PTAC Meeting, Day 1, Hospital at Home Plus Provider-Focused Payment Model – Part 3

PTAC Meeting, Day 1, Hospital at Home Plus Provider-Focused Payment Model – Part 3


SO I WOULD ASK COMMITTEE MEMBERS IF THERE
ARE ANY OTHER ADDITIONAL COMMENTS THAT PEOPLE WANT TO MAKE ON THE COMMITTEE.
IF NOT, I’M ASKING THE COMMITTEE ARE WE READY TO START DELIBERATING AND VOTING AT THIS POINT
IN TIME?>>I HAVE ONE COMMENT, MR. CHAIRMAN.
>>JEFFREY BAILET, MD: ABSOLUTELY.>>ONE COMMENT.
I JUST WANT TO SHARE THAT I SEE THIS PROPOSAL AS PART OF THE EVOLUTION OF MEDICINE.
I BELIEVE THIS IS PART OF OUR WORK TO ACTUALLY TRANSITION FROM HOSPITAL SETTING, WE ALREADY
DID SOME OF THIS WORK WHEN WE DID ELECTIVE SURGERIES AND ASC E’S, WHEN WE ACTUALLY MOVED
CHRONIC CARE TO HOME CARE AND COMMUNITY BASED CARE, NOW WE’RE TALKING ABOUT A LOWER ACUITY,
ACUTE CARE THAT CAN BE DONE AT THE HOME. I THINK SOME OF THE COMMENTS WE HEARD FROM
THE PUBLIC AND SUBMITTER ABOUT STRENGTHENING PATIENT SAFETY ACT, TO FORMALIZED TRAINING,
ACCREDITATION IS HELPFUL AND WILL MAKE THE PROPOSAL STRONGER AND I ALSO APPRECIATE THE
COMMENTS AND THE RECOMMENDATIONS FROM SOME OF THE FOLKS ON THE PHONE ABOUT NOT ONLY DOING
THE INTERNAL WORK OF ENSURING THAT THE APPROPRIATE PATIENT IS A CANDIDATE FOR THE IN-HOME CARE
BUT ALSO THE POSSIBILITY OF A CMS EXTERNAL AUDIT TO BE DETERMINED.
END OF COMMENTS.>>JEFFREY BAILET, MD: THANK YOU, DR. MEDOWS.
I GUESS I’M GOING TO TAKE THE LIBERTY TO MAKE AN ADDITIONAL COMMENT, AS I THINK ABOUT THE
SECRETARY’S CRITERIA AND THE BACKBONE OF WHY WE’RE HERE TODAY, THE GUIDING PRINCIPLES WERE
THESE PROPOSALS NEED TO ENHANCE QUALITY AND ALSO IF POSSIBLE, WHEN POSSIBLE, LOWER COST,
AND THERE IS CLEARLY CONNECTIONS HERE, BUT I WANT TO MAKE A COMMENT RELATIVE TO QUALITY,
YOU KNOW, THERE ARE QUALITY METRICS WE TRACK AND MONITOR, BUT THERE’S ALSO SOME QUALITY
METRICS RELATIVE TO COMPASSION AND ALLOWING PEOPLE WHO OTHERWISE WOULD BE IN HOSPITAL
SETTINGS TO HAVE THE OPPORTUNITY TO BE AT HOME WITH THEIR FAMILIES, AND I THINK THAT’S
VERY IMPORTANT. I SEE THAT AS IMPORTANT RELATIVE TO A QUALITY
METRIC, IF YOU WILL, THAN SOME OF THE OTHER CLINICAL QUALITY METRICS THAT WE ALL TRACK
AND MONITOR. SO I WANT TO PERSONALLY CALL OUT THE FACT
THAT WHEN I LOOK AT THE BACKBONE OF WHY WE’RE HERE TODAY, THAT THIS COVERS A LOT OF WATERFRONT
RELATIVE TO QUALITY. AGAIN, THIS MODEL ISN’T FOR ALL PATIENTS,
IT’S FOR A SELECT NUMBER OF PATIENTS WHO CAN TOLERATE AND HAVE THE SYSTEMS AND PROCESSES
TO SUPPORT THEM AT HOME. SO WE’RE GOING TO GO AHEAD AND START TO DELIBERATE
AND VOTE, AND LET ME WALK PEOPLE THROUGH THE PROCESS.
FIRST, I NEED THE COMMITTEE TO ACKNOWLEDGE THAT WE ARE READY TO MOVE FORWARD TO ACTUALLY
START VOTING.>>READY.
>>SO MOVED.>>JEFFREY BAILET, MD: OKAY.
SECOND. ALL IN FAVOR?
>>AYE.>>JEFFREY BAILET, MD: ALL RIGHT.
SO WE’RE GOING TO GO AHEAD. IT IS A SIMPLE MAJORITY OF THOSE PRESENT FOR
THE MOTIONS TO CARRY. SO WE HAVE TEN PEOPLE HERE TODAY THAT WILL
BE VOTING, AND AS I UNDERSTAND IT, THERE WILL BE — IS THERE ONE EXTRA, OR HAS THAT BEEN
–>>THAT WILL SHOW ON THE SLIDE, THE SLIDE
THAT EVERYONE WILL SEE WILL SHOW ELEVEN MEMBERS, THAT’S JUST THE PERSON RECORDING THE VOTES.
SO WE HAVE TEN MEMBERS VOTING AND SIX MEMBERS IS THE MAJORITY.
>>JEFFREY BAILET, MD: RIGHT. SO ANN AS OUR DFO WILL BE GOING BACK AND FORTH
TO CONFIRM THE NUMBERS OF VOTES AND THEN WE WILL MOVE THROUGH THE TEN CRITERIA.
WE’RE VOTING USING AN ELECTRONIC TOOL. THE GRAPHS AND TRACKING OF THIS WILL BE DISPLAYED
ON THE SCREEN BEHIND ME, BUT ALSO ANN WILL CALL OUT THE VOTE FOR FOLKS WHO ARE PARTICIPATING
VIA TELECONFERENCE. SO WE’RE GOING TO GO AHEAD AND START WITH
FIRST –>>JUST A MOMENT, PLEASE.
