with Paulina Firozi


You wouldn’t know it from President Trump’s recent incendiary claims about Obamacare, but his Department of Health and Human Services is working behind the scenes to advance the law’s goals of rewarding doctors for better medical care.

Starting in January 2020, primary doctors for those using Medicare will be able to participate in a new experiment in which they’ll be paid for keeping patients out of the hospital and healthy at home (and could lose some money if they don’t.) The Centers for Medicare and Medicaid Services is also rolling out a program where larger physician practices could take on more risk but also reap bigger rewards than ever before for keeping seniors well.

It will be done through CMS’s innovation center, a new department created under the Affordable Care Act to test better models of paying providers. The center will offer four new payment options – and consider a fifth – in which primary care doctors and larger practices would collect per-visit fees and monthly payments based on their volume of patients, instead of separately billing Medicare for every separate test, exam or procedure.

In an announcement yesterday at the American Medical Association, Health and Human Services Secretary Alex Azar and other top health officials said more than one-fourth of seniors in the traditional Medicare program – nearly 11 million people – could be affected by the five-year experiment.

Health care is a contentious subject in Washington, but this idea largely isn’t: The need to reform Medicare, Medicaid and private health insurance payments so that providers are incentivized to care for patients in such a way that they will need fewer health-care services, not more of them.

Mike Leavitt, who served as HHS secretary under President George W. Bush, was among the first to raise the idea of such payment reforms, and his successors under President Barack Obama – former HHS secretaries Kathleen Sebelius and Sylvia Burwell – started serious efforts through ACA’s innovation center.

Now Azar is trying to expand those efforts, calling the new payment experiments “a pivotal hockey stick moment.”

“It’s only thanks to the efforts of my predecessors that we get to take this step forward,” Azar said.

Azar named payment reform as a key goal last year, along with lowering drug prices, combating the opioid epidemic and making health care more affordable. But designing payments so that doctors are rewarded for quality instead of quantity – and persuading them to participate in new methods of payment – is no small task.

Despite a number of payment experiments tried by CMS over the past decade, physicians still earn the most through the traditional fee-for-service method in which they’re compensated for each individual service. Nearly 60 percent of doctors in a 2017 AMA survey reported their practices had received some revenue from a value-based payment model, but these alternative payments comprised only 17 percent of their profit.

“We’re not going to fix this overnight,” Azar told attendees. “I have to remind the president of that occasionally.”

Doctors wouldn’t be required to participate in the new Medicare experiment. But Adam Boehler, director of the innovation center, predicted wide interest in the program, saying doctors could spend less time on billing Medicare and more time with patients. But Boehler said doctors could also boost their payments if they show good outcomes like better management of patients with high blood pressure or diabetes.

“They’re creating a significant amount of financial upside for doing the right thing,” Boehler said.

Primary care doctors in small practices could increase their Medicare revenue by as much as 50 percent but would risk losing no more than 10 percent. Larger practices could choose between two options, a version where they could stand to gain or lose up to 50 percent of their payments and a risker version where 100 percent of payments would be at stake.

Bigger Medicare payments sound great to doctors and hospitals, but they're typically less enthused about risking earning less. Providers participating in similar arrangements have recently pushed back when CMS moved to subject them earlier to financial losses for underperforming. But like Boehler, Azar said he’s confident doctors will want to participate in this latest experiment without any mandates. There’s “no need to do mandatory for the sake of mandatory,” Azar told me over the phone yesterday afternoon.

“We believe this will be a very attractive opportunity for practitioners to have the opportunity to do what they say they have always wanted to do in medicine,” Azar said.


AHH: Medicare’s Hospital Insurance Trust Fund, which pays for critical inpatient hospital services for seniors, is expected to run out of money by 2026. The trust fund, which pays for things like services and hospice care for Medicare beneficiaries, will have the revenue to pay for just 89 percent of costs by 2026, our Post colleague Jeff Stein reports, following the release of a report from the Social Security and Medicare Board of Trustees. The report also found Medicare costs are set to spike in the next several decades, increasing from 3.7 percent of the total U.S. economy to 5.9 percent.

The 2026 date is unmoved from last year, when the trustees predicted the same deadline for the hospital insurance fund. “The projections indicate that Medicare still faces a substantial financial shortfall that will need to be addressed with further legislation,” the report said. “Lawmakers should address these financial challenges as soon as possible.”

Meanwhile, the reserve fund for Social Security is expected to run out by 2035, after which payments will shrink for recipients. The program is set to exceed its total income in 2020 for the first time since 1982, the New York Times’s Alan Rappeport reports.

OOF: In rare public remarks on behalf of some of the family members that control Oxycontin maker Purdue Pharma, attorney Mary Jo White told Reuters the Sackler family wants to reach a broad settlement to end the thousands of lawsuits over the family and company's role in the opioid crisis. 

“The objective is and remains to try to achieve a global resolution,” White told Reuters’s Alison Frankel. “Purdue and the Sackler family members, given this litigation landscape, would like to resolve with the plaintiffs in a constructive way to get the monies to the communities that need them, to the people that are addicted ... rather than to pay attorneys’ fees for years and years and years to come. You’re talking 2,000 cases. How long will they take to go through the court system?”

White, who is a former chair of the Securities and Exchange Commission and a former U.S. attorney, added it would be difficult to settle the cases because “[y]ou have municipalities and counties as well as state AGs involved in these matters… And getting all of those plaintiffs in a global resolution is very difficult.”

