[Senate Hearing 118-781]
[From the U.S. Government Publishing Office]
S. Hrg. 118-781
BOLSTERING CHRONIC CARE THROUGH
MEDICARE PHYSICIAN PAYMENT
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HEARING
BEFORE THE
COMMITTEE ON FINANCE
UNITED STATES SENATE
ONE HUNDRED EIGHTEENTH CONGRESS
SECOND SESSION
__________
APRIL 11, 2024
__________
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Printed for the use of the Committee on Finance
__________
U.S. GOVERNMENT PUBLISHING OFFICE
63-287-PDF WASHINGTON : 2026
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COMMITTEE ON FINANCE
RON WYDEN, Oregon, Chairman
DEBBIE STABENOW, Michigan MIKE CRAPO, Idaho
MARIA CANTWELL, Washington CHUCK GRASSLEY, Iowa
ROBERT MENENDEZ, New Jersey JOHN CORNYN, Texas
THOMAS R. CARPER, Delaware JOHN THUNE, South Dakota
BENJAMIN L. CARDIN, Maryland TIM SCOTT, South Carolina
SHERROD BROWN, Ohio BILL CASSIDY, Louisiana
MICHAEL F. BENNET, Colorado JAMES LANKFORD, Oklahoma
ROBERT P. CASEY, Jr., Pennsylvania STEVE DAINES, Montana
MARK R. WARNER, Virginia TODD YOUNG, Indiana
SHELDON WHITEHOUSE, Rhode Island JOHN BARRASSO, Wyoming
MAGGIE HASSAN, New Hampshire RON JOHNSON, Wisconsin
CATHERINE CORTEZ MASTO, Nevada THOM TILLIS, North Carolina
ELIZABETH WARREN, Massachusetts MARSHA BLACKBURN, Tennessee
Joshua Sheinkman, Staff Director
Gregg Richard, Republican Staff Director
(II)
C O N T E N T S
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OPENING STATEMENTS
Page
Wyden, Hon. Ron, a U.S. Senator from Oregon, chairman, Committee
on Finance..................................................... 1
Crapo, Hon. Mike, a U.S. Senator from Idaho...................... 4
WITNESSES
Navathe, Amol S., M.D., Ph.D., professor of health policy,
medicine, and healthcare management, Perelman School of
Medicine and The Wharton School, University of Pennsylvania,
Philadelphia, PA............................................... 6
Furr, Steven P., M.D., FAAFP, president, American Academy of
Family Physicians, Jackson, AL................................. 7
Turner, Patricia L., M.D., MBA, FACS, executive director and
chief executive officer, American College of Surgeons, Chicago,
IL............................................................. 9
Matthews, Melanie, MSN, chief executive officer, Physicians of
Southwest Washington; and president, MultiCare Connected Care,
Olympia, WA.................................................... 11
ALPHABETICAL LISTING AND APPENDIX MATERIAL
Crapo, Hon. Mike:
Opening statement............................................ 4
Prepared statement........................................... 35
Furr, Steven P., M.D., FAAFP:
Testimony.................................................... 7
Prepared statement........................................... 36
Responses to questions from committee members................ 43
Matthews, Melanie:
Testimony.................................................... 11
Prepared statement........................................... 55
Responses to questions from committee members................ 59
Navathe, Amol S., M.D., Ph.D.:
Testimony.................................................... 6
Prepared statement........................................... 73
Responses to questions from committee members................ 82
Turner, Patricia L., M.D., MBA, FACS:
Testimony.................................................... 9
Prepared statement........................................... 100
Responses to questions from committee members................ 106
Wyden, Hon. Ron:
Opening statement............................................ 1
Prepared statement........................................... 117
Communications
Alliance for Home Dialysis....................................... 121
Alliance for Women's Health and Prevention....................... 123
Alliance of Specialty Medicine................................... 124
American Academy of Dermatology Association...................... 132
American Academy of Home Care Medicine........................... 136
American Academy of Ophthalmology................................ 142
American Academy of Orthopaedic Surgeons and American Association
of Orthopaedic Surgeons........................................ 146
American Academy of Otolaryngology--Head and Neck Surgery........ 161
American Association of Clinical Urologists...................... 165
American Association of Hip and Knee Surgeons.................... 165
American Association of Nurse Practitioners...................... 171
American Association of Orthopaedic Surgeons..................... 178
American Clinical Neurophysiology Society........................ 183
American College of Allergy, Asthma, and Immunology Advocacy
Council........................................................ 186
American College of Lifestyle Medicine........................... 188
American College of Physicians................................... 193
American College of Radiology.................................... 197
American College of Surgeons..................................... 199
American Diabetes Association.................................... 200
American Geriatrics Society...................................... 202
American Medical Association..................................... 205
American Medical Women's Association............................. 211
American Nurses Association...................................... 212
American Occupational Therapy Association........................ 215
American Osteopathic Association................................. 221
American Physical Therapy Association............................ 225
American Psychological Association Services, Inc................. 232
American Society of Health-System Pharmacists.................... 235
American Society of Pediatric Nephrology......................... 236
American Society of Retina Specialists........................... 238
American Urological Association.................................. 243
Association for Clinical Oncology................................ 245
Borelli, A. Joseph, Jr., M.D..................................... 249
Coalition of State Rheumatology Organizations.................... 250
College of American Pathologists................................. 252
Emergency Department Practice Management Association............. 259
Healthy Aging Coalition.......................................... 261
Infectious Diseases Society of America........................... 262
Medical Group Management Association............................. 265
National Academy of Neuropsychology.............................. 268
National Association of ACOs..................................... 271
Obesity Care Advocacy Network.................................... 274
Primary Care Collaborative and Better Health--NOW................ 277
Society of General Internal Medicine............................. 280
Society of Gynecologic Oncology.................................. 282
UsAgainstAlzheimer's............................................. 284
BOLSTERING CHRONIC CARE THROUGH MEDICARE PHYSICIAN PAYMENT
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THURSDAY, APRIL 11, 2024
U.S. Senate,
Committee on Finance,
Washington, DC.
