>> RHONDA?
>> SO, I'LL BE THE LAST DOC ADDED TO THE PILE.
I'M AN OLD DOC, FAMILY MEDICINE, DID HOME VISITS, DID INPATIENT CARE, DID DELIVERIES,
ALL THAT WONDERFUL THING, QUITE A WHILE AGO.
IT WAS CHALLENGING.
IT WAS ALSO REWARDING.
THERE ARE A COUPLE QUESTIONS I HAVE ABOUT WHAT PHYSICIAN WOULD AGREE TO DO THIS NOW
IN TODAY'S WORLD.
GRACE ADDRESSED LOGISTICS THEY WOULD HAVE TO.
NOT ONLY PANEL SIZE BUT HOW MANY PARTNERS TO SHARE CALL WITH.
ONE OF THE COMMENTS IN THE PRT REPORT MAY HAVE ADDRESSED QUESTIONS, WHICH PHYSICIAN'S
COMMUNITY DO YOU THINK WOULD BE MOST EASILY AMENABLE TO DO THIS?
ACADEMIC MEDICINE, RURAL PRACTICE?
YOU GET WHERE I'M GOING WITH THIS, RIGHT?
WE HAVE AN EASIER TIME ADAPTING.
THE QUESTION IS A QUESTION.
PATIENT REPORTED OUTCOMES, THAT'S GREAT, I UNDERSTAND FOR THOSE POPULATIONS THAT ARE
ALREADY IN ACO NOT WANTING TO ADD ON EVEN MORE MEASURES, BUT FOR POPULATION NOT AN ACO,
JUST CONSIDER, OPEN TO THE IDEA THERE SHOULD BE SOME TYPE OF PATIENT SAFETY OR QUALITY
MEASURES, NEEDS TO BE PART OF THE MODEL REPORTED ON BECAUSE QUITE FRANKLY EVEN IN DEMONSTRATION
WHEN WE'RE TRYING TO FIGURE OUT WHETHER OR NOT THIS IS DOABLE IT NEEDS TO BE HIGHLIGHTED
IN THE BEGINNING, WHAT IS THE OUTCOME TO THE PATIENT, ARE THEY SAFE IN THE MODEL, WHAT
IS THE RESPONSE RATE TO THE PHYSICIANS WHEN THE PAYMENT IS CALLED BECAUSE THE ASSUMPTION
IS THIS IS GOING TO BE THEIR ENDALL BE HAD BEEN ALL, PROVIDER OF CARE, BUT IF YOU WOULD
SPEAK A LITTLE BIT ABOUT WHO YOU THINK WOULD BE EASIER TO ADAPT THAT WOULD BE GREAT.
>> A COUPLE THINGS.
LET ME DO THE MEASURE ONE FIRST AND I'LL GO TO THE PANEL SIZE AND COMMUNITY HOSPITAL ONE.
WE'RE VERY MUCH OPEN TO MEASURES.
WE DON'T OBJECT TO THEM.
WE'RE WORRIED ABOUT PRACTICALITY.
QUESTIONS YESTERDAY WHO IS GOING TO ENSURE PEOPLE ANSWER SURVEY QUESTIONS, WE DIDN'T
KNOW HOW COMFORTABLE CMS WAS WITH REQUIRING THINGS LIKE THAT AND DIDN'T WANT TO BUILD
SOMETHING ON TOP OF IT THAT WE DIDN'T KNOW THE� LIKE WE MEASURE EVERYTHING IMAGINABLE
IN THIS STUDY AND CAN GIVE YOU A WHOLE LIST OF WHAT'S MOVING AND NOT MOVING, LIKE WE'RE
TOTALLY OPEN TO THAT.
SO THAT'S THAT.
AND FOR THE PANEL SIZE WE TALKED ABOUT IF YOU HAVE AN IDEA, COMMUNITY HOSPITALS, SO
WORKING WITH EMILY AND HER MOM AT INGALLS HOSPITAL, A LARGE NUMBER OF PHYSICIANS LIKE
THE ONES TIM FOUND AT HARVARD WERE CARING FOR THESE PATIENTS IN THE HOSPITAL BECAUSE
THEY BELIEVE IN IT AND NO ONE MADE THEM STOP.
THEY ARE STRUGGLING BECAUSE THEY DON'T HAVE ENOUGH PATIENTS.
WE'VE ACTUALLY BEEN PARTNERING WITH THOSE DOCTORS ALREADY THERE, TO HELP THEM FORM A
GROUP, WORK THROUGH THIS, AND HELP THEM FIND PATIENTS AT HIGH RISK OF HOSPITALIZATION SO
WE CAN SOLVE THE CLAY CHRISTIANSEN PROBLEM, EXACTLY WHAT TIM HAS DONE, GETTING HIGH RISK
PATIENTS TO THE DOCTORS WHO WANT TO DO THIS.
I'D GONE TO RURAL HOSPITALS IN ILLINOIS, I'VE GOTTEN PHONE CALLS FROM FOLKS IN TINY COMMUNITY
HOSPITALS, IN VULNERABLE URBAN AND RURAL COMMUNITIES, PEOPLE WILL DO THIS.
I THINK THE DEMONSTRATION WILL PROVE PEOPLE ARE INTERESTED IN THIS.
I THINK THAT'S A REASON TO DO IT.
I ALSO THINK ACADEMIC MEDICAL CENTERS THERE ARE DOCTORS WHO WANT TO DO THIS, TRAINEES
WHO ARE INTERNISTS, WE'VE THEM THEM RETRAIN AND RETOOL.
THEY WEEK THIS IS DOABLE.
>> I WANT TO THE PIPELINE IS RECENT, INTERNAL MEDICINE RESIDENT TO GRADUATE, SO MANY COLLEAGUES
WERE LOOKING FOR JOBS TO SEE PATIENTS IN INPATIENT AND OUTPATIENT SETTINGS, WEREN'T JOBS AVAILABLE,
YOUNGER DOCTORS WILL BE INTERESTED IN THIS TYPE OF MODEL AS WELL.
>> I WANT TO JUST FOLLOW THAT TRAIN OF THOUGHT BECAUSE A LOT OF WHAT I SEE AS YOUNGER GENERATION
OF PHYSICIANS WHO ARE COMING OUT TODAY, LIFESTYLE IS VERY IMPORTANT TO THEM.
BEING ABLE TO BE PREDICTIVE, THEY DON'T WANT TO GET UP IN THE MIDDLE OF THE NIGHT AND GO
TO THE HOSPITAL, AND I UNDERSTAND THAT THIS DOESN'T HAVE TO APPLY TO EVERYBODY, I GET
THAT.
BUT I ALSO AM SENSITIVE TO THE ECOSYSTEMS THAT HAVE BEEN CONSTRUCTED, AND THE CHALLENGES
THAT THIS COULD PRESENT TO THOSE SYSTEMS, PARTICULARLY IN THE SMALLER COMMUNITIES, WHERE
NOT EVERYBODY WANTS TO DO THIS, AND SO YOU STILL NEED THAT HOSPITALIST BACKBONE, RIGHT?
AND DO YOU HAVE SOME I UNDERSTAND YOU'VE DONE IT IN ONE PLACE, WORKING IN A RURAL HOSPITAL,
HOW WILL THAT PLAY THROUGH IN LARGER ECOSYSTEM, SOMETHING ULTIMATELY SCALED ACROSS THE COUNTRY,
COULD YOU HELP ME WITH THAT?
>> YEAH, SO, YOU KNOW, I THINK WE'VE BEEN THROUGH THE ISSUES.
THERE'S SOME PHYSICIANS WHO THIS IS NOT GOOD FOR THEM.
SOME FOR WHOM IT IS.
I THINK THERE ARE ENOUGH.
WITHIN THESE ECOSYSTEMS, HOSPITALIST PROGRAMS NEED A CERTAIN VOLUME, THEY ARE USED TO A
CERTAIN VOLUME AND ARE PRACTICING IN A GIVEN LEVEL AND HAVE A FAIR BIT OF TURNOVER, OFTEN
JOBS ARE COMING OPEN.
THESE DOCTORS CCPs CAN ESSENTIALLY FUNCTION AS HOSPITALISTS, AS THEY ARE GETTING STARTED,
CARE FOR PATIENTS.
SO WHEN I STARTED HCIA AWARD INTERPOLATED PEOPLE WE HIRED INTO THE HOSPITALIST PROGRAM,
FIRST TWO AND THEN THREE, SEVERAL YEARS UNTIL WE REACHED FIVE, SO THERE ARE WAYS TO DO THIS
PRACTICALLY, WE UNDERSPENT OUR HCIA AWARD IN THE FIRST FEW YEARS, DIDN'T NEED AS MUCH
CLINICAL RESOURCE TO LAUNCH AS WE THOUGHT.
THERE'S PRACTICAL WAYS TO SOLVE THESE PROBLEMS.
PART OF THE BEAUTY OF, YOU KNOW, HAVING CMS DEEPLY INVOLVED IN THIS IS TECHNICAL ASSISTANCE
TO ADVISE HOW TO DO THIS WELL.
WE'RE ALREADY RUNNING A TCPI LEARNING COLLABORATIVE AROUND CCP, THAT COULD BE EXPANDED PARTICULARLY
IN THE CONTEXT OF THIS PAYMENT MODEL.
BUT MORE GENERALLY.
AND WE THINK THERE'S A LOT OF VERY PRACTICAL SOLUTIONS TO ALL THESE PROBLEMS.
WE DON'T THINK ANY OF THIS IS UNMANAGEABLE.
>> ONE SPECIFIC EXAMPLE TO HIGHLIGHT, UNIVERSITY OF CHICAGO WE ACTUALLY PARTNER THIS PROGRAM
WITH THE HOSPITALIST PROGRAM, SO IF A PATIENT DOES COME IN IN THE MIDDLE OF THE NIGHT, THAT
NIGHT THEY ARE ADMITTED BY A HOSPITALIST AND SEEN BY THEIR COMPREHENSIVE CARE PHYSICIAN
THE NEXT DAY, OPPORTUNITIES TO INTEGRATE WITH SYSTEMS ALREADY IN PLACE.
>> OKAY.
THANK YOU.
THAT'S HELPFUL.
BOB?
>> YEAH, SO EARLIER, DAVID, YOU MENTIONED THAT POINTING TO US SAYING CONCERNS ABOUT
GENERALIZABILITY.
MY CONCERN IS ABOUT LIMITING GENERALIZABILITY.
THE ENTRANCE CRITERIA SEEM LIKE VIRTUALLY ANY RURAL PHYSICIAN SEEING THEIR OWN PATIENTS
IN THE HOSPITAL WOULD MEET THE QUALIFICATIONS, UNLESS I'M MISSING SOMETHING, WOULD BE ELIGIBLE
FOR ADDITIONAL PAYMENTS, DIDN'T SEE A MINIMUM THRESHOLD, NOT SAYING IT'S NECESSARILY A BAD
THING BUT WONDERING WHETHER THIS IS A MUCH LARGER SCOPE ISSUE THAN� THIS IS MY SPECIFIC
REQUEST, UP TO 3.8�MILLION MEDICARE BENEFICIARIES WOULD BE ELIGIBLE, COULD YOU GIVE A SENSE
OF WHERE THAT COMES FROM?
I GUESS WHAT I'M SUGGESTING IS IT'S MORE THAN 5 TO 10% OF DOCTORS NOW OR WOULD BE SEEING
THEIR OWN PATIENTS IN THE HOSPITAL.
>> YES, OUR ESTIMATE WAS BASED ON THE IDEA THAT PEOPLE WERE REALLY FOCUSING THEIR PRACTICE
ON THIS, RATHER THAN DOING IT AS A TINY PIECE OF IT.
YOU'RE RIGHT.
IT COULD BE A RURAL PHYSICIAN WOULD LOOK AT THIS AND THEY MIGHT BILL FOR IT.
IN THAT SENSE WE'D BE PAYING FOR MORE SOMETHING THEY WERE ALREADY DOING.
I WOULD BE FINE WITH SOME MINIMUM NUMBER, IF YOU WERE TO RECOMMEND THAT.
THE ONLY THING I WOULD JUST SAY IS, YOU KNOW, EVEN THOSE RURAL PHYSICIANS ARE ABANDONING
THIS MODEL.
AND IT'S UNFORTUNATE FOR THEM.
SOMETIMES IT'S NOT IMPRACTICAL FOR THEM TO DO IT.
THERE'S A LOT OF CAPACITY IN SOME RURAL ENVIRONMENTS IRONICALLY, A LONGER CONVERSATION.
BUT ANYWAY WE WOULD BE TOTALLY OPEN TO THAT.
>> NO, I'M NOT NECESSARILY TAKING A POSITION.
I'M JUST TRYING TO CLARIFY IT.
IN MY VIEW IT'S ONE WAY TO PARTLY ADDRESS THE MALDISTRIBUTION OF MONEY ACROSS SPECIALTIES
WHICH MAYBE THIS WOULD BE A WAY TO DO THAT AND IF THE RETURNS ARE WHAT YOU'RE SUGGESTING
IN DIFFERENT PRACTICE ENVIRONMENT, RANGE OF PRACTICE ENVIRONMENTS, THAT MIGHT BE A VERY
GOOD INVESTMENT.
>> RIGHT.
>> BUT THAT'S WHAT I WANTED TO CLARIFY, THAT RIGHT NOW THERE WOULD BE NOTHING ABOUT THE
WAY YOU'VE ESTABLISHED THIS THAT WOULD PREVENT A RURAL PHYSICIAN WHO IS CARING FOR THEIR
OWN PATIENTS TO BILL FOR THE SERVICE.
>> ALTHOUGH LET ME JUST MENTION ONE THING.
I BELIEVE THE WAY WE DESCRIBE THIS, SORT OF BETA TEST, CMS WOULD GET APPLICATION AND REVIEW
SITES.
