patients every day and regulatory burden is wearing down this backbone of our system and so this is why we launched cms's patients over paperwork initiative which involves updating regulations that are outdated, duplicative, unnecessary or overly burdensome. the regulations cms rolled out over the years also accelerated the consolidation that we are seeing in the healthcare system. the cost to comply with our regulations have in many cases become too high for independent physicians to bear from requirements around dhrs to new regulations, independent physicians are increasingly selling their practices to hospital systems and new physicians often start their careers as employees of larger systems and according to a survey by the american medical
association the percentage of clinicians with ownership status in their practice declined from 53% in 2012, to 47% in 2016 with young physicians more than 3 times as likely as older physicians to be employed by hospitals. consolidation has downstream effects in the healthcare system and impact patient care. they face higher prices when there are fewer competitors. physicians have less autonomy in consolidated systems and we have seen cases of large systems controlling referral patterns to keep patients in house regardless whether that is the most convenient site of care for a patient and if consolidation continues, patient choice and patient freedom takes a backseat. donald trump's executive order promoting healthcare choice and
recently we change our payment policies to move more towards fight neutral payments which means the agency and patients would not pay different amounts but the exact same service depending on location. so today a patient can pay more for the same healthcare service such as an office visit if they go to an office owned hospital system and if they go to an independent physician office. and if an independent office is acquired by hospital, the amount of patient pays goes up, even if nothing about the office changes. so we can't have the government favor any one type of provider if we want real competition that drives towards the highest quality and the lowest cost here so we just finalized a rule that will implement fight neutral payments for clinic visits.
this change will directly benefit patients pick cms estimate beneficiary copayments will be $380 million lower in 2019 as a result of these changes. so, for example, a clinic visit hospital-based office cost-sharing is about $23 $23 d under our new policy cost-sharing would drop to $16. so for a a senior that is living on a fixed income seven dollars saving every time have a clinic visit does make a difference. our site neutral policy builds on other changes that we put forth to promote competition and counter the push towards consolidation. this includes setting payment for drugs under the 340 the discount program to more closely match drug prices. we have seen the trend of hospitals within 340b acquiring clinics to gain access to discount 340 b prices after after they were acquired, and
hospitals than profit from billing medicare for the full sales price of the drug. we changed our payment for 340 b drugstore closely matched the discount drug prices and again to remove the incentive or consolidation. we also propose changes to medicare accountable care organization to recognize that small providers are showing great result in terms of lowering costs. so it should be clear to anyone paying attention that we are focusing our efforts to reduce regulatory burden and bolster competition in order to support independent practices and increased choices for patients. our changes to physician documentation are another example of these efforts. so in my meetings with clinicians, i repeat a source of frustration that i heard is a documentation requirements that physicians face, and the terms of our codes, this is about 40%
of all billing and medicare, these of the requirements under these codes, the documentation, these of the requirements of the kinds of information that clinicians have to include in a chart in order to bill medicare. all of the 1.6 million medicare clinicians operate under these requirements. tried to cms's recent change, the requirements have not been updated since 1997 -- prior to -- even though medical practices change and we've seen the advent of electronic medical records, the documentation requirements that clinicians faced are based on the way that medicine was practiced in the 1990s. and this mainly involve the patient seen a single clinician with the patient presenting discrete issues that were resolved during the visit. but over the last 20 years medical care has transformed to include greater emphasis on
clinical teams working together to manage chronic conditions, with patients and more clinicians and seeing the more frequently. but to bill medicare clinicians still have to submit all of the information that was required to bill a visit back in 1997. electronic medical records could have made things easier compass and documentation requirements did not change, those were based on paper records. so this leads to clinicians having to document information that is only marginal relevance to a modern visit. and since the requirements are the same from one visit to the next, clinicians spend a large fraction of the day copying and pasting information from a prior visit. the duplicate nature of documentation requirement is the risk to patient safety. a doctor pulling up a chart a prior visit may have trouble finding important information
