The Center for Healthcare Quality and Payment Reform (CHQPR) is a national policy center that facilitates improvements in healthcare payment and delivery systems. Since its founding in 2008, CHQPR has been a nationally-recognized source of unbiased information and assistance on payment and delivery reform.
CHQPR’s publications are among the most widely used and highly regarded resources on payment reform and accountable care in the country. CHQPR has provided information and technical assistance to Congress, to federal agencies such as CMS and MedPAC, to national organizations such as the American Medical Association and the American Hospital Association, and to physicians, hospitals, employers, health plans, and government agencies in both the United States and other countries to help them design and implement successful payment and delivery system reforms.
Harold D. Miller is the President and CEO of the Center for Healthcare Quality and Payment Reform (CHQPR). Miller also serves as Adjunct Professor of Public Policy and Management at Carnegie Mellon University.
Miller is a nationally-recognized expert on healthcare payment and delivery. He has twice given invited testimony to Congress on how to reform healthcare payment, and he has worked in more than 40 states and in other countries to help physicians, hospitals, employers, health plans, and government agencies design and implement payment and delivery system reforms. He served for four years as one of the initial members of the federal Physician-Focused Payment Model Technical Advisory Committee (PTAC) that was created by Congress to advise the Secretary of Health and Human Services on the creation of alternative payment models.
Miller’s work has appeared in multiple peer-reviewed journals, including “From Volume to Value: Better Ways to Pay for Healthcare” in Health Affairs, “Making Value-Based Payment Work for Academic Health Centers” in Academic Medicine, “A Better Path to Value in Cancer Care” in JCO Oncology Practice, “New Approaches to Both Health Care Delivery and Payment Systems Are Needed in Rural Areas” in the Journal of Ambulatory Care Management, “How to Create Successful Alternative Payment Models in Oncology” in the American Journal of Managed Care, and “Aligning Payments, Services, and Quality in Primary Care” (with John Wasson and Harold Sox) in JAMA. He has written a number of widely-used papers and reports on health care payment and delivery reform, including the Center for Healthcare Quality and Payment Reform’s reports How to Create an Alternative Payment Model, Why Value-Based Payment Isn’t Working and How to Fix It, Saving Rural Hospitals and Strengthening Rural Healthcare, and Patient-Centered Payment for Primary Care. He co-authored A Guide to Physician-Focused Alternative Payment Models that was jointly published by the American Medical Association and the Center for Healthcare Quality and Payment Reform.
He has assisted the American Academy of Hospice and Palliative Medicine, the American Academy of Neurology, the American College of Allergy, Asthma, and Immunology, the American College of Cardiology, the American College of Emergency Physicians, the American College of Rheumatology, the American Society of Addiction Medicine, the American Society of Cataract and Refractive Surgery, the American Society of Clinical Oncology, and the American Medical Association in developing alternative payment models designed to support better care for patients at lower cost. He assisted the Centers for Medicare and Medicaid Services with the implementation of its Comprehensive Primary Care Initiative in 2012, and from 2015 to 2018, he assisted the Washington State Hospital Association and the State of Washington to develop an improved payment system for small, rural Critical Access Hospitals.
From 2008 to 2013, in addition to leading CHQPR, Miller served as the President and CEO of the Network for Regional Healthcare Improvement (NRHI), the national association of Regional Health Improvement Collaboratives. He served as a member of the Board of Directors of the National Quality Forum from 2009 to 2015. Prior to founding CHQPR, Miller served as the Strategic Initiatives Consultant to the Pittsburgh Regional Health Initiative (PRHI), and his work there demonstrating the significant financial penalties that hospitals can face if they reduce hospital-acquired infections was featured in Modern Healthcare magazine in December 2007. In 2007, Miller served as the Facilitator for the Minnesota Health Care Transformation Task Force, which prepared the recommendations that led to passage of Minnesota's path-breaking healthcare reform legislation in May 2008.Download Harold Miller's Bio
Insurance plans have spent decades trying to control the rising cost of healthcare by transferring a higher percentage of those costs to patients, according to Harold Miller, president and CEO of the Center for Healthcare Quality and Payment Reform. "The real problem is that insurance plans pay too little for primary care and other high-value services, and they pay too much for unnecessary and ineffective treatments," Miller says. "To solve this, fundamental reforms are needed in the way healthcare providers are paid."
