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The Burwell roadmap
  1. Joshua A Hirsch1,
  2. Thabele M Leslie-Mazwi1,
  3. Robert M Barr2,
  4. Geraldine McGinty3,
  5. Gregory N Nicola4,
  6. Aman B Patel1,5,
  7. Laxmaiah Manchikanti5,6
  1. 1NeuroEndovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
  2. 2Mecklenburg Radiology Associates PA, Charlotte, North Carolina, USA
  3. 3Department of Radiology, Weill Cornell Medical College, New York, New York, USA
  4. 4Hackensack University Medical Center, Hackensack, New Jersey, USA
  5. 5Pain Management Center of Paducah, Paducah, Kentucky, USA
  6. 6Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, Kentucky, USA
  1. Correspondence to Dr Joshua A Hirsch, NeuroEndovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; Hirsch{at}


In January 2015 the current Secretary of the Department of Health and Human Services (HHS) outlined a bold initiative to shape the delivery of healthcare through a set of strategies aimed at improving the quality of care and reducing the growth of healthcare costs. The strategies include increasing payment incentives tied to higher value care, increasing care coordination and integration, and increasing access to information to guide patients and clinicians. Significantly, the proposal includes specific goals for alternative payment models and value-based payments for the first time in the history of the Medicare program.

  • Economics

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It has been approximately 5 years since the President signed the Affordable Care Act (ACA) into law. Seen as a predominantly Democratic Party effort, the ACA has been beleaguered politically since its introduction and has come under further fire with the Republican victories in the midterm election of November 2014. Prominent Republicans including House Majority Whip Kevin McCarthy and Speaker of the House John Boehner have indicated plans to introduce a Republican alternative to the ACA in 2015. Despite this, most observers believe that, since so many elements of the law are in place and accepted, the ACA is here to stay. Notwithstanding the political wrangling, within the general populace there is popular support for features of the ACA such as the ban on pre-existing condition denials and the right of children to stay on their parents’ plan until age 26. Any alternative would need to incorporate a variety of the ACA's costly requirements and thus the challenges of paying for the new package.

The ACA falls under the purview of the US Department of Health and Human Services (HHS), the principal agency charged with protecting the health of Americans and providing essential human services, especially for the most vulnerable in the population. HHS is responsible for almost a quarter of all federal outlays and administers more grant dollars than all other federal agencies combined.1

Sylvia M Burwell, the 22nd Secretary of HHS, helms the HHS currently. She replaced Kathleen Sebelius, who famously served during the initial tumultuous years of the ACA. A former Rhodes Scholar with a variety of accomplishments in both the public and private sectors, Ms Burwell received a notable level of bipartisan support for her candidacy. Prior to HHS, Ms Burwell served as Director of the Office of Management and Budget where she was well regarded for being a results-driven manager. According to her biography, in that position she “led the Administration's efforts to deliver a smarter, more innovative and more accountable government”.2

She has brought the same results-driven approach to her new position. On 26 January 2015 Ms Burwell published a comment in the New England Journal of Medicine that was titled ‘Setting Value-Based Payment Goals—HHS Efforts to Improve US Health Care’.3 In this piece Ms Burwell unambiguously defines the evolving agenda of the administration and its surrogates at HHS. Observers of Ms Burwell's history would note that she is a person who often accomplishes that which she sets out to do. Her perspective is thus very relevant for neurointerventional specialists.

Burwell's HHS plan

There are three primary areas of focus for augmenting healthcare reform.

  1. Using incentives to motivate higher value care by increasingly tying payment to value through alternative payment models.

  2. Changing the way care is delivered through greater teamwork and integration, more effective coordination of providers across settings, and greater attention by providers to population health.

