Chiquita Brooks-LaSure’s Mappa Mundi for Federal Healthcare Policy in the Next Few Years

The 300-hospital-member Washington, D.C.-based America’s Essential Hospitals, which describes itself as “the leading champion for hospitals and health systems dedicated to high-quality care for all, including the most vulnerable,” released a statement attributed to the association’s senior vice president of policy and advocacy, Beth Feldpush, DrPH. Dr. Feldpush said, “America’s Essential Hospitals congratulates Chiquita Brooks-LaSure, MPP, for her confirmation as administrator of the Centers for Medicare & Medicaid Services (CMS). Brooks-LaSure takes the reins at CMS at a critical juncture for our nation, as COVID-19 and its lingering economic effects make access to health care coverage more important than ever. Her intimate knowledge of, and experience with, Medicaid and Medicare make her well suited to meet these challenges. We also welcome Brooks-LaSure’s long-standing focus on disparities in health and health care, such as Black maternal mortality and morbidity. We look forward to working with Brooks-LaSure and her team to eliminate health disparities and strengthen access to care among the underrepresented populations our hospitals serve.”

In a similar vein was robust praise from the Washington, D.C.-based Association for Community Affiliated Plans (ACAP), which represents safety-net health plans nationwide. Margaret A. Murray, ACAP’s CEO, said in a statement that “We congratulate Ms. Brooks-LaSure on her confirmation. ACAP stands ready to work with her to strengthen and expand affordable, high-quality health coverage. Ms. Brooks-LaSure has a strong record of advocacy for improving access to health coverage. We celebrate particularly her efforts to oppose barriers—such as work requirements—that further complicate Medicaid eligibility determination, her support for policies that root out racial inequities in maternal health, and her spoken desire to strengthen the Affordable Care Act and restore protections lost over the last four years. ACAP is fortunate to have worked with Ms. Brooks-LaSure in the past and we look forward to her leadership as we continue our work to make Medicaid, Medicare, and Marketplace coverage work better for the millions of Americans who rely on it,” she added.

And the leaders of the Children’s Law Center, a non-profit organization that advocates for the rights of children in the District of Columbia, posted a statement to their organization’s Facebook page that read, “Congratulations to Chiquita Brooks-LaSure on her selection to lead the Centers for Medicare and Medicaid Services! Chiquita has long championed #DC children’s health as a CLC board member and has spent her career fighting to improve and expand Medicaid — which plays a huge role in our kids’ mental and physical health. Her experience will be invaluable as our country navigates this unprecedented public health crisis,” adding at the end the hashtags #HealthAccess and #HealthEquity.

Meanwhile, Don Crane, president and CEO of the Los Angeles-based APG, America’s Physician Groups, said in a statement that “APG congratulates Chiquita Brooks-LaSure on her appointment as the next head of CMS. We look forward to working with Ms. Brooks-LaSure as she leads CMS efforts to end the COVID-19 pandemic, expand affordable healthcare, and promote equity within healthcare. APG members are especially eager to work with CMS on addressing the many challenges within our healthcare system, strengthening Medicare Advantage, and lowering our nation’s healthcare costs by continuing to move toward value-based care and away from expensive and wasteful fee-for-service care,” Crane stated, reinforcing his association’s core strategic aims. “As the largest association of physician groups practicing risk-based coordinated care, APG and its members believe strongly in and are committed to reimbursement systems such as capitation and holding physicians accountable for care, coordination, and quality to improve patient health,” Crane said.

Nor were the establishment healthcare associations reserved in their praise. In an April 9 letter to Senate Finance Committee Chair Ron Wyden (D-Oregon) and Ranking Member Mike Crapo (R-Idaho), Richard J. Pollack, president and CEO of the American Hospital Association, wrote to highly recommend Brooks-LaSure. Pollack wrote that “Ms. Brooks-LaSure has more than 20 years of experience in health policy, contributing to implementation of significant health care legislation such as the Affordable Care Act, which has afforded health care coverage to more than 23 million Americans. As deputy director for policy at the Center for Consumer Information and Insurance Oversight within the Centers for Medicare & Medicaid Services, and earlier at the Department of Health and Human Services as director of coverage policy, she led the agency’s implementation of Affordable Care Act coverage and insurance reform policy provisions. Ms. Brooks-LaSure also worked on the staff for members of the United States House Committee on Ways and Means. She has extensive experience working in a bipartisan manner and with various outside stakeholders. The AHA has worked with Ms. Brooks-LaSure during her career, she has been a champion for health care coverage and affordable health care, which the AHA has long supported. Throughout her time in public service, it is clear that Ms. Brooks LaSure has consistently made people across America and their health a top priority.”

