October 6, 2021
To: Ms. Chiquita Brooks-LaSure, Administrator, CMS and Ms. Liz Fowler, Deputy Administrator and Director, CMMI
From: Randy Oostra, President and CEO, ProMedica
Re: Response to Recent Interviews and CMMI Vision Blog Requesting Comments
I am writing in response to your Health Affairs’ interviews on August 12th and June 3rd, respectively, during which you both expressed interest in receiving comments from “folks on the ground” to help shape CMS’ future policy direction. Your recent blog post outlining a CMMI’s vision also expressed interest in partnering with providers and others “to support,” as you wrote, “meaningful health care transformation over the next decade.”
ProMedica, a national health and wellness organization that serves individuals and communities in 28 states, is more than convinced, as Ms. Fowler argued, that healthcare systems and value-based care are “at a crossroads.” We strongly support CMS’ efforts to emphasize and address health equity, patient centeredness, primary care, social determinants, value-based care and achieving outcomes that are meaningful to patients.
Concerning health equity, it is important to note upfront research published in JAMA in 2018 concluded, “there has been a clear lack of progress on health equity during the past 25 years in the United States” – a reality further demonstrated by the disproportionate number of minority fatalities directly and indirectly related to COVID-19.
Because federal healthcare policy has lost focus, in mid- 2017 we succeeded in convincing Senators Brown and Cassidy to write DHHS Secretary Price urging him to, “convene a diverse commission of national health care experts to develop a strategy for improving and advancing our nation’s health care delivery system so that it can effectively meet the needs of all Americans.” The letter did not prove successful, in part, because, as you will recall, Secretary Price resigned three week later. Nevertheless, I, along with a dozen like-minded hospital CEOs, followed-up this effort by meeting with numerous Senate and House members and their office staff, professional staff on germane healthcare committees and with DHHS officials over the subsequent two years in which we argued for the creation of a Congressional commission, or a like body, that would advance five reform principles: universal healthcare; primary care, behavioral health and healthy aging; greater integration of social service supports; improved spending efficiency or spending that is increasingly of higher value; and, workforce development to meet moreover behavioral health and rural healthcare needs. I provided an overview of our effort in a January 2020 Modern Healthcare essay.
Measuring for Value
Our effort was compromised by Congressional impeachment proceedings, the pandemic and the 2020 campaign. However, we were successful in convincing the HELP Committee to modify Section 303 of Senator Alexander’s “Lower Health Care Cost Act of 2019” (S. 1895) such that the nonprofit funded to collect national claims data to inform patients about the cost and quality of care would also provide the public with information about the “value of their care.”
S. 1895 did not reach the Senate floor, however, we viewed modifying Section 303 a noteworthy achievement. Despite the fact CMS makes incessant reference to value, the agency does not measure for value, defined as outcomes achieved relative to cost. The failure to measure for value may be the agency’s most significant regulatory policy failure. Simply stated, how can the agency possibly make Medicare an efficient payer or get pricing right without measuring for value or a result and how can CMS expect price transparency to be legitimately beneficial when no one knows the value of the healthcare dollar spent. (CCSQ’s Dr. Lee Fleisher is familiar with Michael Porter and ICHOM and/or Andrew Ryan’s related work.)
We are aware CMS has been slowly moving its MIPS Value Pathways (MVPs) policy that will, as I understand, correlate MIPS quality and cost. We encourage you to move forward with this policy in a time efficient manner. We, too, encourage you to forward similar regulatory policies under Part A, where some providers presently suffer from perverse Robin Hood effects, in Part C and in all CMMI demonstrations. I will add, measuring for value is a must if you are genuinely committed to health equity.
In addition to measuring and rewarding for value, here are six additional issues begging for CMS’ attention and rulemaking.
The Climate Crisis
After assessing damage left by climate crisis-charged Hurricane Ida on September 7, President Biden drew the obvious conclusion, “climate change poses an existential threat to our lives.” A day prior 200 health journals from around the world, with the notable exception of JAMA and Health Affairs, signed onto an editorial published around the world titled, “Call for Emergency Action to Limit Global Temperature Increases, Restore Biodiversity and Protect Health.” It too made the obvious point that, “health is already being harmed by global temperatures increases.”
As we well know Anthropocene warming poses the greatest threat our planet’s survival in recorded history. If you want to, literally, get picture of what this means for Medicare and Medicaid beneficiaries, view the Trudy Lampson photo of frail elderly sitting in neck deep water for eight hours at the La Vita Bell Skilled Nursing Facility after Hurricane Harvey.
