Complexity and ambivalence are inherent in Israel’s relationship with its Middle Eastern environment. Israel’s national security agenda is shaped by the hostility of a large part of the Arab and Muslim worlds. During the past 66 years, Israel has been able to crack the wall of Arab hostility, to make peace with two Arab neighbors, and to establish semi-normal relations with several Arab states. But the Arab-Israeli conflict, and its Palestinian core in particular, rages on, and Iran has joined the fray as a powerful and determined adversary.

In Israel, debates over the state’s identity, its place and role in the region, and the more specific issues of the future of the West Bank and Israel’s relationship with the Palestinians, govern the country’s politics and national discourse. The March 2015 Israeli elections are being conducted over a wide range of issues, but they are seen first and foremost as a referendum on these key questions. Politics and policy can hardly be separated. Appearances can be misleading. Currently, the focus of the election campaign seems to be on socio-economic issues. The main challenger of Netanyahu’s current government and potential right-wing coalition is “The Zionist Camp” led by Isaac Herzog and Tzipi Livni. They are strong advocates of reviving a peace process with the Palestinians, but they realize that the Israeli public has drifted to the right. Furthermore, the primaries in the Labor Party produced a left-leaning list of candidates. But whatever the current drift of the campaign, in the elections’ immediate aftermath, whoever forms the next government will have to deal primarily with the Palestinian issue and the national security challenges facing the country.

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• Israel and the Changing Middle East

       

Editor’s Note: This analysis is part of The Leonard D. Schaeffer Initiative for Innovation in Health Policy, which is a partnership between the Center for Health Policy at Brookings and the USC Schaeffer Center for Health Policy and Economics. The Initiative aims to inform the national health care debate with rigorous, evidence-based analysis leading to practical recommendations using the collaborative strengths of USC and Brookings.

The passage of the Medicare Access and CHIP Reauthorization Act (MACRA) just over a year ago signaled a strong and unique bipartisan agreement to move towards value-based care, but until recently, many of the details surrounding how it would be implemented remained unknown. But last week, the Centers for Medicare and Medicaid Studies (CMS) released roughly 1,000 pages that shed more light on how physician payment will hopefully dramatically change for the better.

Some Historical Context

Prior to MACRA, how doctors were paid for providing care to Medicare patients was subject to a reimbursement formula known as the Sustainable Growth Rate (SGR). Established in 1997 to control the rate of increase in spending on physician services, the SGR pegged total spending among all Medicare-participating physicians to an overall budget target. Yet in this “tragedy of the commons,” no one physician benefitted from her good stewardship of health care resources. Total physician spending often exceeded the overall budget target, triggering reimbursement rate cuts. However, lawmakers chose to push them off into the future through what were called “doc fixes,” deferring the rate cuts temporarily. The pending cut rose to over 21 percent before MACRA’s passage as a result of compounding doc fixes.

Moving Forward with MACRA

When it was signed into law on April 16, 2015, MACRA ended the SGR, its cuts, and many previous payment incentive programs. In their place, MACRA established two overarching payment incentive schemes for providers to choose from:

1. the Merit-Based Incentive Payment System (MIPS) program, which supplants three previous payment incentives and makes positive or negative adjustments to a physician’s payment based on her performance; or


2. the Alternative Payment Model (APM) program, which awards a 5 percent bonus through 2024—with higher annual payment updates thereafter—for having a minimum percentage of Medicare and/or all-payer revenue through eligible APMs. Base physician fee rates for all Medicare providers would be updated 0.5 percent for each of the first four years, followed by no increases until 2026, when base fees would increase at different rates depending on the payment incentive program in which a physician participates.