Challenges and opportunities ahead

And if APG’s leaders were explicit in asking Brooks-LaSure to lead CMS forward in strengthening Medicare Advantage, supporting “reimbursement systems such as capitation and holding physicians accountable for care, coordination, and quality to improve patient health,” the leaders at the Alexandria, Va.-based American Medical Group Association (AMGA) offered Brooks-LaSure an entire memo’s worth of requests.

In a letter posted to their association’s website, AMGA’s leaders made several key recommendations, asking Brooks-LaSure to consider making changes in key areas. Here’s a brief summary:

> AMGA’s leaders want CMS to “use its authority to the fullest extent possible to eliminate the geographic and originating site requirements for telehealth services, particularly for those providers in alternative payment models. Payment parity between telehealth and in-person services is also needed, as the resources required to deliver care do not change depending on modality,” they note.

>   With regard to alternative payment models, “CMS should offer a harmonized portfolio of models that work together to improve quality and reduce spending. The models’ features should complement each other and offer providers the tools needed to deliver care in a value-based reimbursement structure. Flexibilities such as telehealth, preferred provider lists, physician self-referral exceptions, and beneficiary incentive programs should not be restricted or limited based on the level of risk in a given model,” AMGA contends.

>   “Medicare should further support care coordination efforts by eliminating the 20 percent coinsurance requirement for Chronic Care Management (CCM) codes, which reimburse providers for primarily non-face-to-face care management. This cost-sharing requirement acts as a barrier to more effective care planning.”

>   AMGA’s leaders also want CMS to reduce the regulatory complexity in Medicare Advantage.

>   And, AMGA leaders say, in order to advance population health management and care management, “CMS should require payers to share all administrative claims data with providers, and AMGA believes application programming interfaces (APIs) can help facilitate such information sharing.

>   AMGA wants the Medicare Advantage program to address the social determinants of health (SDOH) and to “minimize the effect of the coding intensity adjustment.”

>   AMGA also wants CMS to permanently expand the Hospital Care At Home program.

Looking at the complex landscape

Chiquita Brooks-LaSure, whose resume and writings show that she knows federal healthcare policy very well and can leap right into the job, takes the helm of CMS at a particularly fraught time. She, together with HHS Secretary Becerra, will be faced with a series of difficult, gnarly choices. Among the biggest areas she will have to steer the agency forward around will be the Medicare cost cliff; issues around the possible expansion of Medicaid or even of the ACA; the huge set of questions around the forward evolution of all the alternative payment models and programs that CMS is overseeing; physician payment specifically; and telehealth regulations; as well as a host of lesser issues.

Let’s look at a few of these in a bit of depth.

First is the cost cliff. Following Brooks-LaSure’s mid-April Senate Finance Committee confirmation hearing, The Advisory Board’s Heather Bell wrote an analysis on April 22 entitled “What last week’s hearings revealed about CMS nominee Chiquita Brooks-LaSure.” As Bell noted, “At some point during Biden's administration it is likely CMS and Congress will have to address the looming Medicare insolvency, and CMS has several levers it can use to control costs. For instance, CMS has the authority to lower provider reimbursement rates and is likely to continue the shift toward outpatient and home-based care, with additional site-neutral payment cuts. The agency also could slow the provider reimbursement rate growth without actually making steep cuts, though they would likely need to find additional cost savings elsewhere.”

Bell wrote that “One place the agency might turn is the Center for Medicare and Medicaid Innovation (CMMI), which is tasked with developing and testing alternative payment models to generate savings. For example, while Democrats in Congress are discussing broader drug pricing reforms, which CMS would have to help implement, CMMI could seek to rein in Medicare drug price spending through new payment models for Part D. While Brooks-LaSure did not directly address value-based payment models in her latest committee hearing, CMMI Director Liz Fowler recently noted that the center is in the process of reviewing existing value-based payment models "to define both the vision and the framework" for CMMI. The center already has delayed several payment models—and Advisory Board is eagerly watching to see what the Biden administration's vision is for the future of value-based care.”

