‘ There will be more tipping points ahead’

Acting CMS Administrator Andy Slavitt has a lot of explaining to do. And a lot of listening. In recent months, the agency issued draft rules carrying out what’s intended to bring transformational change to the way Medicare pays physicians. It also rolled out a slew of experiments with payment and delivery reforms, including its first mandatory demonstration programs. In the process, Slavitt has become highly visible on social media and in person, and he has developed a reputation for unusual candor in conversations with healthcare leaders and clinicians. Slavitt spoke last week with Modern Healthcare managing editor Gregg Blesch. This is an edited transcript.

Modern Healthcare: Are we seeing so much come out of the CMS now because your time is running out?

Andy Slavitt: We’ll be working on Jan. 20, and one of the things I feel really good about is I’ll have virtually my entire team still in place, because there is a lot of important work and everyone’s really excited about it. And it is work we’re executing hand in hand with hospitals, physicians and others.

Having said that, it’s not my intention to drop a bunch of stuff off at the end of this administration and leave. It’s to create a launching pad for whoever comes next so that we’ve planted the appropriate seeds in the appropriate lanes. For example, in our cardiac work we did a medical bundle for (myocardial infarction), which is an innovation. That’s an example of not just feeling the market was ready and it was the right thing to do, but also leaving tracks that others can follow.

MH: But do you feel extra motivated by a sense that another administration might pull the plug on some of this work and the Innovation Center?

Slavitt: The Innovation Center has demonstrated to be a saver. As a result, I think it’s become an important, permanent part of the infrastructure. They have a lot of work to do, so I think they’re motivated, and I’m motivated, by the moment and the inflection point.

We’re always going to be going a little too slow for some and a little too fast for others. If we get it right, we’ll be giving opportunities for some to move fast, and that will move the market faster than anything else. And if we move smart, we’ll also be creating carve-outs for rural practices and rural hospitals and things like that so we don’t overwhelm areas.

MH: Do you see the mandatory bundled-payment demonstrations as signaling a tipping point?

Slavitt: I suspect that there will be several tipping points and I think this is one of them.… I talk to hospitals that are not even in the regions affected by some of these bundles and they’ve told me we’re using this as an excuse to get right with how we do post-acute care and rehab. That’s a tipping point, right? Because it’s tipping something else over. I don’t want to overstate it. There will be more tipping points ahead.

MH: How rapidly should we expect to see additional mandatory demonstrations of bundles with other episodes of care?

Slavitt: From a lot of the conversations I have with specialists and specialty societies, I can conceive that almost every surgical or medical area will want something here, and I think that’s largely due to MACRA. We made a very strong—I think, hopefully—that we’re going to want to look at our existing models and retrofit them as much as we can to qualify for an advanced APM under MACRA. We don’t want to just push the market. We want the market to pull us and show us when they’re ready. We’ll obviously keep consulting with all the industry participants to make sure we do gauge it right, and I think we’ll go as fast as the evidence allows us to go.

MH: The American Hospital Association’s statement on your new bundled-payment proposal expressed enthusiasm for the goals but also said you’re risking the success of other initiatives by adding new ones so quickly.

Slavitt: I never expect one of the associations to be any more committal than they’ve been. That’s the reason we speak directly to hospital CEOs—both the leaders and the people that don’t consider themselves leaders in this area.

I can tell you that many CEOs I talk to are guns blazing asking for what we just did. I won’t say that’s universal but there are many that are.

MH: You’ve been unusually visible on Twitter and in person in engaging the community on MACRA. What’s your sense of their understanding about what’s about to hit them and if they’re buying in?

Slavitt: There are a couple things at work. The first and most important is for us to listen and really signal we can listen. The most important job we have right now is to get it as right as possible coming out of the gate. And these things aren’t works of art. You don’t perfect them. But if we listen well, we’ll get it a whole lot more right and a whole lot better than we would otherwise.

I think it’s absolutely true that most physicians don’t know what MACRA is—may have heard of it, may not have heard of it. What I can tell you is that every physician,

“It’s not my intention to drop a bunch of stuff off at the end of this administration and leave. It’s to create a launching pad for whoever comes next so that we’ve planted the appropriate seeds in the appropriate lanes.”

no matter how disengaged they are, no matter their specialty, no matter their level of skepticism, has had their voice represented by other physicians.

We’ve been very successful in making sure all parties are heard from and that when we hear things we go deeper. And we’re really overweighting input from the most skeptical, the least-resourced physicians—the people who might be the most frustrated.

We’re not going to win back hearts and minds by trying to sell them an oversimplified vision. What we are going to be able to do is hopefully get this so it is as right as possible in terms of the four or five things physicians said matter to them, and then be able to make some good decisions in the final rulemaking process.

MH: Is it fairly certain at this point that there will be accommodations for certain types of practices in the final rulemaking as you mentioned in the Senate Finance hearing?

Slavitt: We’ll announce that with the final rule. Our goal is to make this successful for our beneficiaries and there is no way to make it successful for our beneficiaries if we don’t do it in a way that all physicians feel like they can be successful in that process. I didn’t intend to makes news when I said we’re going to find a way to get this off to the right start. That’s not the same thing as a delay. There are lots of ideas that have come to us and we are considering all of them.