In this enlightening episode of Enabling Health Value, we sit down with Susan Dentzer, the President and Chief Executive Officer of America’s Physician Groups (APG). With her extensive background in health policy and leadership in the value-based care movement, Susan offers invaluable insights into the current state and future of healthcare.
We dive into the true meaning of value-based care and discuss how it diverges from common misconceptions. The interview also provides a detailed analysis of the proposed 2025 Medicare Physician Fee Schedule, including its potential impact on ACO models and primary care reimbursement. We also cover the implications of recent regulatory changes, such as the Supreme Court’s rejection of the Chevron doctrine, and its effect on future healthcare lawmaking. There is also a compelling discussion on the ongoing challenges and opportunities with the looming sunset of ACO REACH and the controversy of Medicare Advantage surrounding risk adjustment and coding practices.
If you are looking for a forward-looking discussion on the future of value-based care, this is a must-listen episode. Tune in now to learn how we can navigate and shape the future in taking responsibility for America’s health!
Podcast Transcript (Bookmarks)
01:30 Introduction to Susan Dentzer, President and Chief Executive Officer of America’s Physician Groups.
04:00 What does value-based care really mean?
05:30 Patients (i.e. normal people) think of value as something at the intersection of K-Mart and Dollar General.
06:00 Higher costs do not equate to higher quality in healthcare. (Instead of “value” should we instead emphasize “coordination” or “person-centered”?)
07:00 The need to explain accountability in healthcare and why incentives matter.
09:00 Implications of the proposed 2025 Medicare Physician Fee Schedule on value-based care.
09:30 Proposed changes to MSSP ACOs include new prepaid shared savings option and adjustments to ACO historical benchmarks to advance health equity.
10:30 “We perceive the proposed rule as a mixed bag.”
10:45 An overview of the positive aspects of the Proposed Rule on value-based care.
11:30 How Austin Regional Clinic (ARC) has reinvested shared savings into improving care delivery.
12:45 Adjusting an ACO’s historical benchmark for dual eligibles and assigned beneficiaries in the low-income subsidy Medicare Part D program.
13:30 CMS has agreed to adjust benchmarks for “significant, anomalous, and highly suspect billing activity” (e.g. fraudulent catheter billing).
14:45 The most negative aspect of the new Proposed Rule is the physician fee cut.
15:00 The flawed budget neutrality provision in the Medicare Physician Fee Schedule.
16:00 Why doing more volume doesn’t work as an offset to reimbursement cuts for PCPs and other cognitive oriented physicians.
17:00 The adverse impact that physician fee schedule cuts have on Alternative Payment Models.
17:45 Will Congress respond to the nearly 3% decrease in physician reimbursement that goes into effect in January?
19:00 The denigration and loss of prestige of primary care due to the cumulative effects of income disparities between PCPs and SCPs.
19:30 There hasn’t been any serious attempt to address primary care reimbursement since the unsuccessful Clinton healthcare reforms.
20:00 The recently proposed bipartisan Pay PCPs Act which would establish hybrid capitation/FFS payments to incentivize high value care.
21:00 “There has been a complete policy failure in the United States with respect to Primary Care going back several decades.”
21:30 Incentives take time to work through the system – why we should have acted 20-30 years ago!
22:00 Medical students not choosing to go into primary care due to lack of funding (only 7-9% of healthcare payments go to PCPs).
23:00 GME and residency programs are still overtraining in hospitals, even for those who will never practice in one.
23:45 The crisis of Primary Care due to acute shortages in PCPs, especially in rural parts in the country.
25:00 The Pay PCPs Act prepays a portion of the FFS payment to the physician so investments can be made in holistic, team-based primary care.
26:45 The prepayment mechanism would be especially beneficial for smaller primary care practices.
27:00 The recent Supreme Court decision to reject the Chevron doctrine which will have significant implications for federal rulemaking and health policy.
