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.
PEPC: (10/31) – PEPC responded to a Congressional Request for Information (RFI) on the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Our response noted that Congress must prioritize Medicare reforms to help control health care costs, ensure better outcomes for patients, and reduce physician burnout. This includes:
Doubling down on the role of physicians and physician-led practices in leading delivery system transformation initiatives;
Ensuring robust Medicare fee-for-service (FFS) reimbursement as a platform for value-based care, and advancing policies that support provider competition;
Aligning the Medicare Quality Payment Program (QPP) to reward physicians and practices that invest in payment and delivery system transformation; and
Re-focusing the CMS Innovation Center on transparent model design and development.
CMS: (11/1) –CMS released the Calendar Year (CY) 2023 Medicare Physician Fee Schedule (PFS) Final Rule. In the rule, PEPC was pleased CMS finalized several proposed changes to the Medicare Shared Savings Program (MSSP) including advance incentive payments to certain accountable care organizations (ACOs) and adjusting ACO benchmarks to account for prior savings. PEPC was disappointed CMS did not fully address the “rural glitch” by removing an ACO’s own beneficiaries from benchmark calculations, and finalized proposals tochange to the benchmarking methodology benchmark to incorporate a prospective, external factor. As noted in our comment letter, we believe this policy will create a significant financial disincentive for independent practices and physicians in certain regions to move into and stay in MSSP. PFS Fact SheetMSSP Fact Sheet
CMS: (11/1) – CMS released the CY 2023 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System (OPPS) Final Rule. The proposed rule included a request for information (RFI) on the use of CMS data to drive competition in health care marketplaces, which PEPC responded to. In the final rule, CMS noted that it received 21 responses to the RFI, in addition to 180 responses related to CMS' hospital price transparency efforts and its role in driving competition. In our RFI response, PEPC had urged CMS to improve the availability and type of consolidation-related data, including information on the impacts of merger activity on access, quality, and health care disparities, to increase transparency and inform future policy. OPPS Fact Sheet
Medical Group Management Association: (11/1) – The Medical Group Management Association(MGMA) released a statement on the CY 2023 PFS, stating that the finalized reduction to the conversion factor will negatively impacting physician reimbursement across the board and that it is critical that Congress act to avert these cuts before the end of the year. MGMA looks forward to working with both Congress and the Administration to mitigate these cuts and develop sustainable payment policies.
California Medical Association: (11/1) – The California Medical Association (CMA) released a statement on the CY 2023 PFS, stating that, unless Congress acts by the end of the year, physicians face more than 8.42 percent in Medicare payment cuts in 2023 due to a confluence of statutory and budget neutrality payment cuts. CMA urges Congress to pass the "Supporting Medicare Providers Act" (H.R. 8800), which would reform the Medicare physician payment system.
American Academy of Family Physicians: (11/1) – The American Academy of Family Physicians (AAFP) released a statement on the CY 2023 PFS, stating that the final rule will result in unsustainable Medicare payment cuts for family physicians and put patients’ timely access to essential primary care at risk. Further, AAFP noted that this policy will setback progress achieved towards building a more value-based health care system and will result in further consolidation of the physician workforce.
American Academy of Family Physicians: (10/24) – AAFP's National Research Network is inviting family physicians to register with the AAFP Researcher Cohort Collaborative and increase the number of family physicians and researchers in the NIH’s All of Us program, helping researchers determine individualized prevention, treatments and care for the general population. The Collaborative’s overall goal is to develop a cohort of physicians, clinicians and researchers who will work together to develop primary care research questions.
American Medical Association: New study shows Medicare Advantage markets lack competition (11/1) – The 2022 edition of Competition in Health Insurance: A Comprehensive Study of U.S. Markets examines Medicare Advantage markets in 380 metropolitan statistical areas (MSAs). Nearly four out of five (79 percent) MSAs had Medicare Advantage markets with low levels of competition and ranked “highly concentrated” according to federal guidelines. Similar to Medicare Advantage, the vast majority (three out of four) of commercial markets at the MSA-level are also ranked “highly concentrated."
Modern Healthcare: CMS makes big changes to Medicare Shared Savings Program (11/1) – CMS will invest in rural and underserved ACOs and introduce more flexibility to the MSSP with the aim of kickstarting stalled enrollment and bridging health equity gaps. The National Association of ACOs cheered CMS’ moves to provide advance shared savings, add a health equity adjustment, factor in ACOs’ past performance to lower their benchmark over time and give ACOs more time before they are forced to take on financial risk. But the trade group decried CMS’ lack of action on the “rural glitch,” under which ACOs no longer benefit from regional adjustments when reducing their spending on assigned patients. The association also criticized CMS for using a prospective projected external factor for ACO benchmarks for their financial spending target and contended that more than a third of ACOs will be harmed by this change.