The hearing was convened, pursuant to notice, at 10:04
a.m., in Room SD-215, Dirksen Senate Office Building, Hon. Ron
Wyden (chairman of the committee) presiding.
Present: Senators Stabenow, Warner, Whitehouse, Hassan,
Warren, Crapo, Grassley, Lankford, Johnson, Tillis, and
Blackburn.
Also present: Democratic staff: Shawn Bishop, Chief Health
Advisor; Eva DuGoff, Senior Health Advisor; Marisa Salemme,
Senior Health Advisor; Joshua Sheinkman, Staff Director; and
Tiffany Smith, Deputy Staff Director and Chief Counsel.
Republican staff: Kellie McConnell, Health Policy Director;
Gregg Richard, Staff Director; and Conor Sheehey, Senior Health
Policy Advisor.
OPENING STATEMENT OF HON. RON WYDEN, A U.S. SENATOR FROM
OREGON, CHAIRMAN, COMMITTEE ON FINANCE
The Chairman. The committee will come to order, and today
we are going to discuss how to update and strengthen Medicare's
guarantee of high-quality health benefits for the next
generation of America's seniors. To be clear from the outset,
traditional Medicare, now used by millions of older people to
secure the vital services of Medicare, is falling behind when
it comes to helping seniors manage their health when they are
living with multiple chronic conditions.
I know members of the committee are interested in reforms
to the way physicians and nonphysician practitioners are paid.
In my view, any update to the way physicians are paid by
traditional Medicare has to provide a lifeline to those older
folks that I was talking about: the millions of seniors who
live with chronic conditions and who are struggling to
coordinate their health care in a fragmented system, in a
peculiar, crazy quilt of services that just does not put
seniors' health first. This hearing is going to jump-start that
debate.
The Finance Committee has had a special interest in this. I
believe this was before our colleague from New Hampshire joined
us, but we delivered a wake-up call to the country when we
passed our first round of reforms to care for chronic
conditions in Medicare. I remember those days like it was
yesterday, because the late Orrin Hatch, the chairman of our
committee, had some concerns about the original idea, and
Johnny Isakson of Georgia and Senator Warner and I and others
were kind of the agitators, and the chairman agreed to work
closely with us. And we made the point that--and it's critical
today--Medicare is no longer just an acute care program.
Back in the days when I was director of the Gray Panthers
and I had a full head of hair and rugged good looks, that was
Medicare. You know, you broke your ankle, and that was Part A
of Medicare. You went to the hospital. If you had a really
horrendous case of the flu, that was Part B of Medicare. That
was the ballgame. In our gerontology classes, we taught that:
Part A, Part B, the end.
That is no longer Medicare. Today, Medicare is
overwhelmingly about chronic conditions: cancer, diabetes,
heart disease, strokes, COPD--you all know the list. And what
we know is that if you do not figure out ways to pull these
services together, as I mentioned, you have this crazy quilt of
appointments and prescriptions and care plans that lead to
confusion and, particularly, worse health care.
When a senior's health gets this complicated, care
coordination is not an option. Recent events have underlined
the growing cost of chronic disease in America. Even before the
COVID-19 pandemic, life expectancy began to dip in the United
States from a 2014 peak of 79 years old. The pandemic led to a
backlog of preventive care that may only accelerate chronic
illness in our country.
The way traditional Medicare pays physicians to manage and
treat these conditions has not kept up with the times.
Democrats and Republicans were right to tackle the problem
earlier. It is now time to act once more. In contrast to
traditional Medicare in the past decade, Medicare Advantage
plans have been given a host of tools to incorporate chronic
disease management into their plan choices.
