tv American Enterprise Institute Discussion of Medicare Payment Rule - CMS... CSPAN November 29, 2018 11:10pm-11:54pm EST
talks about medicare payment rules and potential changes to the program. this is hosted by the american enterprise and to take -- institute. i'm with at 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 centers for medicare and medicaid services recently released a final regulation that made some changes, made a watching is actually, but the key changes that we would focus on the most have to do with the
way that your doctor gets paid when you have a normal office visit. that's a big change for a program for the medicare physician fee schedule program that has been slow moving. it's about 30 years now and it's pretty much the same with some modifications. i think the regulation is one of the larger changes that have occurred over the past few decades and it tended to reduce paperwork burden and improve the relationship between the physician, patient and 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 here to lead us off with a keynote speech. the administrator is well known to everybody, she's been the administrators and the 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 a little sum thing to do with their medicaid program as well. but today the topic is the new changes, so with that please welcome the administrator verma. [applause] >> good morning and thank you for that introduction. before i get into the policy, i wanted to take a moment to
applaud aei. i was honored to participate in the leadership network and i want to thank you for also sending us great leaders. it's a privilege to work with your former colleagues. we are very proud to have them. think tanks served a critical role in the policy development process and your work helps us develop policies. for example here's the analysis from last year that looked at their own data on the national health expenditures and claim key insights. the report made it clear attempts from the prior administration after the affordable care act hadn't changed the rate of spending growth. reports like this are critical in drawing attention to the
unsustainable trajectory of the nation's health-care setting, and that's something i worry about every single day. i appreciate aei inviting us to this discussion on a very important topic. it's a wonderful opportunity to unpack a policy that we've recently issued. but before i delve into the actual policy, i would like to take this time to put the policy into the broader context. i'm often asked in my role as the administrator what keeps me up at night and the answer is simple. one in every $5 spent in america is projected to be spent on healthcare. for 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. health care spending will crowd out funding for other priorities like defense, public safety,
education and infrastructure and the reality is small businesses will face barriers to an resting in jobs in growing their businesses, and american household budgets will be stretched because they paid for higher premiums and copayments. as the administrator of the programs i've been given charge of medicare, medicaid and the exchanges took up the largest faction of the healthcare system serving over 130 million americans and cms we are aware due to the size of the footprint on oufootprint, our policies haa spillover effect on the entire healthcare market has many private payers place their payment for medicare policies. it's become very clear to me that many times the government
is the problem. to get the government out of the way and unleash the ingenuity and creativity of the american people and as we all know there's plenty of this to be done in healthcare. regulatory health burden as a major driver of health care cost. the american hospital association found health system, hospitals and post acute providers collectively spent nearly $39 billion a year on regulatory compliance. an average hospital dedicates 59 full-time employees to compliance over one quarter of which are doctors and nurses. i have seen not only are the regulation increasing cost, they
are also contributing to the physician and provider burnout. a recent survey of over 15,000 physicians from 29 specialties found that a striking 42% of physicians report and 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 the nation must have a workforce ready to serve our aging baby boomers. take a moment to consider this we are at the age of amazing technological innovation. technology allows us to cure illnesses that would have been impossible to treat generation ago. but even with all of these advances, our health care system relies on the doctors and nurses that serve our patients every
day and the regulatory burden is wearing down the backbone of our system so this is why we launched a patient initiatives updating regulations that are outdated, duplicative, unnecessary or overly burdenso burdensome. the thicket that is rolled out over the years have also accelerated the consolidation that we are seeing in our health care system. the cost to comply with our regulations have in many ways become too high for and physicians to bear independent physicians are selling the practices. according to the survey, the american medical association,
the percent of clinicians with ownership status in their practice declined from 53% in 2012 to 47% in 2016. what young physicians, more than three times as likely as older physicians to the employed by hospitals. consolidation has downstream effects and the health-care system and impact patient care. they are controlling the referral patterns to keep them in half regardless of whether that's the most convenient site of care for a patient and its consolidation continues to patient choice and freedom takes a back seat.