IF CMS GOT APPLICATION FROM A RURAL PHYSICIAN, I CARE FOR MRS.�JONES EVERY TIME SHE'S IN
THE HOSPITAL BUT NOBODY ELSE, WASN'T AN EXTRA $40, THEY WOULDN'T DO THAT.
>> IF I WAS AT CMMI, I WOULD WANT ONE OF THOSE PRACTICES IN THERE TO KNOW THE BEHAVIORAL
RESPONSE.
>> MY MORE OPTIMISTIC MOMENTS I THINK IT SHOULD BE MORE THAN 20 INSTITUTIONS AND PRACTICES,
BUT, AGAIN, >> 3.8 WAS BASED ON
>> BASED ON CALCULATING HOW MANY PEOPLE IN MEDICARE WOULD BE HOSPITALIZED IN A GIVEN
YEAR WHO POTENTIALLY WOULD BE ELIGIBLE.
I DON'T REMEMBER WHERE WE DISCOUNTED FOR WHAT FRACTION WOULD GO INTO THIS OR NOT.
>> BUT LOOKING AT UNIVERSITY OF CHICAGO KINDS OF LOCATIONS AND FIGURING WHO WOULD BE CAPABLE
PUTTING ON SUCH A PROGRAM.
>> ABSOLUTELY.
WE'RE LIKE A 500 BED HOSPITAL, SOMETHING LIKE THAT.
AND WE HAVE HAD MORE THAN AN ADEQUATE PATIENT VOLUME, NOT JUST SUPPORT A PROGRAM, BUT TO
SUPPORT A PROGRAM AND RANDOMIZED HALF THE PEOPLE AWAY AND HAVE ANOTHER BUNCH OF PEOPLE
REFUSE BECAUSE THEY DON'T LIKE TO DO RESEARCH.
SO LIKE I THEN YOU HAVE THE ROUNDER MODEL.
I THINK SCALE IS TOTALLY SOLVABLE ON THIS.
>> YEAH, AND THE OTHER THING WHICH I WANT TO CLARIFY, JUST SORT OF WAS WHISPERING TO
KAVITA, ENROLLMENT, EMPANELMENT, IT'S A BASIS FOR DOING THE CALCULATIONS, WHAT IS THE PURPOSE
OF ENROLLMENT IS THE QUESTION.
>> THE PURPOSE OF ENROLLMENT IS TO MAKE IT CLEAR BOTH TO THE PATIENT AND TO THE DOCTOR
THIS PERSON IS RESPONSIBLE FOR THEM.
ALSO TO MAKE SURE THE PATIENT MEETS CRITERIA, SO THERE'S A LIMITATION OF PATIENT CHOICE
IN THE FOLLOWING SENSE IF YOU HAVEN'T BEEN HOSPITALIZED OR MEET CRITERIA, PREDICT RISK
OF HOSPITALIZATION, YOU CAN'T ENROLL WITH THIS FEE.
RIGHT?
BUT THAT'S REALLY SORT OF MEDICAL INDICATION FOR A SERVICE LIKE YOU CAN'T GET DIALYSIS
IF >> THERE'S NO LIMITATION ON PATIENT CHOICE.
>> RIGHT, NO.
>> THANK YOU.
TIM AND THEN HAROLD >> WELL, SORRY, I DIDN'T IT'S LIKE A TENNIS
MATCH HERE, FOR CRYING OUT LOUD.
[LAUGHTER] OKAY.
>> THIS IS A PRETTY WONKY QUESTION, YOU REFERRED TO RISK ADJUSTMENT, DEALING WITH OUTLIERS
OF OUTLIERS.
SO HUGE REGRESSION TO THE MEAN ISSUE.
>> YEAH.
>> I JUST WANT TO ASK, HOW THEN WITH THE VERY OPEN CRITERIA FOR ENROLLMENT IN YOUR PROPOSED
BETA TEST, WITH 20 SITES, HELP ME UNDERSTAND THE EVALUATION.
>> YEAH, YEAH, GREAT QUESTION.
>> BECAUSE THERE'S YOU COULD HAVE REALLY DIFFERENT POOLS IN EACH OF THE SITES, BECAUSE THERE
ARE REALLY OPEN ENROLLMENT CRITERIA.
>> YEAH.
>> AND HOW WOULD YOU KNOW.
>> YEAH, YEAH.
>> GIVEN THE RISK ADJUSTMENT PROBLEMS THAT YOU VERY ACCURATELY
>> YEAH, SO IF I WERE A FOUNDATION PRESIDENT OR SOMETHING LIKE THAT, INTERESTED IN THIS
AREA, YOU KNOW, MY IDEAL WOULD BE TO FUND MORE RCTs PROBABLY AT SOME LEVEL BECAUSE WE'VE
GOT THIS CLEAN INTERVENTION AND CONTROL GROUP AND I THINK THAT'S GREAT.
I RECOGNIZE CMS DOESN'T DO THAT SORT OF STUFF SO MUCH.
SO, I THINK THINKING ABOUT THINGS LIKE A SORT OF STEPPED WEDGE DESIGN WHERE, FOR EXAMPLE,
YOU TAKE A GROUP OF PEOPLE WHO MEET ELIGIBILITY CRITERIA AND THEY SORT OF DEFINE AT LEAST
THE CHUNK OF YOUR DENOMINATOR, AND THEN SO, FOR EXAMPLE, PEOPLE WHO HAVE BEEN HOSPITALIZED
IN THE PAST YEAR, AND THEN YOU'RE SORT OF FOLLOWING THEM OVER TIME, AND THEN, YOU KNOW,
BOOM, THE PROGRAM GETS APPROVED AND THEN YOU LOOK AT THE PEOPLE WHO NOW ARE ELIGIBLE FOR
THAT BY VIRTUE OF HAVING BEEN HOSPITALIZED, SOME FRACTION WILL GO IN, YOU'LL HAVE TO DEAL
WITH INTENTION TO TREAT ANALYSIS ISSUES AND THE UPTAKE ISSUE BUT THAT'S ALL STATISTICALLY
MANAGEABLE.
AND THEN, YOU KNOW, YOU WOULD HAVE A SERIES EVER THINGS LIKE THAT WHERE YOU COULD GRADUALLY
PUT THEM IN OVER TIME.
WE TALKED ABOUT THIS IN THE PROGRAM, THE IDEA OF A STEPPED WEDGE DESIGN, SOMETHING CMS HAS
DONE BEFORE AND IS REASONABLE.
SO THOSE ARE THE THINGS THAT COME TO MIND.
WE WERE VERY GRATEFUL THAT HCIA ALLOWED US TO DO AN RCT AND IT'S THE GOLD STANDARD, AND
I WOULD LIKE TO IMAGINE THAT IT'S POSSIBLE TO DO THAT BUT DO THINK A STEPPED WEDGE DESIGN
WITH REASONABLE DENOMINATORS THAT FOCUS ON AN ELIGIBLE POPULATION COULD MAKE A LOT OF
SENSE.
>> THAT'S GREAT RESPONSE, AND I GUESS I WOULD JUST SAY THAT HAVING SOME EXPERIENCE WITH
IMPLEMENTATION OF DEMONSTRATION PROJECTS, I'VE BEEN IMPRESSED AT HOW YOU CAN GIVE A
REALLY BIG BINDER ABOUT HOW TO DO IT TO MULTIPLE SITES, AND HAVE PHONE CALLS AND CHECK INS
AND EVERYTHING, AND THEN A YEAR LATER EVERYONE IS DOING SOMETHING COMPLETELY DIFFERENT.
>> ABSOLUTELY.
AND I'M VERY FAMILIAR WITH HOW MUCH WORK YOU'VE PUT IN BECAUSE I'VE READ A LOT OF IT SO I
AGREE WITH YOU.
BUT AGAIN I THINK THIS IS WHERE THEY ARE REAL OPPORTUNITIES WITH LEADERSHIP FROM CMMI AND
CMS TO, YOU KNOW, GIVE THE VERY BEST TECHNICAL ASSISTANCE.
WE LEARN FROM OUR EXPERIENCES.
I'M SURE YOU WOULD HAVE A LOT OF ADVICE ABOUT HOW IF YOU DID IT AGAIN YOU MIGHT DO IT A
LITTLE DIFFERENTLY, IF WE'RE FORTUNATE ENOUGH TO REACH THAT POINT I HOPE WE AGAIN FIT FROM
THAT.
>> HAROLD?
NO, LEN.
JEEPERS, WALLY.
LEN, PLEASE.
>> SO YOU REMEMBER WHEN I WAS TALKING BEFORE YOU ALL CAME UP, I THINK ONE OF THE BIG ISSUES
IT'S GOING TO COME DOWN TO THIS $3000 VERSUS WHAT THE EVALUATION THAT THE OFFICIAL HCIA
THINKS.
TELL ME WHY YOU BELIEVE $3000.
>> YEAH, HCIA EVALUATION WAS BASED ON CMS TRADITIONAL CLAIMS DATA.
TWO REASONS, IN THE CMS DATA WE HAVE FROM THE PERIOD THAT WE HAVE SO FAR, THAT IS THE
MEAN ESTIMATE WE SEE IN OUR COST DATA FOR THE FIRST YEAR AND A HALF.
IN THE TRADITIONAL MEDICARE POPULATION WHICH ISN'T BIASED BY THE DROPOUT IN THE MEDICARE
THE DUAL ELIGIBLE.
THE SECOND THING, IF YOU TAKE THE ESTIMATES WE SEE FROM THE PATIENT REPORTED HOSPITALIZATIONS,
WHICH ALIGNS VERY WELL WITH WHAT WE SEE IN THE CLAIMS DATA, AND THEN WE TAKE REASONABLE
ESTIMATES OF THE COST OF HOSPITALIZATION, WE GET THAT SAME NUMBER.
IN THE PATIENT REPORTED OUTCOME YOU WORRY THERE'S BIAS AND NOT HIGH REPORTING RATES
AND MAYBE ONLY SOME PATIENTS ARE ANSWERING.
WE GET LIKE 95% COMPLETION RATES OF DATA.
WE HAVE I TORTURE OUR STUDENTS TO KEEP CALLING AND CALLING.
ONE PATIENT SAID WILL I HAVE TO DIE BEFORE YOU STOP CALLING ME?
WE GET INCREDIBLY HIGH RESPONSE RATES AND WE'VE USED PATTERN MIXTURE MODELING TO DEAL
WITH DROPOUTS SO WE'RE DEALING WITH THE SELECTION ISSUES AROUND THIS.
I MEAN, I CAN'T KNOW 100% IT'S GOING TO COME OUT EXACTLY THERE, BUT IT IS MY BEST SCIENTIFIC
JUDGMENT THAT THOSE NUMBERS ARE PRETTY REASONABLE ESTIMATE.
>> JEFF, DO YOU MIND IF I >> PLEASE.
>> TWO QUICK FOLLOW UPS, DAVID.
NUMBER ONE, YOU'VE JUST DESCRIBED WHAT I THINK HAD BEEN A CONUNDRUM FOR US, NOT JUST DISPARITY,
YOU TALK ABOUT CORRELATION WITH UTILIZATION CLAIMS BASED MEASURES, THAT'S ALL CMS IS GOING
TO HAVE.
AND TO GET TO THAT 95% I'D EVEN TAKE, YOU KNOW, 40% AT TRIP POINT, BUT WHATEVER, TO
GET TO THAT PERCENT YOU HAD TO PUT IN QUITE A BIT OF ENERGY, AND THOSE PROCESSES AS WELL
AS STRUCTURE AND DONNA BEADIAN FRAMEWORK IS NOT REFLECTED IN WHAT WE HAVE, MY CONCERN
ANYBODY WHO TRIED TO DO THIS EVEN IN THE 20 BETA SITES AS GREAT AS YOURS WOULD NEED TO
FIND A WAY TO GET TO THAT LEVEL OF EXCELLENCE, I GUESS THAT'S JUST ONE POINT I WANTED TO
MAKE.
THAT'S A CONCERN.
YEAH, PLEASE.
THE SECOND YOU CAN ANSWER WITHOUT STRAINING YOUR BRAIN HOPEFULLY.
HAVE YOU EVER TALKED TO CMS ABOUT THE HCIA AND WHAT HAS THAT RESULTED IN?
>> IT'S BEEN A LONG MORNING.
I TALKED TO PATRICK CONWAY, BECAUSE OF PATRICK WE APPLIED.
YEAH, HE USED TO WORK HERE.
AND SO IT WAS PATRICK WHO SUGGESTED THAT I WASN'T EVEN AWARE, FRANKLY, EMBARRASSINGLY
OF THE PROCESS, HE TOLD ME ABOUT IT, IT WAS ON THE BASIS OF THAT WE STARTED TALKING ABOUT
THIS.
AND THAT WAS REALLY MY MAIN CONTACT.
SO WE READ ABOUT IT AND LEARNED AND SO ON.
SO THAT WAS THE MAIN THING.
I'M SORRY.
>> TO LEN'S POINT, NOT EVEN VALUE, I'M CONCERNED THERE'S A STRUCTURAL PROCESS ELEMENT, NOT
QUITE ARTICULATED, TO ACHIEVE THE SUCCESS THAT WOULD ULTIMATELY LEAD TO THIS.
>> LET ME SAY WE HAVE TWO SEPARATE OPERATIONS.
ONE IS CLINICAL OPERATION WHERE WE TALK TO PATIENTS AND CARE FOR THEM, INTERACT.
ANOTHER IS OUR RESEARCH AND EVALUATION OPERATION.
AND BASICALLY A BUNCH OF UNDERGRADUATES FRANKLY WHO CALL AND CALL AND CALL AND CALL.
