WASHINGTON — Secretary of Health and Human Services (HHS) Alex Azar said that moving to a value-based healthcare system is a top priority for the Trump administration, speaking Thursday at the Patient-Centered Primary Care Collaborative annual conference here.
Azar also stressed that to achieve this transformation requires “real experimentation” using mandatory payment models.
“I want you all to imagine a system where patients are in the driver’s seat, able to shop among providers who are empowered as navigators of patient decisions rather than paperwork; where payments reward outcomes, not box-checking; and where diseases are effectively prevented or cured long before they cause unnecessary suffering and cost,” he said.
In speaking of the path to value, Azar emphasized mandatory models. “We know they are the most effective way to know whether these bundles can successfully save money and improve quality,” he said, referring to bundled payments for episodes of care.
Last year, under the previous HHS Secretary, Tom Price, MD, the Centers for Medicare & Medicaid Services (CMS) eliminated certain payment models — related to episodes of care and to cardiac rehabilitation — before they were launched. Unlike, Azar, Price was not supportive of mandatory payment models.
(Price, an orthopedic surgeon, resigned in September 2017 following a scandal over his use of charter and military planes.)
Since then, the department has begun to reconsider those actions, Azar said.
“We intend to revisit some of the episodic cardiac models that we pulled back, and are actively exploring new and improved episode-based models in other areas, including radiation oncology,” he said.
HHS is also looking “to build on the lessons and successes” of the Comprehensive Care for Joint Replacement model, which was scaled back significantly during Price’s tenure.
In his speech, Azar also outlined an agenda based on the “four Ps,” which he described as key to a value-based system.
The “four Ps,” which originated with Adam Boehler, director of the Center for Medicare and Medicaid Innovation, are “making patients into empowered consumers; making providers into accountable navigators of the health system; paying for outcomes; and preventing disease before it occurs or progresses.”
Paying for Outcomes
While underscoring his focus on mandatory models, in moving toward value, Azar said his department won’t be “overly prescriptive.”
“We’re going to tell you ‘the what’ that we want — better outcomes at a lower cost — but we’re not going to be overly specific about the how,” he said.
What’s most important in this shift is a focus on patient outcomes, not processes, he said.
As an example, the measure of success for providers caring for Azar’s ailing relative, who’s currently in a rehabilitation hospital, is straightforward, he said.
Providers should be paid more if his relative walks out the hospital door, and less if he leaves in a wheelchair, Azar said.
One way to make an outcomes-driven system work is, by bundling payments rather than paying for every single service, he continued.
In addition to reconsidering the elimination and reduced scale of the three bundles he mentioned and hinting at a radiation oncology bundle, Azar said, “you are going to see a lot more such ideas in the future.”
Providers as Navigators
Azar also highlighted the role of physicians and other clinicians not as “gatekeepers” but as “navigators” of the healthcare system.
The department thinks it’s time for providers to take “full accountability” for patient outcomes, he said. Those who take such a step will be relieved of some of their administrative and regulatory burdens, in order to focus on patients.
“We envision a spectrum of risk: Different sizes and types of practices can take on different levels of risk…. Even smaller practices want to be, and can be, compensated based on their patients’ outcomes,” he added.
Deputy Secretary Eric Hargan is already assessing how four laws — the Stark Law; the Anti-Kickback Statute; HIPAA (the Health Insurance Portability and Accountability Act of 1996); and 42 CFR (Code of Federal Regulations) Part 2 (which gives patients the right not to share all of their protected health information related to substance use) — may hamper care coordination, Azar said.
In addition, CMS released and completed a request for information on the Stark Law, and the Office of the Inspector General has made a similar request related to the Anti-Kickback Statute.
“This is not an ordinary regulatory burden exercise…. We’re focused on how current interpretations of these laws are preventing physicians, patients, and others from working together to unlock value,” he added.
Azar noted that these laws may be preventing providers without a common owner from collaborating, and “we want to enable small-scale providers to collaborate as much as possible.”
Patients as Consumers, Preventing Disease
In the patient realm, Azar also addressed skepticism over whether patients are really interested in “shopping” for healthcare, arguing that patients are are in fact keenly interested in comparing prices — for instance, for prescription drugs or the cost of an MRI.
He pointed to the recent efforts by HHS to mandate the price of drugs in TV advertisements and to other actions like requiring hospitals to post their prices online.
Azar said the agency is continuing to look for ways to share cost and quality information with patients when they need it.
Finally in speaking of disease prevention, Azar again returned to his focus on effective payment models. “Imagine a system where, through long-term payment models, providers actually see the financial results of helping their patients stay healthy — instead of being financially rewarded when they get sick,” he said.
Azar highlighted the success of patient-centered medical homes in the private sector and in HHS-funded community health centers.
While prevention begins with patients, Azar said, physicians have a critical role to play in helping patients make informed decisions.
His department aims to support new models that not only help prevent costly conditions and diseases, but also allow everyone to share in the savings that stem from preventing illness, he said.