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.
White House: (8/13) – President Biden laid out his vision for reducing the high cost of prescription drugs – as part of his Build Back Better agenda. As part of his vision, President Biden is calling on Congress to allow Medicare to negotiate drug prices, make other needed reforms including a firm cap on the amount that Medicare beneficiaries have to pay out-of-pocket for drugs each year, and to build on existing progress to improve competition, increase wages and reduce prices.
Centers for Medicare and Medicaid Services (CMS): (8/13) – CMS released updated guidance on the resumption of Medicaid operations after the end of the PHE. The guidance extends the timeframe for states to complete pending eligibility and enrollment work to up to 12 months after the PHE ends and requires states to complete a redetermination of eligibility after the PHE for all beneficiaries prior to taking any adverse action.
Health Affairs: (8/12) – CMMI Director Liz Fowler along with, CMS Administrator Chiquita Brooks LaSure, Director of the Center for Medicare, Meena Seshamani, and Director for Medicaid and CHIP Services, Daniel Tsai released a blog post on the future of CMMI and value based care, ten years out from the Affordable Care Act. The post discusses lessons learned that will inform the development of future models and a renewed emphasis on health equity. The authors say that more information will be forthcoming.
Government Accountability Office (GAO): (8/12) – GAO issued a report finding that new competitive bidding requirements to determine which suppliers may furnish certain durable medical equipment (DME) to Medicare beneficiaries in designated geographical areas did not negatively affect small suppliers from participating. In 2021, small suppliers received 58 percent of the contracts.
Rep. Gomez (D-CA): (8/13) – Rep. Gomez (D-CA) and six cosponsors introduced the Choose Medicare Act (H.R. 5011), which would provide for the establishment of Medicare part E public health plans. This bill gives all Americans the choice of buying Medicare as their health insurance plan. Unless an individual is already in Medicaid or traditional Medicare, they will be able to choose Medicare on all State and Federal exchanges, and use Affordable Care Act (ACA) subsidies to help pay for it. Summary Section-by-section
Medical Economics: (8/13) – The Medical Group Management Association (MGMA) is calling for a prohibition on insurers charging electronic fund transfer (EFT) fees. According to a news release, a recent MGMA Stat poll found that 57 percent of medical groups reported being charged fees by health insurers. This is a large increase from the 26 percent who reported paying the fees in 2020.
Aledade: (8/7) – In 2020, Aledade and the Community Health Center Association of Mississippi (CHCAMS) launched a collaborative effort to serve the Medicaid population through Aledade’s primary care-centered accountable care organizations (ACOs). This collaborative effort with Mississippi’s community health centers (CHCs) yielded an increase of 106 percent in primary care visits from 2019 - despite the COVID-19 pandemic.
Health IT Analytics: (8/17) – Population health analysis is closely intertwined with value-based care. Not only can population health analytics help identify patient care gaps, but strategies can identify patient-wide interventions and programming that enable better patient outcomes, and ultimately, more success in value-based care contracts.
Modern Healthcare: (8/17) – Health systems, accountable care organizations and other operators are largely responsible for engaging providers in value-based care, as CMS policies and programs aren’t especially prescriptive on that front. The agency could help clinicians buy into value-based care by simplifying its programs, improving information sharing, designing clinician-centric models and holding healthcare organizations more accountable.
AJMC: (8/17) – CMS’ Merit-Based Incentive System (MIPS) is CMS’ first attempt to integrate several different incentive-based programs under one umbrella. Although the program’s intentions are good, stakeholders have shared criticism of potential structural flaws in MIPS; these flaws may serve to prevent widespread adoption and discourage commercial payers from fully embracing the program and value-based care. CMS is attempting to rectify many of these critiques about MIPS by introducing MIPS Value Pathways (MVPs).
Modern Healthcare: (8/17) – While CMS could improve its payment policies and information sharing, those changes are unlikely to make much of a difference so long as it’s easy for providers to make money through fee-for-service reimbursement. Congress must make fee-for-service medicine less attractive than risk-bearing payment models for value-based care to succeed, experts said.
Modern Healthcare: (8/17) – Value-based care is supposed to encourage health systems to reduce utilization and improve quality. But that happens only when clinicians actually curb their use of low-value services and better coordinate and manage care to stop patients from getting sick in the first place. As adoption of value-based care models has been lacking, more healthcare executives and experts have taken aim at how doctors get paid, blaming antiquated compensation plans, in part, for the failure of value-based payment to deliver on its promises.
JAMA Network: (8/16) –In this article, authors Bob Kocher and Rahul Rajkumar lay out four strategies for improvements in cost quality. For example, the authors write that a major challenge to building a collaborative value-based delivery system arises when downstream specialist physicians still operate on a fee-for-service basis. As a result, they recommend broadening the value-based payment portfolio by creating APMs for specialists.
Becker's ASC Review: (8/16) – Recently, insurance companies have begun to seek to partner with or employ physician groups to keep them independent of hospitals.Traditionally, insurance companies have primarily focused on complex contracts with hospitals. However, since the pandemic began, a steep uptick in employed physicians has some companies looking for ways to support independent practices as well. Insurance companies typically pay less for services provided by physician-owned practices and surgery centers than in hospitals, and benefit from more competitive markets.