buried among all of the facts it to be copied and pasted to meet our documentation requirements. we all looked at hand -- we all understand how it feels as joe pointed out as a patient when a doctor is staring at a computer screen instead of looking directly at you. clinicians are many of our nation's brightest minds. very few professions demand of their members the amount of training that medicine does. and the fact that we're having these highly trained individuals spend time clicking through screens is a very poor use of one of our greatest resources and is contributing to provider burnout. in a a powerful article publisd in the "new york times," an oncologist wrote about his experience in medical school, and he explained as emr have become more widespread, a doctors day felt more robotic and dehumanized. in one night, he wrote, he
overheard a young resident breaking down in tears. her face silhouetted against the sharp light of the terminal as she typed manically. and the resident said, i've spent two nights in the hospital, and i haven't even touched a patient. in this is not what i came here to do. enough is enough, and so that's why in this year's rule for physician payment in medicare we proposed an overall of the current system of billing medicare for evaluation and management visits. these of the checks apps in which the focus on managing a a patient's condition rather than performing procedures. and we received over 15,000 comments on our role. we get a lot of comments but that is certainly one of the higher numbers, which provide us with a specific feedback on how to improve the proposal.
we listened. cms moved to finalize improvements the documentation requirements starting in 2019, suggest a few months. also finalized more fundamental changes to the system of billing medicare but the changes are not going to take effect until 2021 because we want to engage further with the medical community on these policies to make sure we get them right. the 2019 proposals, however, will make clinicians life easier, and there's a lot of consensus around these proposals and this will help increase the amount of time a doctor spends with the patients. these changes include a line clinicians to focus documentation on what's changed since the last visit instead of having to reenter the patients complete medical history. we will also allow information that is entered into a chart by other members of the medical team such as residents per patients to account for billing purposes instead of making clinicians retype everything.
we took action earlier they sure to allow this for medical students, and we are hearing a lot of great result from medical schools. the fact that make it all of these commonsense changes required a drawnout regulatory process that took years to happen, is a prime example of why i have serious concerns about proposals from medicare for all. instead of doubling down on a government program that is slow to adapt to innovation, creates perverse payment incentives that drive up costs, and is prone to in action, we are rolling up our sleeves to fix the problems in medicare as it exists today in order to serve seniors better. president trump has made it very clear to me that he wants us to strengthen and modernize medicare. and cms takes responsibility very seriously. we are committed to increasing
the solvency of the medicare program so that it exists for future generations. instead of further jeopardizing an already fragile financial picture and putting at risk the security that american seniors enjoy today by expanding the program. medicare for all which come at a staggering cost to taxpayers. under one estimate even doubling all individual and corporate taxes would not cover the cost of the proposal. and so the implications for government spending alone make this proposal a reckless one. but also medicare for all would reduce physician payment and, therefore, would also accelerate consolidation. clinicians could make up to 40% less under medicare for all been under today's system. and so how could he practice state independent when faced with those finances?
and with the nation's brightest students even go to medical school in the first place? and as i mentioned before, the backbone of our healthcare system is the people who serve patients every day. so it defies intelligence to advocate for government solution that would drive providers after the system leaving patients with that anyone to administer the care that they need. so we need to fix the problems in medicare today, and that is what our proposal for physician documentation is all about. in addition to the changes outlined for 2019, we are making more fundamental changes to reduce burden though take us back in 2021. secretly there are five levels that exist for codes with high levels represent more complex cases. in 2021 we won't collapse levels two through four into a single level with a single payment amount.
the document requirement for this new code will be similar to the requirements for a level to visit and so this will substantially reduce the amount of documentation that clinicians have to complete. now, we did hear a lot of concerns of collapsing the code levels will fail to account for patient complexity, and so, therefore, we maintained level five which is, level v, which is a highest level of complexity and we introduced new add-on codes to increase payment for patients that required extra time. and our team has modeled the financial impact of the changes and we found that most specialties would see an aggregate change of plus or minus one to 2%. however, all specialties would benefit from the historic reduction in documentation burden, and clinicians could use this extra time to see more patients are spend more time with their existing patients.
