PTAC Public Meeting | Performance Measures Public Comments and Committee Discussion | 03.26.24 | 9/9

>> Angelo Sinopoli: Welcome back, everybody. I believe that we do have a public commenter that's ready to make some comments. I can introduce Jennifer Gasparini, who is the director of regulatory and quality affairs at the National Association of ACOs, or NACOs. Jennifer? >> Jennifer Gasparini: Thanks. Can you hear me? >> Angelo Sinopoli: Yes, we can. >> Jennifer Gasparini: Okay, great. Well, I wanted to thank, first, PTAC for the important discussions over the last two days. Quality assessments are critical to value-based care work, and getting those quality approaches right is really important to clinician engagement and the success of these models. So we heard a lot -- >> Angelo Sinopoli: Welcome back, everybody. I believe that we do have a public commenter that's ready to -- >> Jennifer Gasparini: Can you -- >> Angelo Sinopoli: -- make some comments. >> Jennifer Gasparini: Can you hear me? >> Angelo Sinopoli: Yes. We have some technical difficulties. >> Jennifer Gasparini: Okay. >> Angelo Sinopoli: Jennifer, are you there? I think we're having some technical difficulties. We're going to get that fixed and let you speak. >> Jennifer Gasparini: I'm here. I'll hold off until you're ready. >> Angelo Sinopoli: Okay. Sorry. >> Jennifer Gasparini: No problem. >> Angelo Sinopoli: They're asking me to ask you to mute your stream, your live stream. Can you hear me? Jennifer? >> Jennifer Gasparini: That better? >> Angelo Sinopoli: I can hear you now. Yes. Perfect. Go ahead. >> Jennifer Gasparini: Can you hear me now? >> Angelo Sinopoli: Yes, we can hear you. Can you hear us? >> Jennifer Gasparini: I can hear you. >> Angelo Sinopoli: Okay. Yes. Go ahead. They're asking me to ask you to mute your stream, your live stream. Can you hear me? Jennifer? >> Jennifer Gasparini: Are you able to hear me? Is that better? >> Angelo Sinopoli: I can hear you now. Yes. Perfect. Go ahead. >> Jennifer Gasparini: Okay. Can you hear me now? >> Angelo Sinopoli: Yes, we can hear you. Different things [spelled phonetically]. >> Jennifer Gasparini: Are you able to hear me now? >> Angelo Sinopoli: Yes. Can you go ahead and speak? >> Jennifer Gasparini: Are you able to hear me now? >> Angelo Sinopoli: Can you hear me? >> Jennifer Gasparini: I can hear you. Are you able to hear me? >> Angelo Sinopoli: Yes. Go ahead and speak. I think maybe there -- we'll keep our fingers crossed that we have -- >> Jennifer Gasparini: Okay. >> Angelo Sinopoli: -- technology refixed. Go ahead. >> Jennifer Gasparini: [laughs] No one wants to hear me on a loop. That's for sure. I think I left off right around talking about what we've heard today, so that's where I'll jump back in. And we heard a lot today during the discussions about alignment efforts, and I wanted to speak to that. Alignment is crucial to reducing administrative burdens and freeing up practices and clinicians to care for patients in new ways in value-based care models, but aligning to the right group is equally important. So right now, CMS is aligning, for example, MSSP ACO quality requirements with MIPS requirements which, as you know, are very focused on providing care in the fee-for-service environment, so this really creates issues when you're trying to apply those measures with the same reporting rules that are, you know, being applied equally regardless of the type of provider when you're applying this in the total cost of care context like for MSSP ACOs. Instead, we believe it's critical that we start looking at the next generation of measures for population health models which, as has been mentioned throughout the meeting, should focus on things like accountability across the system and not with an individual provider, focus on things like care coordination and team-based care, access, and other population health goals that make sense to evaluate at the ACO level and less so at the individual clinician level, for example. And there's been a lot of discussion also today around digital quality measurement and interoperability, and moving toward digital measures and reporting methods will reduce administrative burdens and allow us to really get closer to receiving real-time data that can be used at the point of care to improve care for patients. However, we also have to have realistic goals for our timelines to move in this direction and take caution to not move forward with requirements before industry is capable of supporting that work. Right now, we're not currently where we need to be in regards to interoperability to transition to fully digital measures in the next year. What we do need is clear direction from CMS and ONC on what that digital quality future is that we're striving for. If it's by our APIs to support digital quality measure or DQM reporting, then we need to focus on that goal and not hold ACOs and other value models accountable for different requirements that also require investments in the interim. And that's really what's happening right now with MSSP ACOs. They're currently struggling with making investments for those interim requirements that are not really fully aligned with the digital future state that CMS and ONC are ultimately working toward. So we don't want to see the system have to invest now in interim technology and work only to have to reinvest in the mapping and infrastructure that are required for fire APIs, for example, in the near future. So those were just a couple of things that we wanted to touch on today. We have lots of additional thoughts on this topic, and we're happy to follow up. Thanks again for your focus on this topic. >> Angelo Sinopoli: Thank you, Jennifer. Those were excellent comments, and we appreciate you taking the time to reach out and share those with us. We thank you. Think now we'll move into our committee discussions. That was the only public commenter, right? Yesterday at the end of the day, we spent a great deal of time talking about what we had heard through the day yesterday, and so today