Med City News: Could value-based care be more than its shortcomings? (10/30) – Regardless of individual interpretations, at the heart of value-based care is the intentional focus to move away from a volume-driven health care system that does not account for quality or outcomes (and zero regard to sky-rocketing costs) to a payment system that is tied to outcomes and quality. Value-based care has provided a platform and a mechanism, where for the first time, health plans, providers and employer groups are sitting around the table with their sleeves rolled up, ready to collaborate and partner. It is not perfect, but it is an alternative to the status quo with each of the health care players sitting on fragmented islands with no incentive to change. It is a journey – a ‘present-continuous’ tense of a concept that is evolving, adapting and being shaped.
Washington Monthly: How Hospital Monopolies Drive Up the Cost of Care (10/30) – Fifty years ago, most hospitals were stand-alone institutions, fixtures of the local community that served as sources of pride as well as medical care. Today, more than half of hospitals are part of regional systems, many of them with a dozen or more hospitals. With the publication of Big Med, the authors David Dranove and Lawton R. Burns offer an exhaustive analysis of the consolidation of U.S. hospitals and the effect it has had on both the cost and quality of health care. The authors argue that there’s no evidence that megasystems are consistently providing higher-quality care than stand-alone hospitals, and they are no less wasteful, and certainly no less expensive, than smaller institutions. Neither vertical integration nor horizontal mergers have brought down costs or led to higher-quality care.
Center for American Progress: How State Health Care Cost Commissions Can Advance Affordability and Equity (10/27) – Studies have shown that consolidation leads to higher health care prices, with hospital consolidation triggering 11 percent to 54 percent higher private insurance prices and 10 percent to 20 percent higher total expenditures per patient. Cost commissions can have the regulatory authority to confront hospital and provider consolidation. While some cost commissions simply set standards and goals, other states can monitor hospital and provider consolidation, administratively review mergers, and limit anti-competitive practices to preserve and promote market competition. Cost commissions can also protect consumers from the harms of health care industry consolidation via market oversight.
Pro Publica: How Effective Is the Government’s Campaign Against Hospital Mergers? (10/27) – What can be gleaned about hospital consolidation 15 months after Biden’s executive order? An examination of the cases the FTC has taken on — and those it hasn’t — suggests that so far the rhetoric has been more muscular than the reality. The agency initiated three challenges of hospital mergers during this period and allowed 54 to proceed without taking public action. One reason the numbers haven’t risen further is an impediment that is rarely mentioned outside of antitrust circles: The FTC’s guidelines focus exclusively on challenging mergers of hospitals within a single geographic region, not when a major player in one region buys up a hospital in a different one. And those so-called cross-market deals make up an increasing portion of hospital mergers. Not only does the FTC face that obstacle, it’s short on the money and staffing it would take to duke it out over big-time cross-market mergers.
Reexamining Social Determinants of Health Data Collection in the COVID-19 Era (10/27) – Data timeliness, a consumer-driven phenomenon, was ascendant even prior to the pandemic. Customers, or patients, have grown accustomed to the convenience of real-time access to people and information. Further, efforts at value-based care require data to be translated into actionable insights far sooner than in the encounter-based FFS business model. Indeed, by replacing FFS with episode-based payments, historic value-based payment models inherently incentivize health systems to address the negative externalities brought on by social determinants of health (ie, worse clinical outcomes and increased preventable health care utilization). New value-based models announced by the CMS Innovation Center are explicitly focusing on health equity as a priority, a necessary precondition to which is securing accurate data on population groups and social needs.
Bipartisan Policy Center: Improving and Strengthening Employer-Sponsored Insurance (10/27) – Policymakers and other stakeholders should address problems in the private health care market. Negotiations between providers and payers shape market prices. Prices are also shaped by geography, the demand for services, the market power of providers and payers, and other factors. Employers often do not possess enough market power to negotiate lower prices due to the consolidation of health care providers. Provider consolidation continues to accelerate, with nearly 67 percent of hospital markets now considered highly or very highly concentrated. Consolidation often drives health care price increases, according to a large body of evidence. BPC has proposed policies to equalize market power dynamics to foster a more competitive employer-sponsored health insurance system.
Center for American Progress: How To Improve Value in Medicare (10/26) – This report examines previous reforms to tie Medicare payment more closely to value, including the MSSP and models implemented through the CMS Innovation Center. It then recommends several policies aimed at reshaping the health care delivery system and leveraging competition in Medicare, including: sharpen the focus of Innovation Center demonstrations and make participation mandatory in models; expand competitive bidding for medical equipment and other supplies; halt the rise of coding intensity in Medicare Advantage; and introduce competitive bidding for Medicare Advantage plans.