>>I THINK WE’RE READY TO GO. — WE’RE READY TO GO.
>>JEFFREY BAILET, MD: SO WE’RE GOING TO CONTINUE TO MOVE FORWARD, AND WE’RE GOING TO GO AHEAD
AND START WITH THE FIRST CRITERIA. AND THIS IS THE SCOPE OF THE PROPOSED PFPM,
HIGH CRITERIA, PROPOSAL TO BROADEN OR EXPAND CMS’S ALTERNATIVE PAYMENT MODEL BY EITHER
ONE ADDRESS AN ISSUE IN PAYMENT POLICY IN A NEW WAY OR, TWO, INCLUDING ALTERNATIVE PAYMENT
MODEL ENTITIES WHOSE OPPORTUNITIES TO PARTICIPATE IN ALTERNATIVE PAYMENT MODELS HAVE BEEN LIMITED.
SO THE NUMBERS HERE ARE NUMBERS 1 AND 2 DO NOT MEET, 3 AND 4 MEET, AND 5 AND 6 MEETS
AND DESERVES PRIORITY CONSIDERATION.>>WE CAN GO AHEAD AND OPEN THE VOTE.
>>SO WE’RE GOING TO GO AHEAD AND OPEN THE VOTE.
AND EVERYBODY PLEASE VOTE. SO ARE THESE WORKING?
>>THEY SHOULD BE WORKING JUST FINE. WE’VE TESTED THEM.
SO GO AHEAD AND PREGNANCY IT AGAIN. IT’S OKAY TO PRESS IT A SECOND TIME.
YOU’LL JUST OVERRIDE YOUR FIRST VOTE.>>IS IT REGISTERING?
>>WHEN IT REGISTERS, IT’S SUPPOSED TO TURN —
>>IT SHOWS YOU ON THE SCREEN WHAT YOUR VOTE IS.
>>I GOT IT, OKAY.>>IT’S SUN SPOTS TODAY, THERE ARE SUN SPOTS.
>>SO ONE MORE TIME WITH FEELING, RIGHT?>>IF WE WAIT JUST ONE MOMENT, I THINK WE’RE
GOING TO SWAP YOUR VOTE.>>MINE MIGHT BE — MINE MIGHT HAVE THE HAROLD
AFFLICTION, I DON’T KNOW. I’M GETTING A BIG GOOSE EGG ON MINE.
>>IT’S NOT OPEN RIGHT NOW, SO YOU WILL GET A BIG GOOSE EGG, WE HAVE TO WAIT UNTIL IT
COMES BACK UP.>>JEFFREY BAILET, MD: ALL RIGHT.
I THINK WE’RE DONE, RIGHT? ARE WE GOOD?
WE HAVE THE MAN BEHIND THE CURTAIN. STAY WITH ME.
STAY WITH THE DOCTOR.>>WE’RE GOING TO SWAP YOU OUT.
>>JEFFREY BAILET, MD: SO WE’RE GOING TO NEED TO VOTE AGAIN?
>>JUST A MOMENT, WHEN WE’RE READY TO VOTE. HOLD ON.
>>VOTING IS OPEN. LOOK AT YOUR CLICKER WHILE YOU PRESS TO MAKE
SURE YOUR VOTE IS REGISTERED.>>COME ON.
COME ON.>>AND YOU CAN VOTE MULTIPLE TIMES.
IT WILL ONLY RECORD YOUR MOST RECENT VOTE. SO IF YOU’RE NOT SURE, ENTER IT AGAIN.
>>MINE WORKED.>>MINE WORKED.
>>WHEN IT WORKS, LEN, IT WILL RECORD YOUR NUMBER ON THAT SCREEN, SO IF YOU’RE NOT GETTING
THE RECORDING, IT’S NOT WORKING. SO IT LOOKS LIKE WE HAVE EVERYBODY’S VOTE.
>>NO, WE DON’T, THAT’S ONLY 8. WE NEED TEN.
>>ERROR MESSAGE?>>IS ANYONE GETTING AN ERROR MESSAGE ON THEIR
KEYPAD? WE’RE DOWN TWO.
WE’RE NOT TRACKING TWO VOTES.>>AND WHO IN THIS ROOM HAS NOT HAD TECHNOLOGY
CHALLENGES AT A MEETING THAT YOU’VE RUN, RIGHT?>>RIGHT.
>>JEFFREY BAILET, MD: WE WILL MOTOR FORWARD HERE IN JUST A MINUTE ONCE WE GET THIS RESOLVED.
ONE AT A TIME? SO WHAT WE’RE GOING TO DO IS HE’S GOING ON
CLEAR IT AND THEN WE’RE GOING TO START WITH RHONDA, ONE AT A TIME, AND AS YOU PUSH IT,
WE CAN WATCH IT RECORD TO FIND THE ONES THAT AREN’T RESPONDING.
SO HE’S GOING TO GIVE US THE GUN HERE.>>ONLY MATT WILL BE ABLE TO SEE IT.
>>JEFFREY BAILET, MD: LIKE I SAID, ONLY MATT WILL BE ABLE TO SEE IT.
SO LET US KNOW, MATT, WHEN WE SHOULD START. WE’LL START WITH RHONDA.
GO AHEAD, RHONDA.>>RHONDA IS GOOD.
BOB IS GOOD. PRESS IT AGAIN.
LET’S SEE WHO WE HAVE. WE MIGHT NEED TO SWAP YOURS OUT.
>>DID YOU GET IT? DID IT RECORD IT?
DID LEN’S GO THROUGH? OKAY.
HERE WE GO.>>OKAY.
IT’S GOOD. GO THROUGH?
PAUL?>>IT WAS WORKING BEFORE.
>>JEFFREY BAILET, MD: HAROLD? FIRM BUT GENTLE, HAROLD.
WE WILL MAY HAVE TO COME UP WITH PLAN B HERE.>>WE HAVE A PLAN B.
IT’S JUST NOT AS FAST.>>HOLD THEM UP.
