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.
Centers for Medicare and Medicaid Services (CMS): (10/8) – On October 8, CMS released the final annual report for the State Innovation Models initiative. Model test states used SIM Model Test funds to test innovative health care models and transform their health care systems to incentivize better care and lower costs. Overall, states increased the use of value-based payment models, particularly in Medicaid, and invested in primary care transformation and behavioral health integration, which increased provider capacity to provide quality care. States that addressed health-related social needs at the community and patient-level also created connections between clinical and community resources. Many states sustained programs after the SIM award.Summary Report
CMS: (10/6) – CMS released a report that showed that social needs data was collected and documented on only 1.59 percent of Medicare FFS beneficiaries in 2019 – which they say is an increase from the 1.31 percent of beneficiaries with social needs documented in 2016. The report found that the five most-utilized Z codes included those for homelessness, disappearance and death of family member, problems related to living alone, problems related to living in a residential institution, and problems in relationship with spouse or partner. Additionally, beneficiaries who are dually eligible for Medicare and Medicaid were overrepresented among the top five Z code claims.
AJMC: (10/10) – Sean Cavanaugh and Travis Broome of Aledade write that the Medicare Shared Savings Program (MSSP) has seen its growth slow, but CMS has an opportunity to act on proposals that would address benchmarking and more fairly allocate savings to accountable care organizations in the program.
Florida Medical Association (FMA): (10/11) – The FMA wrote a letter in opposition of the second Interim Final Rule implementing the No Surprises Act. The letter states the new Interim Final Rule will instate a federal prohibition on out-of-network balance billing effective Jan 1st, which will be an unfair handout to health insurance companies at the expense of access to high-quality, readily available health care in Florida.
California Medical Association (CMA): (10/4) –The CMA is urging physicians to reach out to their Members of Congress and ask that they cosign a high-priority, bipartisan “Dear Colleague” letter aimed at halting the nearly 10 percent Medicare provider pay cuts that are slated for the new year. The letter initiative is being led by Congressmen Ami Bera, M.D. (D-CA), and Larry Bucshon, M.D. (R-IN), who are urging the U.S. House of Representatives leadership to stop the Medicare provider payment cuts before they take effect on January 1, 2022. The letter highlights the financial uncertainty within the Medicare payment system and the dangers these cuts could have on physicians’ ability to provide quality care for their patients if Congress fails to enact legislation to address these problems.
AHIP: (10/12) – AHIP writes that one driver behind the rising costs is the surge in physician practice acquisitions by private equity firms. The increased private equity purchases are driving up health care costs for Americans. By 2018 private equity represented 45 percent of all health care mergers and acquisitions. Initial private equity acquisitions targeted specialties like orthopedics, dermatology, urology, and gastroenterology, where potential profits were highest, but the firms are now expanding their targets.
Modern Healthcare: (10/8) – Physician groups are lobbying Congress for a one-time spend of billions of dollars on Medicare Physician Fee Schedule clinician pay raises. It would be a short-term fix to what medical groups and some lawmakers say is a flawed system of paying physicians, but if Congress doesn't act by the end of the year, some specialties will see cuts to their rates. Physicians are once again taking issue with the Physician Fee Schedule’s' budget neutrality requirement. Pay increases authorized by the CMS for one group of clinicians can mean decreases for others.Congress essentially overrode most of those cuts last year when CMS proposed increases for primary doctors at the expense of other specialties. But the extra $3 billion in temporary funding Congress put in the fee schedule last year expires Dec. 31, putting providers right back in the same place they were before Congress acted, with radiologists, anesthesiologists, surgeons and others facing cuts.
Modern Healthcare: (10/8) – While most providers say they agree with the intent of the price transparency law, smaller hospitals are struggling to gather the data and present them in a useful format. Hospitals were required as of Jan. 1 to post machine-readable files of the rates they negotiate with payers, gross charges and discounted cash prices, which CMS hopes will curb higher-than-average prices. CMS recently sent a second round of warning letters to hospitals that haven't disclosed the rates of 300 "shoppable services" in a consumer-friendly form, threatening a maximum yearly fine of more than $2 million for larger hospitals and almost $110,000 for those with fewer than 30 beds.
