HHS Chief: Medicare Payment Should be 'Patient-Centered'

New primary care payment models are a good start, says Azar.

This story was first published on Tuesday, July 23, 2019, in MedPage Today.

By Joyce Frieden, News Editor, MedPage Today July 23, 2019

WASHINGTON -- The way physicians are paid needs to become more "patient-centered," Health and Human Services Secretary Alex Azar said Tuesday.

"Sometimes 'patient-centered' can sound like a cliché, especially here in Washington," Azar said in a speech during a meeting of the Better Medicare Alliance, a trade group for Medicare Advantage plans. "But the way we pay physicians today truly is not patient-centered. Instead, it's procedure-centered, oriented around the Medicare physician fee schedule."

"In such a system, physicians aren't incentivized to help you stay healthy -- they're driven to order more procedures," said Azar. He recounted a story told by Marty Makary, MD, a surgeon at Johns Hopkins in Baltimore, who saw a strange practice at some health fairs he attended.

"Health professionals were meeting with older patients, doing tests, and asking them if they had any leg pain -- and who doesn't?" said Azar. "If they had leg pain, the doctor would suggest this might be a symptom of narrowing of the arteries -- and that can be easily fixed, they were told, with a stent or balloon. Makary was shocked to see this, because these surgeries aren't necessary as a preventive measure -- clinical best practices generally don't even recommend screening for the condition they address."

The patients were then signing up for these unnecessary procedures, "costing Medicare, and sometimes their own pocketbooks, thousands and thousands of dollars," he said. "There's a better way -- a system where the profitable path for physicians isn't more procedures, but better health for their patients." Azar was referring to the new Medicare primary care payment models that the Centers for Medicare & Medicaid Services rolled out in April; the models require doctors to assume varying levels of risks for their patients' healthcare costs.

The Trump administration also is working on improving coordination of care, he added. "One of the downsides to this Balkanized health IT [information technology] system is how time-consuming it can be to go from doctor to doctor. But the barriers to effective coordination among providers are much steeper than just excessive paperwork."

"In many cases, it doesn't matter how much paperwork doctors are willing to put up with," said Azar. "Coordinating care and sharing risk for outcomes among providers simply isn't allowed under the current interpretations of some statutes. Addressing these regulations that impede care coordination are part of a much broader regulatory reform effort at HHS. ... Last year, I had [HHS] Deputy Secretary Eric Hargan launch a regulatory sprint on examining barriers to coordinated care, which is getting very close to proposing new rules that will free up opportunities for information sharing, care coordination, and value creation."

Azar also continued the administration's attack on some Democrats' proposals for implementing a Medicare for All system. Currently, he said, 60 million people are enrolled in either Medicare or Medicare Advantage, 180 million people are in employer-sponsored private health plans, 70 million are enrolled in Medicaid, 10 million are in plans from the Affordable Care Act (ACA) heath insurance exchanges, and about 29 million are uninsured.

Azar hovered over the 10 million in the ACA exchange plans, which he pointed out represents only 3% of the healthcare system. "Many of them have suffered greatly, and we need to improve their experience -- but healthcare is much more than just Obamacare," he said. "The world is bigger than the debate over the Affordable Care Act."

Although most people are happy with their health insurance coverage, they see problems with it, and the Trump administration is working to fix them, Azar said. He emphasized that the administration "will always protect Americans with preexisting conditions -- a guarantee we will maintain at the federal level." He then discussed the administration's "new, affordable options" for people who buy individual insurance, including short-term, limited-duration plans; those plans are not required to include all the areas of coverage mandated by the ACA, such as mental health or maternity care benefits.

"We look forward to a day when Congress is willing to work with us to replace Obamacare for good, with affordability, options and control, and quality as the guiding principles," Azar said. In April, President Trump said the Republicans would become the "party of healthcare" and that congressional Republicans were developing a plan to replace the ACA; no such plan has yet been forthcoming.

Azar noted that the number of seniors choosing Medicare Advantage plans instead of traditional Medicare has been increasing, "yet some are proposing to expand the traditional Medicare program to cover all Americans, no matter their age, income, or circumstances. This is not only ignoring the lessons of our programs as they stand today -- it is also a path to undermining Medicare's promise and delivering fiscal ruin, doubling Americans' tax bills and increasing the size of the federal government by more than half."

"No American should ever lose his or her house because of their healthcare bills," he said. "But we have to provide that protection in a fiscally sustainable way."