White House healthcare leader expresses skepticism of mandatory models

• A White House senior healthcare leader said he is “skeptical” of mandatory models.
• Providers and some members of Congress have criticized two mandatory models that were proposed this summer.
• Move value-based payment initiatives are coming, the White House executive said.

The healthcare policy leader in the White House was doubtful about expanding the use of mandatory payment models, which have drawn backlash from many providers.

When asked during a recent media briefing about whether the administration will accelerate the push toward value-based payment, Joseph Grogan, JD, assistant to the president and director of the Trump administration’s Domestic Policy Council, said he was “skeptical” about any program that required participation by either providers or beneficiaries.

“We need to make sure that patients and physicians have the flexibility they need to make the healthcare choice that’s going to make the patient healthier,” Grogan said. “We’re about the patient being in control and the patient being at the center of this, so any time we’re talking about forcing arrangements, it’s something we would be very skeptical about.”

In speeches this year, Alex Azar, secretary of the Department of Health and Human Services (HHS), and Seema Verma, administrator of the Centers for Medicare & Medicaid Services (CMS), promised increased use of mandatory payment models, which often draw provider criticism.

“Looking forward, you can expect that some of the models we have under development will be mandatory,” Verma said at a spring meeting of the National Association of Accountable Care Organizations. “One reason for mandatory models is that selection effects can be significant in voluntary models.”

Grogan’s skepticism toward mandatory models is significant because — as he made clear — his policymaking position in this administration outranks that of any officials at HHS or CMS.

Two new mandatory models loom

The latest proposed mandatory Medicare payment models produced concerns from many providers, including hospitals that cited the potential for adverse financial impacts.

In July, CMS proposed mandatory provider enrollment in both the Radiation Oncology (RO) model and the ESRD Treatment Choices (ETC) model. The five-year RO model would provide bundled payments for 90-day radiotherapy episodes of care, while the 6 ½-year ETC model would include a two-sided payment adjustment based on performance on home dialysis and transplantation rates.

A number of provider organizations and provider groups submitted comment letters in September, voicing opposition to the mandatory nature of both models. The RO model also drew critical written responses this week from Congress members of both parties. In October, a letter from nearly 75 members also was critical of the model.

In a Nov. 7 speech at an American Society of Nephrology meeting, Azar noted that HHS was reviewing comments it received on the ETC model but gave no indication his department was reconsidering the model’s mandatory nature.

Value-based payment remains a priority

Grogan agreed that the administration generally will accelerate efforts to push providers toward value-based payment (VBP).

“We are looking at more aggressive value-based payment arrangements,” he said, including through a proposed overhaul of operating rules for the Stark and anti-kickback laws.

“It’s a delicate balance. We don’t want to force anybody, necessarily, into a value-based arrangement when a patient doesn’t choose [it],” Grogan said.

As an example of adverse consequences that can occur when the federal government forces providers into initiatives for which they are unprepared, Grogan cited the electronic health record (EHR) incentive program that was implemented by the Obama administration. Grogan said that, counter to promises, the program did not broadly improve quality, lower costs or allow for interoperability. On a practical level, it required physicians to spend most medical exams staring at their computer screens rather than engaging patients.

That “is an example of what happens when we don’t think of the patient first,” Grogan said.