to focus on the trend and to bolster competition in the marketplace. in this administration they are unafraid to challenge the status quo in order to take bold action and deliver results and i can tell you that i've never received a phone call from the white house asking the two avoided policy because of the reaction it might elicit from an entrenched special interest group. the status quo has led to americans spending more on health care while still feeling dissatisfied with the system and it comes as a little surprise healthcare remains a top area of concern for voters and this is why more importantly, now more than ever we rise above ideological political considerations and commit ourselves to doing what is right for patients, write for the system and rights for all
americans. to this end we are taking action across the board to promote competition and remove policies that are accelerating consolidation. they move towards the sit site natural pigments which means the agencies and patients wouldn't pay different amounts for the exact same service depending on the location of said today they can pay more for the same healthcare service such as an office visit if they go to an office owned by a hospital system damn if they go to an end and physician office if it is acquired by a hospital, the amount it pays go 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 high quality and lowest cost.
so, we finalized a rule that will implement the site neutral payment for the clinic visits. this will directly benefit patients. cms estimated the beneficiary copayments will be $380 million lower in 2019 as a result of the changes come as fo for example e clinic visit and the hospital-based office cost sharing is about $23 under our policy it would drop this team dollars so for a senior on a fixed income, $7 every time they have a clinic visit does make a difference. it's counter to thit countered s consolidation and this includes the payment for drugs under the discount program is acquired in the clinics to gain access to
the prices after they are required and profit from billing medicare for the full sales price of the drug and we changed the payment to more closely match the discounted drug prices and begin to remove the incentive for consolidation. they are showing great results in terms of lowering the cost. it should be clear to anyone paying attention we focus the efforts to reduce regulatory burden and bolster competition in order to support independent practices and increase choices for patients. in my meetings with clinicians, the day had a reputed source of
frustration that the physicians face and in terms of the code this is about 40% of all billing and medicare and these are the requirements, so under these code in the documentation of these are the kind of information that clinicians have to include in a chart in order to bill medicare. prior to the change, the requirements haven't been updated since 1997. and even though the medical practice test changed dramatically and we see the electronic medical records to the documentation requirements that clinicians face are based on the way medicine is practiced in the 1990s with a 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 their chronic conditions with patience seeing more clinicians and seeing them more frequently. but clinicians still have to submit all of the information that was required to build a visit back in 1997. electronic medical records could have made things easier but since the documentation requirements didn't change, those were based on paper records. so this leads to clinicians for me to document information that has only marginal relevance to the modern visit and since the requirements are the same from one visit to the next, they spend a large faction of their day copying and pasting information from a prior visit. the nature of the requirement is a risk to patient safety.
a doctor pulling up a chart from a prior visit may have trouble finding the important information. among the texts that had to be copied and pasted to me to the documentatiothedocumentation red while i understand how it feels as joe pointed out as a patient when the doctor is staring at a computer screen instead of looking directly at you, clinicians are many of the nation's brightest minds. the professions demand the amount of training that medicine does and the fact that we are having these highly trained individuals spend time clicking through screen is a poor use of one of the greatest resources and is contributing to the provider turnout. in and a powerful article receny published in "the new york times," an oncologist wrote about his experience in medical school and explained that they had become more widespread and
it felt more robotic and dehumanized. in one night, he wrote he overheard a young resident breaking down in tears. her face against the sharp light of the terminal and the residents said i've spent two nights in the hospital and i haven't even touched a patient. the focus is managing a patient's condition rather than performing procedures we've received over 15,000 comments on kabul and we get a lot but that
is certainly one of the higher numbers to provide us very specific feedback on how to improve the proposal. they have defined the debate for finalized improvements starting in 2019 for just a few mom this. we also finalized more fundamental changes to the system of filling medicare but those changes are not going to take affect until 2021. the focus what has been changed since the last visit instead of having to reenter the patients complete medical history and also allowing information that is entered into the chart by other members of the medical team such as residents or patients to account for the
. >> instead of further jeopardizing the fragile and financial picture to put at risk the security that american seniors enjoy today by expanding the program. and for one estimate to double all corporate taxes not covering the cost of a proposal. and then to make this a reckless one but also medicare for all that reduces physician payments and therefore accelerate the consolidation. they could make 40 percent less and with those finances
and led those students who even go to medical school in the first place? and as i mentioned before the backbone of our health care system is the people who serve patients every day. so despite intelligence to advocate for government solutions to drive providers out of the system leading patients without anyone to administer the care that they need. we need to fix the problems of medicare today that is the proposal for physician documentation is all about. in addition to those changes of 2019 we are making more fundamental changes to reduce burdens to take us back into 2021. there are currently five levels for code higher worth