28:30 “Everybody in the sector that is knowledgeable about this Supreme Court decision is terrified.”
28:45 How will laws possibly get passed and implemented in the future, especially in healthcare?
29:00 The Affordable Care Act was more than 2,000 pages. The regulations that were written to implement that law were over 1 million pages!
29:30 “It’s one thing to put words on paper in a law, and it’s another thing to put that law in reality in the context of a very complicated reality.”
30:30 Because of this Supreme Court decision, all regulatory ambiguities will have to go back to the courts (instead of agencies making a determination).
30:45 “This was a really good decision if you live in a world where you don’t want to see Congress pass laws, and you don’t want to see regulatory agencies implement them.”
32:00 “No good will come out of this if you believe the government has a role in addressing issues and solving problems.”
32:30 Every health system right now is hiring attorneys to fight this! (e.g. Hackensack Meridian recently filed a suit related to the Chevron deference arguing about DSH payments).
34:00 The pending fate of the ACO REACH model with its scheduled termination date at the end of 2026.
34:45 The recently released evaluation report of the 2022 Performance Year for the GPDC Model.
36:00 “There is every expectation that ACO REACH will sunset, and the logical next pathway would be a new enhanced track of the MSSP.”
36:30 The need to avoid repeating the mistake that occurred when sunsetting the Next Generation ACO program (there was no other immediate advanced alternative available).
37:00 The importance of understanding what happened in the first two years of the GPDC program.
37:30 Understanding the variability in the performance of Direct Contracting Entities (DCEs) to optimize the design of a new enhanced MSSP track.
38:30 The current skepticism, particularly from House Republicans, about CMMI due to the recent CBO report that points to lack of overall savings.
39:30 How much of the pronounced skepticism is partisan based? Will a change in the Administration help to resolve?
40:00 Lack of CMMI savings has created political consternation. Should the sales proposition for value-based care include achievements in quality or equity?
42:00 “What comes next for ACO REACH will need to have clear guardrails to mitigate the risk of increased spending. The current climate will not tolerate that.”
43:00 Current headwinds with Medicare Advantage across market cycles (e.g. high MLRs, declining Star scores, HCC v28, recent health system contract terminations).
43:00 Poor public perception of MA (referencing recent WSJ Article: “Insurers Pocketed $50B from Medicare for Diseases No Doctors Treated”)
44:45 “If we had 1/10th of the scrutiny on Traditional Medicare, as we have with MA, we would all be knowledgeable about the entirety of the system that has been created for Medicare enrollees.”
45:00 Wasteful and low value care is in the 25-30% range (e.g. inappropriate cardiac catheterizations, excess imaging) is much more than $50B!
46:00 Not all MA plans are the same – do not generalize! (The preponderance of payments are FFS. Delegated arrangement that transfer risk to providers are few and far between.)
47:00 MA headwinds related to risk adjustment and the need to move away from HCCs.
48:00 Inappropriate coding and MedPAC’s interest in eliminating Health Risk Assessments.
49:00 Revenues from risk adjustment flow down to patients through increased benefits.
50:00 Don’t throw the baby out with the bathwater! (We can’t just rely on uncoordinated Traditional Medicare with no one accountability.)
54:00 Confidence that value-based care is the path forward (there is no other alternative).
54:30 PwC: Healthcare costs are expected to increase by 8% next year.
54:45 How does anyone think escalating healthcare costs are sustainable for any business enterprise?
55:45 Many of the champions of VBC are leaving Congress next year. (How will we have a rational conversation about VBC in the future landscape?)
56:45 The surge of acute care needs for the aging Baby Boomer population. (We need to make tradeoffs in the Medicare program to ensure cost and quality.)
58:45 Cutting is the only other alternative option to value-based care. (Is rationing care where we want to go.)
59:45 “We have to figure out how to make value-based care much more pervasive, and we need to make it work through smart laws and regulations, aligned health plans, and accountable providers.”