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# Mission

The Center for Healthcare Quality and Payment Reform (CHQPR) is a national policy center that facilitates improvements in healthcare payment and delivery systems. Founded in 2008, CHQPR has become an internationally-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 world. 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.

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# Contacting Us

CHQPR is located at:

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320 Fort Duquesne Boulevard<br>
Suite 20-J<br>
Pittsburgh, PA 15222
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You can contact CHQPR at:

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[Info@CHQPR.org](mailto:Info@CHQPR.org){target="_blank"}<br>
or<br>
+1 (412) 803-3650
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# Leadership

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.

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<img alt="Harold D. Miller" class="img-fluid" src="/images/Harold_D_Miller.png">

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Miller is an internationally-recognized expert on healthcare payment and delivery.  He has worked to help physicians, hospitals, employers, health plans, and government agencies across the U.S. and in other countries design and implement payment and delivery system reforms.  He has twice given invited testimony to the U.S. Congress on how to reform healthcare payment, and he served for four years as one of the initial members of the federal Physician-Focused Payment Model Technical Advisory Committee 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*, “Aligning Payments, Services, and Quality in Primary Care” (with John Wasson and Harold Sox) in *JAMA* and “Patient-Centered Payment for Care of Chronic Conditions” in the *Journal of Ambulatory Care Management*. 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.

Miller 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.

You can contact Harold Miller by email at [Miller.Harold@CHQPR.org](mailto:Miller.Harold@CHQPR.org){target="_blank"} or on Twitter [@HaroldDMiller](https://twitter.com/HaroldDMiller){target="_blank"}.

[Download Harold Miller's Bio](https://chqpr.org/downloads/HaroldMillerBio.pdf){target="_blank" .bio-link}

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# In the News

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Harold Miller, the president and CEO of the Center for Healthcare Quality and Payment Reform ... spoke about ways hospitals can restructure and rethink how they deliver services and how they are paid so they can thrive in challenging economic times. 

"...we need to fundamentally change the way hospitals are paid.	The standard formula for success for hospitals for years has been to do as many procedures and tests as possible and to charge as much as you possibly can for them. This has led to an unaffordable health insurance system and to personal bankruptcies. I think the mission of the hospital has to be reoriented. The mission of the hospital must be to deliver necessary services as safely and efficiently as possible and to charge only what is necessary."

"The problem that hospitals have faced though, is that they do two fundamentally different things — but they are only paid for one of them. Hospitals deliver services to patients when they are sick, and they are paid for that. But the other thing that hospitals do, which is essential for a community, is that they are available when somebody needs them — that standby capacity is critical for a community. But hospitals aren't paid for that. 

We don't pay for other essential community services that way. We don't pay fire departments based on whether there's a fire and we don't pay police departments based on how many crimes there are, and we shouldn't be paying hospitals solely based on how many services they deliver. They need to be paid a standby capacity payment so that the hospital can maintain its essential fixed costs and then the hospital should only charge and be paid a smaller amount for an individual service whenever it delivers. And with that combination of payment, the hospital can then have adequate payment to deliver appropriate services... without feeling compelled to deliver unnecessary services and the pressure to make high profits."

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[*HealthLeaders*<br>January 25, 2023](https://www.healthleadersmedia.com/finance/how-hospitals-can-thrive-under-economic-pressure){target="_blank" title="How Hospitals Can Thrive Under Economic Pressure"}

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Miller, the CHQPR president, told the Mississippi Free Press that while Medicaid expansion would help at the margins and "it certainly would be helpful for hospitals if fewer of their patients were uninsured," it is not a silver bullet. "Based on what has happened in other places where Medicaid has been expanded, the small rural hospitals in those states benefited slightly, but it didn't change the picture for them," he said. "The reason is very simple. Because most of the problems they are facing are not due to uninsured patients; it's due to underpayments by commercial insurers and even by Medicare."

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[*Mississippi Free Press*<br>February 9, 2023](https://www.mississippifreepress.org/30978/number-of-at-risk-rural-mississippi-hospitals-falls-to-28-report-says){target="_blank"}

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"Once a hospital closes it is very difficult, if not impossible, to reopen it," he said. "And you don't suddenly wait until the hospital is going to close and say, 'Let's find a solution.'" 