>>JEFFREY BAILET, MD: ALL RIGHT. MAYBE THAT’S THE PROBLEM.
TIM, TRY IT. SO DID YOU GET 11?
OKAY. AWESOME.
HOLD IT UP, MAYBE HOLD IT UP A LITTLE HIGHER, YOU KNOW.
YEAH, BUT YOURS DID GO THROUGH. YOU NEVER GOT THE RIGHT MESSAGE?
BUT HE RECORDED YOURS. HE DID SAY IT WORKED AT ONE POINT.
WE’LL TRY IT AGAIN. SO WE HAVE THE NUMBER HERE, MATT?
>>YEAH.>>ALL RIGHT.
LET’S GO AHEAD. LET’S GO AHEAD AND SHARE THE RESULTS, PLEASE.
MATT, LET US KNOW WHEN WE CAN GO AHEAD, WE’LL JUST REVOTE ON THIS ONE LAST TIME.
WE HAVE TO WAIT. THERE WE GO, IT’S COMING UP, HANG ON.
ALL RIGHT. WE CAN GO AHEAD AND VOTE.
ALL RIGHT. IT WORKED.
GREAT. POETRY.
ANN?>>OKAY.
SO WE HAVE ONE MEMBER VOTING 6 MEETS AND DESERVES PRIORITY CONSIDERATION, 7 MEMBERS VOTING 5,
MEETS AND DESERVES PRIORITY CONSIDERATION, TWO MEMBERS VOTING MEETS, AND 0 MEMBERS VOTING
3, 2 OR 1, SO THE MAJORITY OF THE COMMITTEE HAS VOTED THAT THIS PROPOSAL MEETS AND DESERVES
PRIORITY CONSIDERATION FOR CRITERION 1.>>JEFFREY BAILET, MD: CRITERION 2, QUALITY
AND COST. THE PROPOSAL IS ANTICIPATED TO, ONE, IMPROVE
HEALTHCARE QUALITY AT NO ADDITIONAL COST, 2, MAINTAIN HEALTHCARE QUALITY WHILE DECREASING
COST. OR THREE, BOTH IMPROVE HEALTHCARE QUALITY
AND DECREASE COSTS. THIS ALSO IS A HIGH PRIORITY ITEM.
WE’RE WAITING FOR THE CIRCLE HERE. AND NOW WE CAN GO AHEAD AND VOTE, PLEASE.>>ZERO COMMITTEE MEMBERS VOTED SIX NEEDS
AND DESERVES PRIORITY CONSIDERATION. FOUR COMMITTEE MEMBERS VOTED FIVE MEETS AND
DESERVES PRIORITY CONSIDERATION. FOUR COMMITTEE MEMBERS VOTED FOUR MEETS, TWO
COMMITTEE MEMBERS VOTED THREE MEETS, AND 0 COMMITTEE MEMBERS VOTED 2 AND 0 COMMITTEE
MEMBERS VOTED 1. SO THE PROPOSAL IS FOUND TO MEET THIS CRITERION
NUMBER 2 ON QUALITY AND COST.>>THANK YOU, ANN.
LET’S GO WITH CRITERION 3, PLEASE. THE PAYMENT METHODOLOGY, SO PAY THE ALTERNATIVE
PAYMENT MODEL ENTITY WITH A PAYMENT METHODOLOGY DESIGNED TO ACHIEVE THE GOALS OF THE PFPM
CRITERIA, ADDRESSES IN DETAIL THROUGH THIS METHODOLOGY HOW MEDICARE AND OTHER PAYERS
IF APPLICABLE, PAY ALTERNATIVE PAYMENT MODEL ENTITIES, HOW THE PAYMENT METHODOLOGY DIFFERS
FROM THE CURRENT PAYMENT METHODOLOGIES, AND WHY THE PFPM CANNOT BE TESTED UNDER CURRENT
PAYMENT METHODOLOGIES. THIS IS A HIGH PRIORITY ITEM.
GO AHEAD AND VOTE, PLEASE. ALL RIGHT.
ANN.>>ONE COMMITTEE MEMBER VOTED SIX NEEDS AND
DESERVES PRIORITY CONSIDERATION. ONE COMMITTEE MEMBER VOTED FIVE MEETS AND
DESERVES PRIORITY CONSIDERATION. FOUR MEMBERS VOTED FOUR MEETS, THREE MEMBERS
VOTED THREE MEETS. AND ONE MEMBER VOTED TWO, DOES NOT MEET AND
ZERO MEMBERS VOTED ONE DOES NOT MEET. THE MAJORITY HAS FOUND THAT THE PROPOSAL MEETS
THIS PAYMENT CRITERION.>>THANK YOU, ANN.
LET’S GO WITH CRITERION FOUR PLEASE. VALUE OVER VOLUME.
THE PROPOSAL IS ANTICIPATED TO PROVIDE INCENTIVES TO PRACTITIONERS TO DELIVER HIGH-QUALITY HEALTHCARE.
WAIT FOR IT. ALL RIGHT.
GO AHEAD AND VOTE, PLEASE.>>ANN.>>ZERO COMMITTED MEMBERS VOTED 6 MEETS AND
DESERVES PRIORITY CONSIDERATION. ONE MEMBER VOTED FIVE MEETS AND DESERVES PRIORITY
CONSIDERATION. EIGHT MEMBERS VOTED FOUR MEETS, ONE MEMBER
VOTED THREE MEETS AND 0 MEMBERS VOTED ONE OR TWO DOES NOT MEETINGS THE MAJORITY FOUND
THE COMMITTEE — THIS PROPOSAL MEETS CRITERION FOUR.>>THANK YOU.
CRITERION FIVE, PLEASE. FLEXIBILITY.
PROVIDE THE FLEXIBILITY NEEDED FOR PRACTITIONERS TO DELIVER HIGH QUALITY HEALTHCARE.
GO AHEAD AND VOTE, PLEASE. ANN.>>ZERO COMMITTEE MEMBERS VOTED SIX MEETS
AND DESERVES PRIORITY CONSIDERATION. FIVE MEMBERS VOTED 5 MEETS AND DESERVES PRIORITY
CONSIDERATION. THREE MEMBERS VOTED FOUR MEETS.