complex cases in 2021 we will collapse level two through four into a single level with a single payment amount the documentation requirement will be similar to the requirement of a level to visit and to substantially reduce the amount of documentation that clinicians have to complete. we did hear a lot of concerns of collapsing that level failing to account for patient complexity so we maintained level five which is the highest and introduced new add on codes to increase payment that require extra time and our team has modeled the financial impact of changes most specialties will see an aggregate change of plus or minus one or 2 percent. however all specialties will benefit from that historic reduction and documentation and clinicians can use as
extra time to see more patients or spend more time with their existing patients. i know all of these patients they will transform the medical practice that is why we are allowing two years for implementation to gather input from the medical community going beyond routine communication so to that end in 2019 with a series of structured sessions these will hopefully facilitate a discussion on those different aspects of the changes made to provide multiple touch points so the goal is to continue to listen and take into account perspectives of those on the front lines to prepare for future role making. i encourage all groups for that input they would like to provide we are committed to
make changes that current system is leading to physician burnout driving consolidation and it cannot be allowed to continue. thank you to aei and to the panelists for participating the medicare fee-for-service program that improvements are long overdue in order to keep a promise that america has made to seniors. every idea that is on the table we are not wedded to the current way to do things and just because it's been that way for many years but we can ensure america's clinicians can spend less time looking at a computer screen and more time with their patients to promote competition in the health care marketplace. thank you very much. [applause]
. >> so physician burnout, it does 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 and become employees is a cultural change. it does suggest to me at least depositions coming out of school now want to have a normal life as opposed to the life they use to have which was very patient centered and also very work centered not family centered.
do you see other changes cms could make in the medicare program that could address this cultural change in the physician workforce? . >> it could be a cultural change that we want to make sure our regulations are not contributing to that but the reality is over the past few years with macro hr regulation there has been a lot put on providers and was not clear a cultural change if there were so many changes in regulation they simply could not keep up with us we also want to make sure there is competition in the marketplace every physician that is employed by a large hospital system what does that look like? we are very focused on regulatory burden not only for providers but across the whole system with 11000 pages of regulations every year so it cost the system a lot of money so this is something we will
be done with this year it is like peeling off paint with layers and layers of regulation but the other thing to point out where looking at the experience that patients are having with doctors to figure out ways to enhance that experience. a lot of what we do at cms is complicated financial systems of how we fund health care but we also try to impact change at the level of patient care and the experience every patient has going into the health care delivery system and we know today people are not necessarily satisfied with the experience they are having because it's not always clear of their cost or the value of their care, quality of transparency, and the other area we have been focusing on will also help physician burnout issues is interoperability to have
complete access to complete medical records and making sure the provider has access to that information as well. that is an area we have been focused on. >> one of the things this suggests to me is the need for better coordination between the patient physician and the insurance company the medicare program as well for those under 65. do you see improvements along those lines? a lot of that information is compartmentalized. the insurance company, company, medicare, privates insurance as a certain set of information for example, where are you on your deductible? most people don't know. was in your preferred provider network? that may not be easy to find. but at the same token the
physician has all kinds of information but it is not in coordinated the patient knows a lot more about the patient and neither one knows very much about the financial circumstances. do you see changes that could be brought about to improve that information coordination? . >> we are focused on price transparency. we did a lot of things last year we require hospitals to post charges. yes yesterday we required the part d plan to make estimator tools available to physicians when they prescribe medication they have that cost information and the impact for the patient. we have to be careful that we have had a lot of conversations about transparency over the years and has not happened but when there has been efforts around price transparency is not always clear patients are using the information.
so in those efforts around interoperability having data does not necessarily mean it will be actionable. so our challenge at cms is to put data out there with that information on claims data for medicaid and medicare to put that out there and also the advent you have artificial intelligence there is the purse ability we could understand that data but the real challenge is to make sure it is actionable and some of that may require changes to the actual program because the way it is structured today that many folks who participate don't have skin in the game and they are not necessarily incentivized to make decisions about their health care based on cost. >> so let me ask a question about the physician fee schedule this is my lease part favorite of the medicare program. the fee schedule was sold
ancient history in 1989 but it is still dominating the way medicare pays physicians today. in 1989 this was a program sold as something to promote primary care by re- leveling of the payment arrangements the physicians who do procedures or surgeons for example, their payment rates for certain kinds of procedures what they could expect than much higher than the internal medicine physician or other primary care physician. that was the promise it did not happen. >> it did not happen. >> what changes do you see short of scrapping the system to ameliorate this obvious issue?
. >> you're right i still think it needs to happen we still see the problems in the health care system because we don't have primary care you'll hear from doctor goodson later he came to see me and gave me a great presentation which i hope he talks about today which essentially he has some great data that shows the cognitive specialties there is a lack of availability of those types of providers that correlates very well with the public health issues and death rates in morbidity and mortality so clearly it points to we need to have a better supply of cognitive specialties to make sure we pay them appropriately. you are right the physician schedule has not done that those are important to solving some public health issues important to improving health outcomes and i think as we move into an era of value
-based care they provide seamless care so we need to figure out how to do that. i am not sure of this iteration of the codes we were more focused on burden reduction but we are open to having more discussion about how the whole system needs to change. one of the things i have challenge the team to do talking about value -based care using that as a euphemism around taking risk, but we need to pay for care even if the fee for service basis. this will be an evolving system it hasn't accomplish the goal to focus on primary care. >> i'm tempted to ask you about this this is a merit-based incentive system a phrase invented by congress. but it is a part of the way
positions are paid in the future and the idea behind it is payments are supposed to be tied to some measure of performance. that said the medicare payment advisory commission and other professionals in the field have said this will not work. it's too burdensome it will not promote the kinds of changes we want to see that lead to higher value health care. short of legislation, i don't anticipate much legislation coming up on this topic anytime soon, do you see actions cms can take to ease the burden to make that program work? . >> we have had some legislative changes attempting to make it work better but first the goals around pay for value to incentivize providers
to achieve quality and low cost are important objectives and we needed to move away for the fee-for-service strictly paying for care so i think that objective down that - - that objective was important but that being said the implementation has been problematic. some folks thought we will make this so difficult and burdensome that everybody will run to the alternative payment models which require providers to take on more risk. there were a couple problems with that but developing these payment models was not an easy process the agency has not put out very many and we are working out toward putting out more but it is a complex process that takes time. that hasn't happened so in the meantime most doctors are stuck and i can start talking
about those measures those in and of themselves are problematic they are process oriented i saw one that said did the physician do a history and a physical? we should not ask them if they should be doing that routinely so we try to look at the measures get rid of the ones that our more profit oriented and moved toward outcome base and we did start with the processed ones to get providers familiar with the program but that being said they need to move to the different types of measures what we have been working on with our initiative to look across the entire agency with over 400 quality measures and last year we reduce that by 25 percent so we are down to 300 i still think that is way too many we have to find a smaller number of measures that mean something to patients and providers that we
agree on to be meaningful measured of quality and value. the second piece is the measures we put in place cannot be difficult for providers to report or increasing burden. those from the emr, the registries but it should not require physicians or providers from entering data i visited a hospital in cleveland ohio down in the basement of the hospital they had 18 people essentially manually abstracting patient records that is an example how the program has gone awry. that being said we are very committed to evolving the program and making it work better for physicians and the measures that we have actually produce value.
>> we have a few minutes for questions from the audience. . >> please identify yourself and make your statement in the form of a question. >> do you ever hear of the coverage of analysis group is under source or do you agree with that assessment because you do hear that from time to time from those that are making drug devices and diagnostics and that interaction with the fda or the national coverage analysis i don't know if you have heard anything to that effect once in a while you hear this business of user fees floating around there is a perception that coverage analysis group's
website to get your reaction. >> i will first start that as we look at the high cost of health care one of the things we look at as a solution is technology and innovation we want to lean into that we want to support innovation as a way to control health care cost. we are looking at some of the concerns we heard from manufacturers in terms of the time it takes to get coverage we will hear more from the agency when we are working over the patient's initiative asking for comments we did get a lot on understanding how the coverage determination process even works there is a lot of ambiguity about that's a recently we updated and put out our policies and try to address some of those concerns we have heard. that was the first step. we are looking at ways to expedite the process to encourage innovation in the
industry. >> from the cms standpoint how are we paying attention to the aging demographics and in particular to incentivize doctors to pay attention and serve this market more effectively? . >> i think that is one of the greatest challenges. if we look at health care expenditures we are really spending 25 percent of expenditures for the last few years of life and there is a lot of opportunities to provide better coordinated care focusing on the quality of life as well not necessarily quantity but the quality to make sure we have a good patient experience. what you will see from the agency we are focusing on models to focus on this
particular area you will see more from us on that. >> thank you very much we appreciate you coming here today. please join me to thank seema. [applause] please stay seated she has to rush off to a meeting i will just say at aei 300 measures of performance at aei 300 measures of performance will take a break for two minutes. [inaudible conversations]