We talked about it, and it is all about giving flexibility
to plans. And the irony of course is, a lot of these additions
were really quite expensive in terms of their cost, but they
could make a difference for seniors--even grab bars in showers.
Now, I have people who run ambulance systems who say
``thank goodness for those grab bars,'' because we do not see
as many older people who have hips that are shattered getting
out of bathtubs. So, these are important kinds of health-care
issues, and ones that can be addressed with services that are
not particularly expensive.
So, MA was built from the ground up to offer more flexible
benefits, to give seniors the option to choose a Medicare plan
that was tailored to their needs. Plans are able to use
rebates, growing from $12 billion in 2014 to $67 billion in
2024, to support this idea of the flexibilities and the added
benefits. Unfortunately, it is increasingly clear that too many
insurance companies are playing too many games with these
rules, particularly in terms of coding games with Medicare's
payment rules to maximize their bottom line but do little or
nothing for seniors. MA plans seem, in too many instances, to
be using more of these extra dollars to juice marketing and
enrollment.
We have been told by experts that MA plans are now spending
$6 billion per year on marketing middlemen. Get that number,
colleagues: $6 billion on marketing middlemen who sell their
plans to seniors. Just last week at our request, the Centers
for Medicare and Medicaid Services announced they are cracking
down on these insurance middlemen selling seniors' personal
information over and over again. So what this means,
colleagues, is an insurance plan gets some personal data from
somebody and then, after they get their data from the consumer,
they just sell it over and over again. We pushed to get that
outlawed, and that is in fact going to be done.
Now, there is plenty more that we need to do in terms of
getting traditional Medicare to keep up with the needs of
seniors when it comes to care coordination, nonmedical
determinations of health, and the like. This could include
steps such as reducing or eliminating cost sharing for care
coordination services. Seniors should not have to pick up the
tab when their primary care doctor works with their
cardiologist or physical therapist to coordinate a care plan
for high blood pressure. It also has to include empowering
primary care. The physicians and the providers who do that play
a critical role in managing chronic illness.
We also have a persistent shortage of primary care
providers in many parts of the country. That is because there
are out-of-whack payment rules that make primary care a less
appealing specialty than other fields. Primary care providers
need to be valued and compensated more fully by Medicare.
Finally, the challenge before the Finance Committee is to
improve the way Medicare pays for services delivered in the
doctor's office or at home, so there is a real focus on
managing those chronic conditions that dominate the health of
seniors.
Last point I want to make, colleagues, is when we got the
original bill passed--and it shows what we can do here in this
committee working in a bipartisan way, with a bit of
imagination--a major section of our chronic care bill was
devoted to telehealth services. They were big, and they just
sat there plopped right in the center of the bill, and for a
year or two nobody paid a lot of attention. One day I was
sitting in my office, and President Trump's director of CMS
called me up and said, ``How would you feel if we were to use
your telemedicine provisions as the basis for dealing with
COVID?'' I said, ``Are you kidding me? How would I feel? I am
going to go and have two hot fudge sundaes. This is
wonderful.'' This is an indication that the Finance Committee,
on a bipartisan basis, can make a difference.
We are still building on that model. So I am going to turn
this over to Senator Crapo, but I just bring this up by way of
saying that this committee, working in a bipartisan way, did
something historic with this change to make Medicare focus as
much on chronic care as it does on acute care. We have to keep
building on it, and it really speaks to what these four
witnesses are going to be talking about today, so we thank you.
Senator Crapo?
[The prepared statement of Chairman Wyden appears in the
appendix.]
OPENING STATEMENT OF HON. MIKE CRAPO,
A U.S. SENATOR FROM IDAHO
Senator Crapo. Thank you, Mr. Chairman, and thank you for
holding this important hearing. We can build strong
bipartisanship and have done so in this area many, many times.
Across the country, more than 60 million Americans rely on
Medicare to meet their health-care needs. Over the next decade,
this population will grow by more than 20 percent. Medicare's
coverage and payment policies play a dominant role in setting
benchmarks and baseline rules of the road, not just for the
program itself, but also for countless other payers, affecting
hundreds of millions of working families.
In short, ensuring a resilient and robust Medicare program
has become more vital than ever. Unfortunately, our current
policies seem poised to fall short of that goal. Today's
hearing highlights the urgency of advancing durable clinician
payment reforms, both for front-line medical providers and,
more importantly, for patients.
In the absence of proactive policy changes, tens of
millions of seniors will suffer the consequences. The risks of
inaction range from surges in wait times and delays including
for critical care, to clinician office closures and cutbacks in
provider participation.
Our committee has an obligation to strengthen the Medicare
program and avert these unacceptable outcomes. A successful
legislative initiative must reckon with the range of challenges
under the current paradigm, which has served to devalue and
distort payments for vital services, as well as to exacerbate
administrative burdens.
