Remarks by Andy Slavitt: Keeping Medicare’s Promise with MACRA
Below are prepared remarks by Andy Slavitt, CMS Acting Administrator before the MACRA MIPS/APM Summit, Washington, D.C. on December 1, 2016.
So, you decided to come to Washington to see what was new and how things might be changing… I am sure we did not disappoint.
I am honored to have been invited to address this summit, which I’m sure will be your first of many. It's a certainty that making our delivery system work better for patients and spend money more wisely will always be in season no matter which party is in charge. And, while many new approaches and changes may come to bear, ultimately health is not a partisan issue.
However, I do hope you all think of a better name– the MACRA MIPS/APM summit sounds like the world’s hardest word scramble. We’ve tried to make MACRA more accessible by naming it the Quality Payment Program… something to think about.
Looking at your speakers today, you have gathered some of the most experienced people across the country focused on the most difficult health care problems we as a nation face. Simply put, how to complete the changes we have begun to make the system more patient centered and accountable. So today, I come here to add my perspective to this discussion and continue to ask for your valuable help.
You, as clinical and business leaders, represent an active and important voice in the delivery of health care for all Americans. As we make changes, you are part of the leadership who will be the first to know what is working and what is not. You will also be the best at articulating what you need from Washington. At CMS, we have worked hard over the last few years to transform from an opaque bureaucracy into an accessible service organization, getting us closest to making decisions based on where care is provided across the country.
I want to talk about the next evolution for our health care system.
For nearly two years, I have had the incredible honor to serve at CMS and to oversee the Medicare, Medicaid, and Marketplace programs, which together provide health coverage to one in three Americans and likely pays for the majority of care that occurs in most health care communities across the nation.
There’s an old joke at CMS that if you find yourself in a tense conversation, you can usually diffuse it by saying, “Well, my mom is a Medicare beneficiary.” Inevitably, the other person will say, “Mine too.” And, from that shared sense of responsibility, you can go forward from the right place – one that is focused on figuring out what's right for the beneficiaries we serve.
That is because Medicare is a uniquely American promise. One that – for more than a half-century – has said to all Americans that as you get older, or if you have a disability, you will be able to access care, and your family won't go broke in the process. Before Medicare, do you know how many seniors in this country lived in poverty? One in three.... One in three. Today, it’s less than one in ten. Our promise to the millions of Americans –our neighbors -- particularly when we are living on a low or fixed income-- is part of what has made us who we are.
Medicare is what provides your parents’ health care and if we do our jobs right, one day, your children’s. Think of it. How we make decisions today will allow us and our children to one day put that Medicare card in our wallets to keep us secure.
So how are we doing to advance Medicare to keep its promise?
Since the passage of the ACA, over the last 8 years, together, we have made significant progress in cost and quality and in evolving to meet the new shape of health care.
Of course, there has been enormous progress extending beyond Medicare:
You have heard the 20 million stat before. But the effects are much more profound in the everyday life and health of people.
If you don’t think this progress has made a major difference in the day-to-day lives of all Americans, you have been paying more attention to politics than people. In fact, there hasn't been a greater stretch of progress in our nation's history as measured by the amount of positive change that has impacted people and their lives and our path to a sustainable future as in the last 8 years.
But this progress should only be the start if we are to fulfill the real promise of caring for people in our country and doing it in a way that reduces the overall burden of the health care system.
Today, taxpayers spend over $500 billion each year for the Medicare program. The question that needs to be addressed head on is how Medicare will continue to control costs in the face of a demographic boom as over 10,000 Americans enter Medicare each day, rising demand for health care's new cures and technologies; and an epidemic of chronic disease.
This is an important way to understand the context behind MACRA.
To build on the foundation we have begun on reforming the delivery system so that value based care can reach every community in America. Given this magnitude of change, I asked the team to approach MACRA differently. After this historic legislation passed, the CMS team was eager to get to work on implementation. But they heard something different from me. Stop writing, get out of DC, and start listening.
Through 4,000 formal comments, nearly 100,000 attendees at our events across the nation, focus groups, design sessions, workshops, physician office visits (and countless tweets), we got to hear patients and clinician points of view on things we can do to make healthcare better for them.
Our challenge isn't about accountability or quality or costs or whatever euphemism people use. It's to recognize that the path forward isn't through any one model or new three-letter acronym or quick fix, but by addressing the basic things, which lead to bad outcomes, physician burnout, or for patients, particularly needier ones, to feel displaced and not get the right care.
Your opportunity with MACRA isn't to implement a new scorekeeping system. If we do that, we will not only miss the opportunity to transform, but we will add complexity to an already overly complex system.
Based on what we heard, we made major changes to how we approached this program holistically.
First, we focused on a lighter touch and less regulation. By adopting the idea that if we simplified and reduced what was measured and gave physicians back more time with patients and instead supported their quality efforts, we would make more progress. And, we reduced the number of requirements in half to help level the playing field for small or independent practices.
Second, we came to realize MACRA is many clinicians’ first experience with reporting and paying for quality for the first time. We created multiple timelines to allow clinicians to pick their own pace of entry and development.
Third, we also recognize that many practices are advanced and ready to go further, so we built more opportunities for clinicians and to allow more innovative models to flourish. We estimate that about 25% of eligible Medicare clinicians will be in an Advanced Alternative Payment Models by 2018, and we have a goal of creating options for physicians in all specialties and geographies in order to allow them to pick models that are right for them.
As we move forward, we all need to keep building on what works while systematically demanding improvement where we can do better.
So how do I suggest we tackle the next opportunities?
One. Build from a foundation of progress, not head backwards. There can be no delivery system reform without building on the foundation of reaching universal coverage. That means building on the record 20 million people who have newly found coverage and continuing the security and protections Americans have found, including no-cost preventive care, the elimination of lifetime and annual coverage limits, and the end of pre-existing condition exclusions. If we want to fix how care is delivered, so that we’re providing value, then we must ensure that Americans can afford and access quality care at every point in their lives. If we lose even some of the coverage gains made under the ACA, or leave people in limbo, people will lose access to regular care and we will drive up long-term costs. This doesn't mean we shouldn't improve how coverage works in a bipartisan fashion. We must always do that and we should now as new leaders bring new approaches and solicit new ideas.
Two. Insist that modernization of Medicare must actually mean modernization. Progress is achieved by ingenuity, innovation, teamwork, and the use of data and technology, not by changing funding formulas.
I’ll say this bluntly: MACRA can't work as well without a CMS Innovation Center that can move quickly to develop and expand new approaches to paying for care. With changes to the Innovation Center, the advanced alternative payment approaches could slow significantly. We will have a much narrower path with fewer specialty options and approaches, which take in patient and physician feedback. Medicare and commercial payers would then fall further out of alignment, and more importantly, less patients would have access to innovative care methods.
Three. Start to demand technology that can exchange data, that supports care, and that is affordable. MACRA is an opportunity to move the focus away from paperwork and reporting and towards paying for what works. For a variety of reasons, EHRs became an industry before they became a useful tool. The technology community must be held accountable by their customers and make room for new innovators and to give clinicians more freedom and more flexibility to focus on their patients, to practice medicine, and deliver better care. We worked alongside physicians to design technology tools (QPP.cms.gov) and a support center that allows physicians to learn about, access, and even design their involvement in the Quality Payment Program.