Take this job and shove it: 2 PTAC members quit in frustration over CMMI opposition to committee recommendations

• Two members of the CMS Physician Technical Payment Advisory Committee (PTAC) are quitting in frustration, according to a report by MedPage Today.
• The PTAC was formed by the MACRA legislation to create a conduit for the industry to provide vetted recommendations for alternative payment models to CMMI.
• Over the last three years, PTAC has reviewed 32 models submitted by a range of industry stakeholders, recommending 16 of those models to CMMI, with none being launched by the innovation center to date.

 MedPage Today is reporting that two members of the CMS Physician Technical Payment Advisory Committee (PTAC) are quitting in frustration. “The PTAC was formed by the MACRA legislation to create a conduit for the industry to provide vetted recommendations for alternative payment models to CMMI,” according to the MedPage Today article.  “It was in response to the critique that many specialist physicians didn’t see a viable risk-bearing model for them in either CMS or CMMI’s portfolios of payment models.

“The committee is staffed by highly respected clinicians, health economists and other subject matter experts. Over the last three years, the group has reviewed 32 models submitted by a range of industry stakeholders. Sixteen of those models have been recommended to CMMI for further development but to no avail. Both members’ frustration is evident based on the sections of their resignation letters quoted by MedPage Today:

Over the last 3 years, we have reviewed 32 proposals submitted by thoughtful practitioners in various fields of health care delivery (with one more on the docket for this December), and we recommended either testing or implementation for 16 of them,’ wrote [Len] Nichols, who is director of the Center for Health Policy Research and Ethics at George Mason University, in Fairfax, Virginia. ‘Every single one of those recommendations has been declined by the secretary of HHS. Of late, public language has been used praising PTAC’s various efforts and contributions, but the outcome is the same: HHS/CMS/CMMI remains opposed to implementing ideas submitted from the field.’ (CMMI refers to the Center for Medicare and Medicaid Innovation at CMS.)”

“The rejections ‘[are] not because PTAC has done a bad job; indeed, both in the formal responses to our recommendations and in a variety of public events, the secretary of HHS, the CMS administrator, and the director of CMMI have repeatedly praised PTAC for its work,’ [Miller], who is president and CEO of the Center for Healthcare Quality & Payment Reform, in Pittsburgh, noted in his letter. However, he continued, ‘it also seems clear that future recommendations will meet the same fate; the former director of CMMI told us there was ‘no circumstance’ in which CMMI would ever directly implement a payment model submitted through the PTAC process.'”

Takeaway

First, the complaint that there aren’t enough specialist models is real. And the PTAC is probably the best place to address this based on what the consumers of alternative payment models (APMs) want/need based on where they see misaligned financial incentives that make providing high-quality care hard.

However, it sounds like PTAC committee members have gotten the message loud and clear. If it’s not on CMMI’s radar and invented at CMMI, then it’s “not invented here.”

As someone who helps our members understand these models, works to understand members’ concerns about these models and provides suggestions to CMMI based on those concerns for improving these models, this is frustrating.

Generally, I think CMMI does good work, and I have a tremendous amount of respect for the team at CMMI. They’re breaking new trails for APMs (on a limited budget under politically complex circumstances), which is what we as a country need.

But I think one of the challenges the models developed at CMMI face is that they are centrally developed, built to an ideal care delivery situation that only works in a limited number of areas based largely on the experiences of the team developing those models (I’d be guilty of the same sin if I worked at CMMI . . . we’re all limited to a certain extent by what we know and our experiences). That’s not to say they don’t consider feedback from the field; they do. But that feedback is solicited after the footers are sunk and the foundation of the model is poured. So, it’s hard to add another room, much less reconfigure the floor plan. And, as an example, the result is that now all medical and procedural bundles look conceptually like the BPCI episodes of care when there may be other approaches that are more conducive to specialist participation.

Second, the PTAC models are also a way to both fill in gaps in the portfolio. For example, (as I have written about in previous HFMA blogs and spoken about on a podcast), multiple health systems are experimenting with models to provide care for low-acuity conditions in the home.

However, there is no Medicare fee-for-service (FFS) payment for home hospitalizations. So, experimentation to date is limited to provider sponsored plans and focused on the relatively narrow population of patients covered by those plans, who end up in the emergency department or physician offices of hospitals owned by/providers employed by the same entity that owns the plan.

However, hospitals faced with short-term capacity issues might be interested in these models for their Medicare FFS patients as a way to avoid building capacity (at $1m or more a bed) that is destined in the long term to sit idle due to changes in care delivery. And the PTAC has sent over two fully developed models (in way more detail than what we’ve seen so far for the Direct Contracting Model) for CMMI to consider. And yet CMMI has passed on opportunities to create a model that will allow providers to deliver care in the most appropriate setting. So, patients continue to get admitted to hospitals where they unnecessarily run the risk of hospital acquired conditions and hospitals continue to pour concrete they’re likely not going to need in 10 years.

These two committee members, Nichols, and Miller, are highly respected health policy experts and passionate about changing the financial incentives to reward the provision of high-quality cost-effective care. So, for them to go full “Johnny Paycheck/Willie Nelson” and take this step speaks volumes about how CMMI and CMS view input from the field.

And their resignations in frustration leaves me less inclined to believe that long-term CMS and CMMI will lead the transition to value with models that work for providers. And if the models don’t work for the people delivering care, they probably won’t work for the people receiving care either.