Miller believes hospitals, health systems, and other healthcare providers should switch to a patient-centered payment system. In a patient-centered payment system, hospitals, doctors, and other healthcare providers are paid sufficiently for providing services each patient actually needs, and they are required to offer high-quality patient care to be compensated for helping that patient. "Under the current payment system in healthcare, physicians and hospitals are financially penalized when they help patients stay healthy," he says. "Most value-based payment reforms don't solve this problem. Health plans need to start using patient-centered payments that pay adequately for high-quality care and stop paying for unnecessary services and avoidable complications. The result would be a financial win-win-win for patients, providers, and payers."
"There are a lot of people ... who are convinced that if you bring smart Silicon Valley people and technology to bear that there's going to be some dramatic change [in primary care]," said Harold Miller, chief executive of the Center for Healthcare Quality and Payment Reform. "But it fundamentally comes back to the issue that primary care will always -- always -- be about a physician and a patient. You can make it more efficient. But you can't turn it into Ford Motors. You can't turn it into an assembly line and get good primary care."
"There is going to be an inherent interest in cherry picking [by Amazon]," Miller said. "The more patients you can get who involve the lowest cost for the primary care practice, the better. And that means those patients are no longer available to other primary care practices that disproportionately end up with patients who need more time and whose insurers may not be paying as generously."
...whether a hospital responded well to COVID-19 or experienced spikes in infections and readmissions is useful information that reflects different levels of performance, said Harold Miller, president and CEO of the Center for Healthcare Quality and Payment Reform..."If you say, 'We're just not going to pay attention anymore because it's a pandemic,' it isn't fair to the patients who are getting those infections," Miller said.
Harold Miller, the director of the Center for Healthcare Quality and Payment Reform and a professor of public policy at Carnegie Mellon, argues that while expanding Medicaid and eliminating sequestration would both be good policy changes for rural hospitals, neither would generate enough new funding to impact a facility’s bottom line.
“The people who are newly getting Medicaid are only a very small proportion of the thing that’s causing the hospital the loss,” Miller said. “That’s not the problem. The problem is [rural hospitals] actually in many cases are losing money on their privately insured patients.”
The CHQPR study suggests the best way to ensure rural communities can access affordable, high-quality healthcare is for health insurance plans to provide hospitals with standby capacity payments that will assist in maintaining the hospitals' ability to provide essential services. The CHQPR says payers will also need to adjust the way they pay small rural hospitals because most of the time they are underpaying these facilities. However, the biggest change is going to need to come from private health insurance companies.
"There are two different types of hospitals in America—large hospitals that make high profits on patients with private insurance, and small rural hospitals that lose money providing care to these patients," Miller said. "Private insurers are paying too much for services at many large hospitals but they are paying too little to sustain essential services in rural areas. Failure to address this will worsen healthcare disparities in the country."
...the Rural Emergency Hospital pay boost won't be enough, said Harold Miller, CEO of the Center for Healthcare Quality and Payment Reform. "Creating global hospital budgets, eliminating federal sequestration, eliminating inpatient services and expanding Medicaid will not solve the serious problems facing rural hospitals," he said... "The only way to ensure that residents of small rural communities have access to affordable, high-quality healthcare is for their health insurance plans to pay adequately for the services delivered by their local hospitals."
Pummeled by the pandemic, at least 40% of rural U.S. hospitals are in danger of shutting down and leaving millions of people in smaller and less affluent communities without a nearby emergency and critical care facility. That's the conclusion of the Center for Healthcare Quality and Payment Reform, whose recent study sees 500 hospitals at immediate risk for closing within two years and more than 300 others at high risk within five years.
As the [technology companies engaged in primary care] seek to establish themselves, they still face skepticism about whether their patients will sustain positive health outcomes in the long run, or that the services they are offering really amount to primary care. “I would say they are cherry-picking opportunities to try to take different pieces of the overall primary care need and find a way to make money at them,” said Harold Miller...He said some digital health companies are doing that by providing predominantly virtual care for minor needs, paired with a limited physical footprint to deal with more complex problems. Others, he said, are deliberately seeking out a sicker subset of patients and trying to reduce the cost of their care in risk-bearing contracts where they can pocket the savings. “It’s not that any of those things is bad,” Miller said. “But it’s not comprehensive primary care.”