Medical Economics: (8/16) – In light of continually increasing administrative burdens, fee schedules that barely keep pace with inflation, and competition from the recruitment capabilities of large hospital systems, many independently practicing physicians are aware that they must change their current model, but they are unsure about their options: build? buy/sell? affiliate/align?This article lays out options for independent practices including: joining or creating a super group, soliciting Private Equity Investment, and forming a Management Services Organization (MSO) Model, among others.
MedCity News: (8/16) – Healthcare consolidation is on the rise. A recent Bain & Company study said 50 percent of hospital administrators say their organizations are highly likely to make one or more acquisitions in the next two years and nearly 70 percent of independent physician practices are amenable to a merger or acquisition.
New England Journal of Medicine: (8/14) – In this article, the authors argue that the current A-APM incentive program needs restructuring. The program has three important deficiencies: incentive payments aren’t well targeted to clinicians caring for A-APM patients; the five percent bonus may not be sufficient to entice physicians to join risk-bearing entities; and bonuses are paid long after the performance period ends (for example, 2023 bonuses are based on 2021 participation). The authors propose that the A-APM incentive program should be extended through at least 2030 and should be restructured.
Health Affairs: (8/13) – In this article, the authors offer three ways that policy makers and practitioners can integrate patient-centered elements into alternative payment models (APMs): emphasize access to community- and home-based care options to meet patients where they are; build capacity to address patient needs holistically to impact social determinants of health (SDoH) and advance health equity and; increase points of communication between providers and patients to strengthen care through telehealth, accessible health information technology and remote patient monitoring among others.
Modern Healthcare: (8/13) – CareMax is joining forces with Anthem to build dozens of medical facilities in a bid to boost value-based care. CareMax, a technology-enabled care platform providing value-based care and chronic disease management to seniors, plans to open about 50 medical centers in Connecticut, Georgia, Indiana, Kentucky, Texas, Virginia and Wisconsin and elsewhere. Anthem will incorporate value-based care into its benefit packages for policyholders treated at the new CareMax locations.
Fierce Healthcare: (8/13) – CMS agency leaders outlined their vision for the future of the Center for Medicare and Medicaid Innovation’s (CMMI's) payment models in an article in the journal Health Affairs this week. After an exhaustive review of the CMMI’s more than 50 models, CMS leaders found major challenges in setting benchmarks that determine cost-saving goals for payment models, and providers find it difficult to accept financial risk. Going forward, the agency will reevaluate how it designs financial incentives and will put healthcare equity at the center of every model.
RevCycle Intelligence: (8/12) – High quality, patient-centered care requires a hybrid primary care payment system that encourages value-based care and physician quality assurance. A recent report from the National Academies of Sciences, Engineering, and Medicine (NASEM), titled “Implementing High-Quality Primary Care” depicted a fragile primary care structure in the US and recommended using a part fee-for-service, part capitated model to pay primary care practices.
Health Affairs: (8/12) – Health Affairs Editor-in-Chief Alan Weil spoke with Chiquita Brooks-LaSure, the new CMS Administrator for a one-on-one discussion about her priorities at the agency. She announced that the Medicare Trustee Report would be coming out this month and also stressed that traditional fee for service cannot be left behind Medicare Advantage. Listen to the full discussion with this link.
JAMA Network: (8/11) – Authors, including William Shrank from Humana and Amol Navathe from MedPAC, suggest that private equity is not inherently good or bad. Instead, it acts to amplify the response to extant financial incentives. Within a fee-for-service construct, this is intrinsically problematic. But value-based payment models can serve as an important guardrail, helping to ensure that financial returns to private equity investors are appropriately aligned with system goals of access, quality, equity, and affordability. The authors cite Oak Street Health as an example of how private equity in a value based care context can facilitate positive outcomes.
Fierce Healthcare: (8/11) – Several North Carolina residents charge in a new lawsuit that hospital chain HCA Healthcare has raised costs and lowered quality after it fully acquired Mission Health in 2019.The lawsuit, filed in a local court Tuesday, alleges HCA is cutting staff and costs at “an alarming rate” and leaves western North Carolina with bad healthcare.
Becker's ASC Review: (8/10) – Hospitals often are able to provide large signing bonuses, while physicians have to spend money initially to open their own practices or buy into a surgery center. Over time, physicians in independent practice tend to receive higher average compensation than physicians employed by hospitals. The Medscape Physician Compensation Report 2021 shows employed physicians earned $300,000, compared with independent physicians who earned $352,000 on average last year.
Health Affairs: (8/10) – The US hospital industry has consolidated at an expedited pace in the last decade, charging ahead despite evidence that horizontal consolidation leads to increased commercial prices and has a mixed or negative effect on care quality. While federal antitrust authorities have become increasingly litigious in prospectively addressing anticompetitive hospital transactions in recent years, research suggests that the judicial remedies such as consent decrees sought by this type of enforcement are poorly equipped to foster healthy hospital markets.