so i know all these policy changes are down in the weeds that they are going to transform medical practice. and that's why we are allowing two years for implementation. we want to continue the conversation and gather input from the medical community that goes beyond just breaking communications and meetings. answer that and end in early 2019 we plan to host a series of structure listening sessions on the changes. these sessions will hopefully facilitate a discussion on the different aspects of the changes we've made and provide multiple touch points. so our goal is to continue to listen and take into account perspective from those that are on the front lines in order to prepare for future rulemaking and guidance. so i encourage all groups to begin thinking about the input that they would like to provide, because we are committed to making changes to reduce burdens for america's clinicians. the current system is leaving the physician burnout and
driving consolidation, and it can't be allowed to continue. so thank you to aei for conveying this event today into such a knowledgeable group of panelists for participating. the medicare fee-for-service program is in many ways an attack with gated program test and liquidated program and equipment to look over date in order to keep the promise that america has made to our seniors. every idea is on the table for this administration. we are not wedded to the current way of doing things. just because it's been that way for many years. so together we can ensure that america's clinicians are able to spend less time looking at the computer screen and more time with her patients. and we can promote competition in the healthcare marketplace. thank you very much. [applause]
>> very good. thank you very much. so physician burnout, you've done something here to reduce to some extent the paperwork requirements, but what else can you do? given, as you say, fewer physicians have decided to go into independent practice. they are becoming employees. i think that's a cultural change. i mean, it does suggest to me at least that physicians coming at a school now want to have a normal life as opposed to the kind of like that physicians used to have, which was very patient centered but also very work centered, not family centered. so do use of the changes that cms could make in the medicare
program -- do you see other changes -- address what i i viw as a cultural change in the physician workforce? >> a couple things. i mean, it could be a cultural change, so be it, but we want to make sure our relations are not contributing to that. the reality is if you look past over the past few years, macro ehr regulations, a lot that's been put on providers and so it's not clear that a cultural change or because of so many change in regulation they couldn't could simply keep up with this. we also want to make sure there's competition in the marketplace, that every physician is employed by a large hospital system, what does it look like? we are very focused on regulatory burden that all four providers but the whole system. we put out from 11,000 pages of regulations every year and so it's costing the system a lot of money to keep up with this. this isn't something we will be done with this year. we will be acted, something like peeling off paint, layers and s
of regulation. the other thing i want to point out is that we are also looking at the experience patients are having with the doctors and try to get ways to enhance that experience. a lot of what we do at cms is we're dealing with complicated financial systems in terms of how we fund healthcare. we're also trying to impact change at the level of patient care. and the experience of the patient has when they go into healthcare delivery system. and we know today people are not necessarily satisfied with experience they're having because there's not always clear what their costs are, with the value of their care is, quality, transparency, cost transparency. and the other airy we have really been focusing on which i think also will help some of the physician burnout issues and some of the challenges they face as rent interoperability and having complete information or having patient have access to their complete medical record and making sure the provider has access to the information as
well. that's also an area we've been focused on. >> one of the things this suggests to me is the need for better coordination between the patient, the physician and entrants company. private insurance as well for people under 65. do you see some approvers along those lines? a lot of information is compartmentalized. information that, for example, where are you on your deductible? most people don't know. you know, who's in your preferred provider network. that may not be easy to find out depending on the circumstances. but by the same token the physician is as a kind of information but they are not coordinated. the physician knows a lot about the patient. the patient is a lot more about the patient. neither one of them knows all
that much about the financial circumstances. you use changes that could be brought about to the medicare program that might lead the way to improve the kind of information coronation -- do you see changes? >> we are focus on price transparency. we've done a lot of things last year, required hospitals to post their charges. just yesterday we proposed a rule that would require part d plans to make estimator tool available to physicians so that when you're prescribing medications they have had thatt information of what the impact would be for the patient. one of the things we have to be careful about is without a lot of conversations about high transparency over the years. hasn't happened. the other thing that when that an effort to transparency it's not always clear that patients are using this information. and so even on some of the efforts that we doing around interoperability, having dated doesn't necessarily mean it's going to be actionable. our challenge at cms is personal
putting data out there. put a lot of information that we've unclaimed data for medicaid and medicare, putting that out there. we're also an ad in a way of artificial so that is a possible we can understand that data but i think the real challenge will be to make sure it's actionable. and some of that may require changes to the actual program because the way it a structure that is many folks that participate in a program don't have any skin in the game and not necessarily incentivize to make decisions about their health care based on cost. >> let me ask a question about the physician fee schedule. this is one of my least favorite part of medicare program. the fee schedule was sold under the theory, talk about 1989, document agent history but ancient history is still dominating the way medicare pays physicians today.