And so of course, the future of all of the alternative payment models and programs that CMS administers is intimately bound up with overall CMS policy on healthcare system costs, and the cost cliff. As numerous observers have noted, to put things bluntly, HHS and CMS have a range of options to deal with the exploding costs in the U.S. healthcare system, but the bluntest tool available to them—massive reimbursement cuts to hospitals and physicians—is also a deeply politically unpalatable one, and would in any case require congressional approval. That’s why most observers believe that Brooks-LaSure will have no choice but to push hard on trying to convince as many providers as possible to plunge into value-based healthcare programs, and, very specifically, to take on two-sided financial risk.

There are, of course, many challenges ahead on that path. As I noted numerous times in 2019 and 2020, the ongoing feud between Seema Verma and several key national healthcare associations around the terms of those programs became a feature of Verma’s interactions with providers, particularly in late 2019 and throughout 2020. And the COVID-19 pandemic only sharpened the differences, with a few of the key associations threatening to encourage their members to pull out of the Medicare Shared Savings Program (MSSP) in particular, if Verma would not agree to make concessions related to financial benchmarks in the MSSP, as well as to modify some of the terms of participation around scheduling, etc.

The issue of the benchmarks might seem to be very specific, but in fact, if the majority of MSSP-participating accountable care organizations flee the program because they feel its terms are unfair, CMS would be up a creek with a very small paddle, when it comes to incenting providers forward into two-sided risk. Could direct contracting programs come to the rescue? Perhaps, but it’s unlikely that they can stimulate the breadth of participation that the MSSP has been able to achieve.

These cost and participation issues further cloud a goal that Brooks-LaSure has written publicly about: the potential of expanding Medicaid coverage under the ACA. As I noted in yesterday’s news report, “Brooks-LaSure coauthored an article with Elizabeth Fowler of the Commonwealth Fund and Gay Mauser of Manatt, published in the March 2020 issue of Health Affairs, entitled ‘Building On The Gains Of The ACA: Federal Proposals To Improve Coverage And Affordability,’ in which the authors wrote that a number of policy options exist for building on the strengths of the ACA, including ‘extend[ing] comprehensive coverage to all low-income Americans and increase[ing] coverage affordability for middle-income Americans.’ The Medicaid program, they wrote, could also be built out by ‘expand[ing] eligibility for Medicaid in the early years of the ACA to states that have not yet expanded Medicaid and increasing Marketplace cost-sharing subsidies.’ The authors also addressed the potential inherent in creating a public option. ‘A public option could also be implemented at the federal level, leveraging the administrative savings and bargaining power of Medicare as proposed in the Affordable Health Care for America Act, an earlier version of the ACA that was passed by the House of Representatives in 2009. In 2013 the Congressional Budget Office estimated that a public plan would reduce the deficit by $158 billion over ten years. A public option could be deployed everywhere or limited to certain geographic regions—such as markets with high premiums, areas with only one or two Marketplace plans, or states that have not expanded Medicaid.’”

The possibility of a public option seems quite remote, politically speaking, right now. Even if the Democrats manage to hold onto their majority in the House of Representatives in the 2022 midterm elections, and to hold onto their majority in the Senate as well, unless they were to make the fateful decision to end their cooperation with the Senate filibuster norm (a political norm that has no force of law, so it could be set aside without any legislation), they would not be able to overcome a near-certain filibuster by Senate Republicans of any public option legislation. Newly renewed healthcare inflation might also become a political obstacle to the possibility of any movement on the public option concept.

Meanwhile, physician reimbursement in particular will most likely need regulatory changes going forward, particularly in the MIPS (Merit-based Payment System) program under Medicare, in any case.

And there remains the tangled set of issues around telehealth reimbursement, particularly that of payment parity. Observers had been divided on whether Seema Verma would extend payment parity beyond the end of the national public health emergency, an action that would require congressional legislation in any case. What might happen now, under a new administration? Those who argue for the permanentization of payment parity believe that such a move will be absolutely necessary in order to make ongoing cost-savings gains through the telehealth option; but nothing is certain in that area, and the future of payment parity remains uncertain.

A host of other issues remain to be resolved as well. But the tangled Gordian knot of the healthcare cost cliff and APMs seems, in my mind, to be the most pressing set of issues facing Chiquita Brooks-LaSure in the next few years. And how she and Xavier Becerra, and their fellow senior officials at HHS and CMS, approach that Gordian knot, could help to shape the healthcare system for many years to come. And though it’s extremely unlikely that Brooks-LaSure will digest wish-lists whole like the one put forward by AMGA’s leaders, the new CMS head will no doubt be spending some time and energy laying out a plan of action—a mappa mundi for the next several years of federal healthcare policy strategy.