Here are a few relevant facts. Health is an inescapably holistic phenomenon, i.e., there is only one health, planetary health. (Myers and Frumkin’s recent Planetary Health: Protecting Nature to Protect Ourselves, should be required CMS reading.) Three-quarters of carbon emissions in the entire history of humanity have been produced since 1968 causing over the past 14 years the earth’s energy imbalance has doubled (meaning heat from the sun that would otherwise escape into space is now trapped in the atmosphere). This means that there is no climate analog for this century in at least the past 50 million years. Translation: per research published in PNAS and elsewhere, the climate crisis has become a major cause of the planet’s current and accelerating sixth mass extinction, an existential crisis of its own. Four of the five previous mass extinctions were caused by similarly high atmospheric carbon concentrations, largely the result of volcanism, that exterminated 70 to 95% of life on earth. Not surprisingly, heat related deaths among the elderly have already increased 50 percent over the past two decades. As for children, a just published UNICEF study concluded half of the world’s 2.2 billion children are already at “extremely high risk” from the impact of the climate crisis, a situation UNICEF terms “unimaginably dire” and “deeply inequitable.” This health harm is disproportionately caused by the US since our country accounts for 25% of total carbon emissions since 1750. As for health equity, we hope you are aware, or at least the HHS Office of Civil Rights, in their early 2020 Juliana decision the 9th Circuit ruled Americans do not have a constitutional right to a survivable climate.
When you search the CMS website for “climate change” yields “no results.” The agency’s 51-page “new roadmap for states to address the social determinants of health,” issued early this year, made no mention of the climate crisis. This is particularly disappointing since health harm caused by the climate crisis disproportionately impacts Medicare and Medicaid beneficiaries. For example, the Medicare and Medicaid programs covered 66% of immediate Hurricane Sandy healthcare costs. Despite all the ink CMS spilled this year in regulatory rule making about achieving health equity, it is remarkable there was no mention of the disproportionate climate crisis-caused health harm minority populations are forced to suffer.
Though disappointing, your ignoring climate crisis-related health harm is not altogether surprising. The latest, or fifth, Lancet “Countdown on Health and Climate Change” report published last December was again forced to remind us, “climate change continues to be framed in ways that pay little attention to its health dimensions.” This is tragically true. For example, last year’s 550-page House Select Committee on Climate Change’s “Surviving the Climate Crisis” report made no mention of Medicare and Medicaid policy, President Biden’s January “Tackling the Climate Crisis” Executive Order failed to address increasingly dire climate crisis-caused health effects and ASPE, MACPAC and MedPAC, PCORI, the Joint Commission, the Center for Medicare Advocacy and related others have never discussed climate crisis-related health effects. Concerning the extent to which physicians are unengaged in addressing the climate crisis, see John Kotcher’s sobering survey conclusions in his May Lancet article, “Views of Health Professionals on Climate Change and Health.”
We expect CMS to demonstrate substantial initiative in addressing this issue. We also expect CMS to proactively engage with the recently created HHS Office on Climate Change and Health Equity (OCCHE). One place to start would be to review the approximately 60 related policy recommendations made by Drs. Frumkin and Benjamin in their April letter to Secretary Becerra (here) and those made in Health Affairs’ December 2020 issue. We also recommend you review: the 2016 report, The Impacts of Climate Change on Human Health in the US: A Scientific Assessment (the report’s lead author, the EPA’s Allison Crimmins, is presently detailed to the White House Office of Science and Technology Policy/OSTP; the last two UN IPCC reports (in 2018 and this past August’s report); the Fourth National Climate Assessment (moreover volume two on risks and impacts); the most recent Lancet “Countdown” report; and, Kristie Ebi’s just published Lancet article, “Hot Weather and Heat Extremes, Health Risks.” You should know the benefits of addressing the climate crisis far outweigh the costs of not acting. For example, see the landmark 2006 volume, “The Economics of Climate Change: The Stern Review.
We realize you, Ms. Fowler, are participating in the National Academy of Medicine’s (NAM’s) recently announced “Action Collaborative” to decarbonize the healthcare sector. Specifically, you are co-chairing with Dr. Berwick the Collaborative’s policy work group. We hope the NAM works quickly to achieve significant regulatory policy reforms that improves Medicare and Medicaid’s ability to respond to the climate crisis, particularly since, again, it disproportionately impacts minority populations.