  3. Harnessing the power of information to improve care for patients.3

Analysis of the plan

Using incentives to motivate higher value care by increasingly tying payment to value through alternative payment models

The current system for deriving payment for professional services is, at its core, governed by a complex interplay between several committees of the American Medical Association, the Center for Medicare and Medicaid Services (CMS), and private insurers.4 ,5 In this system the majority of specialists are paid on a fee-for-service basis.6 ,7

As part of the evolving healthcare payment policy, many providers—including neuroendovascular specialists—are already participating in programs that link their fee-for-service payments to quality and value metrics. While there are challenges with the metrics that have been chosen, it is clear that the incremental incentives and disincentives associated with quality and value are attractive to CMS and that Burwell's articulated goal of having 85% of all Medicare fee-for-service payments tied to quality or value by 2016 (and 90% by 2018) are likely to be realized. One could argue that this represents change around the margin.

Alternative payment models are widely considered to be a more disruptive approach than value or quality incentives or penalties. Ms Burwell indicates ambitious near-term targets for use of these types of models. Currently, 20% of Medicare payments to providers are through these alternative structures. HHS plans to increase this to 30% of Medicare payments tied to alternative payment models by the end of 2016, and 50% of payments by the end of 2018.

It is important to note that the term ‘alternative payment models’ is deliberately general. An assumption that a 30% target in less than 2 years is achievable because such models have been explicitly defined would be incorrect. The ‘alternative payment model’ universe includes accountable care organizations (ACOs) as well as other bundled payment arrangements likely familiar to readers of this article. What readers may be less familiar with is how far from mature these ‘at risk’ arrangements are. It is clear that HHS and its branch CMS plan to significantly diminish the role of fee-for-service payments in the near future. Questions remain about whether payment for professional services will be based on historic claims data, physician-run ACOs, or health system-based programs that control physician payments—to name just a few of the possible scenarios.

Of specific interest to readers of this article is Ms Burwell's stated plan to develop new payment models for specialty care. The New England Journal of Medicine article notes that these new payment models will start with care of cancer patients. Reflecting on some of the imperfections in the rollout of these models over the last few years, Ms Burwell commits that HHS will continue to make efforts to build consensus on quality measures and will address issues related to risk adjustment in these new models.

It is worth noting that the Burwell plan might allow for different solutions for varying circumstances, but the overriding element will be the sought-after dramatic shift away from fee-for-service. She points out that this is “the first time in the history of the program that explicit goals for alternative payment models and value-based payments have been set for Medicare”.3

Changing the way care is delivered through greater teamwork and integration, more effective coordination of providers across settings, and greater attention by providers to population health

There are elements of the second goal that should be attractive to readers of this article. It is clear that patients suffering from cerebrovascular challenges often require the coordinated care of multiple specialists including neurologists, neuroradiologists, neurosurgeons, emergency room physicians, hospitalists, rehabilitation specialists, and non-physician providers. These services occasionally occur across institutions. Currently, these integrative services are, in essence, provided without a specific plan for how to compensate that coordination. There is little doubt that improving the way we coordinate among the services is a valuable goal. If professional payments represent a zero sum game, it will be important to know where the money will come from.

There are a variety of mechanisms through which HHS plans to implement this focus on greater teamwork and integration. We draw particular attention to the CMS Innovation Center (the Innovation Center) that was established by the Social Security Act. The Innovation Center was created for the purpose of testing “innovative payment and service delivery models to reduce program expenditures … while preserving or enhancing the quality of care for those individuals who receive Medicare, Medicaid, or Children's Health Insurance Program (CHIP) benefits”.8

An initial budget was granted by Congress of $10 billion with a task of returning at least that amount in 10 years’ time. To date, the Innovation Center has had two rounds of fund releases totaling roughly $2 billion. Landmark innovations, including the funding and creation of ACOs, have been launched by this initiative. One initiative receiving far less press, but having potentially more impact on the neuroendovascular community, is Bundled Payments for Care Improvement (BPCI). This initiative is testing four models, one of which includes acute care hospital stay only (Model 4).