TWO MEMBERS VOTED THREE MEETS AND ZERO MEMBERS VOTED 1 OR 2, THE MAJORITY FOUND THIS PROPOSAL
MEETS THE CRITERION.>>CRITERION SIX.
ABILITY TO BE EVALUATED, HAVE A VALUABLE GOALS FOR QUALITY OF CARE, COST AND OTHER GOALS
OF THE PFPM. GO AHEAD AND VOTE.
I THINK BOB — ONE MORE TIME.>>THERE YOU GO.
ZERO COMMITTEE MEMBERS VOTED FIVE OR SIX MEETS AND DESERVES PRIORITY CONSIDERATION.
SEVEN MEMBERS VOTED FOUR MEETS, THREE MEMBERS VOTED THREE MEETS.
AND ZERO MEMBERS VOTED TWO OR ONE DOES NOT MEETINGS THE MAJORITY FINDS THIS PROPOSAL
MEETS CRITERION SIX ABILITY TO BE EVALUATED.>>THANK YOU, ANN.
CRITERION 7. INTEGRATION AND CARE COORDINATION, ENCOURAGE
GREATER INTEGRATION AND CARE COORDINATION AMONG PRACTITIONERS AND ACROSS SETTINGS WITH
MULTIPLE PRACTITIONERS OR SETTINGS WHERE MULTIPLE PRACTITIONERS OR SETTINGS ARE RELEVANT TO
DELIVERING CARE TO THE POPULATION TREATED UNDER THE PFPM.
VOTE.>>ONE COMMITTEE MEMBER VOTED SIX MEETS AND
DESERVES PRIORITY CONSIDERATION, FIVE MEMBERS VOTED FIVE MEETS AND DESERVES PRIORITY CONSIDERATION,
THREE MEMBERS VOTED FOUR MEETS, ONE MEMBER VOTED THREE MEETS, AND ZERO MEMBERS VOTED
ONE OR TWO DOES NOT MEET THE MAJORITY HAS FOUND THAT THIS PROPOSAL MEETS AND DESERVES
PRIORITY CONSIDERATION UNDER CRITERION 7.>>THANK YOU, ANN.
CRITERION 8. PATIENT CHOICE.
ENCOURAGE GREATER ATTENTION TO THE HEALTH OF THE POPULATION SERVE WHILE ALSO SUPPORTING
UNIQUE NEEDS AND PREFERENCES OF INDIVIDUAL PATIENTS.
GO AHEAD AND VOTE, PLEASE. THERE YOU GO, BOB.
>>TWO COMMITTEE MEMBERS VOTED SIX MEETS AND DESERVES PRIORITY CONSIDERATION.
SEVEN MEMBERS VOTED FIVE MEETS AND DESERVES PRIORITY CONSIDERATION.
AND ONE COMMITTEE MEMBER VOTED FOUR MEETS. ZERO COMMITTEE MEMBERS VOTED THREE OR TWO
OR ONE. SO THE MAJORITY FINDS THAT THIS PROPOSAL MEETS
AND DESERVES PRIORITY CONSIDERATION UNDER CRITERION 8.>>THANK YOU, ANN.
CRITERION 9, PATIENT SAFETY. HOW WELL DOES THE PROPOSAL AIM TO MAINTAIN
OR IMPROVE STANDARDS OF PATIENT SAFETY? PLEASE VOTE.
WE’RE HUNG UP ON ONE. THERE WE GO.>>ZERO COMMITTEE MEMBERS VOTED FIVE OR SIX
MEETS AND DESERVES PRIORITY CONSIDERATION. TWO COMMITTEE MEMBERS VOTED FOUR MEETS, EIGHT
COMMITTEE MEMBERS VOTED THREE MEETS, AND ZERO COMMITTEE MEMBERS VOTED ONE OR TWO DOES NOT
MEET THE MAJORITY FINDS THAT THIS PROPOSAL MEETS CRITERION NINE ON PATIENT SAFETY.>>THANK YOU, ANN.
THE LAST CRITERION, NUMBER TEN, HEALTH INFORMATION TECHNOLOGY.
ENCOURAGE USE OF HEALTH INFORMATION TECHNOLOGY TO INFORM CARE.
PLEASE VOTE.>>ZERO COMMITTEE MEMBERS VOTED FIVE OR SIX
MEETS AND DESERVES PRIORITY CONSIDERATION. FOUR COMMITTEE MEMBERS VOTED FOUR MEETS, SIX
COMMITTEE MEMBERS VOTED THREE MEETS AND ZERO COMMITTEE MEMBERS VOTED ONE OR TWO DOES NOT
MEETINGS THE MAJORITY OF COMMITTEE MEMBERS FINDS THIS MEETS CRITERION 10 FOR HEALTH INFORMATION
TECHNOLOGY.>>THANK YOU, ANN.
SO NOW IS THE MOMENT WHEN WE HAVE THE OPPORTUNITY TO ASK ADDITIONAL CLARIFYING QUESTIONS THAT
WE MAY HAVE THOUGHT ABOUT BEFORE WE ACTUALLY ARE GOING TO VOTE.
AND THIS IS A VOTE THAT WE DO INDIVIDUALLY, WE’RE GOING TO GO AROUND THE ROOM, RELATIVE
TO THE RECOMMENDATION. THE OVERALL RECOMMENDATION OF THE MODEL TO
THE SECRETARY. AND WE HAVE — ANN, WE HAVE —
>>JUST A RECAP.>>PLEASE.
GO AHEAD.>>SO OF THE TEN CRITERION — CRITERIA, THE
COMMITTEE FOUND ON SEVEN OF THOSE CRITERIA THE PROPOSAL MET THAT CRITERION.
ON THREE OF THE TEN CRITERIA, THE COMMITTEE DECIDED THAT IT MET AND DESERVED PRIORITY
CONSIDERATION AND THOSE CRITERION WERE ON INTEGRATION AND CARE COORDINATION, PATIENT
CHOICE AND THE SCOPE OF THE PROPOSED MODEL.>>THANK YOU, ANN.