MIPS addresses providers’ longstanding complaints that reporting that reporting under the existing programs—the Physician Quality Reporting System, the Value-Based Modifier, and Meaningful Use — is duplicative and cumbersome. Under the new MIPS program, physicians report to the government payer directly (CMS) and receive a bonus or penalty based on performance on measures of quality, resource use, meaningful use of electronic health records, and clinical practice improvement activities. The bonus or penalty physicians may see starts at 4 percent of the fee schedule in 2019 (based on their performance two years prior—in this case 2017) and increases successively to 5 percent in 2020, 7 percent in 2021, and 9 percent from 2022 onward. From 2026 onward, MIPS providers would receive an annual increase of 0.25 percent on their base fee schedules rates.

In contrast, the APM incentive program awards qualifying physicians a fixed, annual bonus of 5 percent of their reimbursement from 2019- – 2024, and provides that their fee schedule rates grow 0.5 percentage points faster than those of MIPS in 2026 and beyond, in recognition of the risk they assume in these contracts.

Yet, according to MACRA, not all APMs are created equal. APMs eligible for this track must use quality measures similar to those of MIPS, ensure electronic health records are used, and either be an approved patient-centered medical home (PCMH) or require that the participating entity “bears more than nominal financial risk” for excessive costs. Then, in order to receive the APM track bonus, physicians must have a minimum of 25 percent of their revenue from Medicare come through eligible APMs in 2019, with the minimum increasing through 2023 up to 75 percent. In 2021, a new all-payer Advanced APM option becomes available, allowing providers in APM contracts with other payers to participate in the Advanced APM incentive. To do so, they must meet the same minimum thresholds—50 percent in 2021, 75 percent in 2023—but through all provider contracts, not solely Medicare revenue, while still meeting a significantly lower Medicare-specific threshold. By creating an all-payer option, CMS hopes to enable greater provider participation by allowing all payer revenue to count toward the same minimum threshold. Under the all-payer model in 2021, for example, providers must have no less than 25 percent of Medicare revenue through Advanced APMs and 50 percent of all revenue through Advanced APMs.

MACRA Implementation Details Revealed

The newly released proposed rule provides answers to significant questions that had been left unanswered in the law surrounding the specifics of implementation of MIPS and the APM incentives. At long last, providers are gleaning insight into how CMS intends to implement MIPS and the APM track. Given the fast-approaching MIPS performance period in January 2017, here are three key highlights providers need to know:

1. Qualifying for the APM incentive track—and getting out of MIPS—will be difficult. In order to qualify for the bonus-awarding Advanced APM designation, APMs must meet the “nominal financial risk” criteria, which will be measured in three ways: an APM’s marginal rate sharing for losses, minimum loss ratio (the threshold above which providers would begin sharing in losses), and total potential risk as a percent of expected costs. Clinicians must further have a minimum share of revenue that comes in through the designated APMs.


2. Providers will have fewer opportunities to see and improve their performance on MIPS. Despite calls from provider groups for more frequent reporting and feedback periods, MIPS reporting periods will be annual, not quarterly. This is true for performance feedback from CMS, as well, though they may explore more frequent feedback cycles in the future. Quarterly reporting and feedback periods could have made the incentive programs more “actionable” for providers, alerting them to their performance closer to the time the services were rendered and providing more opportunities to improve performance.


3. MIPS allows greater flexibility than previous programs. Put simply, MIPS is the performance incentive program clinicians will participate in if not on the Advanced APM track. While compelling participation, the proposed MIPS implementation also responds to stakeholder concerns that earlier performance incentive programs were onerous and sometimes irrelevant—MIPS reduces the number of measures required in some categories and allows physicians to select from a set of measures to report on based on relevancy to their practice.

With last week’s release of the proposed rule, the Leonard D. Schaeffer Initiative for Innovation in Health Policy is kicking off a series of work products that will focus dually on further MACRA implementation issues and on translating complex policy into providers’ experience. In the blogs and publications to follow, we will dive into greater detail and discussion of the pieces of MACRA implementation highlighted here, as well as many other emerging physician payment reform issues, as the law’s implementation unfolds.