AND, YOU KNOW, I'M NOT SURE, I MEAN, IF ANYTHING I THINK ALL THE CALLING WE DO MAKES THE PROGRAM
WORK FOR THEM BECAUSE THEY GET TIRED OF BEING CALLED SO MUCH.
BUT I WANT TO BE CLEAR, OUTSIDE OF THE MEDICAID GROUP WE HAD PRETTY GOOD RETENTION BECAUSE
WE HAVEN'T HAD A LOT OF PEOPLE MOVING INTO MEDICARE ADVANTAGE IN OUR ENVIRONMENT.
SO THE CLAIMS DATA IS ACTUALLY REALLY QUITE GOOD.
AND I WOULD ALSO ARGUE, I DON'T UNDERSTAND ENOUGH ABOUT WHAT DATA CMS HAS OR DOESN'T
HAVE RIGHT NOW, BUT LIKE IF YOU COULD DO AN EVALUATION THAT INCLUDED, YOU KNOW, MEDICARE
ADVANTAGE CLAIMS AND UTILIZATION TOO, THAT WOULD BE A REALLY BIG PLUS IN SOME OF THIS.
I THINK SOME OF THAT DATA EXISTS BUT I DON'T KNOW ENOUGH TO KNOW WHETHER IT'S REALLY USABLE.
YOU COULD MAKE SOME OF THAT A CONDITION HOW YOU DESIGN THE PROGRAMS, POSSIBILITIES.
>> HAROLD, TAKE US HOME.
>> THE FINAL QUESTION, THIS IS REALLY A FOLLOW UP TO THE QUESTIONS BOB WAS ASKING.
WE GET A NUMBER OF APPLICANTS WHO HAVE WHAT THEY BELIEVE IS A DESIRABLE CARE MODEL, AND
THEY HAVE NO WAY TO PROVE THAT IT'S REALLY IMPACTFUL BECAUSE THEY NEED TO GET A NUMBER
OF OTHER SITES TO BE ABLE TO DO IT AND THEY ARE LOOKING FOR SOME WAY TO ENABLE OR ENCOURAGE
OTHER SITES TO DO IT WHICH SOUNDS LIKE WHAT YOU'RE TRYING TO DO.
BUT THE ISSUE IS WE'RE NOT APPROVING RESEARCH PROJECTS.
WE'RE SUPPOSED TO BE LOOKING AT PAYMENT MODELS THAT COULD POTENTIALLY BE EXPANDED NATIONALLY.
SO I GUESS I'M CURIOUS AS TO HOW YOU ENVISION IF SOMEHOW IT GETS THE THE EVALUATION GETS
DONE AND SHOWS WHAT YOU BELIEVE IT'S GOING TO SHOW, THIS IS GOING TO BE EXPANDED, HOW
PEOPLE WOULD PARTICIPATE AND GET PAID IN THE FUTURE.
WOULD PRACTICES WOULD THERE BE A NEW BILLING CODE THAT THEY WOULD SAY I'M GOING TO BILL
$40 FOR A PATIENT AND SOMEBODY'S GOING TO THEN CALCULATE CMS IS GOING TO CALCULATE SOME
RETROSPECTIVELY DETERMINE IF THEY SAW PATIENTS ENOUGH AND PENALIZE THEM, WOULD THEY HAVE
TO APPLY AS A PRACTICE AND SAY I AM STRUCTURED IN THE FOLLOWING WAY, AND THEREFORE I'M GOING
TO GET PAID THIS WAY?
HOW WOULD YOU ENVISION THAT WORKING?
>> I THINK WHAT YOU DESCRIBED, THERE WOULD BE SOME WAY TO APPLY TO BE PART OF THIS, AND
IF YOU APPLY THEN WE'RE ACCEPTED, BASED ON SOME INTERNAL REVIEW PROCESS THAT CMS THOUGHT
MADE SENSE, YOU WOULD BEGIN TO EMPANEL PEOPLE AND BILL USING THESE CODES IN THE PROCESS
OF THEM HAVING AGREED TO DO THIS.
MY UNDERSTANDING, I THINK THIS IS PARTIALLY FROM MY CONVERSATIONS WITH PATRICK, THE PTAC
COULD SORT OF SCALE THINGS UP AS THE EVIDENCE FOR THEM INCREASED.
AND THAT IT WAS WISER TO COME IN WITH A PROPOSAL THAT WAS MORE LIMITED RATHER THAN GLOBAL AT
FIRST SO THERE COULD BE LEARNING AND PERHAPS IN A YEAR OR WHATEVER COME BACK AND SAY, LOOK,
THE INITIAL DATA LOOKS PROMISING, WE HAD A BUNCH OF QUESTIONS WHETHER, FOR EXAMPLE, A
RURAL SMALL PRACTICE, WE GOT 200 APPLICATIONS, ACCEPTED 20.
>> BUT WE WOULD NOT SCALE, THAT'S CMS.
THE QUESTION IS WHETHER YOU THINK THE $40 IS SOMETHING THAT IN FACT WOULD BE THE PERMANENT
MODEL OR WHETHER IT'S ENOUGH TO BE ABLE TO DO SOMETHING IN THE SHORT RUN BECAUSE I'M
WONDERING IN IT'S AN APPLICATION PROCESS RULINGS WILL HAVE TO BE ESTABLISHED HOW BIG YOU HAVE
TO BE AND MAKE AN EXCEPTION FOR THIS RURAL PRACTICES WITH 149 PATIENTS.
YOU'RE AT LEAST AT THE MOMENT ENVISIONING IF IT WORKS, THE $40 IS THE PAYMENT MODEL
THAT EVERYBODY WOULD BE USING IN THE LONG RUN.
>> COULD IT BE $30, $50.
>> I'M TALKING ABOUT SOMETHING LIKE THAT.
>> NOT SOMETHING NECESSARY JUST TO GET A RESEARCH PROJECT UNDERWAY?
>> NO, THIS IS A CREDIBLE MODEL THAT COULD POTENTIALLY BE SCALABLE, PROPOSED AS A FIRST
STEP.
HEALTH CARE DELIVERY IS SHORT ON EVIDENCE, THIS IS STRATEGY TO GENERATE HIGH QUALITY
EVIDENCE.
ALSO I FEEL A SENSE OF URGENCY, WE HAVE BIG PROBLEMS IN THIS COUNTRY WITH RESPECT TO HEALTH
CARE, AND I WANT US TO MOVE QUICKLY BUT WANT US TO MOVE QUICKLY TO SOMETHING THAT WORKS
AND WE HAVE AN EXPERIENCE IN OUR SITE AND VANDERBILT AND OTHER PLACES BUT IT'S SO EARLY,
BUT THIS COULD REALLY HELP US MOVE THAT PROCESS AHEAD.
>> SO I WANT TO PERSONALLY THANK ALL OF YOU FOR YOUR DILIGENCE AND PATIENCE WITH US.
IT'S BEEN VERY HELPFUL.
AND THANK YOU FOR PUTTING THIS PROPOSAL FORWARD AND ATTENDING TODAY AND WE'RE NOT DONE.
BUT I'M GOING TO I KNOW YOU GUYS PROBABLY ARE.
SO THANK YOU, IF YOU COULD TAKE YOUR SEATS.
>> THANK YOU ALL SO MUCH.
>> YOU BET.
>> REALLY GRATEFUL.
>> YOU BET.
I UNDERSTAND THERE'S NO ONE ON THE PHONE TO MAKE PUBLIC COMMENTS ABOUT THE PROPOSAL.
I'D LIKE TO TAKE A BREAK, BUT I WANT TO CONFIRM WITH THE OPERATOR BEFORE WE BREAK THAT THERE
ISN'T ANYBODY ON THE PHONE REGISTERED TO SPEAK.
OPERATOR?
>> WE HAVE NO ONE REGISTERED AT THIS TIME, SIR.
>> VERY GOOD.
WHAT I'D LIKE TO DO IS TAKE A 10 MINUTE BREAK AND WE'LL RECONVENE.
THANK YOU.
(RECESS)
>> ALL RIGHT.
IF EVERYBODY COULD TAKE WE'RE SEATS WE'RE GOING TO GO AHEAD AND CONTINUE ON HERE.
I ASK MY COLLEAGUES, ARE WE READY TO VOTE ELECTRONICALLY ON THE INDIVIDUAL CRITERIA?
ALL RIGHT.
LET'S GO AHEAD AND GET STARTED.
CRITERION ONE, SCOPE, HIGH PRIORITY CRITERION, AIMED TO EITHER DIRECTLY ADDRESS AN ISSUE
IN PAIN AND POLICY THAT BROADENS AND EXPANDS APM PORTFOLIO OR INCLUDE APM ENTITIES WHOSE
OPPORTUNITIES TO PARTICIPATE IN APMs HAVE BEEN LIMITED.
PLEASE VOTE.
>> ONE MEMBER VOTED SIX MEETS AND DESERVES PRIORITY CONSIDERATION, FOUR MEETS.
TWO, THREE MEETS.
TWO VOTED TWO, DOES NOT MEET.
ONE MEMBER VOTED ONE, DOES NOT MEET, AND ZERO MEMBERS VOTED NOT APPLICABLE.
A SIMPLE MAJORITY IS NEEDED, AND WE WILL DOWN SO THE FINDING OF THE COMMITTEE IS THAT THE
PROPOSAL MEETS CRITERION ONE SCOPE.
>> THANK YOU.
CRITERION TWO IS QUALITY AND COST TO HIGH PRIORITY CRITERION, ANTICIPATED TO IMPROVE
HEALTH CARE QUALITY AT NO ADDITIONAL COST, MAINTAIN HEALTH CARE QUALITY WHILE DECREASING
COST OR IMPROVE QUALITY AND DECREASE COST.
PLEASE VOTE.
>> ZERO MEMBERS VOTE SIX, MEETS AND DESERVES PRIORITY CONSIDERATION; TWO VOTE FIVE, MEETS
AND DESERVES PRIORITY CONSIDERATION; ZERO MEMBERS VOTE FOUR, MEETS; FIVE MEMBERS VOTE
THREE, MEETS; TWO MEMBERS VOTE TWO, DOES NOT MEET; ONE MEMBER VOTES ONE, DOES NOT MEET.
AND ZERO MEMBERS VOTE NOT APPLICABLE.
THEREFORE THE FINDING OF THE COMMITTEE IS THE PROPOSAL MEETS CRITERION TWO, QUALITY
AND COST.
>> THANK YOU.
CRITERION THREE PAYMENT METHODOLOGY ANOTHER HIGH PRIORITY CRITERION, APM METHODS DESIGNED
TO ACHIEVE CONTROLS ADDRESSES IN DETAIL THROUGH THIS METHODOLOGY, PAY AMENITIES AND HOW THE
PAYMENT METHODOLOGY DIFFERS FROM CURRENT PAYMENT METHODOLOGIES, LASTLY WHERE THE PHYSICIAN
FOCUSED PAYMENT MODEL CANNOT BE TESTED UNDER CURRENT METHODOLOGIES, HIGH PRIORITY, PLEASE
VOTE.
>> ZERO MEMBERS VOTE SIX, MEETS AND DESERVES PRIORITY CONSIDERATION.
ONE MEMBER VOTES FIVE, MEETS AND DESERVES PRIORS CONSIDERATION.
ZERO MEMBERS VOTE FOUR, MEETS.
TWO MEMBERS VOTE THREE, MEETS.
FIVE MEMBERS VOTE TWO, DOES NOT MEET.
TWO MEMBERS VOTE ONE, DOES NOT MEET.
AND ZERO MEMBERS VOTE NOT APPLICABLE, THE FINDING PROPOSAL DOES NOT MEET CRITERION THREE,
PAYMENT METHODOLOGY.
>> THANK YOU, SARAH.
VALUE OVER VOLUME PROVIDE INCENTIVES TO PRACTITIONERS TO DELIVER HIGH QUALITY HEALTH CARE.
PLEASE VOTE.
>> ZERO MEMBERS VOTE SIX, MEETS AND DESERVES PRIORITY CONSIDERATION.
ONE MEMBER VOTES FIVE, MEETS AND DESERVES PRIORITY CONSIDERATION.
THREE MEMBERS VOTE FOUR, MEETS.
SIX MEMBERS VOTE THREE, MEETS.
ZERO MEMBERS VOTE ONE OR TWO, DOES NOT MEET, AND ZERO MEMBERS VOTE NOTABLE, THE FINDINGS
OF THE COMMITTEE IS THE PROPOSAL MEETS CRITERION FOR, VALUE OUR VOLUME.
>> AND CRITERION FIVE FLEXIBILITY NEEDED FOR PRACTITIONERS TO DEVELOP HIGH QUALITY HEALTH
CARE.
PLEASE VOTE.
>> ONE MEMBER VOTES SIX.
ONE MEMBER VOTES FIVE, MEETS AND DESERVES PRIORITY CONSIDERATION, THREE MEMBERS VOTE
FOUR, MEETS.
FOUR MEMBERS VOTE THREE, MEETS.
ONE MEMBER VOTES TWO, DOES NOT MEET.
ZERO MEMBERS VOTE ONE, DOES NOT MEET.
AND ZERO MEMBERS VOTE NOT APPLICABLE.
THEREFORE THE FINDING OF THE COMMITTEE IS THE PROPOSAL MEETS CRITERION FIVE, FLEXIBILITY.
>> THANK YOU.
CRITERION SIX, ABILITY TO BE EVALUATED, AND ANY OTHER GOALS OF THE PFPN.
PLEASE VOTE.
>> ZERO MEMBERS VOTE SIX, MEETS AND DESERVES PRIORITY CONSIDERATION; THREE MEMBERS VOTE
FIVE, MEETS AND DESERVES PRIORITY CONSIDERATION.
ONE MEMBER VOTES FOUR, MEETS.
FOUR MEMBERS VOTE THREE, MEETS.
TWO MEMBERS VOTE TWO, DOES NOT MEET.