we just want to take a few minutes and have some time to rediscuss that and add any comments from the subject matter experts that we heard from today. So I'm going to open it up to the committee members to make some comments about what we've heard. All right. Jennifer. >> Jennifer Wiler: Thank you, Mr. chairman, for the opportunity. Without going over what we discussed yesterday, I thought the panelists today were phenomenal, and again, want to thank our PTAC staff, ASPE, NORC [spelled phonetically] staff, for putting together a really wonderful meeting and exceptional group of experts. I heard a number of things today that are takeaways that I think are important for us when we're thinking about our summary report. The first is acknowledging the heavy lift and significant importance of our federal agencies working together to focus on creating a data infrastructure that allows for fundamental data sharing and aggregation through simplification processes, which are easy to say and really hard to do, and creating this digital platform where data, as we've talked about in the past, is a utility. And then we heard today that tech is the commodity. I think we're really poised to make sure that if financial incentives are necessary beyond will, that this is critical to the success of any focus on quality outcomes that we want to achieve. Secondly, I think we continue to hear there has to be a business case for change, and there's very different business case for voluntary programs versus mandatory programs. Voluntary programs need high incentives, and it needs to be moderated with an appropriate level of risk. And there's ways to moderate that risk, but one thing we continue to hear is that payer alignment or all-payer participation in addition to the simplification of measures that are of high priority is one critical component of that. Next, I think we heard about this idea around a balanced score card approach, and I think my takeaway is that that has to be at the ''system level,'' although we heard what's the definition of a system, but let's assume that that's known from a population perspective. And I think it really comes back, to me, to that value equation of quality, safety, patient experience, equity over cost and efficiency. And if we think about measures that really focus back to those fundamental areas of value using the rubric that our PCD group put together, I think that's a nice place to think about how we pick measures under this simplified and prioritized process. The next thing I heard was around data, that, again, data and information change performance and outcomes, so why that is so critically important, and that anything we can do to encourage sharing of data or decreasing the friction associated with that is really important. And so when thinking about drivers, we heard in the first panel around, you know, this idea, my takeaway was whoever has the data needs to be forced to share it, and whoever is the accountable entity shouldn't be the only one responsible for having to pull it. And so creating some incentives for that sharing, financial or not, are -- is important, because that data, again, has to be actionable. It needs to be specific. It can't be aggregated. And what we heard today, a lot was around a couple of simple measures, and I can -- I know I'll put that in quotes, because we heard about even blood pressure being not a simple metric. But again, a lot of really smart, talented people are thinking about this, and there's a way that -- we heard from our Epic colleague, if we can all just agree on what the definition is, it can be executed. So although data, sharing of information is fundamental, critical, and essentially difficult for us to move forward, I also heard that ideally, each of our accountable practices would like to have insights also. So if there was a possibility to have a version two, insights would be ideal. And whatever we can do to necessitate, regulate, or pay for this information sharing -- and maybe it has to be very tactical. We heard about paying for consultation notes to be shared, so a way to engage our specialists, which we've talked about in the past as being a challenge. Paying for inpatient hospitalization discharge summaries -- you can get very tactical very quickly, but I do think those incremental components of important data actually is a place for us to explore. Then last but not least, we heard a lot about timeliness of care and access as a metric for both quality and safety, and it sounds like there's an opportunity to get a nice list of those timeliness metrics around things that maybe are intuitive. What we heard was a diagnosis of cancer and then seeing a specialist. It'd be nice to have a list of those timeliness metrics that if they're not ready to be leveraged within a CMMI or CMS model, maybe within the other payer programs or communities. Those could start to be used and tested. But we kept hearing over and over what an important outcome -- what an important, essentially, process measure for quality and safety they could be. Thank you. >> Angelo Sinopoli: Excellent comments. So anything to add to that, Walter? >> Walter Lin: You know, it's always very hard to follow Jennifer, because she does a thorough job of [inaudible]. >> Angelo Sinopoli: Want to call on her first? >> Multiple Speakers: [laughter] >> Walter Lin: In addition to the things that she gave to the staff, I also wanted to thank the PCD team as well for putting together an excellent two-day public session. I thought we heard from multiple very different perspectives from a small, essentially, solo practice in the middle of Kentucky to mid-size practices to very large, integrated health practices like Geisinger to, you know, Health Plans and that kind of practices. So it was valuable perspective to hear from all different levels. You know, the -- I won't repeat what Jennifer said. I think it's very thorough. But I will just maybe ruminate a bit about the last session we heard where we were reminded how little impact healthcare has on