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What Does Performance Under Medicare's Value-based Modifier (VM) Program Suggest Concerning Physician Performance Under MACRA: A Conversation With Kelly Cleary (July 20th)

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The 2015 Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) will sunset three current Medicare performance measurement and incentive payment programs in 2018.  (This year, 2016, will be the last year these programs will be measuring and rewarding Medicare physician performance.)  These are: the Physician Quality Reporting System (PQRS); the HIT Meaningful Use (MU) program; and, the Value-Based Modifier (VM) Program.  The VM Program, modified under the 2010 Affordable Care Act, is designed to incent Medicare physician performance by updating annual Part B physician payments based on their quality and cost (or spending) performance.  (The performance and payment years are two years apart, e.g., the 2016 payment year is based on 2014 performance.)     

During this 23 minute conversation Ms. Cleary explains how the VM program is designed, how physicians have performed to date under the program, the extent to which physicians use VM data to inform or improve their practice, how the program will be translated, or continue, under the MACRA Merit-Based Incentive Payment System (MIPS) and quality and value performance expectations under MIPS beginning in 2017, the first MACRA performance year.   

Ms. Kelly Cleary is a DC-based health care attorney with the firm Akin Gump.  Her work primarily concerns health care related legislative and Cleary_Kelly_highres regulatory initiatives, matters involving state and federal fraud and abuse laws and cybersecurity, privacy and data protection issues.  Prior to joining Akin Gump, Ms. Clearly clerked for the Honorable Claude M. Hilton in the US District Court for the Eastern District of Virginia.  She was graduated from Catholic University's School of Law.  While there she served as editor-in-chief of the Catholic University Law Review.   

For more on the CMS VM program go to:


"Where's The Value In MACRA?" (June 24th)

Students of the Medicare program are well aware in late April, CMS dropped its proposed Medicare Access and CHIP Reauthorization Act (MACRA) rule.  Specifically, the rule addresses MACRA Title I.   At 424 Federal Register pages the rule will make considerable changes to how CMS will, beginning in 2019, annually update Medicare Part or physician payments.  For all the Strum and Drang surrounding MACRA and regulatory implementation thereof, the proposed rule represents conventional thinking.  Despite the considerable rhetoric about moving Medicare payments from volume to value, remarkably, value goes undiscussed, i.e., value as the relationship between care outcomes and spending.  If we're serious about "bending the Medicare cost curve" and/or expecting providers to accept downside financial risk via ACOs and other models or CMS demonstrations, we'll not get there by continuing to ignore measuring for value.  

If you're interested please feel free:


Recent Efforts to Improve Quality Measurement: A Conversation with Dr. Helen Burstin (June 15th)

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Measuring health care quality and outcomes effectively and efficiently remains a daunting task.  Quality measures are largely seen as too process versus outcome focused, substantially irrelevant to patients and insufficiently aligned between and among payers.  Measuring care or care quality, ironically, can and does detract from actual care delivery, can have no relationship to spending efficiency and on its own is costly.  A recent article published in Health Affairs found physician practices spent over $15 billion in 2014 in reporting quality measures.  Concerning the Medicare program's quality measurement activities, MedPAC in a 2014 report to the Congress went so far as to state, "Medicare's current quality measurement approach as gone off the rails." 

During this 23 minute conversation Dr. Burstin briefly describes the work of the National Quality Forum (NQF), the work done by the CMS-led Core Measure Collaborative, quality measurement under the CMS proposed MACRA (Medicare Access and CHIP Reauthorization Act) rule, risk adjusting measures for socio-demographic factors, the role of PREMS and PROMS or patient reported experience and outcome measures and correlating care quality and spending or measuring for healthcare value.  

Dr. Helen Burstin is the Chief Scientific Officer at the NQF.  Prior to serving in her current position, Dr. Burstin was NQF's Senior Burstin PhotoVice President for Performance Measurement.  Prior to NQF Dr. Burstin was the Director of the Center for Primary Care at the DHHS Agency for Healthcare Research and Quality (AHRQ).  Prior to AHRQ, Dr. Burstin was an Assistant Professor at Harvard Medical School and the Director of Quality Measurement at the Brigham and Woman's Hospital in Boston.  Dr. Burstin has published more than 80 articles and book chapters on quality, safety and disparities.  She was recently selected as a 2015-2016 Baldridge Executive Fellow.  She currently is also is a Professorial Lecturer in the Department of Health and Policy and a Clinical Associate Professor of Medicine at George Washington University and serves as a preceptor in internal medicine.

For information concerning NQF go to:




How CMS Proposes to Annually Update Medicare Physician Reimbursement Under MACRA: A Conversation with Mara McDermott (June 14th)

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In an extremely busy year for Medicare delivery and payment reform,  regulatory implementation of the 2015 Medicare Access and CHIP Reauthorization Act (MACRA) stands out.   This past April CMS published the agency's 960-page proposed rule to implement the law.  The proposed rule, that will go final this fall, will change the way Medicare physician payments (Medicare Part B) are annually updated beginning in payment year 2019.   Payment updates, either at the individual provider or at the group level, will be calculated either by the Merit-based Incentive Payment System (MIPS), a composite score based on four, differently weighted, component scores, or via provider participation in what CMS defines as an "advanced" Alternative Payment Model (APM) pathway, e.g., Track 2 and 3 ACOS and Patient Centered Medical Homes that meet certain financial risk criteria.

During this 22-minute discussion Ms. Mara McDermott evaluates how CMS proposes to define APM nominal risk, how the agency has defined the MIPS composite score, the effect MACRA will have on small practices, how Medicare Advantage plans and physicians can be included in MACRA, and several inter-related issues.   (While the introduction to this discussion provides some brief explanatory information, our conversation assumes the listener has some familiarity with Title I of the MACRA law.)    

Mara McDermott is the Vice President of CAPG (formerly the California Association of Physician Groups) where she leads the Mara McDermott_smorganization's federal legislative and regulatory activities in Washington, D.C.  Prior to joining CAPG, Mara was Counsel in the health industry practice of Akin Gump Strauss Hauer and Field.  Mara received her JD with high honors and her MPH from George Washington University School of Law in 2007.  She received her BA in 2003 from the University of California, Davis.

The CMS MACRA proposed rule is at:

 Information concerning CAPG is at:



"About Hastert’s “Known Acts:” The Indifference Is as Disturbing as the Crime" (June 6th)


This past April 27th former US House Speaker, Denise Hastert, was convicted of violating federal banking laws resulting from his efforts to buy the silence of a high school student he sexually molested several decades ago while Hastert was employed as the school's wrestling coach.  Since Hastert's sentencing no Congressional leader nor the White House has bothered to condemn Hastert's "known acts" much less recognize the adverse life time health effects survivors' suffer, nor has the health care media, nor leading health care associations.  This behavior is the status quo.   If your interested in the Hastert case and non-response to it, here is the link to: "About Hastert's "Known Acts:" The Indifference is as Disturbing as the Crime."

See also this related January 2013 Health Affairs blog post:

My podcast interview with Diane Champe, noted in the above THCB blog post, is dated December 7, 2012. 



Andrea LaFountain Discusses Her Recent Work: "How Patients Think: A Science-based Strategy for Patient Engagement and Population Health" (May 26th)

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What accounts for so called patient compliance or adherence or why is it the case physicians and other providers are frequently unable to successfully engage their patients.  Why is it the case, for example, that patients adhere to highly toxic regimens of such as chemo therapy and not to more tolerable drugs such as statins.  What explains adherence or non-adherence?         

During this 22-minute conversation Dr. LaFountain explains why, using her phrase, the "epidemic of non-adherence" persists. She discusses the "importance of differentiation," the application of "cognitive profiling" or "cognitive restructuring," and provides examples using treatments for ADHD, breast cancer and diabetic patients at the Cleveland Clinic.

Dr. Andrea LaFountain is CEO of Mind Field Solutions Corporation, a firm specializing in the application of cognitive LaFountain Photoneueroscience to health behavior and patient engagement.   Prior to establishing Mind Field, she worked for AstraZeneca Pharmaceuticals leading consumer research and analytics for their oncology portfolio.   Before moving to the US, Dr. LaFountain was a Lecturer at The University of Liverpool.   She is a fellow of the American Psychological Association and the British Psychological Society and a scientific reviewer for the International Society of Pharmaco-economic Outcomes Research.  Dr. LaFountain earned her Ph.D. in pre-frontal cortex executive functioning at Imperial College, London.  

For information concerning Dr. LaFountain's work go to:


"Nature Bats Last: A Warming Earth Will Exact Adverse Health Effects But Our Responsibilities Are . . . ?" (May 25th)

In early April the White House released a report titled, "The Impacts of Climate Change on Human Health in the United States: A Scientific Assessment."  The report, unfortunately, received limited attention in DC health care policy circles.   If you're interested in an summary of the 400 page document (though I highly recommend you read it in its entirety) and a few comments concerning the extent to which federal health care agencies and professional health care associations have been interested in the "climate penalty," please see this essay via the Altarum Institute.    


