An Open Letter To Donald Berwick, CMS Administrator

August 4, 2011

Donald Berwick, MD, MPH
Centers for Medicare & Medicaid Services (CMS)
Department of Health and Human Services
Room 445–G, Hubert H. Humphrey Building, 200
Independence Avenue, SW.,
Washington, DC 20201

RE: Availability of Medicare Data for Performance Measurement Proposed Rule Medicare data for performance measurement regulation, as created by Section 3001(a) of the Patient Protection Affordable Care Act (PPACA).

Dear Dr. Berwick:

The Niagara Health Quality Coalition (NHQC) appreciates the opportunity to submit comments regarding the above referenced proposed regulations intended to make Medicare more transparent about its dealings with providers, insurers and other stakeholders. In that context, NHQC feels it is important to be candid.

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A Victory for Coverage With Evidence-Development

Merrill Goozner

First posted 9/8/11 on GoozNews

A federal study of a new stent designed to prevent repeat strokes was stopped early because 2 1/2 times (14.7%) more people either died or had a repeat stroke after receiving the stent than those who received drugs and counseling (5.8%). The $20 million study, stopped after just 451 stroke victims had been enrolled because of the alarming trend in the results, was sponsored by the National Institute of Neurological Diseases and Stroke.

The Gateway-Wingspan system, manufactured by Stryker, was approved by the Food and Drug Administration in 2005 based on “a small, less rigorous study,” according to this morning’s Washington Post. But use has been limited by a decision by the Centers for Medicare and Medicaid Services to deny reimbursement unless patients receiving the device were enrolled in a clinical trial. This “coverage with evidence development” policy began during former CMS director Mark McClellan’s tenure during the Bush administration.

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CMS Center for Innovation Announces Bundled Payments for Care Improvement Initiative

David Harlow

First posted 8/24/11 on Health Blawg

Many health care provider organizations that have not been overly eager to jump onto the Accountable Care Organization (ACO) bandwagon, citing high startup costs and uncertain returns on investment given the complexity of the program.  Well, recently, the CMS Center for Innovation has announced the Bundled Payment for Care Improvement initiative.  This initiative incorporates elements of earlier CMS demonstration projects — the gainsharing demos and ACE (acute care episode) bundled payments demonstrations which the HealthBlawger has helped a number of clients around the country qualify for in the past — and builds on the broad authority granted to the CMS Center for Innovation under health reform.

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Prosecuting Medicare Fraud – The Untold Obama Administration Success Story

Merrill Goozner

First posted 8/24/11 on Gooz News

One wonders what the Obama administration has to do to get a little credit. I’m sitting on vacation, looking at the ocean most of the day, and spending about a half hour on line at night erasing unread emails, killing out unread RSS feeds, and checking up on my declining retirement prospects. Amid the clutter, a series of press releases from the Inspector General of the Health and Human Services Department caught my eye. Here are the headlines, with links (I’d link to the press coverage, but near as I can tell, there was none):

Miami-Area Doctor Pleads Guilty in $25 Million Health Care Fraud Scheme

Owner of Miami-Area Mental Health Care Corporation Convicted on All Counts for Orchestrating $205 Million Medicare Fraud Scheme

Miami-Area Medical Equipment Company Owners Sentenced to Prison for Medicare Fraud Scheme

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Six Quick First Impressions of CMS’ Bundled Payment for Care Improvement Initiative (BPCII)

Vince Kuraitis

First posted 8/23/11 on e-CareManagement Blog

This afternoon CMS announced the Bundled Payments for Care Improvement Initiative (BPCII). For details, start reading here.

Here are six quick first impressions:

1. It’s very creative and innovative. CMS has demonstrated out-of-the-box thinking and leaves a lot of room for applicants to propose their own approaches. Expect to have to read the materials 2-3 times to wrap your thinking around it.

Unlike the Medicare Shared Savings ACO rule, the BPCII is flexible. Expect some innovative and non-traditional proposals from diverse applicants. Unlike the Medicare ACO Shared Savings rule, the BPCII invites flexibility in:

  • Definition of care bundles
  • Proposal of specific financial terms
  • Participation by diverse care providers (see below)
  • Risk adjustment of beneficiaries

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A Legal Challenge to CMS’ Reliance on the RUC

Brian Klepper and David C. Kibbe

First posted 8/09/11 on The Health Affairs Blog

Copyright ©2011 Health Affairs by Project HOPE – The People-to-People Health Foundation, Inc.

This week in a Maryland federal court, six physicians based at the Center for Primary Care in Augusta, GA filed suit against HHS Secretary Kathleen Sebelius and CMS Administrator Donald Berwick. The complaint, spearheaded by Paul Fischer MD with DC-based lead counsel Kathleen Behan, alleges that the doctors have been harmed by the Medicare payment structure developed through the agencies’ reliance on the American Medical Association’s Relative Value Scale Update Committee (RUC).

The suit also claims that the agencies have functionally treated the RUC as a federal advisory committee. But they have not required the RUC to adhere to the Federal Advisory Committee Act’s (FACA) stringent management and reporting rules – e.g., balanced representation, transparent proceedings, and scientifically valid analytical methodologies – that keep the proceedings in the public interest. The plaintiffs request injunctive relief, which would freeze the relationship between CMS and the RUC until the advisory group complies with FACA’s requirements. Of course, compliance would drastically change the way the RUC conducts its affairs, something it is almost certainly loathe to do.

Continue reading “A Legal Challenge to CMS’ Reliance on the RUC”

Dealing Strategically With the RUC to Boost Family Physician Payment

Lori Heim

First posted 7/13/11 on AAFP News Now

Brian’s Note: Regular readers will recall that in January, David C. Kibbe and I wrote a piece calling on America’s primary care societies to quit the RUC, the secretive, specialist-dominated AMA committee that has been the sole advisor to CMS on medical services valuation and reimbursement for the past 20 years. It is not unreasonable to assert that the RUC’s relationship with CMS is one of the deep roots of America’s health care cost crisis, an extraordinarily destructive mechanism that has had severely negative impacts on patients, purchasers and, of course, primary care physicians.

The AAFP initially rejected our suggestion, but has thought better of it over time. As Dr. Heim describes in this explanation to AAFP’s members, they issued a series of requests to the RUC: more primary care seats, a permanent seat for Gerontology, the sunsetting of some rotating sub-specialty seats, and the addition of some non-physicians (e.g., consumers, purchasers, health economists) to the committee. Obviously, the real question remaining is whether, if the RUC rejects these changes, the AAFP Board will have the will to walk.

All that said, her comments below are a good description of how they’re approaching this very complicated set of dynamics. 

Lori J. Heim, M.D., F.A.A.F.P.

Improving payment for the cognitive services we family physicians provide is, undoubtedly, the most crucial and challenging issue the Academy must resolve. The payment disparity between primary care and procedural specialties undermines every family physician who struggles to redesign and improve his or her practice in this economy, and it also drives medical students away from primary care.

The Academy has been working on many fronts to rectify this payment disparity. One important part of that effort is to make sure CMS receives recommendations on the relative values of CPT codes from experts who understand primary care. Unfortunately, that’s not happening now to the extent necessary. The only body making recommendations to CMS is the AMA/Specialty Society Relative Value Scale Update Committee, commonly called the RUC.

Continue reading “Dealing Strategically With the RUC to Boost Family Physician Payment”

Why Its OK That EHR Adoption Will Fall Below 2011 Goals

David C. Kibbe and Brian Klepper

First posted 7/06/11 on Kaiser Health News

2011 will be a disappointing year for the Centers for Medicare and Medicaid Services and the Office of the National Coordinator’s electronic health record incentive programs. We predict that few doctors and hospitals will meet the objectives set for the “meaningful use” of certified EHR technology. Meaningful use is, of course, the term that describes the objectives and measures providers and hospitals must meet in order to receive financial bonuses authorized by Congress in the HITECH portions of the economic stimulus bill of 2009. David Blumenthal, the former national coordinator, had hoped large numbers of doctors and hospitals would adopt EHRs starting in 2011, the first year bonuses are available. But, in reality, by the end of the year the percentage of physicians using EHRs won’t likely rise much above the current 20 to 25 percent rate.

This isn’t necessarily a bad thing. This year and, to a lesser extent, 2012, could be for “cleaning house.” Many older, costly and difficult-to-implement legacy EHRs will be replaced by less expensive, more agile systems that have been developed specifically for meaningful use and are deliverable in the cloud as Software-as-a-Service. Transitions like these take time, but the dynamics are foreseeable.

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The Awful Dichotomy Between Health Care Politics and Policy

Robert Laszewski

First posted 7/6/11 on Health Policy and Marketplace Review

Amy Goldstein has an important article in today’s Washington Post detailing the place Don Berwick, the Medicare and Medicaid administrator, finds himself in.

It is all but certain he will have to leave his post at year’s end, when his recess appointment expires, because the Senate will not confirm him for a lack of Republican support.

Berwick is one of the most respected health care experts in the country—his career has been dedicated to improving quality first and with that the cost of care. With the new law giving his agency more opportunities to experiment with new approaches and the ability to more quickly implement the things that work, he was the ideal choice.

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Stifling Primary Care: Why Does CMS Still Support the RUC?

Brian Klepper, Paul Fischer and Kathleen Behan

First published 5/24/11 on the Health Affairs Blog.

Copyright ©2010 Health Affairs by Project HOPE – The People-to-People Health Foundation, Inc.

Last October, the Wall Street Journal ran a damning expose about the Relative Value Scale Update Committee (RUC), a secretive, specialist-dominated panel within the American Medical Association (AMA) that, for the past two decades, has been the Centers for Medicare and Medicaid Services’ (CMS’) primary advisor on valuation of medical services. Then, in December, Princeton economist Uwe Reinhardt followed up with a description of the RUC’s mechanics on the New York Times’ Economix blog. We saw this re-raising of the issue as an opportunity to undertake an action-oriented campaign against the RUC that builds on many professionals’ work – see here and here – over many years.