health. You know, and I think that's pretty well documented in the literature in health economics and other disciplines as well. And this reminded me of a conversation that we -- as most of the committee was there, actually, last night at dinner, and Angelo, you were there, too -- where the really interesting idea was brought up, why shouldn't we maybe think about having more federal inter-agency cooperation to address some of these social determinants of health. You know, so just to name a few, for instance, housing, right? Housing is a big social determinant of health. Can we maybe somehow get HUD involved? Or food insecurity -- is there some way we can kind of think about getting USDA involved? Education. You know, so kind of -- the list goes on. And it was probably a very unrealistic, wild idea, but something that kind of I was thinking about during Karen's presentation today, maybe we should look outside of CMS to help with some of these STOH issues, big, big challenges that are very hard to solve. And kind of in the climate of growing inequality in our country, I would say they're very important to solve, and I think has the intention of not just those in healthcare, but those outside as well. So anyways, that's it. >> Angelo Sinopoli: Thank you. Great additions. Jim. >> Jim Walton: I agree with Walter. The only thing I would say just to strengthen his comment would be it -- I think it's our responsibility for the healthcare -- for the health -- the common, so to speak, as physicians as a profession to do that. And I think our conversation with CMS physicians, I thought was very powerful, because there was a certain degree of solidarity in the profession that we need to speak into the space to call out more thoughtful action around social determinants of health. Investment, we heard a number of times -- different kinds of investments that are needed so that the next generation can have something more to work with and maybe accelerate what we've been doing over the last few years. >> Angelo Sinopoli: Thank you for that. Lindsay? >> Lindsay Botsford: Yeah. Thanks, Angelo. You know, I think we heard in a variety of our presenters the idea that -- you know, and we went into this kind of knowing it, but that our current measures don't really account for everything that we're going to need in evaluating total cost of care. We heard alignment that ER and admission rates are certainly good ones that need to be included, but might be too late for really showing some of the things we need to show along the way as we think about how we evaluate total cost of care. Think we heard that, you know, access to care, population health measures, mental health, and things like language are probably things that we need to look at as we're looking at evaluation of total cost of care models. Resonating back from yesterday's conversation, the idea that as we think about, you know, looking at more patient-reported measures, patient experience measures, that some of the existing surveys and tools might not meet the needs of all the populations, so high-needs populations, and how can we make it easier to collect the data that we know is important. Reflecting from today, think we heard themes that we heard in our last meeting, too, about how much upfront investment in team-based care is important when it comes to building the teams that are able to succeed in some of these population health-focused activities. I think the final concept I heard today was -- maybe it's more of a warning or a caution as we move forward to thinking about new measures was the phrase quality industrial complex. And I think that does echo some of the fears here around as we talk about all the new types of measurement needed, word of caution as to how we think about who is developing these, where the data comes from, and how can we get ahead of making sure that that data does not become proprietary or having to rely on certain people that are -- maybe have adverse financial incentives being the ones to help innovate in this space. And I think the final thing from the last presentation was just when I looked at one of the lessons learned about promoting equity in measurement is when we heard from our -- from Dr. Friedberg the idea of when you're introducing equity measures, to think about just comparing -- not comparing to others and just showing improvement. Kind of the all boats rise concept in that you don't have to be better than the one around you, and the idea as we think about encouraging equity, encouraging improvement at the population level, how can we just slowly nudge along and encourage that one percent better as opposed to having to be above a certain threshold? It takes time and it takes money, and that investment is needed to nudge things along. >> Angelo Sinopoli: Thank you. Lee? >> Lee Mills: I agree with my colleagues. Perhaps after another two years of practice here at PTAC, I'll be as comprehensive and clear headed in my remarks as Jen is already. It seems unlikely, but I'm willing to go for it. Heard a couple of themes, but first of all, I want to say just recency effect -- thought the very last panel we had, all three members were remarkably clear headed and clear spoken. I think maybe the single best listening panel -- conversation panel we've had in two years, so I would, to staff, recommend we think about ways to program them and invite them back at future meetings. So we heard themes, as Lindsay said, themes that have gone meeting to meeting, year to year. The first was data, data, data. You know, information is the lifeblood of any effective population health, public health perspective and approach, and it's still incredibly -- the data infrastructure of the country is incredibly archaic, incredibly siloed. You know, it's better now than four years ago, and yet still, the data burden is falling on the physicians and practices to generate the data the entire system is operating on. So it's like those least able to bear the cost and with the least expertise in generating it are the ones that are