“Under Model 4, CMS will make a single, prospectively determined bundled payment to the hospital that would encompass all services furnished during the inpatient stay by the hospital, physicians, and other practitioners. Physicians and other practitioners will submit ‘no-pay’ claims to Medicare and will be paid by the hospital out of the bundled payment. Related readmissions for 30 days after hospital discharge will be included in the bundled payment amount. Participants can select up to 48 different clinical condition episodes.”9 Of the 48 episodes being tested, table 1 shows diagnostic related groups traditionally paid under the Inpatient Prospective Payment System of specific interest to NeuroInterventionalists that are currently being evaluated.

Table 1

Diagnostic related group (DRG) codes under evaluation by the Bundled Payments for Care Improvement, Model 4

An additional example of an initiative directed towards communication and teamwork is the Transforming Clinical Practice Initiative. In this, $800 million will be invested in providing hands-on support to 150 000 providers “for developing the skills and tools needed to improve care delivery and transition to alternative payment models”.3 The sheer dollar investment within this initiative demonstrates the administration's resolve. It is also worth noting that CMS is under no obligation to wait for the results of these Innovation Center projects.

Harnessing the power of information to improve care for patients

While the third major agenda item seems straightforward, it is—not surprisingly—a more complex issue than one might at first perceive. Certainly, nobody can or should argue with the value of harnessing the power of information to improve care. The issue is that one group's perception is often different from another's reality. There was a remarkably low participation in federally-funded Meaningful Use Programs which, by their nature, were designed to increase utilization of electronic health records (EHRs). Burwell points to massive increases from 18% to 78% of physicians using EHRs between 2001 and 2013. It is difficult to know to what extent meaningful use incentives and penalties impacted on this process. What is certain is that the limited participation resulted in very divergent payments across the US healthcare system. Indeed, monolithic approaches to the implementation of information technology solutions within a complex healthcare endeavor can lead to a variety of unintended problems with resultant consequences, as exampled by large-scale security breaches that can literally be pulled right out of the day's news.10 ,11

Burwell describes recent efforts to enhance transparency in the healthcare marketplace.12 We are cautiously optimistic about the opportunities that come with price transparency; optimistic because an educated healthcare consumer should be beneficial for quality providers, and cautious as we remember the data dump that represented the CMS foray into sharing provider payments this past year. This data release occurred without any effort at providing context, such that patients were left to derive their information from a variety of sources that few would argue at times were less than ideal.13 Additionally, there are many elements that are reflected in physician charges and potentially quality ratings that require significant education beyond simply comparing numbers. Examples include in-office payments versus community hospital versus tertiary care environments.

A portion of Ms Burwell's discussion is directed to harnessing information related to the Patient Centered Outcomes Research Institute (PCORI). PCORI is one of two independent boards that were created by the ACA. Its activities relate to comparative effectiveness research (CER).14 We recently reviewed the progressive development of PCORI.15 The authors of this article are supportive of efforts to enhance the availability and utilization of CER.16 Indeed, many professional societies that have as their members neuroendovascular specialists formally supported its creation and development. With that support in mind, it is relevant to note that some of the interventions that neuroendovascular specialists consider a routine part of their practice are potentially vulnerable in an environment that is managed through CER.


It has been 5 years since the ACA was passed into law. Multiple elements of that law are currently at work in the USA. The original formulation involved a multi-year rollout that extended into the latter part of this decade. After a series of challenges, many of which are ongoing, it seems evident that this law or—at the very least—major elements are here to stay. The Department of HHS has laid out an outline of their priorities over the next few years. The changes that are planned will likely have a meaningful impact on neuroendovascular specialists. It is imperative that we remain informed about expected developments to best be able to respond to them appropriately.



  • Contributors JAH drafted the original manuscript. All authors reviewed the draft, provided meaningful edits and contributed to the final version.

  • Competing interests None.

  • Provenance and peer review Not commissioned; internally peer reviewed.