Joe Rice, co-lead counsel in the multidistrict case that combines 1,500 opioid suits in federal court in Cleveland told Alison: “The issue is who are ‘they,’ what are they willing to settle, how, when, and for what consideration.”

OUCH: Health officials have for the fourth week in a row added dozens of new cases of measles to the growing list of confirmed cases this year, bringing the current total to 626, our Post colleague Lena H. Sun reports.  The United States is now set to surpass the record number of measles cases in a single year since 2000, when the disease was declared eliminated.

There were 71 new cases of the vaccine-preventable disease in the third week of April, with 22 states now reporting cases. 

The updated numbers on Monday are for cases as of April 18, Lena writes, but health officials are expecting another spike in cases because of the chances of increased spread during holiday gatherings over the weekend because of Easter and Passover. 

The largest outbreak in the country is currently in New York, with at least 303 cases reported this year. And New York City Health Commissioner Oxiris Barbot said officials there are prepared for an increase. 

— Meanwhile, health officials in the city issued summonses to the parents of three children in separate households last week because they did not vaccinate their children against measles, even after the city's emergency order requiring immunizations. 

"The adults face civil penalties of $1,000 if an officer upholds the summons at a hearing," Lena writes. "Health officials identified three children who were exposed to the severe respiratory virus but were not yet vaccinated by April 12, in violation of the order. Failing to appear at the hearing or respond to the summons will result in a $2,000 fine but city authorities have said they will not face criminal prosecution."


— It didn't take long for Rep. Seth Moulton (D-Mass.), the latest Democrat to join a growing group of 2020 presidential contenders, to weigh in on the issue of single-payer health care.

He took a jab at his opponents, some of whom have been pushing for Medicare-for-all, during an interview on ABC's "Good Morning America" hours after he posted his campaign announcement video on his website. 

"I think I'm the only candidate who actually gets single-payer health care," he said, explaining his own experience with a single-payer system through Veterans Affairs soured him on the concept of such a system for all Americans. 

“I made a commitment to continue getting my own health care at the VA when I was elected to Congress. That's single-payer, and I'll tell you — it's not perfect,” he said. “So if I'm elected, I'm not going to force you off your private health care plan. I want Medicare, or a more modern version of Medicare, to be available to everybody but I'm not going to force you off your private health-care plan if you like it. 

But he also said he thinks health care is "a right. "I think every American should have access to good affordable health care," he said.


— In a new report, the Congressional Budget Office found more than 1 million Americans have lost health coverage since 2016.

The report also suggests the number of uninsured Americans has grown from 27.5 million in 2016 to 28.9 million in 2018, Vox’s Sarah Kliff writes. A large part of the increase in the uninsured rate is from the Medicaid program – under President Trump, new regulations such as work requirements in various states have made it more difficult for potential beneficiaries to enroll in the program.

Sarah notes the report was released on Thursday, within hours of special counsel Robert S. Mueller's report, and so it didn’t get a ton of attention.

From Larry Levitt, senior vice president of the Kaiser Family Foundation: 

“The CBO report does note that measuring the uninsured rate is a challenging task,” Sarah writes. “It largely relies on survey data that Americans submit, rather than measuring enrollment in government programs, for example, where the agency can turn to administrative data sources. Still, this report isn’t the first to sound alarm bells about a rising uninsured rate.”

— Protecting Immigrant Families, a group made up of hundreds of advocate organizations, is releasing a new fact sheet warning about concerns related to the Trump administration’s public charge proposal, which could make it more difficult for immigrants to stay in the United States permanently if they have used government assistance programs.

The report, provided to The Health 202, compiles data and analysis suggesting the Trump administration’s proposal has already had a negative impact on immigrant communities even though the rule has not been finalized.

“The proposed changes to public charge policy in the U.S. are not final, but they are already causing significant harm,” the sheet reads. “Fear and confusion - known as the chilling effect - are causing people to disenroll from programs or forgo benefits to which they are eligible. The impact is far-reaching, given that one in four children in the U.S. has at least one foreign-born parent.”

The group says that in Texas, for example, a Medicaid health plan saw decreases in enrollment after versions of the  proposal were leaked. In California, a Medicaid health plan and providers have said they get calls from enrollees worried about the proposed policy.


— The Trump administration last week announced an ambitious $353 million effort aiming to reduce 40 percent of opioid overdose deaths in three years, our Post colleague Lenny Bernstein reports.

The program intends to “test the idea that the best approaches to combat the drug crisis are well known but poorly implemented and coordinated” and will involve doctors, treatment providers, law enforcement, courts, churches and housing providers in a system, for example, in which these groups work in tandem to offer continued support for substance abusers to try to avoid repeated relapses.

“We don’t have to be intimidated by the scope and scale of this challenge,” Azar said at a news conference late last week. “We can do it now.”

“The money will come from the National Institutes of Health’s Helping to End Addiction Long-term initiative and will go to the University of Kentucky ($87 million); Boston Medical Center ($89 million); Columbia University ($86 million) and Ohio State University ($65.9 million),” Lenny writes. “Each university will work with at least 15 towns or counties in its state to design programs and assess how well they work.”

— And here are a few more good reads: 


Coming Up

  • The House Veterans Affairs Subcommittee on Economic Opportunity, and House Education and Labor Subcommittee on Higher Education and Workforce Investment holds a joint field hearing on “Protecting Those Who Protect Us: Ensuring the Success of our Student Veterans” on Wednesday.

Democratic 2020 contenders are split over whether Congress should pursue impeachment proceedings against the president: