The DC Backstep

Submitted by hci3-usr on Friday, April 15, 2016 - 05:18

Newtown, CT – April 15, 2016

One step forward and one-and-a-half steps back. We call it the DC backstep – On the heels of the half-step back made with the implementation of the Comprehensive Joint Replacement (CJR) bundled payment program, CMS has done another net half-step back with its introduction of the Comprehensive Primary Care Plus (CPC+) payment program. The only thing that’s comprehensive about both these programs is the disappointment they engender. The CJR took a solid half-step back compared to the already flawed Bundled Payment for Care Improvement by removing the few truly innovative aspects of that pilot, in particular the ability for conveners to take on risk, and for various provider organizations to take charge of the patient and assume financial responsibility. In the next few weeks we’ll be releasing a Case Study on a year-long total knee and total hip replacement bundled payment pilot program and readers will (re)discover what most already know, namely that physicians are the real leaders of practice transformation, even though the active participation of all providers touching the patient is critical to success. But in its DC backstep, CMS has stripped the physicians of that role, dumping it all on the acute care facility. As for the CPC+, CMS took a step forward by removing the ludicrous total cost of care targets in the original CPC, which is good, and then provides a fixed payment which helps fund the management of patients with chronic conditions, while maintaining fee for service for the more acute conditions. And the fixed payment is adjusted to reflect the potential higher use of services for patients who need more intensive care management. But in its latest DC backstep, CMS introduces a massively complex “track 2” which muddies the waters, makes it almost impossible for physicians to participate and forces a pre-emption on other PCP-based alternative payment models being tested by private and public sector payers in the states.

What this means to you – The momentum behind the move to alternative payment models is now well engaged and, as we’ve said several times before, thanks to the Affordable Care Act and MACRA, there’s no turning back. And CMS has done its part by implementing the alternative payment model pilots that were recommended by the ACA. Much has been learned from them, and yet most of those important lessons have been ignored in DC. Fortunately, states and private sector payers have adapted their models to mitigate the shortcomings of the DC ones, and that’s really added to the national momentum. But what we now have seen twice is concerning because it’s disruptive instead of being supportive. Most providers can’t ignore Medicare and yet they should be ignoring these latest programs if they have the option. And at a time when many states are implementing their menu of alternative payment models, some may pause to determine whether they also shouldn’t ignore Medicare’s latest move, perhaps not wanting to believe that it’s actually a back step instead of a step forward. And so here we are, at that awkward moment when someone asks you to dance a tango, and instead of saying yes, everyone needs to say no because the dance isn’t a tango at all, it’s the DC backstep.


Francois Sig


Francois de Brantes
Executive Director