"Mississippi needs to be doing things now to try to help make sure that these hospitals don't close."

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[*Mississippi Today*<br>February 8, 2023](https://mississippitoday.org/2023/02/08/mississippi-rural-hospital-closure-report/){target="_blank"}

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For now, it seems hospital-at-home will share the fate of American health care generally: It'll go to where the money is. From multibillion-dollar medical centers, hospital-at-home will flow to those in metro areas, cities and towns, eventually making its way to patients near larger rural hospitals and then — maybe, if ever — trickling down to the people who, cruelly, already live the farthest from any hospital. What would it take to redirect this path? "If we as a society think that hospital-at-home services are in fact desirable," Miller says, "then they need to be paid for and covered — at whatever the cost of it is."

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[*New York Times Magazine*<br>January 26, 2023](https://www.nytimes.com/2023/01/26/magazine/hospital-at-home.html){target="_blank" title="Your Next Hospital Bed Might Be at Home"}

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"While most urban hospitals and larger rural hospitals make profits on patient services, most small rural hospitals lose money delivering services to patients," CHQPR says in its report. "The biggest cause of these losses is inadequate payments from private insurance plans. Although large hospitals can offset losses on Medicaid and uninsured patients with the profits they make on patients with private insurance, small rural hospitals cannot."

Rural hospitals are paid less than what it costs to provide care, according to CHQPR. Rural hospitals will lose money when providing services to patients because of insufficient payments from private insurance companies. Insurance providers tend to pay rural hospitals less than their larger counterparts for the same services. 

"The problem is not just the amount of payment, but the method of payment," CHQPR says in its report. "Current payment systems do a poor job of supporting the delivery of high-quality healthcare in rural areas. If a small hospital provides primary care and other services designed to help patients stay healthy, the number of ED visits and treatment services at the hospital is likely to decrease, which will increase financial losses for the hospital."

To help keep rural hospitals open, CHQPR says there needs to be a fundamental shift in the way these organizations are paid. A more patient-focused payment system for rural hospitals would ensure that essential services remain available, ensure these services are delivered in a timely fashion, and support the delivery of high-quality and affordable care that is appropriate for the patient's needs. "A patient-centered approach to payment is designed to support the services that patients need, not to increase profits for either hospitals or health insurance plans," CHQPR says. "Since the payments are specifically designed to support both the fixed and variable costs of delivering services, the hospital would neither lose money when patients are healthier nor make excessive profits when patients need more services."

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[*HealthLeaders*<br>January 26, 2023](){target="_blank" title="What Will It Take to Keep Rural Hospitals Open"}

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"What I would call the traditional myth is that the reason why small rural hospitals lose money is because they're providing inpatient care to a very small number of patients. Therefore, if you could somehow relieve them of that responsibility, then everything would be fine," Harold Miller, president and CEO of CHQPR, told The Health 202. "The problem is that's not necessarily true."<br><br>Miller said that if hospitals eliminate their inpatient unit, they usually can’t recoup all of the costs that are associated with it, but they do miss out on its revenue. For example, a nurse working in the inpatient unit at a small rural hospital will typically also tend to the emergency department. So, even if inpatient care is eliminated, the hospital still needs that nurse.  "That means they would lose money by closing their inpatient unit as well as not providing the service that the community needs," he said. 

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[*Washington Post*<br>January 17, 2023](https://www.washingtonpost.com/politics/2023/01/17/rural-hospitals-say-they-stuck-between-rock-hard-place/){target="_blank" title="Rural Hospitals Say They're Stuck Between a Rock and a Hard Place"}

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For 46 million Americans, rural hospitals are a lifeline, yet an increasing number of them are closing. The federal government is trying to resuscitate them with a new program that offers a huge infusion of cash to ease their financial strain. But it comes with a bewildering condition: They must end all inpatient care.

"On one hand, you have a massive incentive, a 'Wow!' kind of deal that feels impossible to turn down," said Harold Miller, the president of the nonprofit Center for Healthcare Quality and Payment Reform. "But it's based on this longstanding myth that they've been forced to deliver inpatient services — not that their communities need those services to survive."