Economic Inequality
No legitimate effort to reshape Medicare and Medicaid regulatory policy can ignore accounting for our country’s extreme economic inequality. Inequities in wealth and income substantially explain our nation's poor population health, or from a comparative perspective our health disadvantage. Economic inequality also compromises providers’ ability to promote health and prevent and successfully treat disease. We are delusional if we expect the poor, or those who lack agency, to maintain their health and/or seek timely care.
As has been exhaustively documented the US has, for example, the highest income inequality among the G7 nations and in the developed world one of the highest Gini coefficients - now approaching that of India. Today, the top 0.1% own more wealth than the bottom 90%. Since the 1980s the top 1% have become $21 trillion richer while the bottom 50%, $900 billion poorer. In aggregate, the bottom 50% are in debt. Since the onset of the pandemic, the 400 richest Americans have increased their wealth by $40 %, or by $4.5 trillion. The 10% of the world’s poorest now includes 34 million Americans. This is largely because, as Philip Alston, the United Nation’s Special Rapporteur on Extreme Poverty and NYU Law Professor, concluded in his 2018 report on extreme poverty in the US, “the persistence of extreme poverty is a political choice made by those in power.”
These and numerous related statistics explain why US life expectancy began to lose pace with comparable countries in the 1980s and why by the mid-late 1990s it declined to a level below the OECD average. Leaving aside so-called deaths of despair, or approximately 100,000 annual deaths among low wage workers aged 25 to 64 due to alcohol and drug abuse and suicide, particularly hard felt in Ohio, mid-life mortality has increased for 35 causes of death including cancer, diabetes, heart disease, obesity and respiratory diseases. This explains why the US has substantially higher, if not the highest, comparative rates of chronic disease burden, amenable or treatable and preventable deaths. To use the IOM report title, we well know why Americans “live shorter lives in poorer health.” For example, in a recent BMJ paper, Steve Woolf was again forced to state, systematic causes for the US health disadvantage are due not only to “deficiencies in health care . . . but also to socioeconomic inequalities, unhealthy environmental conditions and detrimental public policies.”
We would be remiss if I did not call out childhood poverty in this country. As you may know the US has the highest youth poverty rate in the OECD. Well over half of all those living in poverty and one in five homeless are children. A just published Russell Sage Foundation (RSF) Journal of the Social Sciences issue titled, “Wealth Inequality and Child Development,” found the percent of wealth for the bottom 50% of child households was -0.36%. While the median wealth of a White household with children is $64,000, for a Black family it is $800 that explains why nearly 40% of Black children live in poverty. This is problematic because childhood poverty, as you are aware, is associated with lifetime adverse health and education outcomes. It is worth noting RSF’s research found Medicaid coverage facilitates increases in a family’s economic resources. However, in a variation of Julian Hart’s inverse care law, the positive effect Medicaid coverage has on family wealth appears to be limited to non-Hispanic white families. Despite these realities, CMS has several opportunities to address the health effects of economic inequality. Here are three.
Adjusting for Social Risk: We are aware this issue continues to be debated. However, on balance we agree with NASEM in that you cannot legitimately design or measure/reward value absent adjusting payments (or move to capitated payments) and do the same for quality performance, weather the quality indicator itself or in the quality payment calculation, absent accounting for social risk.
Medical - Financial Partnerships: A recent NEJM Perspective essay called attention to Medical-Financial Partnership (MFPs) where providers, moreover pediatricians to date, have implemented collaborations with financial services organizations to improve patients’ financial and health status. For example, in connecting qualifying patients to tax credits. For example, in 2020 $10 billion in EITC benefits went unclaimed.
Prioritizing Primary Care: Beyond, for example, CMS’ recent payment reforms regarding E/M services, we are sure you will agree CMS needs to do more to recognize the importance of primary care. As you know PCPs make up approximately 30% of the workforce but account for only about 6% of health care expenditures and that the decline in primary care workforce explains why 20% of Americans live in a HRSA primary care health shortage area. We encourage CMS is carefully review NASEM’s recent, and fourth, primary work titled, “Implementing High-Quality Primary Care,” that, in part recommends the creation of a Council on Primary Care and that CMS appreciate the report’s recommendation that the percent of total health spending going to primary care be tracked for the purposes of increasing primary care service utilization – a policy that has benefitted at least four states. Also too, we encourage you evaluate Harold Miller’s recent related writings, for example, his recent JAMA Viewpoint essay.