Rural Americans form 15-20% of the U.S. population but face disproportionate healthcare inequities. More than 130 rural hospitals have closed over the past decade. Eight hundred additional American rural hospitals — over 40% of all rural hospitals in this country — are at risk of closing, according to a report from the Center for Healthcare Quality and Payment Reform.
"If you're a health plan, and you're going to invest $1, where's that dollar going to be best invested?" said Harold Miller, CEO of the Center for Healthcare Quality and Payment Reform. "Is it going to be in finding diagnoses to add to people, which can then double my revenue for the patient, or spending more on care improvement that might, but not certainly, reduce total spending on that patient? The sure bet is to go out and find diagnosis codes for people."
Some policy experts said increased use of telemedicine will accelerate the nation’s slow-moving shift toward value-based care, in which doctors are paid a lump sum to manage their patients, instead of collecting a fee for every service delivered. But that requires a delicate rebalancing of costs and clinical needs in a new system that mashes together video visits, telephone check-ups, and traditional office consultations. “We’re not talking about a small tweak here,” said Harold Miller, chief executive of the Center for Health Care Quality and Payment Reform, a policy research organization. “You’re talking about something that could fundamentally change the way you manage a patient’s care. The assumptions behind how much those things cost and who should be getting which services are going to change.”
With great fanfare, the Centers for Medicare & Medicaid Services (CMS) announced its new proposed Primary Care First (PCF) reimbursement models for Medicare on April 22, heralding them as good ways to help primary care providers get paid for all the work they do in addition to seeing patients. So what has happened since the initial rollout? Harold Miller, president and CEO of the Center for Healthcare Quality and Payment Reform, in Pittsburgh, who in May laid out a list of changes that he thought would improve the models, is not impressed with what he has seen so far. "CMMI [Center for Medicare & Medicaid Innovation] made a couple of small changes to Primary Care First that were positive, but they didn't solve any of the problems that I described in the piece I wrote in the spring," Miller said in an email to MedPage Today earlier this month. "Moreover, it's not clear why it took 6 months to make those small changes, and that delay has ended up delaying the start of the entire program for a year."
CMMI has only said that it would incorporate some of the "concepts" from PTAC-recommended models within the programs that CMMI develops, which "is completely inconsistent with the spirit of MACRA; Congress clearly envisioned that at least some of the good payment models developed by physicians would be implemented if they were recommended by PTAC," Miller said. The 16 models recommended by PTAC have spanned many areas of practice, including oncology, primary care, and home hospitalization.
"I do not want to be part of a process that misleads physicians and other stakeholders into thinking that if they develop a good physician-focused payment model, go through the rigorous review process PTAC has established, and receive a positive recommendation, they will have a chance of seeing their work implemented," he wrote. "The people who have submitted proposals to PTAC have spent many hours and significant amounts of money to develop their proposals, respond to our questions, and attend our meetings. All of this work has been wasted since it has been made clear that their work will not be implemented, and it does not appear that the outcome will be any different for future proposals, no matter how good they are."
Miller said he wished that "the Administration would enable individual teams of healthcare providers (physicians, hospitals, etc.) to implement innovative approaches to delivering services to Medicare beneficiaries that would improve quality and reduce spending. In every other sector of the economy, the federal government encourages entrepreneurship and innovation, but in healthcare, it favors large businesses (e.g., large integrated delivery systems, accountable care organizations, and health plans) and central planning (CMS-designed delivery and payment models)."
"Congress created a process to encourage physicians to develop innovative approaches to healthcare delivery, but the CMS [Centers for Medicare & Medicaid Services] Innovation Center has refused to implement even one of more than a dozen such innovations," he wrote. "None of the current CMS value-based payment programs have achieved significant savings, and it's time to support bottom-up innovation rather than more top-down planning. This can and should be done in the regular Medicare program, not just through Medicare Advantage plans."
"The billing system is based on procedural codes that don't say why care was delivered or what the outcome was," said Harold Miller, chief executive of the nonprofit Center for Healthcare Quality and Payment Reform. "You get all these tests, but why did you get them? None of that is on the bill." Furthermore, he said, patients must decipher charges that come from multiple physicians, therapists and other caregivers. Insurance covers some charges, but not others. And each individual interaction with a doctor or health system results in yet another bill and explanation of benefits. The process often leaves patients surrounded by reams of invoices and other documents that make little sense. "You could certainly make medical bills more understandable than they are today," Miller said. "But explaining each individual billing event does not help people understand how it all connects and why they got the services they got."