By skyforbes 
Earlier this year, Tincture spoke with Acting Administrator at Centers for Medicare and Medicaid Services (CMS), Andy Slavitt. Below is the first transcribed portion of the conversation between Andy and Dr. Jordan Shlain, Tincture’s founder and editor-in-chief. It has been edited for clarity. (This is the first part of a series; see here for the second part and the third part.)
Jordan Shlain: Hello Andy — thank you for taking the time to interview with Tincture, a new publication in health care that aims to simplify the complex and make health care interesting and engaging again.
I want to talk with you about the Medicare Access and CHIP Reauthorization Act (MACRA) today, in a way that brings it down from 30,000 feet to the level of the person on the street. That might be a doctor, a patient, or just be anybody that’s trying to get his or her head around this.
Most people probably think of MACRA as inside baseball, but there are a lot of other people around the country who aren’t part of the health policy wonk club. MACRA will mostly impact doctors and hospitals, given it’s a new financial incentive, but more fundamentally, it will impact the patient.
Andy Slavitt: Let’s start with patients. If you’re one of the tens of millions of people in Medicare, what is the program and what does it feel like? This is a program with among the highest level of satisfaction for consumers, for patients for almost any product or service, something like 85 percent satisfaction. It’s an enormous commitment that our country has made to people. If you look at the Medicare beneficiary today, it’s a far different picture from what you’d get if you looked at it 50 years ago when the program started, or even 20 years ago.
These are people living with disabilities. These are older Americans, and almost entirely they are people on fixed incomes, or even lower incomes if they’re part of a dual-eligible population. They experience a very fragmented health care system for care. They’re increasingly mobile, and they’ve got a lot of needs. There are a lot of chronic conditions, a lot of medications to take.
Their aspirations are consistent with what we as a health care system are trying to do: People want to stay at home and in their communities, rather than an institution if they can avoid it. They want relationships with physicians that can help quarterback them through the various challenges they have. They want to know what’s ahead of them. They want to build relationships. And all of those things are increasingly difficult the more complex our health care system gets.
If you look at legislation passed by Congress, what did it try to do in that context? The last big change for beneficiaries was the Prescription Drug Benefit. If you take the experience of flying an airplane, the prescription drug benefit added more features, more things to improve the experience; whereas MACRA really addresses the underlying engine of the aircraft, and the ability of the plane to take you more places, go further, and give you a better, safer flight overall. It addresses the question, “How do we look at the thing we value in the system? How do we move from a system that pays for things that people do, to paying for the things that we think work, and pay more for the things that work?”
It’s the kind of thing that may be invisible to the naked eye of the consumer at first, but the downstream impacts will result in a much better program than we’ve got today. Physicians will be more comfortable and secure in the program, because they won’t be facing the SGR that threatens to dramatically reduce their incomes. If we do this well, physicians will have more control and flexibility in their ability to practice medicine. We believe that at a broad level, these benefits will trickle down and improve patient care and the patients’ experience getting care.
Jordan: In the Fee-for-Service model there’s a moral hazard: If you go into muffler shop with a rattling muffler, you’re probably going to get a new muffler. They make money on the transaction. And that flies into the bundled payment model. MACRA is trying to enable doctors to restructure their models around outcomes that matter to patients, more than a billing transaction, and a lot of coding, which is very cumbersome, particularly for the physician practice. Is that a fair way to assess what MACRA is trying to do?
Andy: Well, I don’t really like that analogy, because I believe that fundamentally, physicians really aren’t driven by “How am I going to get paid for this.” When the patient and physician are together, we are not trying to coerce physicians into doing what they don’t think is right. We know that won’t work. What we can do is make it easier by allowing the physician to invest in the things that will matter.
Take the medical home model — which is a prominent feature and opportunity in MACRA. It gives doctors a lump sum every month to invest in care coordination. For small practices, the idea is to invest in care coordination and finding patients who are most in need of care, or to invest in software that tracks what happens with patients. That sort of thing isn’t widely available to small practices. What we’re looking at is a model that puts more of the decision-making in the hands of physicians and patients, and then saying, “Let’s figure out how to support it.”