ZERO MEMBERS VOTE ONE DOES NOT MEET, ZERO MEMBERS VOTE NOTABLE, THEREFORE THE FINDING
OF THE COMMITTEE IS THE PROPOSAL MEETS CRITERION SIX, ABILITY TO BE EVALUATED.
>> CRITERION SEVEN, INTEGRATION AND CARE COORDINATION, ENCOURAGE GREATER COORDINATION AMONG PRACTITIONERS
AND ACROSS SETTINGS WHERE MULTIPLE PRACTITIONERS OR SETTINGS ARE RELEVANT TO DELIVERING CARE
TO THE POPULATION TREATED UNDER THE PFPM.
PLEASE VOTE.
>> ZERO SIX, THREE VOTE FIVE, ZERO VOTE FOUR, MEETS.
FIVE MEMBERS VOTE THREE, MEETS.
ONE MEMBER VOTES TWO, DOES NOT MEET.
ONE MEMBER VOTES ONE, DOES NOT MEET.
ZERO MEMBERS VOTE NOT APPLICABLE.
THEREFORE THE FINDING OF THE COMMITTEE IS THE PROPOSAL MEETS CRITERION SEVEN, INTEGRATION
AND CARE COORDINATION.
>> CRITERION EIGHT, PATIENT CHOICE, ENCOURAGE GREATER ATTENTION TO THE HEALTH OF THE POPULATION
SERVED WHILE ALSO SUPPORTING UNIQUE NEEDS AND PREFERENCES OF INDIVIDUAL PATIENTS, PLEASE
VOTE.
>> ZERO MEMBERS VOTE SIX, MEETS AND DESERVES PRIORITY CONSIDERATION.
TWO MEMBERS VOTE FIVE, MEETS AND DESERVES PRIORITY CONSIDERATION.
FIVE MEMBERS VOTE FOUR, MEETS.
THREE MEMBERS VOTE THREE, MEETS.
ZERO ONE OR TWO, ZERO NOT APPLICABLE.
THEREFORE THE FINDINGS OF THE COMMITTEE IS THE PROPOSAL MEETS CRITERION EIGHT, PATIENT
CHOICE.
>> CRITERION NINE, PATIENT SAFETY AIMED TO MAINTAIN OR IMPROVED STANDARDS OF PATIENT
SAFETY.
PLEASE VOTE.
>> ONE MEMBER VOTES SIX, MEETS AND DESERVES PRIORITY CONSIDERATION.
ZERO MEMBERS VOTE FIVE, MEETS AND DESERVES PRIORITY CONSIDERATION.
ONE MEMBER VOTES FOUR, MEETS.
SEVEN MEMBERS VOTE THREE, MEETS.
ONE MEMBER VOTES TWO, DOES NOT MEET.
ZERO MEMBERS VOTE ONE, DOES NOT MEET.
AND ZERO MEMBERS VOTE NOT APPLICABLE.
THEREFORE THE FINDING IS THE PROPOSAL MEETS CRITERION NINE, PATIENT SAFETY.
>> LAST CRITERION, TEN, HEALTH INFORMATION TECHNOLOGY, ENCOURAGE USE OF HEALTH INFORMATION
TECHNOLOGY TO INFORM CARE.
PLEASE VOTE.
>> ZERO FIVE OR SIX, MEETS AND DESERVES PRIORITY CONSIDERATION.
ONE MEMBER VOTES FOUR, MEETS.
NINE MEMBERS VOTE THREE, MEETS.
ZERO MEMBERS VOTE ONE OR TWO, DOES NOT MEET.
AND ZERO MEMBERS VOTE NOT APPLICABLE.
THEREFORE THE FINDING OF THE COMMITTEE IS THE PROPOSAL MEETS CRITERION 10, HEALTH INFORMATION
TECHNOLOGY.
>> THANK YOU, SARAH.
SO YOU WANT TO SUMMARIZE FOR US PLEASE?
>> . >> COMMITTEE FOUND THE PROPOSAL MET ALL OF
THE CRITERION EXCEPT FOR CRITERION NUMBER 3, PAYMENT METHODOLOGY, WHERE IT FOUND PROPOSAL
DID NOT MEET THAT CRITERION.
>> THANK YOU.
ANY MORE DISCUSSION AMONG THE COMMITTEE MEMBERS BEFORE WE VOTE ON THE RECOMMENDATION?
>> CAN I JUST ON THE RECOMMENDATION, WILL YOU CLARIFY WHETHER THAT NEW OPTION
>> IF WE'RE READY THAT'S THE NEXT BODY OF WORK TO GO THROUGH.
PUT UP THE SLIDE.
SO YESTERDAY THE LANGUAGE WE REMOVED NOT APPLICABLE, AND WE PUT LANGUAGE IN THAT REQUIRED I THINK
REQUIRED ATTENTION OR WHAT CAN YOU REMEMBER THE PHRASE WAS?
RECOMMEND FOR ATTENTION.
WHICH COULD BE IN THIS INSTANCE ANOTHER OPTION.
>> THAT WOULD BE A ZERO VOTE.
>> RIGHT, ZERO VOTE.
I GUESS I'LL MAKE A MOTION THAT THAT WOULD BE AN OPTION.
>> SECOND.
>> ALL IN FAVOR.
>> AYE.
>> OKAY.
SO WE'RE GOING TO GO AHEAD AND VOTE.
TO BE CLEAR, THAT OPTION IS A ZERO.
>> WE'RE USING LIMITED SCALE TESTING LANGUAGE FOR TWO.
>> CORRECT.
>> PLEASE VOTE.
>> SO ZERO MEMBERS VOTE 4, RECOMMEND THE PROPOSED PAYMENT MODEL FOR IMPLEMENTATION AS A HIGH
PRIORITY.
ONE MEMBER VOTES 3, RECOMMEND THE PROPOSED PAYMENT MODEL FOR IMPLEMENTATION.
SIX MEMBERS VOTE 2, RECOMMEND THE PROPOSED PAYMENT MODEL FOR LIMITED SCALE TESTING.
ZERO MEMBERS VOTE 1, DO NOT RECOMMEND.
AND THREE MEMBERS VOTE RECOMMEND FOR ATTENTION., 2/3 MAJORITY IS NEEDED, AND THEREFORE WE RULE
DOWN, SO THAT THE FINDING OF THE COMMITTEE IS RECOMMEND PROPOSED PAYMENT MODEL TO THE
SECRETARY FOR LIMITED SCALE TESTING.
>> OKAY.
I'D LIKE TO GO AROUND INDIVIDUALLY AND COMMENT AND THINK ABOUT WHEN YOU MAKE YOUR COMMENTS
FOR SALLY TO CAPTURE TO PUT IN THE LETTER OF OUR RECOMMENDATION.
SO WE'LL START WITH YOU, TIM, PLEASE.
>> GREAT.
I VOTED TO LIMITED SCALE TESTING, I WANT TO HAVE MY COMMENTS IN TWO DIFFERENT, ONE IS
ABOUT THE PROPOSAL, THE OTHER IS ABOUT THE CATEGORIES THAT WE'RE VOTING ON.
ABOUT THE PROPOSAL, IMPORTANT PROBLEM, SIMPLE, NOT SIMPLE MINDED, BUT SIMPLE PAYMENT MODEL
THAT IS SCALABLE.
I THINK IT'S UNLIKELY TO BE GAMABLE, EVERYTHING'S GAMABLE AT SOME LEVEL BUT THE SIMPLICITY AND
POPULATION SELECT ISSUES, I'M CONCERNED ABOUT THE OPENNESS OF THE POPULATION SELECTED, SELECTION
ISSUES, BUT I THINK THAT'S AN ADDRESSABLE PROBLEM.
AND I WAS ACTUALLY JUST TO COMMENT ON THE PROCESS, IT IS REMARKABLE HOW MUCH EVEN AFTER
THE PRT AND WE SPENT A LOT OF TIME TALKING AND THINKING ABOUT THIS, HOW MUCH THIS ADDITIONAL
PROCESS ESPECIALLY THE COMMENTS AND QUESTIONS OF MY COLLEAGUES, HELPED ME PROCESS THIS,
TO COME TO THIS CONCLUSION THAT THIS IS SOMETHING THAT'S VERY IMPORTANT TO THE HEALTH AND SAFETY
OF PATIENTS IN THE UNITED STATES AND SHOULD BE TESTED.
HAVING SAID THAT, I DID THINK IT WOULD BE TESTING GREATER TESTING IS THE RIGHT THING
TO DO HERE, AND I GUESS WE HAVE HAD SOME FRUSTRATION OVER FEEDBACK FROM CMS THAT THEY ARE NOT IN
A POSITION TO DO LIMITED SCALE TESTING.
I THINK THAT, TO MY MIND, THAT SHOULDN'T DISSUADE US FROM MAKING A RECOMMENDATION FOR LIMITED
SCALE TESTING BECAUSE THANKS TO YOU, JEFF, IN READING OUR DEFINITION OF LIMITED SCALE
TESTING THIS SEEMS TO FALL PRECISELY INTO THE CATEGORY OF REALLY GOOD IDEA, CAN'T POSSIBLY
WORK OUT THE DETAILS WITHOUT A LARGER SCALE, AND SO THIS IS THIS DOES ACTUALLY, TO ME,
FIT INTO THAT.
AND WE SHOULD CONTINUE THIS VERY HEALTHY DIALOGUE WE'RE HAVING WITH CMS AND THE SECRETARY AROUND
THE IMPORTANCE OF THIS.
I WILL JUST POINT OUT FOR THE RECORD SINCE AT LEAST THE EARLY '80s, MAYBE THE LATE 70s,
CMS HAS BEEN DOING DEMONSTRATIONS, I RAN ONE FOR NINE YEARS, PRECISELY THE THING THAT WOULD
BENEFIT FROM THAT DEPLOYMENT TO GENERATE THE KNOWLEDGE HERE.
AND SO THAT WAS BOTH MY COMMENTS ABOUT THE MODEL AND ABOUT THE CATEGORIES THAT WE VOTE
UNDER.
>> THANK YOU, TIM.
GRACE?
>> I WAS THE ONE WITH MY THUMB ON THE SCALE TOWARDS THE SIXES AND POSITIVE DIRECTIONS
FOR MOST OF THE CRITERIA.
THE REASON I DID THAT, ALTHOUGH I DON'T DISAGREE WITH PROBABLY MOST OF THE LOGIC OF WHAT TIM
JUST SAID AND THE REST OF YOU ARE GOING TO SAY, THAT SORT OF LANDED YOU AT LIMITED SCALE
TESTING, I DO THINK THAT THIS IS PROBABLY THE MOST CRUCIAL ISSUE THAT IF WE CAN SOLVE
IT IN A SIMPLE WAY, IN A WAY THAT I THINK WOULD BE EASILY SCALABLE, COULD BE REVOLUTIONARY
AND WOULD BE ONE OF THE BEST QUICK WINS FOR PTAC, AS WELL AS THE HEALTH CARE SYSTEM IN
THE COUNTRY.
SO I SAY THAT IN THE CONTEXT BEING TRAINED AS IN A PRACTICING GENERAL INTERNIST, AND
EVERY WHAT I THOUGHT I WAS BEING TRAINED TO DO AND WHAT I WOULD LOVE TO DO IS EXACTLY
WHAT THESE GUYS HAVE DESIGNED THEIR CARE MODEL TO DO.
BUT WHAT HAPPENED BETWEEN THE TIME OF MY TRAINING AT DUKE IN THE MID 1980s AND MY BEGINNING
PRIVATE PRACTICE IN THE EARLY 1990s IS THAT WHAT A GENERAL INTERNIST WAS CHANGED AS A
RESULT OF THE PAYMENT POLICY CHANGE, AND THAT WAS WHEN WE MORPHED INTO SOMETHING CALLED
PRIMARY CARE PHYSICIANS, WHICH WAS ABOUT A CO PAY SYSTEM.
AND SO SUDDENLY YOU'VE HAD FAMILY PHYSICIANS, AND GENERAL INTERNISTS AND PEDIATRICIANS OCCASIONALLY
OB/GYNs THAT BASICALLY HAD A MODEL OF CARE THAT WAS ABOUT SEEING AS MANY PATIENTS AS
COULD YOU IN AN EFFICIENT OUTPATIENT SETTING, AND THEN TRYING TO SCRAMBLE TO DO EVERYTHING
ELSE AND YOU COULDN'T CONCENTRATION ON WHAT INTERNISTS WERE TRAINED TO DO, ELDERLY, SICK
AND FRAIL PATIENTS IN A WAY THAT WE'RE MORE THAN A 99213 AND OFFICE VISIT 15 MINUTES.
THEN WE ENDED UP WITH HOSPITALISTS, ABOUT ANOTHER PAYMENT SYSTEM, DRG SYSTEM, WHERE
YOU NEEDED TO HAVE EFFICIENT RVU BASED CARE AT HOSPITALS, AND WE ENDED UP WITH A DIVIDE
SYSTEM.
MOST OF WHAT VALUE BASED CARE HAS BEEN AT THE LEVEL OF REDESIGNED HEALTH CARE OVER THE
LAST FEW YEARS RELATED TO MY SPECIALTY HAS BEEN TRYING TO SOLVE IN A NEW PAYMENT SYSTEM
THOSE PROBLEMS THAT WERE SOLVING THEIR OWN PROBLEMS AT THE TIME THAT WE'VE NOW GROWN
BEYOND.