responsible for doing it all for the benefit of the entire population, which just seems mis-calibrated to me. So we heard a outcry for, you know, essentially, health data utility approach and routine data aggregation for quality measures. We're certainly on that path towards moving to eCQMs. Really clear appeal from the provider in Kentucky about just, you know, why is he having to report on things that -- you know, it's not just Medicare -- that payers already know. And then there's got to be a way to aggregate that and share that back in a combined denominator as opposed to relying on the physician directly. Certainly heard, again, about the need for risk adjustment, and I feel like we haven't talked this -- about this much, that, you know, programs in retrospective data review, actuarial studies often are using, you know, prospective for comparing effectiveness, quality change, provider to provider, and yet what the providers need to actually effect change at the individual or group level is concurrent risk adjustment in an ongoing fashion, which -- and they're two different things, and that's not widely talked about. Certainly heard an appeal for moving away from care process measures that are not, you know, more directly tied to outcomes, moving towards patient-oriented measures. Think those, of course, raise a whole level of just operational tactical complexity, because you can't administer them at a practice collection level. Right? It's got to go directly to the patient, and how does that work -- raises a whole series of questions that we don't have answers for right now. Let's see. Certainly -- there was a -- one speaker spoke to a fundamental problem. It's not new. It's not -- it's been ongoing. I certainly faced it in my work with the provider on plan. It's just that CMS is leading the way and, I think, doing, you know, great work in many fronts to point the direction and provide leadership in this. And the rising sea does lift all boats, but to that point, every private health plan is getting the benefit of CMS's leadership without contributing the additional investments because every health system and practice can't operate differently for this payer versus that payer. And so you build your operation to produce consistent results, and every patient gets the benefit, which just is -- speaks to a fundamental inequity and a fundamental kind of systematic lack of the adequate investment we're going to need to really change operations for population health. Heard a clear call for a multi-year glide path to where we're going, especially around proms and health equity. I think there's a real role there for -- CMS has the ability to step into with a transitional plan, much like they've done in other venues, saying, okay, we're going to put it out there that 20 -- you know, proposal we're making -- 2027, we're going to switch 25 percent to a prospective population-based PMPM payment and 75 percent current system, and transition it over four years or six years or whatever it is. Just get something out there for people to start getting their minds around it's really coming, right, after talking about it for 20 years. Struck again by the quality industrial complex. I don't know what that means to me, but it's really kind of off putting and scary -- means a lot. And then struck -- my final comment, struck -- really, really struck by that healthcare is only a very small part of health, and so this belief that we can re-jigger the incentives around healthcare being at, you know, call it 20 percent of health outcomes, we're going to see dramatic changes in health was hubristic from the start. And yet here we are. That's what we do, and those are the tools we're paying attention to. But it does speak to a need for a broader conversation involving a public health approach to health, that it doesn't rely on practices. So, thank you. >> Angelo Sinopoli: Thank you, Lee. Lauran? >> Lauran Hardin: So, in addition to all the excellent comments, just one thing I'd like to call out. So, people made it very clear when -- one statement that was made that I thought was really powerful was winnable measures and the ability to have some input into what those look like. People were consistent around calling out the cost for the -- building the analytics, building the ability to understand the data and collect it. And I thought Mark's example from a payer perspective was a great example of how things could be a glide path toward incentivizing and helping people to change. So the payer provided a dashboard, actionable data, things that helped inform the providers. Then that was partnered with a learning community. So people could come together and learn with each other, and that was tied to a grant program so that they could choose a way that they wanted to invest and learn and change. And once that was built, then incentive-based outcome measures would -- were put into play. I thought that was a really brilliant pathway to share. >> Angelo Sinopoli: Perfect. Thank you. So before I close out, Audrey, are there any other questions or comments that you want to add? Okay. Well, I want to thank everybody for participating today, our expert presenters, panelists, my PTAC colleagues, particularly my PTAC colleagues. This has been a very intense couple of days with great information and very engaged PTAC members. Want to particularly thank the PCD team for a really excellent presentation that I know took you all a lot of work put together. So we explored a lot of different facets regarding accruing performance measures and development and implementation in population health total cost of care models. We'll continue to gather information through a request for input on our topic. We're pushing it on the Ask PTAC website and sending it out through the PTAC listserv. If you can offer your input on our questions by April the 26th, it'd be appreciated. The committee will work to issue a report to the secretary with our recommendations from this public meeting, and with that, we'll end this session. Thank you.