How Can CMS Improve Value In the Most Valuable?

Arguably the practices of most value are those with lower cost relative to patients seen or outcomes achieved. Small and rural practices have long been paid the least and cover more complex patients often without access to local resources or other local types of providers. They have demonstrated same or similar outcomes. They are also the most valuable as their existence is often the difference between access to care and no access to care. So how can CMS improve value in practices most valuable.

Despite greatest value, CMS apparently sees the need to improve value. One would think that CMS would have the small and rural practices instruct others and the nation about value, but such is not the case. A new grant program has been promoted by CMS and the usual associations to increase value in the most valuable practices. 

This latest grant is another in a long series of 100 million dollar CMS grant distractions. Apparently associations such as AAFP will continue to promote this even though the dollars are not going to them or to their members, not to mention that the training competes with their own value-based training. 

Why have small and rural practices avoided participation? Some have been excluded from participation as they are small. Also small and rural practices have not adopted many of the innovations because they cost too much and are a poor fit. When you are already the highest value, why should you participate in innovations of little value? How can value be added to what is most valuable? 

CMS has decided to send 20 million a year to facilitators or 100 million dollars to help train small and rural practices to be value-based. Is this SMART? 

  • Most specific training would be a replication of the office manager round tables set up by SERPA in Nebraska where training and other expertise has long been shared between rural practices. This is less costly and most specific to the practices, team members, and populations served. This actually sends dollars to small and rural settings - addressing the problem that prevents access. This may also help reduce turnover via additional support specific to team members. Thirty years of experience with rural practices and training shout that it is not SMART to train from afar. Another choice would be telehealth training via established mechanisms such as Project Echo in New Mexico. Such is not the case in CMS where one silo fails to learn from another.
  • Small and rural practices were determined by RAND (the CMS consultant for MACRA) to be too small to participate in MACRA as the ability to discern quality is questionable at best and fails entirely for the smallest. Many have been excluded for this reason. CMS has already published that most penalties would be going to small and rural practices. MACRA itself fails in discernment, risk adjustment, complexity, and other key areas.
  • Pay for performance is not specific for significant outcome improvements as established by the evidence basis of two major reviews. In fact, Pay for Performance is specific for discrimination against the small and rural practices caring for the populations most complex with inherently poor outcomes
  • The spending provided by the grant does not go to small and rural practices. 
  • The size of a small practice is usually 9 physicians or less, not 15.
  • The spending does not go to support team members. The training will give them more to do rather than patient care. HITECH to ACA to MACRA have resulted in declines in productivity and new training is not likely to help to improve efficiency or increase revenue.
The MACRA CMS grants do not provide services 
and represent health care dollars expended 
 for the result of ZERO Value. 
  • This grant is not set up to be measurable.
  • As with many Accountable Care derivatives, this one is not accountable.
  • Practice interventions are limited in the ability to improve outcomes - outcomes that are predominantly shaped by patient, community, social, and local environment, situation, and similar factors.
  • Training is complicated by far too many practices to address.
  • Training will be wasted for many that are trained due to high turnover - the result from the financial design for small practices with too little paid and accelerating costs of delivery. 
Small and rural primary care team members can find better pay, more support, and less complexity in almost every other health care job because of payment design. This grant does not address these huge problems and can make them worse.

  • This 100 million has Zero Value as it represents a cost with no service result. 
  • The grant is supposed to help practices toward greater value even though these small practices already have the highest value. 
  • There are many questions that should be asked and answered, but CMS has long failed to listen. Reality testing fails for CMS and may fail most in the treatment of small and rural practices.
  • Why is CMS supporting costly regulations when the current President is indicating the need to cut regulation?
  • Small and rural team members attend training will have to retrain the trainers. Will CMS get this feedback and change in a timely way?
Perhaps CMS has a problem with relevant information in its haste to bring "progress" at any cost. This would explain measuring the wrong measures, funding the wrong providers, and paying the wrong consultants.

There are some concerns regarding those who will do the training.
  • What can those of no value (20 million dollars a year while delivering zero care) teach small and rural practices of highest value. 
  • What can consultants teach about preventable deaths avoided best by small and solo practices (Casalino)?  
  • What can consultants teach about continuity, outreach, and community in places that best demonstrate each because it is about neighbors, friends, daily contacts, and what these people and places most value.
  • If those receiving grants are SMART, they will hire small and rural team members to do the work - but this increases turnover and provides an exit of valuable team members. 
The CMS Payment Policies are Not SMART - this remains the major problem
  • It is not SMART to spend just 160 billion a year on primary care or only 6% of health spending for 55% of visits a year. 
  • It is not SMART to distract team members from delivering care by burdensome regulations, or by additional training to address such regulations.
  • It is not SMART to marginalize Small Health Care - care for most Americans most left behind by past, present, and future designs. 
  • It is not SMART to undermine the primary care contribution that dominates basic access to care and delivers 50% of mental health services because mental health is also grossly underfunded.
  • It is not SMART to delay real solutions such as a decent financial design while innovations that lack evidence basis are promoted, maintained, and expanded.

Is CMS SMART in Primary Care?

Specific     Measurable 
Attainable   Realistic

Twenty million dollars a year for 5 years sent to training entities that do not deliver care in small or rural practices is dollars spent for no care or Zero Value.
It is not valuable to pay 20 million to educate small and rural practices about value since they are the most valuable. 

Small and rural practices already have the least payment for the most services, scope, and complexity - real value by actual measure. 

The training will not change the fact that HITECH to ACA to MACRA continues to make the team members in these practices less productive.

Readmissions Penalties Fail to Indicate Quality or Predict Outcomes

Pay for Performance has failed to deliver on promised outcomes, has driven up the cost of delivery, has added distractions for team members, has distorted health services research, and has contributed to two forms of discrimination with regard to most needed providers. It is time for something else such as returning the focus to support for the team members that deliver the care.


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