       

       

       

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Register for the Event
From a bureaucratic backwater in the waning days of the Cold War, the fight against global poverty has become one of the hottest tickets on the global agenda. The cozy, all-of-a-kind club of rich country officials who for decades dominated the development agenda has given way to a profusion of mega philanthropists, new bilaterals such as China, "celanthropists" and super-charged advocacy networks vying to solve the world's toughest problems. While philanthropic foundations and celebrity goodwill ambassadors have been part of the charitable landscape for many years, the explosion in the givers' wealth, the messaging leverage associated with new media and social networking, and the new flows of assistance from developing country donors and diasporas together herald a new era of global action on poverty. The new scale and dynamism of these entrants offer hopeful prospects for this continuing fight, even as the new entrants confront some of the same conundrums that official aid donors have grappled with in the past.

On August 1-3, 2007, the Brookings Blum Roundtable gathered representatives reflective of this dynamic landscape to discuss these trends. Through robust discussion and continuing cross-sector partnerships, the conference hopes to foster lasting and widespread improvements in this new field of development.

2007 Brookings Blum Roundtable: Related Materials
	Read the roundtable report - Making Poverty History? How Activists, Philanthropists, and the Public Are Changing Global Development »  Download the participant list » (PDF)  Download the scene setter » (PDF)

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2007 Brookings Blum Roundtable Agenda:

1. Fighting Global Poverty: Who'll Be Relevant In 2020?
   • Matthew Bishop, The Economist, "Fighting Global Poverty: Who'll Be Relevant In 2020?"
   • Homi Kharas, The Brookings Institution, "The New Reality Of Aid"
   • Jane Nelson, Harvard University, "New Development Players And Models"
2. Angelina, Bono, And Me: New Vehicles To Engage The Public
   • Darrell M. West, Brown University, "Angelina, Mia, And Bono: Celebrities And International Development"
   • Joshua Busby, University of Texas, Austin, "Is There A Constituency For Global Poverty? Jubilee 2000 And The Future Of Development Advocacy"
   • Ngozi Okonjo-Iweala, The Brookings Institution, "Nigeria's Fight For Debt Relief: Tracing The Path"
3. Leveraging Knowledge For Development
   • Ashok Khosla, Development Alternatives Group, "Leveraging Knowledge To End Poverty"
   • Eric Brewer, University of California, Berkeley, "Development And Engineering"
4. Social Enterprise And Private Enterprise
   Chaired by: Mary Robinson, Realizing Rights: The Ethical Globalization Initiative
   • J. Gregory Dees, Duke University, "Philanthropy And Enterprise: Harnessing The Power Of Business And Entrepreneurship For Social Change"
5. Africa's Economic Successes: What's Worked And What's Next
   Moderated by: Paul Martin, former Prime Minister of Canada
   Panelists
   • Donald Kaberuka, African Development Bank
   • Ngozi Okonjo-Iweala, The Brookings Institution
6. Effecting Change Through Accountable Channels
   • Jane Nelson, Harvard University, "Effecting Change Through Accountable Channels"
   • Simon Zadek, AccountAbility, "Accountability Compacts: Collaborative Governance For The 21^stCentury"
7. Global Impact: Philanthropy Changing Development
   • Mark R. Kramer, FSG Social Impact Advisors, "Philanthropy, Aid, And Investment: Creating A Common Language"
   • Joseph O'Keefe, The Brookings Institution, "Aid - From Consensus To Competition?"
8. Keynote Address
   • Former Vice President Al Gore, Generation Investment Management

       

       

Event Information

The biomedical innovation ecosystem continues to evolve and enhance the processes by which treatments are developed and delivered to patients. Given this changing biomedical innovation landscape, it is imperative that all stakeholders work to ensure that development programs, regulatory practices, and the policies that enable them are aligned on and achieving a common set of goals. This will require a thorough reexamination of our understanding of biomedical innovation – and the subsequent ways in which we seek to incentivize it – in order to more effectively bridge research and analysis of the process itself with the science and policy underpinning it.

