The Big Short: Why and How It's Happening - Marcia Nusgart, R.Ph. Executive Director Alliance of Wound Care Stakeholders Bethesda, Maryland ...

The Big Short:
Why and How It’s
Happening

Marcia Nusgart, R.Ph.
Executive Director
Alliance of Wound Care Stakeholders
Bethesda, Maryland

The Biggest Change to Health Care Payment
Since the Beginning of Medicare- Why?

                                                     http://www.pgpf.org/analysis/the-medicare-trustees-report-in-charts
         ($14 BILLION)   Medicare Deficit for 2014
                                                                                                                           2

Medicare Access and CHIP Reauthorization Act
of 2015 (MACRA)

• MACRA was passed in 2015 with bipartisan support to
  replace the SGR formula.
• Legislation passed by Congress that reforms practitioner
  payment
  • Without it, Medicare physician payment would have suffered a 25%
    pay cut
  • Payment reform targeted advanced practitioners because they
    determine >80% of spending
  • With few exceptions, if you see Medicare patients, it affects you

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Facilitates MIPS and APMs

• The long term goal is to get everyone into Alternative Payment Models (APMs)
  (the final destination)
        •   Accountable Care Organizations
        •   Patient Centered Medical Homes
        •   Bundled Payments
        •   Medicare Shared Savings Program
• Initially, most practitioners are subject to the Merit-based Incentive Payment
  System (MIPS)
• When CMS issued the proposed rule on MACRA, the Alliance of Wound Care
  Stakeholders began preparing its comment letter to CMS.
    • We asked the simple question, “How do we ensure that wound care patients and
      practitioners are not overlooked as CMS makes the biggest change to payment in a
      generation?”
    • We asked Dr. Sam Nussbaum this question and he said, “CMS pays attention to the
      conditions that it knows it is spending the most money on. Do you have good data on
      how much money Medicare is spending on the care of patients with wounds, or
      indeed what percentage of Medicare beneficiaries have them?”

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Why Did the Alliance Care about MACRA?

➢ It’s who we are:
   ▪ We are a non-profit, multidisciplinary “association of clinical associations”
     and patient organizations
   ▪ Wound care is multidisciplinary – and so are we. Our members are
     clinicians of different backgrounds and certifications who TREAT wounds,
     or are patients with wounds
   ▪ We come together to have “one voice for wound care” when speaking to
     regulatory agencies and legislative bodies
➢ Our Mission:
   ▪ To promote quality care and access to wound care products and services
     for people with wounds and the clinicians who care for them
   ▪ Focus on issues of common interest that affect reimbursement and access
     to care
   ▪ We work for you through comments submitted on every policy that
     impacts the coverage of wound care services – currently on OPPS!
   www.woundcarestakeholders.org
   ▪ Workplan, Comments, Achievements of the Alliance                                Monitor policies that impact wound care on
                                                                                     our website!

Wound care clinicians treat a symptom of some
other specialty’s diagnosis
                                  Those other medical
                                  specialties often do a
                                  very good job of
                                  making their voice
                                  heard in the halls of
                                  Congress!

How much does Medicare spend on chronic
wounds? (Even we were surprised by the results.)
• Alliance recognized that wound care treatment is                                  Read our MACRA letter!
  expensive and wanted to inform CMS of this in our 2016
  comments on MACRA
• Problem: we could not find studies on the true costs of
  Medicare expenditures on chronic wounds
• Most of literature focused on inpatient not outpatient
• How could we get the data that was needed?
    • The Alliance reached out to Joan DaVanzo who has expertise with
      the Medicare dataset, and to the US Wound Registry, our partner
      for quality reporting and measure development.
    • The result was a landmark study, published in Value in Health
      2017- “An Economic Evaluation of the Impact, Cost, and Medicare
      Policy Implications of Chronic Nonhealing Wounds” Samuel R.
      Nussbaum, MD , Marissa J. Carter, PhD, MA , Caroline E. Fife, MD , Joan
      DaVanzo, PhD, MSW , Randall Haught , Marcia Nusgart, RPh, Donna Cartwright,
      MPA
• http://www.woundcarestakeholders.org/advocacy/areas-of-focus

Future Trends and Challenges

• Aging population creates increasing demand for
  medical products and services

• Cost conscious government and insurance
  payers- leads to unfavorable payment rates and/or
  discretionary coverage policies

• Need to demonstrate value to patients, payers
  and the health care system overall

• Need to focus on generating new types of data
  to demonstrate value-- especially in wound care -
  using real world evidence.

21st Century Cures- we need to find what works

• Goal: Bring US Healthcare innovation infrastructure into
  21st Century
• Advances personalized medicine; emphasizes patient
  centered outcomes and data
• Allows FDA streamline clinical trials, expands trial-design
  framework, opens door for application of real world
  evidence (RWE)—pathways for approval of wound
  products and technologies
• Dr. Scott Gottlieb blog- FDA Budget Matters: A Cross-
  Cutting Data Enterprise for Real World Evidence
https://blogs.fda.gov/fdavoice/index.php/tag/real-world-
evidence/

    How will we take advantage of these changes?

The Big Short:
Why and How It’s
Happening

Marcia Nusgart, R.Ph.
Executive Director
Alliance of Wound Care Stakeholders
Bethesda, Maryland