SO WE ARE NOW GOING TO ACTUALLY VOTE ON THE RECOMMENDATION TO THE SECRETARY AND THERE
ARE SEVERAL OPTIONS I’M GOING TO READ THEM. FIRST IS DO NOT RECOMMEND THE PROPOSE — PROPOSAL
PAYMENT MODEL TO THE SECRETARY. WE HAVE THREE OPTIONS UNDER RECOMMEND THE
PROPOSAL TO THE SECRETARY. ONE IS LIMITED SCALE TESTING OF THE PROPOSAL,
SECOND IS IMPLEMENTATION OF THE PROPOSAL PAYMENT MODEL OR THREE, IMPLEMENTATION OF THE PROPOSED
PAYMENT MODEL AS A HIGH PRIORITY. SO WE’RE GOING TO — THAT’S WHAT WE’RE — WE’RE
GOING TO VOTE ELECTRONICALLY FIRST AND THEN INDIVIDUALLY PUBLICLY ONE AT A TIME.
SO THE FIRST IS — WOULD BE A VOTE, ONE LIKE I SAID, ONE IS DO NOT RECOMMEND, TWO IS RECOMMEND
FOR LIMITED SCALE TESTING, THREE IS RECOMMEND FOR IMPLEMENTATION AND FOUR IS RECOMMEND FOR
IMPLEMENTATION AS A HIGH PRIORITY. CAN WE GO AHEAD AND VOTE?
SO GO AHEAD AND VOTE. PLEASE.>>ANN.>>SIX COMMITTEE MEMBERS VOTED THAT THE — TO
RECOMMEND THE PROPOSED PAYMENT MODEL TO THE SECRETARY FOR IMPLEMENTATION AS A HIGH PRIORITY.
FOUR COMMITTEE MEMBERS VOTED TO RECOMMEND THE PROPOSED PAYMENT MODEL TO THE SECRETARY
FOR IMPLEMENTATION, THE MAJORITY FINDS THAT THIS TO RECOMMEND THE PROPOSED MODEL TO THE
SECRETARY FOR IMPLEMENTATION AS A HIGH PRIORITY.>>THANK YOU, ANN.
SO I’M — RON, YOU’RE ON THE END SO I’LL START WITH YOU.
WE HAVE — SO WE HAVE OUR PLACARDS.>>AND IF YOU CAN SAY IT VERBALLY SO IT WILL
BE CAPTURED IN THE TRANSCRIPT. NUMBER 3 RECOMMENDED PROPOSED PAYMENT MODEL
TO THE SECRETARY FOR IMPLEMENTATION.>>YOU DON’T HAVE TO HOLD THEM UP IF YOU DON’T
WANT TO, IT WAS OUR BACK UP IN CASE SOMETHING HAPPENED WITH TECHNOLOGY.>>THE STYLE IS NICE.>>I WOULD LIKE TO GET A SHOT OF RHONDA HOLDING
UP THE PLACARD. THANK YOU.
VERY GOOD.>>BOB.>>SO I RECOMMENDED 3, AFTER 20 YEARS IT’S
TIME WE FOUND OUT WHETHER THIS THING WORKS OR NOT.
AND THE LOGIC OF IT IS PRETTY STRONG. I THOUGHT THE BRT DID A VERY GOOD JOB IDENTIFYING
CONCERNS AND I WAS WITH PAUL, YOU HAD A LOT MORE WEAKNESSES THAN STRENGTHS IN A COUPLE
OF THOSE AREAS SO WHY WE CAME OUT POSITIVE, I NOW UNDERSTAND WHY THEY CAME OUT POSITIVE
BUT I DON’T THINK THE PAYMENT MODEL IS A LAY UP BY ANY MEANS.
AND WHAT WE DIDN’T REALLY DISCUSS IN MUCH DETAIL AT ALL AND I RAISED IT, WAS WHETHER
THE SHARED SAVINGS MODEL AROUND TOTAL COST OF CARE REALLY IS WHAT WE SHOULD BE REWARDING
OR IS IT PERFORMING ON QUALITY METRICS THAT WE HAVE SOME CONCERNS ABOUT, WHICH COULD EVEN
INCLUDE METRICS AROUND APPROPRIATENESS. SO I WOULD — I THINK THIS HAS TO GO FORWARD,
IT NEEDS TO BE TESTED BUT I DO THINK THE SECRETARY SHOULD USE SOME DISCRETION AND TRY TO GET
THE PAYMENT MODEL RIGHT, IN FACT MAYBE EVEN TRY A COUPLE OF DIFFERENT VERSIONS OF THE
PAYMENT MODEL TO SEE WHAT WORKS BEST.>>SO BOB, I’M JUST WONDERING IN THE INTEREST
OF EXPEDIENCY AND RHONDA, WE MAY HAVE TO GO BACK TO YOU, IF THERE ARE — AS YOU PROVIDE
YOUR INSIGHTS, IF YOU HAVE A SPECIFIC COMMENT THAT YOU WANT TO MAKE SURE IS IN THE RECORD,
I WANT TO MAKE SURE YOU WEAVE THAT IN TO YOUR DISCUSSION, TO YOUR POINTS AS WE GO AROUND
JUST FOR EFFICIENCY. SO I DON’T KNOW, RHONDA, IF YOU HAVE ANYTHING
SPECIFIC YOU WANTED ON THE RECORD.>>WE HAVE A PLAN TO DO INTERNAL
ASSESSMENT AND DO EXTERNAL AUDITS.
>>OKAY.>>THE SECOND PIECE WAS THE PART
ABOUT FORMALIZING THE TRAINING.>>THANK YOU.
>>BOB?>>ASSUMING THAT A LOT OF THE
GOOD BULLET POINTS CAN BE CAPTURED ON PAPER I JUST ADDED
THE ONE WHICH IS THE CONCERN ABOUT THE SHARED SAVINGS.
I DON’T KNOW WHETHER THAT’S APPROPRIATE.