CMMI
Per your August 12th blog post to (re)define CMMI’s vision, we appreciate and/or support your interest to give greater priority to health equity, simplifying the Center’s portfolio, addressing the self-selection problem, setting more appropriate financial benchmarks, helping providers better manage financial risk, providing more real time data, better engaging Medicaid, etc. We also support, per my related comment above, improving risk adjustment and transparency. Perhaps moreover, it defies belief that the Center’s ACO demonstrations are unable to benefit from the MSSP program, because the agency continues to fail to evaluate MSSP. This is particularly disappointing since the MSSP, to which over 10 million Medicare beneficiaries are currently assigned annually, is the flagship APM model. Concerning ACOs or total cost of care models, we applaud the agency for contracting with Dr. J. Michael Williams. We hope the Center and agency give his policy recommendations careful consideration.
That said, we offer four recommendations. First, in addition to the Medicaid program, the Center needs to do a far better job of engaging Medicare Advantage providers. With 42 percent of Medicare beneficiaries, the program is far too big to not to formally score savings. (Research just published also showed, though authorized by the Congress, paying double bonuses to MA plans is ineffective and disproportionally benefits White versus Black beneficiaries.) Second, both the MSSP and related total cost of care demonstrations need to be on a level playing field with MA. As you are aware, these models use different benchmark formulas, quality metrics, risk adjustment and marketing rules. ACOs exclude Part D; MA is allowed to vary clinical care and offer non-clinical benefits. Varying regulations confuse the beneficiary that is particularly problematic since one-third of them are cognitively impaired. Moreover, while these programs should be synergistic, i.e., make the Medicare program greater than the sum of its parts, they are not because ACOs are unable to compete against the far more favorably regulated MA program. Third, CMS/CMMI recognizes the need to better engage commercial plans, for example, make far better use of the HCPLAN. Lastly, CMS should stop ignoring the PTAC.
Social Determinants of Health
Per my economic inequality comments above, policy makers have on balance ignored the importance of social determinants - that account for upwards of 80 percent of health status - in determining population health. What largely explains our inability to appreciate the importance of social determinants, we would argue, is our history of fetishizing individualism. Regardless, despite the fact the research literature is unequivocal, the US still spends far less than comparative countries on social spending. For example, a 2016 RAND Europe study found such an association and found further the association was stronger when accounting for public social spending versus private social spending. As you likely know we have the lowest ratio of health care spending to social spending to in the OECD. Our health to social spending ratio is 1:1. The ratio is on average 1:2.50 for all other OECD countries. Concerning the US healthcare’s direct investment in social determinants, largely via housing, research published in 2020 found healthcare’s direct investment in social determinants between 2017 and 2019 amounted to only $2.5 billion, a trivial amount compared to total US healthcare spending.
We recommend first CMS consider underlying systemic or upstream community-wide issues. For this we recommend CMS identify programming partners within HHS and throughout the federal government, for example, at DOT, HUD, USDA and the EDA as it relates to Opportunity Zones - created under the 2017 tax law. We also encourage CMS to continue to study what states are doing to incorporate SDOH for the purposes of improving Medicare, particularly ACO programming, MA and CMMI demonstrations. Currently, over 40 states integrate at least one non-health program in their Medicaid managed care plans. For example, there are noteworthy efforts in Oregon, Minnesota, Rhode Island and North Carolina where respectively COOs are required to invest in health-related services, ACOs partner with CBOs to implement community-based interventions, investments are made in Health Equity Zones and case management efforts that address interpersonal violence. Regarding this last issue, we encourage CMS both in Medicaid and in Medicare to do far more in addressing elder abuse.
Addressing elder abuse must include accounting for kodukushi, or dying alone. Loneliness or social isolation in senior adults is a serious health risk affecting the 33% of all Medicare beneficiaries who live alone and 50% over those over 85 living alone. These percentages have certainly worsened due to the ongoing pandemic. Loneliness or social isolation is associated with a 50% increase in dementia, a 30% increase in heart disease and stroke, depression, anxiety and suicide and significant increases in ED visits and hospitalizations. There is a growing literature regarding policy approaches/solutions. For example, see Dr. George and Whitehouse’s recent, American Dementia, Brain Health in an Unhealthy Society.
Long Term Care
As you are aware, the US, unlike comparative nations, has no non-catastrophic LTC policy. This remains true despite, among other facts, the US has a rapidly aging population, 12% of the elderly will need five or more years of substantial care, less than 10% of middle-income people have LTC insurance and those in significant need of LTC essentially require a family member’s full-time attention - that comes at considerable health and economic costs to the family caregiver. Nevertheless, among the 91 demonstration’s CMMI currently lists, none address LTC even though PTAC recommended a proposed LTC payment model in 2018 and seven of the then ten PTAC members voted to recommend or recommend with priority the model be tested. While the Congress continues to consider LTC legislation, for example, Rep. Souzzi introduced the WISH Act in early July, it appears likely the Congress will again take no action in the near term.