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[*New York Times*<br>December 9, 2022](https://www.nytimes.com/2022/12/09/health/rural-hospital-closures.html){target="_blank" title="A Rural Hospital's Excruciating Choice: $3.2 Million a Year or Inpatient Care?"}

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Value-based payments, which offer healthcare providers financial incentives for the quality of care they give to people with Medicare, haven't resulted in lower healthcare costs, with some programs making it harder for patients with complex conditions to receive the right care, says Harold Miller, president and CEO of the Center for Healthcare Quality and Payment Reform.

"Most value-based payment programs have failed to significantly reduce healthcare spending or improve the quality of care for patients," Miller says in a report titled 4 Steps to Successful Value-Based Payment. "Many have resulted in higher healthcare spending, and some have made it harder for patients with complex conditions to receive adequate care."
						
Miller says that a value-based payment program can only be successful when it is designed to directly support value-based care.  "Providers deliver care, not payers, so value-based payments must be designed to ensure that providers are able to deliver high-value services to their patients," he says.

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[*HealthLeaders*<br>September 8, 2022](https://www.healthleadersmedia.com/finance/these-4-steps-are-key-successful-value-based-payment-strategy){target="_blank" title="These 4 Steps are Key to a Successful Value-Based Payment Strategy"}

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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."

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[*HealthLeaders*<br>August 4, 2022](https://www.healthleadersmedia.com/finance/healthcare-spending-tops-3t-hospitals-and-health-systems-can-help-alleviate-burden){target="_blank"}

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"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."<br><br>"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."

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[*STAT*<br>July 21, 2022](https://www.statnews.com/2022/07/21/amazon-one-medical-acquisition-impact-competition/){target="_blank"}

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...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.

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[*Modern Healthcare*<br>July 5, 2022](https://www.modernhealthcare.com/safety-quality/report-or-not-report-cms-covid-quality-plan-prompts-questions){target="_blank"}

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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."

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[*NC Health News*<br>May 21, 2022](https://www.northcarolinahealthnews.org/2022/05/17/billions-in-federal-funds-may-make-rural-hospitals-look-more-stable-than-they-really-are/){target="_blank"}

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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."

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[HealthLeaders*<br>May 6, 2022](https://www.healthleadersmedia.com/finance/chqpr-offers-strategies-keep-rural-hospitals-open){target="_blank"}

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...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."

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[*Modern Healthcare*<br>April 21, 2022](https://www.modernhealthcare.com/operations/medicare-cuts-squeeze-rural-hospitals){target="_blank"}

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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.

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[*Bloomberg*<br>March 9, 2022](https://www.bloomberg.com/news/articles/2022-03-09/heartland-hospitals-face-wipeout-with-800-at-risk-of-shutdown){target="_blank"}

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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."

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[*STAT*<br>January 13, 2022](https://www.statnews.com/2022/01/13/primary-care-oak-street-teladoc-health/){target="_blank"}

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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.

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[*Forbes*<br>December 16, 2021](https://www.forbes.com/sites/forbestechcouncil/2021/12/16/how-the-digital-healthcare-industry-can-go-further){target="_blank"}

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"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."

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[*Modern Healthcare*<br>September 22, 2021](https://www.modernhealthcare.com/insurance/some-medicare-advantage-insurers-blame-half-undiagnosed-claims){target="_blank"}

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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."

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[*STAT*<br>June 11, 2020](https://www.statnews.com/2020/06/11/telehealth-silver-lining-of-pandemic-implementing-permanently-wont-be-easy/){target="_blank"}

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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."

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[*MedPage Today*<br>December 29, 2019](https://www.medpagetoday.com/publichealthpolicy/medicare/84126){target="_blank"}

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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."

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[*MedPage Today*<br>November 21, 2019](https://www.medpagetoday.com/publichealthpolicy/medicare/83502){target="_blank"}

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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."

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[*MedPage Today*<br>February 5, 2019](https://www.medpagetoday.com/publichealthpolicy/healthpolicy/77822){target="_blank"}

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"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."

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[*Cleveland Plain Dealer*<br>May 18, 2016](https://www.cleveland.com/healthfit/2016/05/a_medical_bill_you_can_actually_understand_metrohealth_part_of_federal_design_team.html){target="_blank"}

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