I WAS ENDORSE A NUMBER OF THOSE BULLETS IN CATEGORY 2 WHICH IS
HOW IT CAN GO WRONG AND WOULD WANT TO WORK THROUGH THAT.
I AGREE IT’S DOABLE BUT I THINK IT WILL TAKE SOME WORK.
>>I VOTED NUMBER THREE TO RECOMMEND THIS TO SECRETARY FOR
IMPLEMENTATION. IT’S A VERY IMPORTANT MODEL.
I THINK IT’S 20 YEARS IN THE MAKING.
THE QUESTION IS HOW APPROPRIATE IT COULD BE GIVEN THE
INFRASTRUCTURE AND TIME IT TAKES TO SET THIS UP.
THE APPROPRIATENESS FOR SMALLER SET I’LL JUST SAY THIS,
ORGANIZATIONS WITH LIMITED CAPITAL RESERVES AND THE SECOND
IS SOME MECHANISM THAT IS NOT SOLELY THE RESPONSIBILITY FOR
THE APM ENTITY FOR WHAT I’LL CALL SAFEGUARDS.
>>DR. NICHOLS.>>I GAVE IT A FOUR BECAUSE I
LIKE IT A LOT IT’S EXTREMELY IMPORTANT FOR OUR NATION TO MOVE
THIS MODEL FORWARD IN BOB’S LIFE TIME WOULD BE GOOD.
I DID HAVE CONCERNS HAROLD EXPRESSED QUITE WELL I DON’T
THINK THE PARAMETERS AS SPECIFIED SHOULD BE ON DAY ONE
AND A PATHWAY TO BEARING MORE RISK OVER TIME OR ENDING UP IN A
FULL BUNDLE GIVING A PRACTITIONER OR APPLICANT A
CHANCE TO GET TO A FULL BUNDLE TO GO THERE AFTER A FEW YEARS.
THAT’S WHAT I’D RECOMMEND. FLEXIBILITY ON THE PARAMETERS.
>>ELIZABETH.>>I GAVE IT A FOUR.
I WOULD JUST ADD TO THE CONCERNS OR SUGGESTIONS TO HAVE AN
EXTERNAL PATIENT SAFETY FUNCTION AND MY CONCERN WAS ON TEN ON
INFORMATION SHARING BECAUSE I ACTUALLY THINK WE’VE TALKED A
BIT ABOUT HIT BUT I DON’T THINK THE STRUCTURES ARE IN PLACE TO
TALK ABOUT IT IN COMMUNITIES THAT WOULD FULLY ENABLE THIS SO
I THINK IT DESERVES ATTENTION.>>THANK YOU.
I GAVE IT A THREE. THE ONE COMMENT I WOULD MAKE IS
I CAN SEE WHERE THIS IS ATTRACTIVE TO PRACTITIONERS
ACROSS THE COUNTRY AND I CAN CAUTION THERE COULD BE
UNINTENDED CONSEQUENCES WITH THE EXPERTISE OF THE TEAM AND
ADVANCED PRACTICE FOLKS AND NURSES AND OTHERS.
ARE NOT WHERE I NEEDS TO BE. THERE NEEDS TO BE A ROBUST, VERY
CLEARLY SPELLED OUT MILESTONES IN TRAINING AND SOME WET LAB
WORK, IF YOU WILL, TO MAKE SURE THE PATIENTS WHO WOULD OTHERWISE
BE IN THE HOSPITAL. WE NEED TO DOUBLE DOWN AND MAKE
SURE THE INFRASTRUCTURE IS IN PLACE TO SUPPORT THEM SAFELY.
THAT’S MY COMMENT. THANK YOU.
>>I GAVE IT A FOUR. I THINK IF WE REALLY BELIEVE THE
TIME HAS COME THEN I THINK WE OUGHT TO STATE WITH SOME
PRIORITY THE TIME HAS COME AND PERSONAL EXPERIENCE MATTERS.
ELIZABETH SHARED HERS WITH US. I FACED A SIMILAR SITUATION A
YEAR AGO. I MISSED A MEETING BECAUSE MY
MOTHER-IN-LAW PASSED AWAY IN HOME AND WE HAD IT HIRE A
NAVIGATOR THOUGH WE WERE IN THE HEALTH CARE FIELD WE DIDN’T HAVE
THE RIGHT EXPERTISE. I BELIEVE THE TIME HAS COME WITH
SOME PRIORITY AND I WOULD ALSO ADD I THINK IT WOULD BE A GOOD
IDEA IN THE EVALUATION TO MAKE SURE THAT IT INCLUDES SOME
EXAMINATION OF THE DRGs AND WHAT HAPPENS TO THEM IF THIS MODEL IS
SCALED UP SO THAT IT REALLY DOES INFLUENCE WHAT KINDS OF CASES
REMAIN IN THE DRGs THAT ARE DONATING PATIENTS FOR HOSPITALS
AT HOME.>>THANK YOU, BRUCE.
PAUL.>>I ALSO RECOMMENDED
IMPLEMENTATION AS A HIGH PRIOR AND TO EMPHASIZE THE POINT OF WE
WANT TO TAKE CARE OUT OF THE HOSPITAL APPROPRIATELY.
I ALSO WANTED TO EMPHASIZE THE NEED FOR EXTERNAL AUDITING.
I DON’T THINK INTERNAL AUDITING WILL BE SUFFICIENT TO ENSURE A
PATIENT — TO BE SURE OF THE APPROPRIATE PATIENT SELECTION
AND TO YOUR POINT ABOUT THE PATIENTS IN THE HOSPITAL ARE NOW
BEING TREATED AT HOME. THOUGH WE HEARD FROM NCQA AND
THE IDEA OF CERTIFICATION IT NEEDS TO BE WELL VETTED BECAUSE
WE DIDN’T RECEIVE THIS TO UNDERSTAND THE SAFETY PART.
>>PAUL.>>HAROLD.
>> I VOTE TO RECOMMEND IT AS A HIGH PRIORITY.
