Breaking Down MACRA: A Chat with Andy Slavitt (Parts I, II, and III)

Breaking Down MACRA: A Chat with Andy Slavitt (Part I)

By Jordan Shlain, Founder, HealthLoop

As originally appears on Tincture.


In late May 2016, Dr. Jordan Shlain, founder of HealthLoop and founder/editor-in-chief of Tincture, spoke with the Acting Administrator at the Centers for Medicare & Medicaid Services (CMS), Andy Slavitt. Below is the first transcribed portion of the conversation between Andy and Dr. Shlain. It has been edited for clarity.


Jordan Shlain: Hello Andy – thank you for taking the time to interview with Tincture, a new publication in health care that aims to simplify the complex and make health care interesting and engaging again.


I want to talk with you about the Medicare Access and CHIP Reauthorization Act (MACRA) today, in a way that brings it down from 30,000 feet to the level of the person on the street. That might be a doctor, a patient, or just be anybody that’s trying to get his or her head around this.


Most people probably think of MACRA as inside baseball, but there are a lot of other people around the country who aren’t part of the health policy wonk club. MACRA will mostly impact doctors and hospitals, given it’s a new financial incentive, but more fundamentally, it will impact the patient.


Andy Slavitt: Let’s start with patients. If you’re one of the tens of millions of people in Medicare, what is the program and what does it feel like? This is a program with among the highest level of satisfaction for consumers, for patients for almost any product or service, something like 85 percent satisfaction. It’s an enormous commitment that our country has made to people. If you look at the Medicare beneficiary today, it’s a far different picture from what you’d get if you looked at it 50 years ago when the program started, or even 20 years ago.


These are people living with disabilities. These are older Americans, and almost entirely they are people on fixed incomes, or even lower incomes if they’re part of a dual-eligible population. They experience a very fragmented health care system for care. They’re increasingly mobile, and they’ve got a lot of needs. There are a lot of chronic conditions, a lot of medications to take.


Their aspirations are consistent with what we as a health care system are trying to do: People want to stay at home and in their communities, rather than an institution if they can avoid it. They want relationships with physicians that can help quarterback them through the various challenges they have. They want to know what’s ahead of them. They want to build relationships. And all of those things are increasingly difficult the more complex our health care system gets.


If you look at legislation passed by Congress, what did it try to do in that context? The last big change for beneficiaries was the Prescription Drug Benefit. If you take the experience of flying an airplane, the prescription drug benefit added more features, more things to improve the experience; whereas MACRA really addresses the underlying engine of the aircraft, and the ability of the plane to take you more places, go further, and give you a better, safer flight overall. It addresses the question, “How do we look at the thing we value in the system? How do we move from a system that pays for things that people do, to paying for the things that we think work, and pay more for the things we work?”


It’s the kind of thing that may be invisible to the naked eye of the consumer at first, but the downstream impacts will result in a much better program than we’ve got today. Physicians will be more comfortable and secure in the program, because they won’t be facing the SGR that threatens to dramatically reduce their incomes. If we do this well, physicians will have more control and flexibility in their ability to practice medicine. We believe that at a broad level, these benefits will trickle down and improve patient care and the patients’ experience getting care.


Jordan: In the Fee for Service model there’s a moral hazard. If you go into muffler shop with a rattling muffler, you’re probably going to get a new muffler. They make money on the transaction. And that flies into the bundled payment model. MACRA is trying to enable doctors to restructure their models around outcomes that matter to patients, more than a billing transaction, and a lot of coding, which is very cumbersome, particularly for the physician practice. Is that a fair way to assess what MACRA is trying to do?


Andy: Well, I don’t really like that analogy, because I believe that fundamentally, physicians really aren’t driven by “How am I going to get paid for this.” When the patient and physician are together, we are not trying to coerce physicians into doing what they don’t think is right. We know that won’t work. What we can do is make it easier by allowing the physician to invest in the things that will matter.


Take the medical home model – which is a prominent feature and opportunity in MACRA. It gives doctors a lump sum every month to invest in care coordination. For small practices, the idea is to invest in care coordination and finding patients who are most in need of care, or to invest in software that tracks what happens with patients. That sort of thing isn’t widely available to small practices. What we’re looking at is a model that puts more of the decision-making in the hands of physicians and patients, and then saying, “Let’s figure out how to support it.”


Winning Back the Hearts and Minds of Physicians: A Chat with Andy Slavitt (Part II)

As originally appeared on Tincture.

In late May 2016, Tincture spoke with Acting Administrator at Centers for Medicare and Medicaid Services (CMS), Andy Slavitt. Below is the second transcribed portion of the conversation between Andy and Dr. Jordan Shlain, Tincture’s founder and editor-in-chief. It has been edited for clarity.