SO I DON'T SEE THAT A $40 PAYMENT, AROUND A FEW PERCENTAGE GROUPINGS, IS GOING TO BE
SUCH A SCARY THING IF WE DIDN'T IMPLEMENT IT IN SOME SORT OF CONTROLLED BUT WIDESPREAD
SCALABLE WAY RIGHT NOW WE COULDN'T SEE SOME CHANGES VERY QUICKLY THAT COULD ACTUALLY BE
PRETTY PROFOUND IN TERMS OF BASICALLY TAKING CARE OF THE MEDICARE POPULATION THAT IS INCREASING
AND GROWING FOR WHICH WE HAVE A SHORTAGE OF QUALIFIED HEALTH CARE PROFESSIONALS TO TAKE
CARE OF, AND THIS COULD BE AN ULTIMATE DESIGN ELEMENT, THAT COULD MAKE A GREAT DEAL OF DIFFERENCE
FOR THAT POPULATION.
AND IT WOULD ACTUALLY BRING THE JOY BACK INTO THE PRACTICE OF GENERAL INTERNAL MEDICINE.
SO WHAT THEY ARE NOW CALLING A COMPREHENSIVE, THIS IS WHAT I THOUGHT I WAS GOING TO BE 30
YEARS AGO WHEN I WENT TO MEDICAL SCHOOL, SO ANYWAY, I HOPE THAT AS WE'RE THINKING ABOUT
THE LIMITED SCALE TESTING CONCEPT THAT OUR COLLEAGUES AT CMMI AND CMS HAVE DISSED US
ON THAT WE'RE TALKING ABOUT GETTING IT RIGHT SO WE CAN DO SOMETHING THAT'S ACTUALLY QUITE,
QUITE IMPORTANT.
>> GRACE, COULD YOU JUST CLARIFY HOW YOU VOTED?
FOR THE RECORD.
>> I VOTED I'M THE 3 THERE AND 6 ON EVERYTHING ELSE.
>> VERY GOOD.
THANK YOU.
HAROLD?
>> >> I VOTED 2 FOR LIMITED SCALE TESTING.
I THINK THIS IS A VERY DESIRABLE METHOD OF CARE THAT WE SHOULD FIND WAYS TO SUPPORT.
I THINK THAT THE FACT THAT IT IS NOT BEING DELIVERED TODAY REFLECTS THE FACT THAT THERE
ARE SOME SEVERE PROBLEMS WITH THE FEE FOR SERVICE STRUCTURE THAT EXISTS.
WE'RE ESSENTIALLY PAYING PEOPLE FOR VERY SHORT VISITS IN OFFICES AND NOT ENOUGH AT THAT LEVEL,
AND THEREFORE IT MAKES IT IMPOSSIBLE AND PRACTICAL FINANCIALLY TO DO THIS KIND OF CARE, THAT
SAYS THERE'S SOMETHING FUNDAMENTALLY WRONG WITH THE PAYMENT SYSTEM WHICH WE KNOW THERE
IS.
I DON'T THINK THE FIX IS TO LEAVE THE PAYMENT SYSTEM IN PLACE AND ADD $40 ADD ON TO THIS
PARTICULAR STRUCTURE.
AS I MENTIONED EARLIER IN MY QUESTIONS THAT LEAVES PROBLEMATIC INCENTIVES IN PLACE, ET
CETERA, AND THAT THIS PROBLEM IS IMPORTANT ENOUGH TO TRY TO SOLVE AND TO BE ABLE TO BROADLY
ACROSS THE COUNTRY THAT WE NEED TO HAVE A MORE FUNDAMENTAL PAYMENT MODEL CHANGE THAT'S
WHAT IN THIS PROPOSAL.
IT SOUNDS TO ME LIKE THE APPLICANT SAID UNDERSTANDABLY WE DON'T HAVE THE RIGHT KINDS OF INFORMATION
AND TOOLS TO BE ABLE TO DEVELOP SUCH A THING.
WE WOULD NEED GOOD AND BETTER RISK ADJUSTMENT MODELS TO DO THAT SO THEREFORE IT SEEMS TO
ME THAT IT FALLS PERFECTLY INTO THE CATEGORY OF THE LIMITED SCALE TESTING WHICH IS THAT
WE WOULD ACTUALLY NEED TO DO MORE WORK TO GET THE PAYMENT MODEL WORKED OUT AND WOULD
HAVE TO FIGURE OUT HOW THIS MODEL WOULD WORK IN A VARIETY OF SETTINGS OTHER THAN THE UNIVERSITY
OF CHICAGO TO BE ABLE TO DO THAT.
THERE'S A SECOND SORT OF PURPOSE THOUGH THAT PROPOSAL CAME TO US AS, WHICH IS TO BE ABLE
TO DO A BETTER EVALUATION OF THE CARE MODEL.
AND THERE IS, IN THE EVALUATION OF THE CARE MODEL, BECAUSE OF OF A HEALTH CARE INNOVATION
AWARD THAT THEY RECEIVED, A GRANT THAT CMMI MADE TO THEM, WHICH WAS AUTHORIZED UNDER THE
LEGISLATION THAT ALLOWS TESTING OF MODELS BECAUSE THE LAW FOR THE INNOVATION CENTER
DOESN'T TALK ABOUT PAYMENT MODELS BUT TESTING AND CARE MODELS.
FOR SOME REASON THE ATTITUDE ABOUT HEALTH CARE AWARDS IS NEGATIVE, BECAUSE HAVE EMERGED
FROM HEALTH CARE INNOVATION AWARDS, IT SEEMS IF THE REAL NEXT STEP NEEDS TO BE TO TRY OUT
THIS APPROACH AT MULTIPLE INSTITUTIONS IT WOULD BE A WHOLE LOT EASIER PARTICULARLY IF
THE INNOVATION HAS LIMITED BANDWIDTH AND CLEARANCE ISSUES TO SELECT ADDITIONAL SET AND ENABLE
A GRANT TO DO WHAT UNIVERSITY OF CHICAGO DID WHICH WOULD ACHIEVE GOALS THAT DAVID AND COMPANY
ARE TRYING TO ACHIEVE WITHOUT HAVING TO GO THROUGH ALL THE RIGMAROLE OF TRYING TO CREATE
PAYMENT CODES AND METHODS, ET CETERA, THAT IF THAT'S THE PURPOSE, SO THERE'S TWO SEPARATE
THINGS ESSENTIALLY THAT NEED TO GO ON.
ONE IS TO DO THIS IN MORE INSTITUTIONS, MORE ROBUST EVALUATION OF THE CARE MODEL AND SECOND
TO DO MORE WORK TO BE ABLE TO DEVELOP A BETTER PAYMENT MODEL THAN $40 ADD ON, BOTH SEEMS
TO FIT INTO LIMITED SQUARE TESTING, ONE POTENTIAL PAYMENT MODEL, ONE THROUGH GRANTS, I THINK
THE GRANT MODEL TO BE DONE MUCH MORE QUICKLY, ALMOST IMMEDIATELY, IF ONE WANTED TO, THAN
THE OTHER APPROACH.
SO THAT'S WHY I VOTED HOW I VOTED AND WHAT I HOPE WE MIGHT BE ABLE TO SAY SOMETHING ABOUT
IN OUR RECOMMENDATIONS.
>> I VOTED RECOMMEND FOR FURTHER CONSIDERATION, AND I THINK THERE'S NO QUESTION HMM?
EXCUSE ME, WHAT IS THE WORDING?
FOR >> RECOMMEND THE PROPOSAL FOR ATTENTION.
>> YEAH, FOR ATTENTION, YEAH.
SO, AGAIN THERE'S NO QUESTION THAT IN TERMS OF A MODEL, AGAIN I'M OF THE SAME ERA WHERE
THIS IS HOW I PRACTICED, LIKE FOREVER.
AND, YOU KNOW, AS A CARDIOLOGIST IN MY PRACTICE WE NEVER ACTUALLY USED A HOSPITALIST.
WE JUST HAD OUR CARDIOLOGY GROUP.
AND SO NOT ALWAYS THE SAME PERSON ROUNDED ON THAT PATIENT DURING THE DAY AS IN THE OFFICE,
BUT STILL A CONTINUITY WAS MUCH BETTER.
AND THAT EVOLVED, INTO IDENTIFYING HIGH RISK GROUPS LIKE THE HEART FAILURE PATIENTS, WHO
THIS IS IDEAL FOR WHERE WE HAD HEART FAILURE FLOOR, HEART FAILURE DOCTORS WHO SAW THE SAME
PATIENTS IN AND OUT, OUTCOMES WERE BETTER.
WE LEVERAGED TRANSITION OF CARE, WE LEVERAGED THOSE CODES TO HELP SUPPORT THAT.
SO I THINK IT CERTAINLY DESERVES ATTENTION, I'M NOT CONVINCED WE NEED A SEPARATE PAYMENT
MODEL SPECIFICALLY FOR THIS AS OPPOSED TO REALLY PAYING FOR THIS KIND OF CARE AND THEN
PEOPLE I THINK WILL CONTINUE TO EVOLVE BECAUSE IT'S SELF EVIDENT FOR THOSE HIGH RISK PATIENTS
IT'S A PREFERABLE WAY TO CARE FOR THEM.
>> THANK YOU, PAUL.
BRUCE?
>> I VOTED FOR LIMITED SCALE TESTING.
I WON'T I AGREE WITH TIM.
I THINK THIS IS A MODEL AND PROPOSAL SUITABLE FOR THAT, AND I THINK WE NEED TO KIND OF RESURRECT
THIS OPTION AS ONE THAT'S ENTIRELY SUITABLE, DESPITE THE NEGATIVE FEEDBACK WE'VE GOTTEN.
I THINK WE CAN CONFRONT THAT NEGATIVE FEEDBACK IN PART BY EMPHASIZING IN OUR DISCUSSION THE
IMPORTANCE OF THE POPULATION BOTH CLINICALLY AND ECONOMICALLY THAT THIS MODEL WOULD SERVE,
AND ALSO THE SCALABILITY OF THE MODEL, EVEN IF IT STARTED IN LIMITED SCALE, ITS POTENTIAL
TO BE EXPANDED UP TO THE POINT WHERE ANYONE WOULD RECOGNIZE THAT IT'S AS DR.
MELTZER SAID, IT'S ADDRESSING THE FOUR Ps, BY THE WAY CONGRATULATIONS FOR GETTING THE
FOUR Ps RIGHT, AND THEN THE SUBSEQUENT, YOU KNOW, SIMPLICITY, ET CETERA, ET CETERA.
YOU OBVIOUSLY WERE PAYING ATTENTION YESTERDAY, PROBABLY BETTER THAN MANY OF YOUR COMMITTEE
MEMBERS WERE.
AND THEN FINALLY, I WOULD LIKE TO SUPPORT WHAT GRACE SAID AND MAYBE EMPHASIZE THAT THIS
MODEL PRESENTS AND EMPHASIZES CRUCIAL ROLE PRIMARY CARE PHYSICIANS CAN AND SHOULD PLAY
IN THE MOVEMENT TOWARD VALUE BASED CARE.
THIS IS A MODEL THAT RELIES ON AND PROVIDES AN OPPORTUNITY FOR PRIMARY CARE PHYSICIANS
IF IT'S SCALED UP, AND THEN A RESULT OF THEIR PARTICIPATION IN HAVING A REALLY CRUCIAL ROLE
IN ADVANCEMENT OF PAYMENT REFORM.
>> THANK YOU, BRUCE.
SO I VOTED TO RECOMMEND FURTHER ATTENTION FOR REASONS PAUL SPOKE TO, I THINK THERE'S
A SOFT SPOT RELATIVE TO THE PAYMENT METHODOLOGY.
I THINK THAT THE BECAUSE LET ME BACK UP.
I THINK THIS IS AN INCREDIBLY IMPORTANT DELIVERY CARE MODEL THAT SHOULD BE FURTHER EVALUATED
AND REFINED FOR TESTING BECAUSE I THINK EVEN WITH ADDITIONAL REFINEMENT IT'S GOING TO REQUIRE
TESTING BEFORE LARGE SCALE DEPLOYMENT BECAUSE THERE'S A LOT OF THINGS THAT YOU JUST WON'T
KNOW RELATIVE TO THE DOWNSTREAM RAMIFICATIONS OF PUTTING A SYSTEM LIKE THIS IN DIFFERENT
COMMUNITIES, AND HOW TO ADJUST FOR THAT TO PROTECT THE SAFETY OF THE PATIENTS WHO ARE
BEING SEEN BY PEOPLE WHO ARE NOT IN THIS MODEL.
THAT SAID, I WANT THIS MODEL TO BE SUCCESSFUL AND THINK WITH FURTHER ATTENTION AND FURTHER
EVALUATION TO TRY AND GET AHEAD OF SOME OF THOSE ISSUES WHICH COULD REQUIRE FURTHER EVALUATION
BEFORE IT'S PUT IN A TESTING ENVIRONMENT, I THINK WILL SERVE THIS MODEL WELL.
SO THAT'S WHY I VOTED WITH THE REQUIRED FURTHER ATTENTION.
I GUESS THE LAST PIECE IS CLEARLY PART OF THE EVALUATION ON THE SECRETARY'S SIDE OF
THE HOUSE IS GOING TO BE HOW DOES THIS IMPACT COST.
AND I THINK INTUITIVELY AND TO SOME DEGREE BASED ON THE EXPERIENCE OF THE SUBMITTER,
IT DOES DEMONSTRATE COST SAVINGS BUT THERE IS THAT DISPARITY, RELATIVE TO THE INCONGRUENCY
POINTED OUT BY THE PRT THAT STILL IS ANOTHER PIECE THAT NEEDS TO GET ADDRESSED BEFORE THIS
GETS RELEASED INTO THE ENVIRONMENT, EVEN IN THE TESTING CIRCUMSTANCE, IN MY OPINION.
SO THANK YOU.
LEN?
>> SO I VOTED FOR LIMITED SCALE.
I WOULD OBSERVE THAT AS FAR AS I CAN REMEMBER, UNLIKE HAROLD I CAN'T REMEMBER EVERY SINGLE
PROPOSAL THAT WE GOT IN ALL THE DETAIL, BUT THIS IS THE ONLY ONE I CAN REMEMBER THAT EVER
ARE THEIR OWN RCT ALREADY FUNCTIONING.
