Two PTAC Members Quit in Frustration

In 3 years, 16 recommendations offered to CMS and none accepted.

This article was first published on Thursday, November 21, 2019 in MedPage Today.

By Joyce Frieden, News Editor, MedPage Today   

WASHINGTON -- As the Centers for Medicare & Medicaid Services works to get its new primary care physician payment models off the ground, the agency now also has to deal with resignations at the organization the government charged with developing new Medicare payment models.

The Physician-Focused Payment Model Technical Advisory Committee (PTAC) was created by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) with the mission to make comments and recommendations to the Secretary of Health and Human Services on proposals for physician-focused payment models. "The secretary is required by MACRA to review PTAC's comments and recommendations on submitted proposals and post a detailed response on the CMS website," according to HHS's description of PTAC.

On Tuesday, PTAC member Harold Miller, MS, resigned from the committee; committee member Len Nichols, PhD, resigned the next day. Miller said his decision to resign was not contingent on anyone else's, while Nichols said that seeing Miller resign helped him make his own decision to do so also.

Frustrations with the Process

In their resignation letters, both men outlined their frustrations with the PTAC process -- specifically, with the fact that none of the models PTAC recommended have been approved by CMS for pilot-testing or implementation.

"Over the last 3 years, we have reviewed 32 proposals submitted by thoughtful practitioners in various fields of health care delivery (with one more on the docket for this December), and we recommended either testing or implementation for 16 of them," wrote Nichols, who is director of the Center for Health Policy Research and Ethics at George Mason University, in Fairfax, Virginia.

"Every single one of those recommendations has been declined by the secretary of HHS. Of late, public language has been used praising PTAC's various efforts and contributions, but the outcome is the same: HHS/CMS/CMMI remains opposed to implementing ideas submitted from the field." (CMMI refers to the Center for Medicare and Medicaid Innovation at CMS.)

The rejections "[are] not because PTAC has done a bad job; indeed, both in the formal responses to our recommendations and in a variety of public events, the secretary of HHS, the CMS administrator, and the director of CMMI have repeatedly praised PTAC for its work," Miller, who is president and CEO of the Center for Healthcare Quality & Payment Reform, in Pittsburgh, noted in his letter. However, he continued, "it also seems clear that future recommendations will meet the same fate; the former director of CMMI told us there was 'no circumstance' in which CMMI would ever directly implement a payment model submitted through the PTAC process."

Wide Variety of Models

CMMI has only said that it would incorporate some of the "concepts" from PTAC-recommended models within the programs that CMMI develops, which "is completely inconsistent with the spirit of MACRA; Congress clearly envisioned that at least some of the good payment models developed by physicians would be implemented if they were recommended by PTAC," Miller said. The 16 models recommended by PTAC have spanned many areas of practice, including oncology, primary care, and home hospitalization.

"I do not want to be part of a process that misleads physicians and other stakeholders into thinking that if they develop a good physician-focused payment model, go through the rigorous review process PTAC has established, and receive a positive recommendation, they will have a chance of seeing their work implemented," he wrote. "The people who have submitted proposals to PTAC have spent many hours and significant amounts of money to develop their proposals, respond to our questions, and attend our meetings. All of this work has been wasted since it has been made clear that their work will not be implemented, and it does not appear that the outcome will be any different for future proposals, no matter how good they are."

In an email to MedPage Today, Nichols described the concerns committee members had and their attempts to do something about it. "A number of us long-time members have discussed steps we might take, including resignation, that might alert more to how ineffective PTAC currently is," he wrote. "We tried to organize a public discussion of the state of PTAC, but were told such a discussion with applicants was out of our legislative scope and forbidden."

In addition, "quite a number of us contemplated resigning and discussed it after the 'big no' letter from the Secretary arrived in June of 2018," Nichols said, referring to a letter from HHS secretary Alex Azar declining to implement 10 of the models the committee had recommended. "Adam Boehler had just come on board [as head of CMMI] and had little or nothing to do with those letters, and so we were persuaded to give the process more time." However, "this last set of rejections, and the way the RFA [request for applications] for PCF [the Primary Care First model] and the oncology model were 'spun,' pushed me and perhaps others back over the edge."

Hopes for the Future

Nichols told MedPage Today that he hopes his resignation "helps convince people inside HHS and the Congress, and throughout the stakeholder community, that something must change for the PTAC portions of MACRA to be effective. At a minimum, the secretary should direct CMMI to comment on proposals before the PTAC in public, so that applicants and PTAC members have a chance of rebuttal before the PTAC letters are written and before the Secretary's response is sealed."

Asked to comment on the resignations, HHS thanked Miller and Nichols for their contributions and added that "PTAC's in-depth deliberations and recommendations are invaluable to HHS and CMS in crafting physician models. HHS and CMS are committed to value-based care, working with stakeholders, and using the extensive work of PTAC to inform physician models implemented through the CMS Innovation Center."

Health economists had varying reactions to the controversy. "When you have a group of experts that aren't listened to, the country suffers," said Paul Hughes-Cromwick, MA, co-director of Sustainable Health Spending Strategies at Altarum, a healthcare consulting firm here.

Michael Chernew, PhD, professor of health care policy at Harvard Medical School, said he didn't follow the PTAC models much, "but I think in general, we don't need a lot more models anyway [though] that doesn't mean there aren't any that could be good. I think we have to think about simplifying the vision of how we do things, so I am skeptical that more models are the solution." Rather than have narrow, specialty-focused models, "I believe we should have broader models and allow underlying things to work out individually between organizations," Chernew said.