 The White House report is at:




Daniel Dawes Discusses His Recent Book,"150 Years of Obamacare" (April 27th)

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Since, in part, April is recognized by DHHS as National Minority Health Month (this year's theme is "Accelerating Health Equity in the Nation") it is thoroughly appropriate to discuss Professor Daniel Dawes's recent work, "150 Years of Obamacare."  Professor Dawes's work begins with a discussion of efforts since the Civil War to reform national health care policy beginning with the 1865 Freedmen's Bureau Act.  The work moreover provides an accounting of his and others efforts to lobby successfully for health equity provisions in passing the 2010 Affordable Care Act ( ACA).  

During this 31-minute conversation, Professor Dawes discusses passage of the ACA, i.e., "Obamacare,", e.g., Republican opposition to the legislation and moreover the importance of the sixty plus health equity-related provisions in the legislation and what are his priorities for furthering health care equity or reducing disparities in health care delivery and outcomes - that sadly remain pronounced.   

Attorney and Professor Daniel E. Dawes is the Executive Director of Health Policy and External Affairs at the Morehouse Dawes_daniel_credit_brigette_martin_mackSchool of Medicine and a Lecturer within Morehouse's Satcher Health Leadership Institute and the Department of Community Health and Preventive Medicine.  He founded and chairs the Working Group on Health Disparities and Health Reform and is the co-founder of the Health Equity Leadership and Exchange Network (HELEN).  Previously, Professor Dawes held positions with the Premier Healthcare Alliance, the American Psychological Association and served on the Senate HELP (Health, Education, Labor and Pensions) Committee under Senator Edward Kennedy.   He is the recipient of numerous award including the Congressional Black Caucus Leadership and Advocacy Award.  He earned his JD from the University of Nebraska and his BS from Nova Southeastern University.

For more information concerning Professor Dawes's work, go to:  


Operational Challenges Associated with Accountable Care Organizations (ACOs): A Conversation with Dr. Richard Morel (April 21st)

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As a follow up to my April 1st conversation with Jim Gera concerning bundled payments, during this podcast Dr. Richard Morel discusses Medicare's other major payment reform program, Accountable Care Organizations (ACOs), or WESTMED Medical Group's three year experience as a Track 1 ACO.   The Medicare ACO program is a creation of the 2010 Accountable Care Act and participation in the program began in 2012.   Currently, there are 434 ACOs (over 90 percent participating in the "no risk" Track 1) caring for approximately 7.5 million Medicare beneficiaries.  The program to date has been a mixed success.  After two performance years (2013 and 2014) only 25 percent of participants have been successful, i.e., have earned shared savings.  (Performance year three or 2015 performance will be made known this September.)  CMS is currently in the process of revising how the agency calculates an ACO's reset financial benchmark.  It is anticipated these changes will improve program performance, or improve both provider interest in participating (or continuing to participate) in the program and participant success in earning shared savings.   

During this 21-minute conversation Dr. Morel provides an overview of WESTMED, explains the organization's interest in becoming a Medicare Shared Savings Program or ACO participant in 2013, WESTMED's experience under their first three year agreement, what explained their success, challenges they've found with the program, how the program could be improved and their expectations now as a second agreement period Track 1 ACO.

Dr. Richard Morel is the Co-Medical Director of WESTMED Medical Group in Yonkers, New York.  Prior to joining WESTMED in 2008 Dr. Morel WESTMEDDr RichardMorel (2)was in private practice affiliated with Columbia-Presbyterian Riverdale Hospital for 12 years.  Dr. Morel is board certified in internal medicine.  He received his medical degree from Columbia University College of Physicians and Surgeons, did his postgraduate training at Columbia-Presbyterian Medical Center and  received his masters of medical management from Carnegie Mellon.  He is a fellow of the American College of Physicians and a member of the American College of Physician Executives.  

For information regarding WESTMED go to:



What Might We Expect in the MACRA Proposed Rule? (April 11th)

For those following Medicare payment reform last April the MACRA (Medicare Access and CHIP Reauthorization Act) was passed by Congress and signed into law by the President.  Title I of the law reforms how Medicare physician payments are annually updated, i.e., the law replaces the 1997 Sustainable Growth Rate.  The proposed MACRA rule, that CMS will publish sometime over the next few to several weeks, is highly anticipated because beginning in 2019 physicians and other eligible professionals can face significant increases or decreases in their annual payment update depending how they perform on quality and/or value under the two MACRA-created payment update pathways: MIPS (the Merit-based Incentive Payment System) and APMs (Alternative Payment Models).  If you're interested in theses provisions of the law and what we might see in the proposed rule, feel free to read this essay posted April 6th on The Health Care Blog.