I THINK — I’LL BUILD ON SOMETHING RHONDA SAID EARLIER
THIS IS A STEP WHAT WE NEED TO DO TO OVERHAUL THE HEALTH CARE
SYSTEM. ONE THING WE DIDN’T TALK ABOUT
HERE BUT AT THE PRT IS WHILE WE’RE TREATING THIS AS A
SPECIFIC SERVICE AND PAYMENT TO SUPPORT IT THAT THE PEOPLE WHO
DO THIS AT HOME AND THE INFRASTRUCTURE IS COMPLIMENTARY.
IF YOU DO A HOSPITAL PROGRAM AND OTHER THINGS AND THE
CAPABILITIES OF HOME VISITS AND OTHER THINGS WOULD BE HELPFUL
FOR ALL THOSE THINGS. WE SHOULD BE THINKING ABOUT
THESE AS BUILDING BLOCKS AND IT’S A GOOD BUILDING BLOCK
TOWARDS THE OVERALL SYSTEM. I BELIEVE IT SHOULD HAVE TO THE
EXTEND THERE ARE ADJUSTMENTS FOR QUALITY MEASURES WHICH I THINK
THERE SHOULD BE, THEY SHOULD BE APPLIED TO THE PAYMENT NOT TO
THE SHARED SAVINGS OR LOSS OR PRIMARILY THERE BECAUSE THE GOAL
IS TO MOVE IT TO A PROSPECTIVE PAYMENT AND THAT’S WHERE THE
QUALITY SHOULD BE ATTACHED. I THINK WE SHOULD BE UNDER
EMPHASIZING THE SHARED SAVINGS PAYMENT AND SHOULD GET IT RIGHT
TO DO THE SERVICE TO BE DONE AND NOT SO MUCH AND SHARED SAVINGS.
I THINK MORE OF THE COMPLEXITY OF THE MODEL IS ASSOCIATED WITH
ASSIGNING BENCH MARKS ETCETERA FOR SHARED SAVINGS.
IF WE MINIMIZE THAT PART I THINK WE’LL BE BETTER OFF.
I THINK THERE NEEDS TO BE THE EXTERNAL REVIEW PROCESS TO
ASSURE SAFETY AND APPROPRIATENESS WHICH WILL
ENABLE IT TO BE DONE IN MORE THAN BROADER COST MODELS.
I DON’T NOT BELIEVE IT SHOULD BE CONTINGENT BY NCQA OR ANYONE
ELSE. THERE SHOULD BE REASONABLE
STANDARDS PUT IN PLACE BY CMS OR OTHER PAYERS TO WHAT AN ENTITY
NEEDS TO HAVE BUT I DON’T THINK THEY SHOULD HAVE TO PAY ANYBODY
TO DO THAT AND I DON’T THINK I THINK IT RISKS ACCREDITATION
STANDARDS START TO METASTASIZE AND WE SHOULD ENCOURAGE THIS TO
BE DONE AS CREATIVELY AND FLEXIBLY AS POSSIBLE TO MAKE
SURE IT’S THE OUTCOMES THAT MATTER.
AS LONG AS THERE’S A GOOD MEASURE FOR PROTECTING FOR
OUTCOME AND QUALITY THE ACCREDITATION THE RULES SHOULD
BE MINIMIZED. AND FINALLY IN GENERAL FOR ALL
THESE MODELS WE’RE TALKING ABOUT AS PHYSICIAN-FOCUSSED SAVINGS
MODELS IT WILL BE ACHIEVED THROUGH REDUCTIONS IN
HOSPITALIZATIONS AND PROCEDURES AND WE NEED TO THINK AS A
COUNTRY AS A BETTER WAY TO PAY HOSPITALS AND WE SHOULDN’T JUST
BE SAYING — I KNOW HOW PEOPLE SOMETIMES FEEL ABOUT HOSPITALS,
YES, WE WANT TO TAKE PATIENTS OUT THEIR HOSPITAL AND THERE’LL
BE THOSE WHO NEED TO BE HOSPITALIZED AND HOSPITALS NEED
TO BE PAID APPROPRIATELY. WE NEED TO FIND BETTER WAYS OF
BEING ABLE TO SUPPORT THE CRITICAL CORE INFRASTRUCTURE
WITHOUT BEING PAID ON A PER EPISODE, PER PROCEDURE BASIS.
WE NEED TO BE MOVING TO THAT. THE MORE WE GET MODELS THAT ARE
TRYING TO KEEP PEOPLE OUT OF THE HOSPITAL THE MORE IMPORTANT I
THINK THAT BECOMES. THAT’S NOT KIND OF IN OUR
PURVIEW AT THE MOMENT BUT NEEDS TO BE PART OF ALL THIS.
THANK YOU.>>THANK YOU, HAROLD.
>>TIM.>>SO I VOTED NUMBER FOUR,
RECOMMEND AS A HIGH PRIORITY. I DON’T WANT TO REPEAT ALL THE
COMMENTS OF MY COLLEAGUES BECAUSE I THINK I AGREE WITH
ABSOLUTELY EVERYTHING EVERYONE SAID WITH TWO SMALL CAVEATS.
ONE IS I THINK GIVEN WHAT I HEARD FROM MY COLLEAGUES I’M
LESS CONCERN WITH THE SAFETY ISSUES.
I’D LIKE TO ASSOCIATE MYSELF WITH DR. MILLSTEIN’S COMMENTS.
HE DID AN EXCELLENT JOB OF CATALOGING THE INFLUENCES AND
PRESSURES ON ANYONE DOING THIS KIND OF PROGRAM THAT IS GOING TO
IN AND OF ITSELF INHERENTLY CREATE INCREDIBLE CAUTION
CAUTION AMONG THE PEOPLE IMPLEMENTING THESE PROGRAMS.
SO GIVEN THE COMMENTS I’M A LITTLE LESS CONCERNED ABOUT
THAT. I ALSO THINK TO DR. BARON’S
COMMENTS AND OTHER COMMENTS, I TOO AM NOT CONVINCED THAT THE
MODEL IS EXACTLY RIGHT ESPECIALLY ON THE SHARED SAVINGS
ISSUES AND SOME OF THE DRG ISSUES MENTIONED.
