Welcome to The Partnership to Empower Physician-Led Care weekly newsletter, which includes news from our members, legislative and Administration updates, news clips, and studies about value-based care, primary care, and independent physicians.
Government Accountability Office (GAO): (10/1) – On October 1, U.S. Government Accountability Office (GAO) released a report of Medicare’s Merit-based Incentive Payment System (MIPS). The report describes the distribution of MIPS performance scores and related payment adjustments, and stakeholders' perspectives on the strengths and challenges of the MIPS program. GAO found that, from 2017-2019, over 90 percent of providers earned a small increase (less than two percent) to their Medicare payments.
Department of Health and Human Services (HHS): (9/30) – HHS, Center for Medicare and Medicaid Services (CMS), Departments of Labor, Treasury and Office of Personnel Management issued an interim final rule with comment period to further implement the No Surprises Act. The rule establishes new protections from surprise billing and excessive cost sharing for consumers receiving health care items/services and implements provisions related to the independent dispute resolution process, good faith estimates for uninsured (or self-pay) individuals, the patient-provider dispute resolution process, and expanded rights to external review. Along with this release, CMS launched a website to provide general information about No Surprises Act provisions. Fact sheetWebsite Interim final rule with comment
CMS: (9/29) – On September 29, CMS released the Calendar Year 2022 Value-Based Insurance Design model participants. Through the VBID Model, CMS is testing a broad array of MA health plan innovations designed to enhance the quality of care for Medicare beneficiaries – including those with low income. For CY 2022, the VBID Model as 34 participating MA organizations (MAOs), up from 14 in 2020 and 19 in 2021.
Modern Healthcare: (10/4) – A new GAO report offers more doubt about the effectiveness of the Merit-based Incentive Payment System. Most stakeholders interviewed by GAO said MIPS lets providers cherry-pick the measures they report and doesn't yield enough of a payoff to be worth participating in. "There is relatively modest upside to the bonuses that MIPS provides medical practices," said Anders Gilberg, senior vice president of government affairs for the Medical Group Management Association. In a 2019 survey, 94 percent of MGMA members said MIPS was moderately to extremely burdensome.
California Medical Association (CMA): (10/4) – CMA, the American Medical Association (AMA), the major impacted specialty societies and the national hospital associations have all expressed serious concern with the new Surprise Billing Interim Final Rule. CMA believes the rule is inconsistent with the No Surprises Act statute and Congressional intent to establish a balanced independent dispute resolution process (IDR). Instead, the rule establishes a legal presumption in the IDR process that the median in-network payment rate is the appropriate rate for out-of-network services.
Modern Healthcare: (10/1) – The Center for Medicare and Medicaid Innovation (CMMI) will take a closer look at value-based payment models, with CMMI's chief operating officer Jon Blum noting that full-risk models can lead to overpayments by federal agencies and penalize providers with more vulnerable patient populations. This direction represents a sharp departure from the previous administration, which "promoted risk over everything else," said Anders Gilberg, senior vice president of government affairs at the Medical Group Management Association. That approach ultimately stalled efforts to promote value-based care nationwide since independent practices and small medical groups structured around a fee-for-service system were unable to make the capital investments necessary to switch their operations to focus on value.
The Heritage Foundation: (10/5) – The lack of competition in the nation’s hospital markets undermines patient choice and increases consumers’ costs. Robert Moffit argues that to foster competition in hospital markets, Congress should: encourage state officials to review, reform, or repeal certificate of need laws; include site neutrality in Medicare payment; and repeal the ACA restrictions on Medicare payment to physician-owned hospitals and specialty hospitals.
Chicago Booth Review: (10/4) – Under US antitrust law, companies must notify the federal government of their plans to merge or buy other companies—but only in large deals. Smaller transactions that fall below legal thresholds are exempt from the notification reporting requirement. In the dialysis industry, two multinational providers built empires through years and years of small deals that largely passed unnoticed by antitrust enforcement agencies.
Fierce Healthcare: (10/1) – Physician and hospital groups are slamming the Biden administration’s latest surprise billing rule, charging that it unfairly tilts a dispute process over out-of-network charges in insurers’ favor. The administration’s interim final rule details how to handle disputes between payers and providers over out-of-network charges. But providers chafed at the rule’s direction for independent arbiters to rely on a benchmark rate to settle disputes.
Fierce Healthcare: (9/30) – CMS Chief Operating Officer Jon Blum said to not expect a lot more fully risk-based payment models from CMMI during the National Association of Accountable Care Organizations' fall conference. Although Blum said it is still important to have risk-based models, there is data that show downsides of full-risk payment models. “We know that when we [incentivize] risk we see some downsides to that,” Blum said. “We see stronger incentives for more diagnosis code submissions, some of which might be appropriate, some of which not.”
STAT News: (9/30) –The article’s authors, Brian J. Miller and Jesse Ehrenfeld, argue for a reversal of the decision that prevents physicians from operating hospitals and billing Medicare. They write that this decision has had a profound impact on competition in hospital markets.
Health Affairs: (9/30) – In Part Two of their Health Affairs piece, Richard Gilfillan and Donald M. Berwick wrote that the best way to mitigate the undesirable effects of Direct Contracting would be to stop the program. Ideally, CMS should announce that the Direct Contracting Model will be replaced in 2023 by a new Medicare Shared Savings Program (MSSP) model that uses CMMI authority to create more advanced tracks for providers, including full capitation.
Health Affairs: (9/29) – In Part One of their Health Affairs piece, Richard Gilfillan and Donald M. Berwick wrote about the increase in financing and acquisitions of firms focused on serving Medicare beneficiaries. They argue that the perverse MA business model is what underlies this elevated level of investment. Gilfilllan and Berwick say this business model is distorting health care delivery, creating excessive costs for taxpayers and Medicare beneficiaries, draining the Medicare Trust Fund, obstructing the badly needed value transformation of American health care, and diverting the money needed to fund other social services and goods.
Healthcare Dive: (9/29) – U.S. health insurance markets have become increasingly concentrated over the past half decade, according to a new report from the American Medical Association, which argues payer M&A results in rising costs and fewer care options for patients, but largely excludes the impact of provider consolidation in driving those trends. Almost three-fourths of metropolitan statistical areas were highly concentrated in 2020 according to federal guidelines used by the Department of Justice and Federal Trade Commission, up from 71 percent in 2014.
Fierce Healthcare: (9/29) – The National Association of ACOs (NAACOS) released a white paper Wednesday that outlines a series of recommendations to better position organizations to help address health equity, a key priority for the Biden administration. These recommendations include calling on the Biden administration to provide more money upfront to help form accountable care organizations in rural areas and give more financial support to address health equity.