in 1989 this is a program that was sold as something that would promote primary care by re-leveling the payment rates so that physicians who do procedures, surgeons, for example, that their payment rates for certain kinds of procedures, or the incomes they could expect from doing the work with the much higher than someone who is in internal medicine or other kind of primary care physician. that was the promise. didn't happen. >> didn't happen. >> what changes do you see sort of scrapping this system that could ameliorate this obvious issue? >> so you're right it didn't happen. i still think that needs to happen. we are seeing similar problems
in her healthcare system because we don't have primary care. you have from doctor goodson later on, and he came interesting and kidney a great presentation which help you will talk about today which essentially think think you goe great data that shows some of the cognitive specialties that when there's a lack of availability of those types of providers that correlates very well with some of the public health issues and death rates and morbidity and mortality and those particular areas, so clearly points to we need to have a better supply cognitive specialties and we need to make sure we are paying them appropriate. you're right, physician fee schedule has not done that. those specialties are important to stopping some of our public health issues, important to improving health outcomes. at a think as we're moving into an era of value-based care, some of those specialists are very important in coordinating factor in providing seamless care. we are going need to figure how we do that.
i'm not sure in terms of this iteration of the codes were more focused on burden reduction but we are certainly open to having more discussion about how the whole system needs to change or i can tell you one of the things i challenge the team to do is as were talking about value-based care and people use that as a euphemism around taking risk, i think we need to pay for care even if the -- long story short, i think this is going to be an evolving system because it is not accomplished the goal of focusing on primary care. >> i'm tempted to ask you about nist. this is a phrase that was invented by i guess congress, but it's a part of a change in way physicians are going to be paid in the future, and the idea
behind this is that payments are supposed to be tied to some measure of performance. that said, medicare payment advisory commission, and a lot of other professionals in this field that said this isn't going to work. it's too burdensome. it isn't going to promote the kind of changes and practice that we want to see that lead to higher value healthcare. is there some way that short of legislation, , because i don't anticipate much legislation coming up on this topic anytime soon, short of that do you see actions cms could take that would ease the burden or make the program work? >> we had that some legislative changes that are attempting to make it work better. so let me first start by saying i think the goals around paying for value and incentivizing providers to achieve quality and low costs are important objectives, and i think we needed to move away from a
fee-for-service system. strickler just paying for care, not tying it to outcomes. the objectives were important. that being said i think that the implementation has been problematic. i think that there are some folks that we're going to make it so difficult and so burdensome that everybody is going to run to these alternative payment models, or a pms, which require providers to take on more risk. a couple problems with that. number one is developing these payment models is not an easy process. you can see the agency has not put up a minute and we're working towards putting out more but is a complex process. it takes time. so that hasn't happened. so in the meantime most of our doctors, i can start talking that the measured i think the measures in and of themselves have been problematic. they are mostly process oriented. i think i saw one that said did the decision to a history in a
physical? we should be asking providers to report things that they should be doing routinely. one of the things we tried it is really take a look at the measures, admitted the ones that are more rfs oriented and move towards more outcomes-based i think they started with process was because they wanted to get providers and they with the program but that being said, we need to move to more outcome measures. the types of measures we've been working on, we have initiative called meaningful measures, and the idea is to look at measures across the entire agency, not just for providers. we have over 400 quality measures. in this last year we produce that by about 25% so we're down to 300. i still think that is way too many. we've got to find a very, a smaller number of measures that means something to patients and to providers that we agree on meaningful measures, quality, value. so that's one area. the second piece of this, the