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Dear CMS: Stop the Proton Beam Arms Race

Paul Levy

First published 5/18/11 on Not Running A Hospital

If Medicare payments for proton beam therapy are what is driving the construction of too many such machines, why doesn’t Medicare change the reimbursement? That’s my simple question for the day.

What prompts it is this story from the Midwest, where University Hospital has entered the proton beam machine arms race with plans to spend $30 million. Here’s the story from MedCity News.


Few argue that proton therapy is ineffective, though many would like to see it subjected to rigorous testing. The National Cancer Institute (NCI) in 2009expressed concern that “enthusiasm for this promising therapy may be getting ahead of the research.” NCI experts worry about a lack of published randomized, controlled trials that show proton therapy works better than standard radiation therapy and increases survival, or improves quality of life for patients.

Cost is also a huge concern associated with proton therapy — and one reason so many hospitals are eager to jump into the proton therapy business. Medicare reimburses proton therapy at about twice the rate of standard radiation therapy, which prompts concerns that patients (or their insurers) could pay twice the price for a treatment that may be no more effective than the cheaper alternative.

This one would be paid for by a “a mix of capital, bonds and philanthropy,” according to What an obfuscation. No, it will be paid for with money! All of which has an opportunity cost. Dear Ohioans, you can do better with your money than throwing $30 million into this machine.

Open letter to Don Berwick at CMS:

Please make them stop. You can dry up this source of funds and improve health care and help control its escalating cost. Use the tools you have at hand.

Berwick on Incentivizing Health Care Value

Brian Klepper

AAFP (The American Academy of Family Physicians) News Now has an excellent interview with CMS Administrator Donald Berwick MD, in which Dr. Berwick describes his vision of more integrated and less fragmented health care delivery, and the changes in reimbursement incentives that will be required to get us there. An excerpt is below. Click the link above to read the entire piece. Worth your time.

Q. You also have talked about this being the era of health care delivery improvement. Can you explain that? 

A. Paying for value is an incentive. It is a motivation toward improvement. The underlying idea of improvement is that American health care, historically built in fragments, often cannot achieve for patients what it really wants to achieve. No one really wants that. Health delivery system reform refers to really reconfiguring care into much more seamless coordinated-care operations so that people, especially those with chronic illnesses, experience continuity of care over time and space.

So when patients come home from the hospital, there is a smooth handoff, and all the necessary information follows them. When they are seeing a specialist, that specialist is coordinating care with their primary care doctor.

In a fragmented payment system, it is so much harder to accomplish this. When payment is based on better integration, the result will be better integration of health care services. A delivery system redesign really means improving care for people when they are sick to ensure that they are safe and care is delivered according to science. And that includes improving seamless and coordinated care for patients — especially people with chronic illnesses. And then there is prevention, (including) a bigger investment in keeping people healthy, helping them to understand how to keep themselves healthy instead of waiting for illness to occur or reoccur, and educating people on how to prevent (illness). All of that involves design.

Q. You spoke briefly about the fee-for-service system. How do you feel about the AMA/Specialty Society Relative Value Scale Update Committee, or RUC?

Continue reading “Berwick on Incentivizing Health Care Value”

Is the ACO DOA? Reasonable Minds Can Improve the Draft Regulations

David Harlow

First published 5/17/11 on HealthBlawg

In the current all-ACO, all the time, health care policy news cycle, we’ve been inundated with declarations that the ACO is dead, because a handful of big boys say they don’t want to play.

Today, CMS announced that it is tinkering with the proposed ACO rules by offering three variations on the ACO theme (link to press release; see also CMS ACO fact sheet).  From the fact sheet:

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Cheryl et al Report on CMS’ ACO Regulations

Paul Levy

First published 5/11/11 on [Not] Running a Hospital

Cheryl Clark and her colleagues at HealthLeaders Media have put together a special report on the industry’s response to CMS’ proposed Accountable Care Organization regulations. This a helpful survey that supplements unsupported comments from people like me. Let’s start with a reminder of the general scope of the regulations:

Groups of ACO professionals with a minimum of 5,000 beneficiaries would be permitted to apply for one of two risk models in order to benefit from shared savings over the three-year program. In the first model, providers would share savings of 50% in all three years, but would be at risk in year three for any losses that exceed 2% of the benchmark established by the Centers for Medicare & Medicaid Services.

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Facing Uncertainty: Why Primary Care Physicians Must Act Now

Brian Klepper

Over the past four months, the germ of a long overdue primary care uprising has sprouted and begun to flower. When David Kibbe and I first tried to think through how to neutralize the RUC’s terrible influence on American health care, we realized the first steps had to be the primary care community’s refusal to continue “enabling” the RUC – we meant this very much in the clinical sense – through its continued participation and complicity. When the game is rigged against you, there is no benefit in staying at the table.

Primary care societies would visibly and noisily abandon the RUC, with the understanding that quietly walking away would be counterproductive in the extreme. It should be a highly publicized exit, filled with righteous indignation and clarifying for the American public how the RUC’s actions and relationship with CMS have shafted patients, primary care physicians, and the people who pay for health care in America.

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