The lack of a LTC policy is particularly disturbing from a health equity perspective. LTC that is available via Medicaid is highly uneven, for example, several states constrain eligibility for LTC. LTC notoriously suffers poor quality. As an example, we are forced to note as The New Times has just reminded us, CMS continues to refuse to address the perverse overuse or misuse of antipsychotics in LTC facilities. As a 2018 Human Rights Watch report documented and again in a House Energy and Commerce Committee 2020 report, the use of antipsychotics for the purpose of chemically restraining the frail elderly, in part via unfounded diagnoses of schizophrenia, widely persists. This is particularly disturbing since at least as far back as 2007 federal policy makers were made aware, via FDA testimony before the House Energy and Commerce Committee, that the off-label use of antipsychotic medications, for indications the FDA knows these drugs do not work, results in approximately 15,000 frail elderly deaths per year. In addition, LTC is generally under-funded that during the pandemic provided the added benefit of further depleting hospital resources and since the Medicaid program disproportionately serves minorities, 60% are Black, Latinx or members of other racial and ethnic minority groups, Medicaid LTC de facto constitutes segregated or separate and unequal care exacerbating inequality.
At minimum, while CMS finally update PACE regulations in 2019, the first major regulatory update since 2006, it remains disappointing the program, created in 1997, still enrolls a small fraction of eligible beneficiaries, at approximately 55,000, particularly considering the programs high quality marks and the fact PACE programs on average cost significantly less than care for a comparable population through other Medicaid services. Despite the 2019 regulatory update, CMS needs to do more to leverage the PACE program.
Accounting for Population Health
Since we fetishize individualism US healthcare assumes a paradigm whereby illness or disease exists at the individual level only. In a perverse, reductionist manner, disease exists only at the biological level. This explains why we no longer understand the health of the public to be different from the health of an individual. This also explains why ACA PPHF funding was repeatedly attacked by the Congress. Virchow’s, “do we not always find the diseases of the populace traceable to defects in society,” was evidently wrong. Poor health is of course a personal failing. Decontextualizing, de politicizing health helps explain, again, why Americans are forced to live shorter lives in poorer health.
Instead, we trust that CMS believes sickness or disease is highly heterogeneous, the result of multiple overlapping pathological abnormalities. We cannot achieve population health without recognizing populations. One immediate, important step CMS and CMMI demonstrations should take is to incent or require shared medical appointments (SMAs). Endorsed by among others the American Academy of Family Physicians and used successfully by the VA, SMAs, where patient groups numbering five to 20 meet with a multidisciplinary team address a wide range of chronic conditions. SMAs improve provider productivity and for patients have shown to decrease ED visits while improving patient motivation and self-management, satisfaction, outcomes and patient camaraderie.
Conclusion
These comments or recommendations are certainly not exhaustive. Since we have not mentioned Part D, leaving aside what the Congress may do this session, there is substantial opportunity to make regulatory improvements.
Concerning public health, the ongoing pandemic is a constant reminder that public health spending funding in the US has been an embarrassment. Already paltry at 3.2% of national health spending in 2002, spending declined further to 2.45 percent in 2019. This meant, in part, that states have spent less than $2 per person per year on hazard preparedness over the past decade. Our response to the pandemic is testimony to the fact that every system is perfectly designed to get the results it gets. (For example, see Eric Reinhart’s recent writings regarding jails and prisons as epidemiological pumps in spreading COVID-19.) These results, that Commonwealth reminds us of over and again, place us last in healthcare performance among 11 high income countries. Per Commonwealth’s latest report just out last month, we are dead last in four of five healthcare performance categories: administrative efficiency; care access; equity; and, healthcare outcomes.
In sum, I encourage you to not spend too much time or become too preoccupied with visioning or “taking stock.” We largely or substantially know what regulatory reform policies are necessary. Since time is truly of the essence, I, along with my colleagues who worked to establish a national commission, encourage you to your staff to rededicate yourselves to the time-consuming task of spelling out necessary regulatory reforms via both your rule making and sub-regulatory guidance processes. We already know in painful detail, as Ms. Fowler candidly admitted, the system works well for everyone except the patient.
Along with my fellow hospital CEOs we are ready to assist you and your colleagues in any way we can to improve care for moreover our Medicare and Medicaid patients. I sincerely encourage both of you to contact me at your earliest convenience.
Thank you.