Jordan Shlain: Andy, you’ve spoken before about winning back the hearts and minds of physicians. I’m wondering – how did we lose the hearts and minds of physicians in the first place? Can MACRA really solve that?


Andy Slavitt: I think you’d probably draw a couple of conclusions. One is, we’ve generated too much paperwork, too much time away from patient care. When we set up a big program like this- it’s very easy to agree that quality should be improved. Very few people would argue with the idea that physicians should be recognized for delivering more quality and value.


The problem is when those ideas get implemented, almost by their very definition they get implemented in a series of pieces over time…and they have the effect of stacking upon one another. So you have different regulations and laws that are passed in various years, and then they add on top of one another. It’s a situation where good things on top of good things can become bad things. Looking at the end result, it’s arguable that the individual pieces were even good things to begin with.


And then if they get implemented for a physician who has more than one health plan paying them, they get implemented differently. Then, all of a sudden it’s not just adding up badly, it’s adding up badly geometrically.


The second point is that the paperwork doesn’t feel relevant to improving patient care. Paperwork is one thing – we all have to deal with it to some degree, and we certainly want to minimize it – but the paperwork needs to feel relevant. Giving physicians information in a registry that helps them understand how they can improve care is one example. Giving them better information about their patients, or their practice – that feels like it’s got some value. I think we’re at a place today where by and large that’s not always the case.


Jordan: Yeah.


Andy: So, that’s how we got to where we are. The only thing I’ll add is that this creates an imperative for us to use MACRA as a platform to take this patchwork of programs that have been put in place, and streamline them into one program that can be simplified and rationalized over time. But even immediately, we can go out of the gate and find redundancies and duplications and eliminate them. We are looking for the things that physicians report on that we don’t need them to report on, because we can get the information some other way. Or, because many physicians are already doing quite well. Something might matter to us, but if we know the physician is doing well, why make people report on it?


Challenging ourselves to think and act on these issues has been what implementing the quality payment program has been all about.



Jordan: You’ve just mentioned it, but let’s talk in more detail about the timeframe for the MACRA rollout. When do you think we’ll see the fruits of this labor? It’s a multi-year process, but how long will it take to start to show some benefits for physicians and patients?


Andy: The law is designed to ramp up. There’s some acknowledgement that there’s going to be a first year to the program, and like the first year of any program we’re going to see people behaving very close to how they’re behaving today. If anything there are lower burdens to measurement and reporting under both components of the Quality Payment Program, which is what we are rolling out to implement MACRA – there are lower burdens than those that exist today. Those will scale and grow over time.


Looking down the line, what the law envisions and what physicians would hope for – are that payment models are more and more relevant to the way they’re practicing, more relevant to the specific needs of their specialty, or their state, or their population. There are things that are gaining traction today – medical homes, bundled payments, accountable care organizations, but which are very, very early.


I described them earlier as being first and second generation models. Generation One was generated in a lab, and Generation Two was generated almost based entirely upon what was learned from the first Generation. So some of the things that physicians and patients have told us they value and they want to keep – like aligning the same incentives for consumers and the physicians, using telemedicine – those are in the new models.


I think we ought to be somewhat modest about what we’ve accomplished so far. In a few years, I suspect a couple of things will have changed. First, we’ll be on Generation Six and Seven – which will be simpler, more sophisticated, easier to use, and working in the background. Second, there will be a lot more model options. So any specialty under MACRA should be able to design and propose a model that we would then put into practice and implement.


I envision the day where different specialties and subspecialties will say, “These are the measures that matter to us – can you put a program into place?” And I think that will help tremendously– there will be a lot of choice flexibility in the models, and in the components of the models.


What outcomes will we see? With many of the things we’ve talked about – reducing readmission rates for example – there’s been a lot of progress over the last five years. I think we will see very specific outcome areas, where physicians feel like there’s the most room to move the needle, and where patients most value, where we’ll see very significant improvement. And finally, and this is very, very important to me is the general, overall satisfaction with the health care experience from both the patient and the physician. Satisfaction rates need to start moving up and I think they will.


What if a Tech-Savvy Business Executive ran CMS? He Already Does: A Chat with Andy Slavitt (Part III)

Os originally appeared on Tincture.

In late May 2016, Tincture spoke with Acting Administrator at Centers for Medicare and Medicaid Services (CMS), Andy Slavitt. Below is the third transcribed portion of the conversation between Andy and Dr. Jordan Shlain, Tincture’s founder and editor-in-chief. It has been edited for clarity (Note: Here are links to parts I and II.)


Jordan Shlain: I’m out here in Silicon Valley. And there are hundreds of startups all over the place – all these entrepreneurs trying to land pilot programs at hospitals and clinics. And now, a few years into the Affordable Care Act and Meaningful Use, there’s all of a sudden this entirely new program for physicians to react to.


