Case management programs could see some effect from the recent canceling of advanced care coordination through episode payment by the Centers for Medicare & Medicaid Services (CMS).

  • The canceled incentive payment models were set to go into effect on Jan. 1, 2018.
  • The change reflects Health and Human Services Secretary Tom Price’s philosophy that doctors know best about improving quality.
  • CMS says its new focus is on letting providers participate in voluntary initiatives, rather than mandatory episode payment model programs.

With recent federal agency action on rolling back initiatives that promoted case management and healthcare cost reductions, there’s a strong focus on letting doctors just be doctors.

The Centers for Medicare & Medicaid Services (CMS) canceled Advancing Care Coordination Through Episode Payment and Cardiac Rehabilitation Incentive Payment Models in a proposed rule issued Aug. 17, 2017.1

The incentive payment models were to take effect on Jan. 1, 2018. Instead, the focus will be on giving providers more opportunities to participate in voluntary initiatives, rather than mandatory episode payment model programs.1

The move reinforces Health and Human Services (HHS) Secretary Tom Price’s philosophy that doctors know best.

“Secretary Price has been on the record saying that he doesn’t like the notion that doctors should be evaluated by anybody,” says Gary Pritts, president of Eagle Consulting, a Cleveland-based organization that works with hospitals and physicians on HIPAA compliance, information technology security, and government regulations.

This is a common viewpoint among doctor groups, Pritts observes.

“Take a basic issue like doctors prescribing medicine,” he says. “A high proportion of patients don’t take the medication. Doctors feel like they gave an accurate prescription, and they should not be held responsible for follow-through on what patients do.”

If public health and payer initiatives were aligned with this viewpoint, then there would be no reason to tie physician compensation and evaluation to the outcomes of whether patients actually took the prescribed medication because doctors would not be responsible for patients’ poor adherence, he says.

Yet, much of healthcare has moved into the direction of making all healthcare entities and providers responsible for outcomes — even those outcomes that might seem to be outside of their control.

“With value-based care, we have a whole paradigm shift,” Pritts says. “The analogy I like to use is a sports analogy. You don’t hire a coach because he has excellent ability to communicate football strategy to the players and identify problems. That’s not enough to hire a coach: they need to do that, and more.”

People hire coaches because they need to win. If coaches inspire their athletes to work together to win, that’s success, Pritts says.

“The federal government has done a shift where they are trying to pay doctors like others pay coaches, and doctors are resisting this change,” he says.

“They’re not trained to empower people to make lifestyle changes, and they’re not trained on how to empower people to take their medicine,” Pritts adds. “I think the whole industry of nurse case management came about because of these failures.”

Self-insured employers and others have recognized that a health coach is needed to motivate people to make healthy changes. Patients need advice from physicians that they can and will act on, he says.

“The whole case management area came about because the traditional model was not working,” Pritts says. “There was no accountability for follow-through ever, and it was costing them for expensive conditions like congestive heart failure.”

Health experts now recognize that someone has to work with patients to get them to take actions that will keep them healthy. Physicians can be, and sometimes are, great coaches for patients, but the CMS move to roll back care coordination reflects a resistance to measuring physicians and holding them accountable for outcomes, he says.

“Major employers already have deals negotiated for cardiac care — bundled payments, and these include case management,” Pritts says. “Major employers are doing it, but Secretary Price is saying, ‘No, it’s not really ready for prime time.’”

Unfortunately, some of the recent government programs designed to promote care quality and efficiency are flawed, he notes. The Merit-based Incentive Payment System (MIPS) is a great notion, but it’s flawed in its implementation, Pritts says.

“It’s not really doing what it’s intended to do, so maybe it’s OK if CMS is gutting it because it’s really flawed,” he says. “How do you come up with one set of rules that applies to one million doctors? It’s probably an impossible task.”

MIPS had an annual performance threshold with half the money above and half below. There was a distribution of funds from low performers to high performers. Each participating provider is supposed to advance quality and move the target higher.

In working with physicians to help them maximize their scores, Pritts learned that a doctor could achieve a good score by knowing the rules. “But getting a good score has virtually nothing to do with improving the value of their care,” he says.

As increasing numbers of people enter the Medicare years, it’s clear that some kind of change is necessary. Advancing value-based care is a positive step, but the CMS changes are steps away from that approach without suggestion of an alternative option, he says.

“I’m a believer in value-based care; that’s my philosophical attitude,” Pritts says. “And I believe we should have a paradigm shift, making everyone responsible.”


  1. Medicare Program; Cancellation of Advancing Care Coordination Through Episode Payment and Cardiac Rehabilitation Incentive Payment Models; Changes to Comprehensive Care for Joint Replacement Payment Model. Fed Reg. 2017:39310-39333. Available at: http://bit.ly/2wHr3IF.