THE GUY USES RANDOM TESTS TO FEED HIS DAUGHTER, I THINK WE CAN TRUST HIM.
I WOULD SAY THIS IS THE PERFECT MODEL FOR BETA TESTING AS WE DISCUSSED YESTERDAY, TIM'S
ELOQUENT ARTICULATION, PRECISELY BECAUSE WE'VE HAD AN ALPHA TEST ALREADY.
TO ME, IT IS ABOUT INCENTIVIZING A DIFFERENT STYLE OF MEDICINE, AND AS FAR AS I CAN TELL
EVERY SINGLE CLINICIAN WHICH MAY ALSO BE UNIQUE IN OUR HISTORY AGREES THIS STYLE OF PRACTICE
NEEDS TO BE ENCOURAGED, INDEED REMEMBERED FROM WHAT YOU DID OR HOPED YOU WOULD BE DOING
AND TURNED OUT NOT TO BE DOING GIVEN WHAT CAPITALISM HAS DONE TO OUR PROFESSION.
THE FINAL THING I WOULD SAY, I AGREE WITH JEFF THAT THE EVALUATION DISPARITY IS GOING
TO BE AN ISSUE.
I WOULD WANT THE LETTER TO REFLECT WHAT WE LEARNED ABOUT THE BIAS IN THE WHOEVER IT WAS
THAT DID THIS HCIA EVALUATION, AND TALK ABOUT HOW THAT'S GIVEN THE RESULTS THAT HAVE BEEN
EXPERIENCED SINCE, THAT'S PRIMA FACIE EVIDENCE, BUT THE LETTER SHOULD REFLECT WHAT WE THINK
IS MAL INTENT, DIDN'T HAVE THE DATA AND LOST CLAIMS FOR BIAS.
>> I VOTED FOR WHATEVER THE CATEGORY IS NOT LISTED.
>> FURTHER ATTENTION FURTHER ATTENTION, THANK YOU.
I'M HAPPY TO SEE WHEN PTAC DOES NOT AGREE WITH THE FINDINGS, I CHANGED MY OWN VOTING
BASED ON OUR CONVERSATION, SO I WANT TO EMPHASIZE SEVERAL ASPECTS IN THE SECRETARY'S LETTER,
I DID NOT VOTE FOR LIMITED SCALE TEGSING BECAUSE OF THE WAIT THAT THAT CATEGORY SEEMS TO NOT
BE DEALT WITH, BY CMS, AND I FEEL STRONGLY THIS SHOULD NOT BE RELEGATED TO JUST AN APM.
TO ME THIS HIGHLIGHTS WHAT I WOULD SAY IS IS IMPORTANT CRITICAL CM IN THINKING THROUGH
THE EXISTING SET OF CODES THAT I TOSSED AROUND AS THE ONES I HAVE TO LIVE ON A LITTLE HAMSTER
WHEEL TO ADDRESS IMPORTANT CONTINUITY OF CARE SO FOR THAT REASON I WANTED TO HIGHLIGHT THIS
FOR ATTENTION AND FOR THE SECRETARY I WOULD SAY THIS GOES WELL BEYOND, IN MY OPINION,
CMMI.
THIS HAS APPLICATIONS IN ALMOST EVERY ASPECT OF MEDICARE AND MEDICAID, BECAUSE THE ISSUES
BROUGHT UP CLINICALLY ARE NOT LIMITED, IN MY OPINION.
SECOND POINT FOR THE SECRETARY'S LETTER THAT WE'VE HIGHLIGHTED SOME OF THE LIMITATIONS,
WEAKNESSES, ET CETERA.
I THINK YOU HEARD IT FROM DAVID MELTZER THAT IT'S EXACTLY THE TECHNICAL ASSISTANCE AND
THINKING THROUGH CONSTRUCTS THAT WE NEED TIME AND SPACE IN WHATEVER FORMAT THAT IS AND HAVING
HEARD FROM THE DEPUTY ADMINISTRATOR YESTERDAY THAT WE'RE GOING TO BE MOVING FORWARD WITH
A SERIOUS ILLNESS MODEL, CHRONIC KIDNEY DISEASE MODEL OF SOME KIND AND PRIMARY CARE MODEL.
I CAN THINK OF EACH OF THOSE THREE MODELS HAVING SOME ELEMENT THAT BUILDS BACK ON WHAT
HAS BEEN DESCRIBED HERE TODAY.
SO I WOULD HOPE THAT SOME OF TODAY'S DISCUSSION IS REFLECTED IN THOSE THREE MODELS WHICH WE'VE
ALREADY HEARD ARE IN FORMATION PROCESS, ET CETERA.
MY THIRD POINT, NOT NECESSARILY JUST FOR THE SECRETARY'S LETTER BUT COLLEAGUES, A FULL
TIME COMMUNITY BASED PRIMARY CARE PHYSICIAN, IF YOU LOOK AT AMGA INDICES AS AN INTERNIST
I CAN MAKE IN THE D.C. AREA AVERAGE SALARY, AVERAGE TAKE HOME AROUND $185,000, MY HOSPITALIST
COLLEAGUES IN THE SAME GEOGRAPHY, I WAS RECRUITED, PEOPLE THOUGHT I WAS SMART ENOUGH, THEY MAKE
$250,000 TO $260,000, THIS IS THE KIND OF MODEL I WANT TO BE IN, I'M WORRIED PEOPLE
WILL USE THAT AS AN EXCUSE TO PAY LESS FOR WHAT I THINK IS CRITICALLY IMPORTANT AND I
WOULD SAY THAT TO ME IT SPEAKS TO POINT NUMBER ONE, WE HAVE TO LOOK AT THE VALUATION OF THIS
WORK, IT'S LIKE PORNOGRAPHY, WE KNOW IT WHEN WE SEE IT, KNOW GOOD CARE WHEN WE SEE IT.
WE HAVE NO WAY OF VALUING IT, I WORRY IF THIS GETS RELEGATED TO LIMITED SCALE OR SOMETHING
SMALLER WE HAVEN'T APPRECIATED THE FULL OPPORTUNITY OF WHAT WE CAN DO HERE.
>> WELL, HAVING JUST HEARD KAVITA, IF WE COULD CHANGE THE RULES SO I COULD VOTE FOR BOTH,
IT NEEDS MORE ATTENTION.
>> THIS IS YOUR LAST MEETING.
[LAUGHTER]
>> IT NEEDS MORE ATTENTION BECAUSE IT'S FUNDAMENTALLY A FEE SCHEDULE OPPORTUNITY TO INCREASE VALUE
IN THE FEE SCHEDULE.
AND IT ALSO NEEDS TO BE DEMONSTRATED.
AND ONE OF THE AMAZING THINGS, I FIND IT AMAZING, WE DO DEMOS OF ALTERNATIVE PAYMENT MODELS
AND NOT ANYTHING COMPARABLE ON THE FEE SCHEDULE MIND.
CMS HAS AN ABSURD PAYMENT MODEL TO GET RID OF DOCUMENTATION GUIDELINES WITH NO EMPIRICAL
EVIDENCE OF BEHAVIORAL RESPONSE FROM ANYBODY SO WE SPEND ABOUT $90 BILLION A YEAR IN THE
MEDICARE FEE SCHEDULE AND DON'T DEMONSTRATE NOTHING, AND HERE WE ARE DOING APMs.
I HAD A DIFFICULTY DECIDING WHETHER TO GIVE THIS A 2 OR 3 ON PAYMENT BECAUSE USING THE
CRITERIA TIM AND LEN AND I WRESTLED WITH ONCE IN OUR PRT WE'RE NOT MEASURING QUALITY, AND
WE'RE NOT REWARDING WE'RE NOT REWARDING WE DO SPENDING, THEY ARE NOT TAKING RISK, SO
IT'S NOT AN APM, AND YET IT'S NEW PAYMENT MODEL.
BUT IT DOESN'T QUALIFY AS A MACRA PAYMENT MODEEL, CERTAINLY NOT ADVANCED MACRA PAYMENT
MODEL AND NEEDS TO BE DEMOED, AND SO I'M WITH KAVITA COMPLETELY THAT WE NEED TO ELEVATE
THIS AS IT'S NOT JUST HERE'S AN OPPORTUNITY TO DO A LIMITED SCALE TESTING AND DEMO, BUT
THAT IT ALSO POINTS TO THE NEED TO WELL, I DON'T KNOW.
I DON'T WANT TO OVERSELL WHAT WE CAN SAY IN A LETTER TO THE SECRETARY, BUT I SEE THIS
FUNDAMENTALLY I ACTUALLY THINK IT COULD BE DONE EITHER WAY, HAROLD RAISED GOOD POINTS
ABOUT MAYBE THIS SHOULD BE THROUGH A PMPM WITH RISK ADJUSTMENT.
DAVID MAKES GOOD POINTS, VERY IMPORTANT POINTS, WE'RE NOT REALLY READY BECAUSE OF THE FAILURE
OF RISK ADJUSTMENT TO MAKE AS MUCH PROGRESS AS WE WOULD LIKE THROUGH APMs AND MAYBE NEED
TO CONTINUE TO FOCUS ON IMPROVING VALUE IN THE FEE SCHEDULE.
I THINK THIS IS THE SORT OF EXEMPLARY SITUATION OF MAKING THE CASE THAT THE FEE SCHEDULE ACTUALLY
NEEDS MORE ATTENTION AND WITH THAT I'LL STOP.
>> BOB, HOW DO YOU VOTE?
>> (INAUDIBLE).
>> HAPPILY VOTED FOR TWO, BUT I'M VERY SYMPATHETIC TO THE ASTERISK.
>> VERY GOOD.
THANK YOU.
RHONDA?
>> I'LL BE SHORT.
I VOTED FOR TWO.
I AGREE WITH MOST OF THE COMMENTS ALREADY MADE, I'M NOT GOING TO REPEAT THEM.
I WOULD LIKE TO MAKE SURE IN THE SECRETARY'S LETTER THE NOTICE THAT THE OPTION THIS MODEL
OF CARE NEEDS FURTHER STUDY AND ATTENTION AND SUPPORT TO GO FORWARD.
IT'S IMPORTANT THE OPTION BE MADE AVAILABLE, BENEFIT OF BOTH THE PHYSICIANS AND PROVIDERS
OF CARE AS WELL AS POPULATIONS WHO WILL GREATLY BENEFIT FROM IT.
I AM VERY HAPPY TO HEAR THE SUBMITTERS TALK ABOUT THEIR WILLINGNESS TO INCLUDE OR AT LEAST
CONSIDER SOME QUALITY MEASURES FOR THOSE POPULATIONS THAT ARE NOT IN ACOs PARTICULARLY AROUND QUALITY
AND PATIENT SAFETY, I THINK THE PAYMENT MODEL NEEDS A LITTLE BIT MORE WORK, A LITTLE BIT
MORE FINE TUNING AS ALREADY ELICITED, I WILL NOT SAY ANYTHING MORE.
THANK YOU VERY MUCH, MR.
CHAIR.
>> THANK YOU.
SALLY?
OH, BRUCE.
SORRY.
>> YEAH, I KNOW WE NEED TO GO THROUGH THAT SO MAYBE THIS IS THE RIGHT TIME BUT I THINK
IT NEEDS TO BE DONE PUBLIC.
I WAS GOING TO PROPOSE WE CHANGE THE CATEGORIES OF RECOMMENDATIONS TO THE SECRETARY, AND MAKE
WHAT'S THE ASTERISK ACTUALLY NUMBER TWO, AND THEN MOVE EVERYONE BELOW NUMBER TWO TO THREE,
FOUR AND FIVE.
DO YOU SEE WHAT I'M SAYING?
>> NO.
>> NO?
WELL, YOU DON'T >> (INAUDIBLE).
>> YOU MEAN FOR THE FUTURE?
>> YEAH, FOR THE FUTURE.
>> OH.
>> WELL, I THINK IT NEEDS TO BE DONE IN PUBLIC.
DO IT IN DECEMBER?
ALL RIGHT.
>> THANK YOU, BRUCE.
>> OKAY.
SO I'M GOING TO LET SALLY GIVE US A READBACK HERE.
THANK YOU.
>> SURE.
I'M GOING TO THANK THE GROUP FOR THE TWO VERY DIFFERENT MODELS.
I'VE BEEN INVOLVED IN TWO DIFFERENT PROCESSES, FASCINATING.
I'M GOING TO FRAME IT MORE I THINK IN TERMS OF HOW THE LETTER WILL DEAL WITH THE VOTE,
HOW WE ENVISION THE LETTER DEALING WITH THE VOTE, REGARDLESS OF HOW PEOPLE VOTED THERE
WAS SUBSTANTIAL ENTHUSIASM FOR THE MODEL.
THERE WAS A VERY STRONG FEELING THAT THERE'S A POPULATION OF PATIENTS AND PHYSICIANS THAT
NEED THIS MODEL TO IMPROVE QUALITY OF CARE.
THERE WERE NO DOUBTS WILL THAT.
THERE WAS SOME BENEFICIAL THINGS LIKE ACKNOWLEDGMENT THAT MORE QUALITY MEASURES COULD BE INCORPORATED
AND WE'LL ADD DETAILS LIKE THAT.
OKAY.
I THINK THAT WHERE WE GET INTO THE ISSUE AND THE MOST IMPORTANT CHANGE, THERE WAS CHANGES
IN THE CATEGORIES OF VOTING, I THINK THE MOST IMPORTANT IS THE PAYMENT METHODOLOGY DOES
NOT MEET >> WHEN YOU SAY THE MODEL, CAN YOU SAY THE
CARE MODEL?
WHAT YOU'RE REFERRING TO IS CARE MODEL.