Modern Healthcare: (10/8) – More hospitals and surgery centers are asking people to pay in advance for nonemergency services as health care costs rise alongside deductibles, increasing patients’ out-of-pocket expenses and the likelihood that they won’t be able to cover the cost of care. The practice could become even more pervasive as hospitals grapple with the financial effects of the COVID-19 pandemic. But many consumers are uncomfortable paying for pricey surgeries and diagnostic tests in advance, based on estimated costs and without the opportunity to assess the quality of care provided. Some question why hospitals should collect payment upfront, while most other service providers, all of whom risk bad debt, send bills only after providing services.
Fierce Healthcare: (10/8) – Private insurers sometimes negotiate rates on hospital services that are higher than the cash price, a New York Times investigation found, and the same basic service can cost widely varying amounts even at the same hospital. The Times surveyed 60 major hospitals that are complying with this year’s new CMS rule that requires hospitals to publish their negotiated, cash and chargemaster rates. Compliance has been spotty, and even with some published prices, the data has been difficult to draw meaning from.
Healthcare Finance News: (10/7) – Congress has been mulling changes to antitrust enforcement in the U.S., but the American Hospital Association is wary of any changes to the existing legal and regulatory framework for evaluating mergers and acquisitions, telling lawmakers in a letter this week that the current framework has benefited the American economy. The group contended that any current concerns with antitrust enforcement should be addressed by providing additional resources to enforcement agencies, and that the merger review process should remain impartial, "guided by the best interests of consumers and innovation."
Fierce Healthcare: (10/7) – More than three-fourths of traditional Medicare beneficiaries live in a full or partial medically underserved area (MUA), leading to questions on how such areas are defined. New data from the Medicare Payment Advisory Commission released Thursday showed that 18 percent of Medicare fee-for-service beneficiaries lived in a MUA in 2018, the latest year for which data are available, and 60 percent lived in a partial MUA. The high number sparked questions over whether the area designation is precise enough to identify safety net providers that need more help.
RevCycle Intelligence: (10/7) – Hospitals and health systems can implement value-based payment models to ensure preparedness for seasonal and pandemic capacity surges. Fee-for-service models reimburse hospitals depending on the volume of patients they treat, not the quality of patient outcomes. For this reason, hospitals are more likely to operate at full capacity on a normal basis to ensure maximum reimbursement. However, this leads to little leeway when hospitals experience patient surges during peak seasons. Value-based payment models reimburse providers based on the quality of care, not the volume. Rather than dividing physicians’ time in a way that will lead to the highest volume of completed services, health systems could refocus their objective to addressing patient needs and improving health outcomes.
MedCityNews: (10/7) – For the first time, a private health plan’s episodes-of-care payment model has been designated as an Advanced Alternative Payment Model, giving specialty practices a path to value-based care and payment incentives. The State of Connecticut Health Plan, which covers more than 220,000 state and municipal employees, retirees and their dependents, received the designation from CMS.
Medical Economics: (10/6) – The rate of hospital and health system mergers has slowed in the U.S. but the size of the entities behind the deals continues to grow. According to a news release, an analysis from consulting firm Kaufman Hall found that the seven transactions involving 20 hospitals were announced within the third quarter with a total transaction revenue of $5.2 billion. Of these transactions, two were “mega-mergers” where the smaller partner or seller has average annual revenues over $1 billion.
MedPageToday: (10/6) – CMMI Director Liz Fowler said the agency has two mandatory models moving through the regulatory process: the comprehensive joint replacement model and the radiation oncology model. She said they have seen risk selection with voluntary models, which she thinks leads to a certain segment of the provider community being excluded from model participation. Fowler said the people who choose to join the models and who stay to the very end are those who are more likely to succeed and who already have the resources to be successful.
Fierce Healthcare: (10/5) – CMMI Director Liz Fowler said that more mandatory models are needed, including those that focus on the total cost of care. The Biden administration wants to move away from creating value-based care payment models for every type of disease, episode of care or specialty groups to streamline its projects. Fowler was more in favor of promoting models that address the total cost of care, like Maryland’s state model that sets a per capita limit on total Medicare costs in the state.