HONESTLY, I THINK I WOULD CONSIDER THOSE THINGS TWEAKS AND
NOT REASONS TO NOT BE HOLY ENTHUSIASTIC GIVEN ESPECIALLY
THE COMPASSION ISSUES ASSOCIATED WITH THIS PROPOSAL.
AND FINALLY, I DO SEE AN OPPORTUNITY IN TERMS OF THE
SPEED OF IMPLEMENTATION OF THIS AND I ALLUDED TO THIS IN SEVERAL
COMMENTS ALREADY BUT IF THIS PROGRAM WERE TESTS AS PAYMENTS
TO EXISTING ADVANCED APMs, A LOT OF THE ACTUARIAL CONCERNS GO
AWAY AND I SEE WITHIN THE
CONTEXT OF ADVANCED AMPs AND GIVE THEM TIME TO WORK OUT THE
MORE ACCREDITATION ISSUES AND OVERSIGHT ISSUES THAT WOULD BE
INHERENT I WOULD LIKE TO SEE THIS BENEFIT THE U.S. POPULATION
AS QUICKLY AS POSSIBLE.>>THANK YOU, TIM.
>>I’LL HAVE ANN PAIGE THE DFO SUMMARIZE WHERE WE ARE AT THIS
POINT.>>SO THE VERBAL VOTES ARE THE
SAME AS THE ELECTRONIC VOTES.>>I WANT TO TAKE A MOMENT AGAIN
TO THANK THE SUBMITTERS FOR THE DISCIPLINE PROCESS AND APPROACH
YOU PROVIDE AND THE CARE IT’S GOING TO EMANATE FROM YOUR WORK
AND NOW WE WILL MAKE A RECOMMENDATION TO THE SECRETARY
AS ANN DESCRIBED. THEN IT WILL BE UP TO THE
SECRETARY TO RESPOND AND NEXT STEPS.
>>TO HEAR MORE, IT WOULD HELPFUL TO HAVE
IT CLARIFIED IN THE REPORT TO THE SECRETARY.
THANK YOU.>>HAROLD.
>>WHAT MOUNT SINAI PROPOSED WOULD BE THE CORE OF A SOLUTION
WHICH IS TO HAVE AN EXTERNAL MONITORING PROCESS.
THE DETAILS OF EXACTLY WHO THAT IS AND WHAT THAT IS NEEDS TO BE
WORKED OUT BUT THAT’S THE CONCERN THERE NEEDED TO BE SOME
MONITORING OF THE MISSION AND ADVERSE EVENTS.
I THINK THEY DID LAY OUT IN ONE OF THE FINAL DOCUMENTS THEY SENT
US A FAIRLY DETAILED PROCESS BUT I’LL LEAVE IT TO RHONDA WHAT SHE
THINK MAY HAVE BEEN MISS FROM THAT.
>>THE EXTERNAL REVIEW IS ONE BUT I DO THINK THE TRAINING PART
NEEDS TO BE FORMALIZED. AND I ACTUALLY DO THINK HAVING
THE ACCREDITATION IS A PLUS. DOES IT HAVE TO BE A
REQUIREMENT? WE CAN DEBATE BUT I THINK IT IS
A PLUS. MY CONCERN IS I WANT TO MAKE
SURE THE PATIENT SAFETY IS STANDARDIZED AND THE APPROACH IS
THERE. I DON’T HAVE THE BENEFIT OF
BEING IN THE MIDDLE OF THE PROGRAM AND HAVING THAT
CONFIDENCE. I’M A HOPELESS CONSERVATIVE WHO
BELIEVES WE TRUST AND VERIFY.>>THANK YOU.
DR. BERENSON.>>I THINK THERE’S CAUTIONS IN
APPLYING THIS APPROPRIATELY. MY CONCERN IS THE OPPOSITE OF
CALLING A HOSPITALIZATION SOMETHING THAT CAN BE DONE
SAFELY. ON THE ACCREDITATION SIDE, THE
OBSERVATION I WOULD MAKE IS WE TALKED ABOUT NCQA AND HOSPITALS
ARE PRIMARILY ACCREDITED BY JACO AND DOES IT LOOK AT THIS
PROGRAMS THAT’S JUST A QUESTION
AND I DON’T THINK IT NEEDS TO BE REFLECTED IN OUR COMMENTS BUT
SOMETHING THAT NEEDS TO BE WORKED THROUGH.
>>HAROLD.>>IN THE SPIRIT OF TRANSITION I
WOULD SAY TO ME ONE SHOULD RELY MORE ON ACCREDITATION TYPE
THINGS EARLY AND MORE ON OUTCOME KINDS OF THINGS LATER.
SO I THINK THE PROBLEM I SEE TODAY IS IT BECOMES PERMANENT
AND IT GROWS. I THINK I DID NOT MEAN TO
SUGGEST THAT ANYBODY IN AMERICA SHOULD SUDDENLY START DOING THIS
WITHOUT HAVING TO MEET MINIMUM STANDARDS BUT I DON’T THINK —
WHEN SOMEONE IS IN PLACE AND HAS APPROPRIATE TRAINING AND
DEMONSTRATING THE APPROPRIATE KIND OF QUALITY CARE THEY SHOULD
NOT HAVE TO GO THROUGH THAT KIND OF EXERCISE AND SHOULD BE BUILT
IN THE MODEL AS A PERMANENT ELEMENT.
>>DR. BERENSON. OKAY.
I WOULD LIKE TO THANK THE AUDIENCE AS WE WORK THROUGH THE
DELIBERATION. I APPRECIATE THE ENGAGEMENT OF
MY COMMITTEE COLLEAGUES. AGAIN I WANT TO COMPLIMENT THE
SUBMITTERS FOR THEIR GOOD WORK. WHAT WE’RE GOING TO DO NOW IS
WE’RE GOING TO TAKE A RECESS UNTIL 1:30.
WE’LL BE BACK AT 1:30. THANK YOU  — 1:30.
THANK YOU.

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