>> I DO MEAN THE CARE MODEL, POSITIVELY RECEIVED, WE DON'T NEED TO SPEND TIME BECAUSE THERE
WAS UNANIMITY ON THAT.
THE ISSUES COMES UP FOR THE PAYMENT MODEL.
I THINK WHERE THAT COMES UP IS PRETTY MUCH THE SPLIT OF THE VOTE.
I THINK THERE'S SOME SUPPORT AND I'VE GOT FOR DIFFERENT MEMBERS, IN TERMS OF TRYING
THIS MODEL FURTHER, I'LL CALL IT A BETA TEST.
WE'LL TRY TO GET THE WORDS RIGHT.
BUT THAT FOR WHAT IS WORKING IN CHICAGO THERE'S INTEREST IN KNOWING IF THAT MODEL WOULD HAVE
SIMILAR EFFECTS IN DIFFERENT SETTINGS.
AND THERE'S SEVERAL MEMBERS OF THE GROUP WHO FEEL THAT WAY.
ON THE OTHER HAND, I THINK THE NEEDS ATTENTION GROUP LARGELY FELT THAT IT WASN'T CLEAR, AND
HERE, BOB, I WAS NOT SURE HOW YOU VOTED AT FIRST, BUT THAT
>> (INAUDIBLE).
>> YEAH, YOU ACTUALLY MENTIONED ALL THREE, WHICH ONE.
I THINK THE POINT IS THAT THE REASON WHY IT DOESN'T MEET THE PAYMENT METHODOLOGY IS REFLECTED
BY THE SPLIT IN THE VOTE, THAT THERE'S SOME PEOPLE WHO WOULD LIKE TO SEE THIS MODEL TESTED
MORE, SEE US GIVING THIS PAYMENT JUST TO HELP THE PRACTICES RESTRUCTURE HOW THEY ARE PROVIDING
CARE, ENABLE THEM TO FOCUS ON THE PATIENT IN BOTH INPATIENT AND OUTPATIENT SETTINGS
SINCE IT'S WORKING WELL IN CHICAGO WELL, I'LL MAKE A COMMENT IN A MINUTE ABOUT THE HCIA
EVALUATION BUT SINCE IT'S REPORTED TO BE WORKING WELL IN CHICAGO, POSITIVE QUALITY IMPROVEMENT
IN THE HCIA EVALUATION, THERE ARE A NUMBER OF MEMBERS WHO FEEL FURTHER TESTING
WOULD BE VERY BENEFICIAL.
THEN I THINK, THIS IS SORT OF THE SPLIT IN THE VOTE PRIMARILY, IN TERMS OF NEEDING ATTENTION,
WHAT IS THE BEST WAY TO GET THE CARE MODEL GIVEN THE AGREEMENT ON THE CARE MODEL, ARE
THERE OTHER APPROACHES, COULD WORKING ON THE FEE SCHEDULE INSTEAD OF APM BE THE BEST APPROACH
HERE, AND THAT CERTAINLY CAME UP IN THE COMMENTS.
I WANTS TO MAKE A POINT ABOUT THE HCIA EVALUATION, THAT IS THAT DAVID MELTZER EMPHASIZED REASONS
WHY HE BELIEVES HIS RESULTS ARE DIFFERENT, FROM
THE HCIA EVALUATION, NOT PROVEN CONCLUSIVELY, I WILL SAY THE CARE MODEL, THE COST OF CARE.
>> I THINK IT'S ALSO TRUE THAT YOU WANT TO INDICATE THAT THERE'S A GOOD REASON TO BELIEVE
THAT THE EVALUATION THAT WAS DONE FOR THE HCIA WAS ACTUALLY FLAWED, NOT BY INTENT BUT
BY THE DATA AVAILABILITY SO I THINK THAT POINT IS IMPORTANT AS CONTEXT FOR WHAT YOU SAID
ABOUT THE NEED FOR FURTHER EVALUATION.
>> ABSOLUTELY.
AND WE CAN EXPAND ON THAT BOTH WITH WHAT DAVID MELTZER PROVIDED AS WELL AS SOME SPECIFIC
POINTS.
>> HAROLD?
>> SO I LIKE YOUR SUMMARY.
I WOULD MAYBE JUST FEEDBACK ON THE STRUCTURE THAT I SEE, AND SEE IF OTHER PEOPLE AGREE
WITH THIS, THE FIRST LAYER IS GOOD CARE MODEL, SECOND LAYER IS WE AGREE NEEDS TO BE REPLICATED
IN MORE SITES, BECAUSE IT NEEDS TO BE EVALUATED, ADDITIONAL EVALUATION NEEDS TO BE DONE.
AND THEN TO ME THERE'S SORT OF A THIRD LAYER WITH TWO PARTS.
ONE, THERE NEEDS TO BE A WAY TO ENABLE THAT ADDITIONAL SITES TO HAPPEN, AND THEN THERE
NEEDS TO BE SOME SORT OF A PAYMENT A WAY OF PAYING THAT WILL SUPPORT THIS CARE MODEL,
IF IN FACT IT'S DEMONSTRATED THAT IT WORKS AS PEOPLE BELIEVE IT IS.
AND THAT WE'RE NOT CONVINCED WHAT IS THE RIGHT WAY TO PAY, THERE COULD BE CHANGES TO FEE
SCHEDULE, ADD ONS, WHATEVER, BUT THERE ARE MULTIPLE WAYS TO DO THAT.
I WOULD SUGGEST WE THINK ABOUT THOSE TWO SORT OF PIECES BECAUSE I BELIEVE THERE'S A WAY
TO GET THIS TESTED IN SEVERAL MORE PLACES WITHOUT NECESSARILY HAVING TO HAVE A NEW PAYMENT
MODEL TO DO IT, A LA MAKING GRANTS, ET CETERA.
BECAUSE THIS MODEL DID NOT HAVE THE PAYMENT MODEL AS PART OF IT.
IT'S NOT THAT THEY DID THIS WITH A $40 ADD ON AND NOW THE QUESTION IS CAN WE DO IT IN
MORE PLACES.
THEY DID IT WITH A GRANT.
THE PAYMENT MODEL THEY ARE PROPOSING HAS NOT BEEN TRIED ANYWHERE AT ALL, SO THE ISSUE IS
IF THERE'S TWO DIFFERENT PURPOSES, ONE IS SEE IF WE CAN GET THIS IN MORE SITES AND EVALUATE,
AND SECOND OF ALL HOW DO YOU PAY TO BE ABLE TO SUPPORT THE APPROACH TO CARE, THOSE ARE
SORT OF TWO DIFFERENT INTERRELATED BUT DIFFERENT THINGS.
AT LEAST THAT'S MY SUGGESTION HOW TO FRAME IT.
>> LEN?
>> THAT MADE ME THINK THAT IT'S PROBABLY WORTH INCLUDING THAT AT THE END OF THE DAY THERE'S
WE WANT TO MOVE WE WANT TO MOVE THIS ABOVE THE OBJECTION OF LIMITED SCALE BEFORE, AND
WHAT I WOULD INVITE YOU TO TRY TO DO, AND I'M NOT SURE HOW TO SAY IT AT THIS MOMENT,
BUT I WAS REALLY STRUCK THAT THE PRT FAILED IT ON SCOPE, AND YET WHEN WE TALK ABOUT IT
AT SCOPE NOW WE'VE GOT SIXES AND FIVES.
GRACE GOT GREATED.
PEOPLE THAT VOTED AGAINST IT AND FOR IT THIS TIME SCOPE IS IMPORTANT, AND SCOPE, THE POTENTIAL
OF WHAT THIS COULD BE, NEEDS TO BE EMPHASIZED TO GET IT ABOVE
LIMITED SCALE.
>> WE NEED TO TALK ABOUT WHAT WE THINK THE LIMITED IMPACT MIGHT BE, TO BE CLEAR.
>> TIM?
>> I MIGHT SUGGEST SINCE IT COMES UP SO FREQUENTLY THE CATEGORY OF SCOPE BECAUSE I NEED TO RAISE
IT ONE MORE TIME IN THIS SESSION, THE CATEGORY OF SCOPE HAS BEEN PROBLEMATIC RIGHT FROM THE
START, BECAUSE THERE ARE SO MANY DIFFERENT CONCEPTS INCLUDED IN THE ONE CATEGORY THAT
WHEN EACH OF US IS VOTING IT'S OBVIOUS WE OFTEN HAVE ARE EMPHASIZING A DIFFERENT PIECE
OF WHAT IS INCLUDED UNDER SCOPE, AND I MIGHT SUGGEST THAT WE AS A COMMITTEE RELOOK AT THAT
CATEGORY AND THINK ABOUT A WAY TO HELP US BE CLEARER, BOTH WITH OURSELVES AND WITH THE
PUBLIC, ABOUT WHEN WE ARE VOTING ON THAT CRITERIA, WHAT EXACTLY ARE WE VOTING ON.
SO FUTURE PROCESS POINT.
>> THANK YOU.
I THANK EVERYBODY FOR GREAT DISCUSSION AND I THINK THAT THE FACT THE PRT HAD THE POINT
OF VIEW ALMOST THE SAME THING HAPPENED YESTERDAY, AND THROUGH THIS DIALOGUE AND DELIBERATION,
WHICH WAS EXACTLY THE PURPOSE OF OUR STANDING UP THE PROCESS THE WAY WE DID, IT ALLOWS THE
INSIGHTS FOR US TO GUIDE OUR ULTIMATE RECOMMENDATION TO THE SECRETARY, SO I THINK THAT THAT ENSURES
THAT THE RECOMMENDATIONS ARE AS RICH AS POSSIBLE.
I WANT TO THANK THE APPLICANTS FOR HANGING WITH US THE ENTIRE TIME, AND I THINK PART
OF YOUR YOUR CONTRIBUTION REALLY HELPS SHAPE THE DIALOGUE AND WHERE WE LANDED SO I WANT
TO THANK YOU FOR THAT, AND ALL THE PATIENTS THAT YOUR PROGRAM TOUCHES TODAY, AND THE FUTURE
PATIENTS THAT WILL BE TOUCHED BY THIS MODEL ULTIMATELY IN THE FUTURE.
SO THANK YOU FOR THAT.
WE ARE NOT GOING TO CLOSE OUT.
WE'RE CLOSING OUT THIS SESSION FOR THE EVALUATION OF THE MODEL BUT WE'RE NOW GOING TO MOVE INTO
THE NEXT PORTION OF OUR MEETING, WHICH IS HEARING PUBLIC COMMENTS, REGARDING OUR PROCESS.
AND SO WE HAVE ONE PERSON HERE IN PERSON.
LIKE I SAID TWO?
WHERE IS THE SECOND PERSON?
OH.
GOT IT, OKAY, I'M SORRY.
WE HAVE SANDY, SANDY MARX HERE.
I DIDN'T SEE YOUR NAME, SANDY.
SORRY ABOUT THAT.
>> I'M SANDY MARX, AMERICAN MEDICAL ASSOCIATION.
THANK YOU FOR THE OPPORTUNITY TO PROVIDE COMMENTS ON PTAC PROCESSES, THE AMA COMMENDS AND THANKS
THE PTAC MEMBERS FOR THE MANY HOURS YOU HAVE DEVOTED TO REVIEWING COMMENTING AND MAKING
RECOMMENDATIONS ON PROPOSALS.
WE HAVE BEEN VERY IMPRESSED WITH THE SPEED, THOROUGHNESS OF OBJECTIVITY, FLEXIBILITY,
AND TRANSPARENCY WITH WHICH YOU'VE CARRIED OUT YOUR WORK TO DATE, AND WE ALWAYS APPRECIATE
YOUR OPENNESS TO FEEDBACK WHICH IS WHY WE'RE ALWAYS HERE PROVIDING IT.
IN A RECENT LETTER TO THE AMA CEO AND ONE ON ONE MEETING DIRECTOR BOEHLER SAID HE AND
HHS AGREE WITH THE AMA THAT, QUOTE, THE CONTRIBUTIONS OF PRACTICING PHYSICIANS IN DRIVING THIS TRANSFORMATION
ARE INDISPENSABLE AND THEY, QUOTE, RESPECT THE GOOD PROPOSALS SUBMITTED TO PTAC BY INDIVIDUALS
AND STAKEHOLDERS THUS FAR.
HOWEVER, PHYSICIANS ARE TRAINED TO DIAGNOSE AND TREAT PATIENTS.
NOT TO DESIGN APMs.
IT IS NOT SURPRISING THAT MANY PROPOSALS TO PTAC CONTAIN GREAT IDEAS FOR IMPROVING DELIVERY
OF CARE BUT HAVE SOME WEAKNESSES IN THE PROPOSED PAYMENT MODELS.
TO ADDRESS THIS, THE PTAC DISCUSSED NEED TO PROVIDE
TO APPLICANTS.
UNFORTUNATELY, UNDER PTAC'S NEW INITIAL FEEDBACK PROCESS, YOU PLAN TO TELL APPLICANTS WHAT
IS WRONG WITH THEIR PROPOSALS, BUT NOT HELP THEM TO CORRECT THE PROBLEMS.
THIS IS NOT CONSISTENT WITH CONGRESSIONAL INTENT AND DOESN'T FILL THE NEED IDENTIFIED.
WE RECOMMEND EXPANDING THE INITIAL FEEDBACK PROCESS IN THREE WAYS.
FIRST, PTAC SHOULD PROVIDE INITIAL FEEDBACK ON PROPOSALS WITHOUT REQUIRING SUBMISSION
OF A COMPLETE PROPOSAL.
PTAC HAS PRELIMINARY REVIEW TEAMS AND THEY SHOULD BE ABLE TO PROVIDE FEEDBACK ON PRELIMINARY
OR LESS THAN COMPLETE AND FINAL PROPOSALS.