There’s something called the ‘Valley of Death’ for startups; I wonder if, given the timeline and scale of the program, will MACRA make the ‘Valley of Death’ into the ‘Grand Canyon of Death?’ How should a young company be thinking about building things for this unknown world?
Andy Slavitt: Absolutely not. This should be the beginning of a much-needed cycle of innovation. The only way true innovation happens is for the innovators to get a crisp understanding of users, and what kinds of problems there are to solve. I think where we have been actually, is that most of the tech and software firms have had to design products to meet the regulatory needs of things like Meaningful Use. You may have as an entrepreneur or software company – put so much time into your roadmap to meet these regulatory requirements that you’ve had very little time left to innovate.


I think the single most important thing we can do to spur innovation is the opening of APIs and the elimination of all barriers. There are barriers of a variety of types that allow new companies to begin to offer technology that eliminates what you call “desktop lock.” Physicians have had to make decisions about their electronic medical records – which is a record keeping system, not really a workflow system. And that decision, and because there was no requirement for an open API layer, it left physicians locked in, saying, “Well, this is the technology that I have – if the vendor’s not going to innovate for me, I can’t move data in and out of other applications. So there is an enormous opportunity to do that.


The other things that will spur this change is that we will have so much more flexibility in the types of programs and types of measures that physicians select. This will give clues to innovative companies on what the market’s real needs are. For example, if a physician selects to be in a certain type of medical home model, it’ll be very clear that care coordination and patient outreach are going to be vital to their success. This should have the effect of creating new markets for innovators.


Jordan: We keep on talking about the patient, and there’s also been a lot of talk about the consumer. You said a while back “we need to make healthcare more like a retail experience.” Retail always involves the consumer. But the retail world wants to make the experience great so you buy something. And I’ve never seen a consumer in the ICU. I’ve never seen the consumer in the hospital. These are patients – I appreciate you calling them patients in this context.


Andy: Yeah, well the “consumer” context for me is when they’re buying insurance. That’s when I want them to be the most empowered consumers they can be. But when they walk through a physician’s door, they’re very different people than who they were when they’re pulling up in the parking lot.


Jordan: That’s right – I think they’re much more anxious. I think of the patient as an anxiety model, where anxiety underpins their logic; whereas the consumer has an excitement model, where they have free choice, free will – as a patient, you don’t have a lot of choices, and you have tethered will.


Jordan: I have a question for you about your use of social media, if I may. Given that we’re entering this new realm of communication, I think it’s a breath of fresh air that you’re tweeting so much. And you are genuinely tweeting yourself, tweeting your own thoughts. It puts a face to this big impersonal institution called “CMS.” I wonder how your colleagues in the beltway, physicians and patients, and the community at large – how they react to your embrace of social media.


Andy: Well, let’s look at what we’re trying to do. What we’re trying to do is move rapidly away from a model where people feel like there is a black box that is disconnected from the realities of day-to-day patient care. The fears and the vulnerability that people feel when they’re a part of the healthcare system, and quite frankly, the frustration that you feel when you feel like someone far away is deciding the rules of how you operate or the test you’re trying to teach to.


Now the reality is: The work gets done at our agency – at 10 regions around the country. In the course of rolling out the quality payment program, we have quite literally had tens of thousands of interactions with physicians through webinars, through learning sessions, through other means. We’ve created all kinds of dynamic feedback loops – white boards, online presentations, conference calls, seeking a massive amount of inputs. In many respects, what you see me doing in social media, we should be seeing others do on social media: Putting up the aperture so that we can be better at listening, and that people can see that we’re listening.
There are times as a leader when you want to motivate your team with inspiration and vision. There are other times when the best motivation they can get is to hear their critics as directly and loudly and clearly as possible. I think that’s a vital part of where we want to be. Social media can help. I also just got back from visiting in person with a number of smaller practices and large practices around the country – as many of my colleagues have done as well. Whether you like CMS or not, and many do not – we’re a vital partner in helping patients and physicians get to where they need to get.


Jordan: This is so important – I wish more people would take your cue and get active on social media. Today’s it’s like having a relationship with a black box – how we make it transparent?


Andy: That’s why this conversation really does help. We want to expand access for people through more means to engage and ultimately to participate. When you put together and implement a law or a regulation, you can’t possibly think of every consequence – intended or unintended – that comes out of the work that you’re doing. The only way you can get higher levels of assurance, optimize the levels of comfort for physicians while minimizing the negative consequences – is with feedback, with interaction. So it’s very important to us that physicians, clinicians, patients, innovators, others, give us comments and feedback.

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