Is the Trump administration undermining value-based care?

Last year, the Trump administration made it clear that it took a different perspective on value-based care than the Obama administration. Based on its actions in 2017, it seemed as though it wanted to erode the previous administration’s progress away from fee-for-service.

The contrast was evident early on. In September 2016, then HHS Secretary Tom Price and other Ways and Means Committee members wrote a letter to CMS, urging the agency to discard mandatory bundled payments. Price called the very idea “experimenting with Americans’ health.” But even despite the many moves that appear to undermine value-based care, the reality is a bit more complicated.

First, let’s evaluate the various pronouncements that seem to be anathema to payment reform and value-based care when Trump took office.

Post-election, Trump’s pick for CMS administrator, Seema Verma, said much of the same on the value-based care front. “We need to make sure we’re not forcing, not mandating individuals to participate in an experiment, a trial that there’s not consent around,” she said in her confirmation hearing before the Senate Finance Committee, according to Health Exec.

At the beginning of 2017, CMS pushed back the expansion of the Comprehensive Care for Joint Replacement Model as well as the implementation of cardiac bundled payment initiatives multiple times. By August, HHS proposed eliminating several mandatory bundled payment programs, including those for heart attacks and joint replacements. Before the end of the year, CMS canceled the mandatory hip fracture and cardiac bundled payment programs. It also made changes to CJR, cutting down the number of mandatory geographic areas participating in it and making participation voluntary for low-volume and rural hospitals.

Instead, the administration has shifted to a focus on voluntary bundles. CMS announced BPCI Advanced, the next-gen version of the original BPCI, in January. The first cohort will start participating in the model, which is voluntary, in October.

Via email, a CMS spokesman said the alterations to the mandatory programs “were made after a robust comment solicitation and were intended to encourage health system change while minimizing provider burden and maintaining access to care.” The agency is examining the models started by the Obama administration “on a case by case basis” to pinpoint opportunities to improve them.

With all these cancellations and changes, is the Trump administration undermining value-based care? One industry expert said no, implying the genie can’t be put back in the bottle.

“I think it’s clear that the principles of value-based care are still endorsed and appreciated industry-wide,” Dr. Charles Saunders, CEO of Integra Connect, said in a recent phone interview. “I don’t think that there’s any backing off.”

Based in West Palm Beach, Florida, Integra Connect is a cloud-based technology company focused on helping organizations address value-based care needs. Saunders noted that going forward, the models are likely to change and evolve, particularly as the culture of healthcare continues to adjust to value-based care.

“I believe that we’ll continue on the course as an industry towards payment for value because the cost of healthcare is on an unsustainable growth path,” he said.

And perhaps he’s right. With Alex Azar taking the seat as HHS secretary earlier this year, the administration appears to be stressing the significance of fee-for-value. At his Senate confirmation hearing in January, Azar surprisingly expressed support of mandatory bundles.

“If to test a hypothesis there around changing our healthcare system it needs to be mandatory as opposed to voluntary to get adequate data, then so be it,” he said.

In early March, he told the Federation of American Hospitals that “there is no turning back to an unsustainable system that pays for procedures rather than value.” Azar noted that value-based care is one of the four areas the administration plans to emphasize in the healthcare realm.

Senators Sheldon Whitehouse and Bill Cassidy sent the new HHS secretary a letter in mid-March pushing value-based care and urging him to outline his goals in the area.

Verma backed Azar’s comments at this year’s HIMSS. She stressed the need for patient engagement and a shift away from the fee-for-service model. During her speech, she also unveiled the MyHealthEData initiative, a government-wide project aimed at giving patients more control over their health information.

To one observer, the policy shift was noteworthy.

“[Azar’s] comments to the Federation were intentional but pretty strong as far as dramatic change,” naviHealth CEO Clay Richards said in a recent phone interview. “I thought that was pretty telling from a policy standpoint.”

Brentwood, Tennessee-based naviHealth is a company that provides both payers and providers with post-acute care management expertise.

But what about the voluntary versus mandatory debate? Will Azar make good on his support of mandatory bundles?

“I think the market feedback to BCPI Advanced was so overwhelmingly positive, they’re going to continue to focus on that,” Richards said of the voluntary bundled plan. That’s not to say they won’t examine mandatory bundled payments at some point, he added. But for now, Richards believes they will concentrate on the latest voluntary model and ACOs.

When asked what solid steps the Trump administration is taking to move the needle on value-based care, the CMS spokesman mentioned MyHealthEData, as well as a request for information regarding policy approaches for the CMS Innovation Center. Comments were accepted through last November, and CMS said it’s currently reviewing responses.

“CMS plans to lead the Innovation Center in a new direction where payment models will allow healthcare providers the freedom to suggest new designs and offer new approaches to delivering care,” the spokesman said. “Our goal is to increase flexibility by providing more waivers from current requirements as needed to test these models and move away from the assumption that Washington can engineer a more efficient healthcare system from afar.”

Photo: JamesBrey, Getty Images