SECOND, IF THERE ARE PROBLEMS WITH THE DETAILS OF A PROPOSED MODEL, PTAC SHOULD SUGGEST POTENTIAL
ALTERNATIVE APPROACHES.
YOU DO NOT NEED TO BE PRE SCRIPT IRKTSVE BUT HELP PEOPLE DEVELOP A BETTER APPROACH.
THIRD, BIGGEST BARRIER MOST APPLICANTS FACE, WE HEAR ABOUT THIS CONSTANTLY, I'M SURPRISED
THERE'S ONLY TWO OF US HERE TODAY FRANKLY BECAUSE PEOPLE ARE ALWAYS TALKING ABOUT THE
PTAC AND MODELS, MAYBE THEY ARE SHY AND WILL SEND YOU LETTERS, I DON'T KNOW.
THE BIGGEST BARRIER MOST APPLICANTS FACE IS THE INABILITY TO OBTAIN MEDICARE CLAIMS DATA
TO QUANTIFY SAVINGS OPPORTUNITIES AND CREATE BUSINESS CASE FOR THE APM.
PTAC GENERATES DATA ANALYSES FOR PROPOSALS BUT THESE NEEDS TO BE PROVIDED TO APPLICANTS
MUCH EARLIER IN THE PROCESS SO THEY CAN USE THEM TO IMPROVE THEIR PROPOSALS.
WE SUPPORT THE PTAC PROCESS AND ENCOURAGE YOU TO PROVIDE AS MUCH ASSISTANCE TO APPLICANTS
AS POSSIBLE, SO YOU'LL GET THE BEST PROPOSALS POSSIBLE.
THE AMA WANTS TO MAKE SURE YOU KNOW WE'RE AVAILABLE TO HELP YOU IN ANY WAY THAT YOU
NEED.
WE HAVE BEEN CONTINUING TO ADVOCATE WITH CONGRESS AND THE ADMINISTRATION ON THE NEED FOR ROBUST
APM PATHWAY UNDER THE QUALITY PAYMENT PROGRAM AND WE FEEL PHYSICIAN FOCUSED APMs CONTINUE
TO BE A KEY MISSING ELEMENT.
THANK YOU.
>> THANK YOU, SANDY.
AND NOW ANN HUBBARD WITH ASTRAL.
THANK YOU.
>> GOOD AFTERNOON, I'M ANN HUBBARD WITH AMERICAN SOCIETY FOR RADIATION ONCOLOGY, I APPRECIATE
THIS OPPORTUNITY.
ASTRO WISHES TO THANK THE PTAC FOR INTEREST IN PUBLIC INPUT AND DIALOGUE WITH REGARD TO
DEVELOPMENT, WE APPRECIATE THE OPPORTUNITY ON THE INITIATIVE AND PTAC PFPM DEVELOPMENT.
ASTRO APPRECIATES MOVING FORWARD, IMPORTANT FOR REVIEW TEAM TO PROVIDE FEEDBACK ON EXTENT
TO WHICH PROPOSAL MEETS SECRETARY'S CRITERIA AND EXPLANATION ON THE BASIS OF THE FEEDBACK.
HOWEVER, THE IMMEDIATE FEEDBACK PROPOSAL INCLUDES QUALIFIERS FOR WITH THE PRT WILL NOT PROVIDE
WHICH INCLUDE INSTRUCTIONS ON HOW TO REMEDY OR ADDRESS SHORTCOMINGS, DATA OR ANALYSIS
TO DEVELOP A PROPOSAL, INDIVIDUALIZE CONSULTATION OR TECHNICAL ASSISTANCE WITH REGARD TO DEVELOPMENT
OF PROPOSED MODEL.
LIMITATIONS THAT PTAC SET FORTH WITH REGARD TO INITIAL FEEDBACK RUN CONTRARY TO CONCERNS
IN AN AUGUST 14, 2017 LETTER, RECOGNIZING SIGNIFICANT NEED AMONG PFPM SUBMITTERS FOR
TECHNICAL ASSISTANCE, ACCESS TO DATA ANALYSIS AND DATA SHARING CAPABILITIES FOR SUBMISSION,
I'M SORRY, FOR PHYSICIAN SUBMITTERS.
PTAC RECOGNIZED THE PHYSICIANS ARE EXPERTS AT DELIVERING CARE BUT NOT NECESSARILY DESIGNING
PAYMENT MODELS, AND RECOMMENDED ESTABLISHMENT OF PUBLIC WORKSHOPS, ACCESS TO DATA AND TECHNICAL
ASSISTANCE ON DATA SHARING TO ASSIST WITH PFPM SUBMISSIONS.
WE'RE URGE PTAC TO ESTABLISH IMMEDIATE FEEDBACK CRITERIA MORE IN ALIGNMENT WITH RECOMMENDATIONS
SHARED IN THE AUGUST 14, 2017 LETTER.
WE BELIEVE THIS WILL RESULT IN PFPMs SUCCESSFULLY IMPLEMENTED, SERVING AS A BENEFICIAL TOOL.
THANK YOU FOR THE OPPORTUNITY.
>> THANK YOU, ANN.
ANYONE ELSE IN THE AUDIENCE WHO DIDN'T REGISTER THAT WANTS TO MAKE A PUBLIC COMMENT REGARDING
OUR PROCESS?
I'D LIKE TO ASK THE OPERATOR IF THERE'S SOMEONE ON THE PHONE WHO WANTS TO MAKE A PUBLIC COMMENT?
>> NOBODY HAS QUEUED UP ON THE PHONE.
>> I WANT TO ALSO NOTE THERE ARE EIGHT PUBLIC COMMENTS THAT HAVE BEEN SUBMITTED BY E MAIL
AND WE'RE GOING TO TAKE A LOOK AT THOSE.
HAROLD AND LEN?
>> I WONDERED IF IT MIGHT NOT BE A GOOD TIME TO YOU HAVE OR MAYBE SARAH OR ANN OR SOMEBODY
EXPLAIN WHY WE CAN'T DO TECHNICAL ASSISTANCE IN THE WAY WE ACTUALLY WANTED TO FOR QUITE
SOME TIME, BECAUSE I THINK MAYBE NOT EVERYBODY UNDERSTANDS THE LIMITS.
YES, THE LAW WAS CHANGED, AND I BELIEVE THE LANGUAGE STARTED OUT AS TECHNICAL ASSISTANCE
AND GOT CHANGED INTO INITIAL FEEDBACK OR WHATEVER BECAUSE OF CONSTRAINTS THAT ARE PERCEIVED
THAT MOST PEOPLE DON'T KNOW ABOUT, I CERTAINLY DIDN'T KNOW ABOUT, AND WE DIDN'T KNOW ABOUT
THE FIRST YEAR, HHS WAS HELPING UNTIL THEY WERE TOLD TO STOP.
>> ALL RIGHT.
SO WE'LL JUST I DON'T KNOW, ANN, I MEAN, SARAH.
>> I'M COMFORTABLE JUST READING THE STATUTORY LANGUAGE ADDED BY THE BIPARTISAN BUDGET ACT
OF 2018.
SO ADDED LANGUAGE THE COMMITTEE SHALL REVIEW MODELS COMMITTED UNDER PARAGRAPH B AND MAY
PROVIDE INDIVIDUALS AND STAKEHOLDER ENTITIES WHO SUBMITTED SUCH MODELS, SO THAT'S SUBMITTERS.
WITH INITIAL FEEDBACK, ON SUCH MODELS, REGARDING THE EXTENT TO WHICH SUCH MODELS MEET THE CRITERIA
DESCRIBED IN PARAGRAPH A, IN EXPLANATION OF THE BASIS FOR FEEDBACK PROVIDED, UNDER THAT
SUBCLAUSE.
SO THAT'S THE ADDITIONAL FEEDBACK THAT IS THE ADDITIONAL LANGUAGE IN AUTHORITY THAT
PTAC HAS BEEN GRANTED.
>> I THINK WHAT WE NEED TO CONVEY TO THE PUBLIC IS WHAT WE WERE TOLD ABOUT WHY WE CAN'T DO
TECHNICAL ASSISTANCE BECAUSE I THINK THAT IT'S NOT THAT WE'RE CHOOSING NOT TO.
WE'RE PREVENTED FROM IT.
>> SO THIS PARTICULAR STATUTORY LANGUAGE CHANGE DOES NOT INCLUDE TECHNICAL ASSISTANCE.
>> (INAUDIBLE).
>> I'M NOT SURE I CAN ANSWER THAT ONE.
IT JUST SAYS INITIAL FEEDBACK.
>> HAROLD?
>> SO, I WAS GOING TO SAY SORT OF THE SAME THING THAT LEN SAID.
I WANT TO SAY TO TO SANDY AND ANN AND ANYONE ELSE WHO MAY BE WONDERING, I WILL SPEAK FOR
MYSELF AND OTHERS CAN ADD ON, I AM NOT HAPPY WITH THE WAY WE HAVE STRUCTURED THE INITIAL
FEEDBACK PROCESS.
I BELIEVE THAT THE INITIAL FEEDBACK PROCESS SHOULD HAVE MORE ASSISTANCE TO APPLICANTS
THAN WHAT IS PROVIDED THERE AND WE SHOULD NOT SIMPLY BE TELLING PEOPLE WHAT IS WRONG
AND SHOULD NOT BE LIMITED IN DATA WE CAN PROVIDE.
HOWEVER, WE HAVE BEEN TOLD BY THE OFFICE OF GENERAL COUNSEL AT THE DEPARTMENT OF HEALTH
AND HUMAN SERVICES THAT WE CANNOT DO THOSE THINGS, BECAUSE THEIR INTERPRETATION OF THE
LAW IS IT IS NOT PERMISSIBLE FOR US TO DO THOSE THINGS.
I BELIEVE THAT IS AN OVERLY NARROW INTERPRETATION, AND I BELIEVE IT COULD BE INTERPRETED MORE
BROADLY BUT IT IS WHAT IT IS. AND SO I THINK IT'S IMPORTANT FOR PEOPLE TO
UNDERSTAND THAT IF IN FACT YOU WOULD LIKE THAT KIND OF ASSISTANCE, THE LAW WILL HAVE
TO BE CHANGED AGAIN, BECAUSE WHAT WE'VE DONE TO THE LAW DOES NOT GO FARTHER WE WENT AS
FAR AS WE COULD GO, IN MY OPINION, IN TERMS OF WHAT WE WERE TOLD WE COULD DO IN THOSE
INITIAL FEEDBACK GUIDELINES.
SO IF ANYBODY WANTS TO CLARIFY, THEY CAN.
IT'S NOT BECAUSE THE PTAC DECIDED IT DID NOT WANT TO DO THOSE THINGS.
IT WAS BECAUSE WE WERE TOLD WE COULD NOT DO THOSE THINGS.
>> ANY OTHER COMMENTS FROM THE COMMITTEE?
I WANT TO THANK THE MEMBERS OF THE PUBLIC, FOLKS WHO EMAILED US AND CAME TODAY TO SHARE
THEIR PERSPECTIVES.
WE'RE GOING TO TAKE THIS INPUT IN AND CLEARLY THIS WAS ITERATIVE PROCESS SO YOUR FEEDBACK,
WE WILL CONTINUE TO SEEK, AND WE GREATLY APPRECIATE IT.
AND WE WILL CONTINUE TO INTERNALLY EVALUATE OUR PROCESS AND SEE WHERE THERE ARE OPPORTUNITIES
TO STRENGTHEN THEM TO MAKE THIS MORE EFFICIENT AND EFFECTIVE.
AGAIN, THANK YOU, EVERYBODY.
I HAVE ONE ADDITIONAL COMMENT THAT I WOULD LIKE TO MAKE AS I CONCLUDE THE MEETING.
IN ADDITION TO THANKING THE MEMBERS OF THE PUBLIC, IN THE INTEREST OF OUR DELIBERATION
ON PROPOSALS AND STAKEHOLDERS WHO TOOK THE TIME TO SUBMIT THEM, I WANT TO THANK MY COLLEAGUES
WHO REALLY BEND WITH THE STRAIN OF THE WORK THAT'S REQUIRED AND DILIGENCE, AND THE CRITICAL
THOUGHT AND ENGAGEMENT THAT'S REQUIRED TO DELIVER THE DISCIPLINE ANALYSES THAT YOU ARE
EXPERIENCING HERE PLAY OUT.
I REALLY APPRECIATE THAT.
AND THE SUPPORT THAT THEY GIVE ME IN MY LEADERSHIP ROLE TO HELP THIS COMMITTEE BE POSITIONED
TO BE GENERATING THE KIND OF INFLUENCE THAT ULTIMATELY THE STAKEHOLDERS EXPECT AND DESERVE.
I ALSO WANT TO PARTICULARLY THANK BOB, DR.
BOB BERENSON, AND ELIZABETH MITCHELL WHO UNFORTUNATELY COULDN'T BE HERE FOR THIS MEETING AS THESE
TWO INDIVIDUALS ARE DEPARTING IN SEPTEMBER, THEY ARE STEPPING OFF THE COMMITTEE, IT'S
BEEN AN ABSOLUTE PRIVILEGE, BOB, TO WORK WITH YOU, AND THE CONTRIBUTIONS THAT YOU'VE MADE
WILL CERTAINLY TRANSCEND YOUR TENURE ON THIS COMMITTEE.
AND YOU MADE TREMENDOUS CONTRIBUTIONS, AS HAS ELIZABETH, AND I WANT TO THANK YOU AND
ELIZABETH IN SPIRIT WHO IS NOT HERE TODAY.
[APPLAUSE]
>> DR.
B!
>> ON THAT, THAT'S A HARD ACT TO FOLLOW, I THINK WE'RE GOING TO GO AHEAD AND ADJOURN.
DO I HAVE A MOTION?
SECOND?
ALL RIGHT.
WE'RE ADJOURNED.
THANK YOU.
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