measures that we put in place can't be difficult for providers to report. shouldn't be increasing burdens. we want to look to measures that can be easily gleaned from the emr. they can come from registries or they can come from claims, that it shouldn't require physicians for providers to have to manual enter into it. i visited a hospital in cleveland, ohio, and down in the basement of a hospital that some 16, 18 people. they're essentially just manually extracting patient records. i think that's an example of how programs have gone awry. that being said we are very committed to revolving the mips program and making it work better for physicians and making sure the measures that we have on more, that actually produce value. >> i think we have a few minutes for questions from the audience. so if you would raise your hand. see if we have a question.
back there. these identify yourself and make your statement in the form of the question. >> mark with spy world. did you ever hear that the coverage and analysis group is under source and happen to agree with that assessment is reason i ask is you kind of you that time to time from makers of drugs and devices of diagnostics, i.e. interaction with fda, national coverage analyses analysis andd so forth. i don't know whether you've heard anything to that effect, and ms. jensen is reluctant to say anything about that in public for once in a while you get this business of user the floating around. there is a perception that coverage analysis group -- i like to get your reaction. >> let me first start by saying as a look at the high cost of
healthcare, one of the things that we look at as a potential solution is technology and innovation. we want to lean into that. we need to support innovation as a way of trying to control health care costs. i can tell you the agency, we're looking at some of the concerns we have heard from manufacturers in terms of the time it takes to be able to get coverage, beginning to hear more from the agency on this issue. when we working on her patients over paperwork initiative and we asked for comments we did get a lot of comments on understanding how the coverage determination process it works. there's a lot of ambiguity about that. so recently put outcome weser updated our policies around that come try to address some of the concern that we've heard. that the csf for step. we are looking at ways that we can expedite the process to encourage innovation in the industry. >> one more quick one, please. >> thank you. lou gagliano, coalition for
advanced care. how will we, from messina standpoint, paying attention to this market, the aging demographics, and particularly how to incentivize doctors to pay attention and serve this market more effectively? >> i think that's one of her greatest challenges. i mean, if we look at our healthcare expenditures, we are really spending over 25% of our expenditures are really for the last, you know, a few years of life. i think there's a lot of opportunities to provide better coordinated care that focuses on the quality of life as well. i think not necessarily quantity but very much focus on the quality, making sure with a good patient experience. i think what you see if of the agency on this is we are focusing on in particular some models that focus on this particular area. so you'll see more from us on that. >> thank you very much. appreciate your coming here
today. please join in thinking seema verma. [applause] >> appreciated. >> please stay seated. she has to rush off to a meeting. i don't know, all i can say is i'm just glad aei doesn't have 300 measures of performance to base our salaries on. okay, and without, have the panel come up. [inaudible conversations] >> does selling thriller author brad meltzer will be our guest on "in depth" fiction edition, i like calling program on sunday at noon eastern. his most recent book the escape artist debuted at number one on the new york times best-sellers
list. join us for "in depth fiction edition" with author brad meltzer live sunday from noon to 3 p.m. eastern on booktv on c-span2. >> former president president t down with former secretary of state james baker and presidential historian jon meacham to discuss their experiences in office bipartisanship and jewish leadership abroad. the discussion was part of the celebration of 25 years of the baker institute for public policy at rice university. this is just under one hour. [applause] [cheers and applause]