Traditional research into the efficiency and effectiveness of drug development programs has tended to focus on the ‘inputs’ and process trends in product development, quantifying the innovation as discrete units. At the opposite end of the research spectrum are potential measures that could be categorized as “value” or “outcomes” metrics. Identifying the appropriate measures across this spectrum – from inputs and technological progress through outcomes and value – and how such metrics can be in conversation with each other to improve the innovation process will be the focus of this expert workshop. On October 14, the Center for Health Policy at Brookings, under a cooperative agreement with the U.S. Food and Drug Administration, convened a roundtable discussion that engaged key stakeholders from throughout the innovation ecosystem to explore the factors and characteristics that could improve our understanding of what constitutes modern “innovation” and how best to track its progress.

Event Materials

• FINAL 1014 BrookingsFDA Agenda
• FINAL 1014 BrookingsFDA Participant List

       

       

Ever since World War II, the American dream has encompassed the four-bedroom house with a white picket fence, tucked away in the suburbs. But this dream has gradually turned into a nightmare, with the increase of traffic, congestion and the general inconvenience of being detached from the city. Whereas people once rejoiced in camping trips to escape metropolitan living, we are now, as a culture, magnetized towards it as the appeal for walking more and driving less steadily increases.

KOJO NNAMDI:Chris you've dubbed this new style of living- "Walkable Urbanism." What is the evidence of a rising demand for it?

CHRIS LEINBERGER: There's demographic evidence; there's consumer research evidence; but probably the most compelling evidence is the price premium people are willing to pay to live in a walkable urban place, that the survey's show anywhere from a 40% to 200% price premium on a price per square foot basis for a walkable urban place as oppose to a competitive near by drivable suburban place.

KOJO NNAMDI: So it used to be that a condo or a townhouse was entry level product for people who couldn’t afford a real house, its beginning to be the other way around?

CHRIS LEINBERGER: In fact in 2003 for the first time in the country's history, condos on a price per square foot basis cost more than single family housing, and that includes all those old condo's that were built to be a alternative to a quote "real house" which was a single family house.  Its fundamentally changed and we've only seen the beginning of this train.

KOJO NNAMDI: I am intrigued about why people's preferences are indeed changing. In your book you give some of the credit to popular culture. Talk about the difference between the baby boomers- who grew up on 'Leave it Beaver,' the 'Brady Bunch' versus Generation Xer's who watch 'Seinfeld, and 'Sex in the City.'

CHRIS LEINBERGER: That’s just a reflection of the market reality. Hollywood does more consumer research than any business in the entire economy, and there out there doing focus groups constantly. So there reflecting what’s going on. Baby Boomers when they would see somebody- an image on the screen of some young woman flimsily dressed, walking down a dark street in a city, they would think- 'Oh my God, Hill street blues, and Blade Runner.' And the Gen-Xer's think, 'oh she is going to go to a new art gallery opening right down the street with all her friends.' Whole different perception of what a city life is like.

KOJO NNAMDI: A generational difference...

  
Listen to the full interview

       

       

The increasing diversification of news media—from online versions of major newspapers to political bloggers, to 24-hour cable news to social media—plus the profession’s changing economics have caused the balance of power between political reporters and presidential candidates to change. Stephen Hess, senior fellow emeritus, says our very good, well-trained reporters are “almost dangerous” to presidential candidates who are trying to stay on message. Thus, says Hess, the way the press covers campaigns has changed as well, and not for the better.

Video

• Stephen Hess: The Changing Balance of Power in Presidential Campaign Reporting

       

       

Although advancements in medical science have greatly improved overall life expectancy and the ability for many to survive a cancer diagnosis, a recent study predicts that cancer care alone will cost the American health system $157 billion by 2020. It is well known that a major driver of these surmounting costs is the rising cost of chemotherapy and other treatments, in addition to the variation in how these treatments are used across the health care system.  However, there are several ways that providers, payers, and patients can work together to establish a more medically and financially effective cancer care model that also reduce costs and inefficiencies in the system.

Figure 1: Estimates of the national expenditures for cancer care in 2010 and estimated increase in cost in 2020

Source: Journal of the National Cancer Institute

Develop “Clinical Pathways” to Reduce Inappropriate Use
For many cancers, there are multiple drugs that can be equally effective in treating a patient’s condition, but the price of these treatments can differ in cost by tens of thousands of dollars. Currently, oncologists are responsible for purchasing their own chemotherapy drugs, processing and maintaining them in a specialized pharmacy-like set up, and then administering them to their patients. Insurers then reimburse the oncologists for the cost of the drugs plus a margin to defray the price of maintenance and administration. Since oncologists receive a share of their income from the margins on the drugs they prescribe, insurers assert that there is an incentive to prescribe the pricier drugs, even when lower cost options of equal effectiveness exist.

One mechanism for ensuring that the most evidence-based treatment is used in the care of cancer patients is to use a set of “clinical pathways.” These pathways are based on clinical guidelines available to the public, but tailored for a particular set of patients or a type of oncology practice. Many professional societies have contributed to these guidelines and are working on developing more advanced tools to manage a patient’s care. The American Society of Clinical Oncology (ASCO) is developing a system to rate drugs for advanced cancer based on a combination of benefit, side effects and price.

Several health plans and providers are already showing results. A Pennsylvania-based collaboration with the University of Pittsburgh Medical Center and commercial payers achieved savings of more than $1 million in only six months by controlling and reducing the use of Avastin through clinical pathways. A Washington-based health plan also achieved $1 million in cost savings through a partnership with 22 medical oncologists.[i] Most recently, one of the nation’s largest health plans announced a new clinical pathways program that provides oncologists with $350 per patient per month (PMPM) for adhering to specific chemotherapy regimens. The program will be rolled out in July across six states with potential for expansion after its first year.

Develop Appropriate Value-Based Incentives that Improve Care and Reduce Costs
It will also be essential to develop alternative payment models that move away from a volume-based fee-for-service model that only pay oncology practices for traditional face-to-face office visits and parenteral medications. Instead, payers should support the transition to value-based models that reward non-traditional care, such as telephone and e-mail clinician support, patient education, and counseling services with a social worker.

ASCO also released a comprehensive payment reform proposal to transition to an episode-based payment system. The proposal outlines five types of flexible, bundled payments built around (1) taking on new patients; (2) providing treatment during a given month; (3) actively monitoring patients when they are not being actively treated; (4) the progression or recurrence of a patient’s disease that requires significant treatment regimen changes; and (5) a patient’s participation in a clinical trial. Additional recommendations include adding penalties or bonuses of up to 10 percent based on the quality of care provided, and complementing other payment reforms such as primary care medical homes and accountable care organizations (ACOs). A number of potential methods of reforming the oncology payment system have been explored elsewhere, including implementation of the Community Oncology Alliance (COA) Oncology Medical Home.

Replicate value-based models across the private and public sectors. Even with momentum from private insurers, comprehensive change must involve the public sector. When Medicare, the largest health insurer in the country, changes policies, many commercial insurance companies follow suit. Cancer care would be an ideal arena to launch a program like Medicare’s Comprehensive Primary Care Initiative, a multi-payer public sector-private sector collaboration to strengthen primary care.

In many ways, insurers’ decisions to take direct action to minimize variations in care and excessive costs sets the stage for what is to come next in health care reform. Not only does this represent a step toward broad payment reform in oncology, but marks a trend toward exploring new methods of payment in other specialties, and to align those efforts with primary care payment reforms.

To learn more about the Engelberg Center's efforts to reform payment in the field of oncology, join us on July 9th from 10:30 AM to 12:30 PM EST for MEDTalk: Reinventing Patient-Centered Cancer Care.