In inflation-adjusted terms, Medicare Physician Fee
Schedule payments have declined by more than 25 percent over
the past 2 decades, even as clinicians continue to face
skyrocketing costs for overhead, equipment, supplies, and
staffing needs. As the Medicare trustees cautioned last year,
the colossal gap between stagnant fees and steep inflation
poses a dire threat to long-term patient access. The current
conversion factor update schedule cannot sustain an effective
or even adequate clinical workforce moving forward.
For many specialists, recent regulatory changes have
further intensified these issues, as new billing codes and
valuation shifts have triggered drastic cuts under the
program's budget-neutrality rules. Based on inflexible cost-
containment measures, a payment bump for primary care prompts
payment reductions for entirely unrelated procedures and
services, from brain surgery to advanced cancer care.
From 2014 to 2023, for instance, even before adjusting for
inflation, the fees for chemotherapy administration and IV
infusions declined. Under these conditions, it should come as
no surprise that many physicians have opted to sell their
practices, join health systems, or limit new Medicare patients.
Structural fee schedule reforms should shift away from the
status quo--which forces clinicians to vie for ever-dwindling
resources--and move forward to models that promote and reward
team-based, patient-centered approaches. Nine years ago,
Congress took concerted action to repeal the draconian
Sustainable Growth Rate system, which had threatened cascades
of dramatic cuts. In enacting the Medicare Access and CHIP
Reauthorization Act, policymakers sought to stabilize the fee
schedule and incentivize value-based care. In practice, these
reforms have largely failed. The Merit-based Incentive Payment
System aimed to establish an accessible on-ramp to
participation in quality-driven alternative payment models, or
APMs.
Instead, this system has buried clinicians in dozens of
hours of paperwork each year, all in exchange for potential
marginal payment bumps based on ambiguous metrics that lack
meaningful value for patients. A number of primary-care-focused
APMs have shown promise, but countless specialties lack access
to any clinically relevant models at all.
While the MACRA-established committee to translate
clinician-developed APM concepts into concrete policy options
has worked through dozens of viable proposals, the Centers for
Medicare and Medicaid Services have largely rejected these
opportunities. Reforms to advance value-based care thus demand
a focus not just on financial incentives, but also on
structural improvements that ensure meaningful options informed
by clinical experience and aligned with patient needs.
I look forward to building on this committee's bipartisan
work to bolster and modernize our clinician payment systems.
The program's current and future enrollees depend on it.
Thank you to our witnesses for being here today, and thank
you, Mr. Chairman.
[The prepared statement of Senator Crapo appears in the
appendix.]
The Chairman. Thank you, and we have four individuals who,
by any objective assessment, are real experts in chronic care.
So we thank you, and we have some brief introductions. We will
go right to your testimony.
Dr. Amol Navathe is a practicing primary care physician,
and an associate professor of health policy and medicine at the
University of Pennsylvania. He is also vice chairman of MedPAC,
the Medicare Payment Advisory Commission.
Dr. Steve Furr is here. He is a family physician and
president of the American Academy of Family Physicians. He also
cofounded a clinic as well in Jackson, AL to serve folks there.
Dr. Patricia Turner is a general surgeon and chief
executive officer of the American College of Surgeons, and she
is also a professor at the University of Chicago. We welcome
you.
And then, Melanie Matthews is chief executive officer of
Physicians of Southwest Washington and president of MultiCare
Connected Care.
To all of our witnesses, we thank you for speaking with the
Finance Committee about these extraordinarily important
issues--chronic care and particularly the Medicare physician
payment system. Please go ahead with your remarks. As you know,
we are trying to keep everybody at 5 minutes, because we think
members--it is going to be a hectic morning here in the
Senate--are very interested in these issues.
Dr. Navathe, please start.
STATEMENT OF AMOL S. NAVATHE, M.D., Ph.D., PROFESSOR OF HEALTH
POLICY, MEDICINE, AND HEALTHCARE MANAGEMENT, PERELMAN SCHOOL OF
MEDICINE AND THE WHARTON SCHOOL, UNIVERSITY OF PENNSYLVANIA,
PHILADELPHIA, PA
Dr. Navathe. Chairman Wyden, Ranking Member Crapo, and
distinguished members of the committee, thank you for the
opportunity to testify. My name is Amol Navathe. I am a general
internist, physician, and health economist.
Before I begin my remarks, I would like to emphasize that
my comments reflect solely my beliefs, and not the opinions of
any organization I am affiliated with, including MedPAC, the
University of Pennsylvania Health System, or Perelman School of
Medicine.
Today, I would like to highlight why the Medicare program
needs to better address chronic disease care, and why this
cannot happen without changes to physician payment. As a
practicing physician, I have witnessed firsthand the challenges
that Medicare beneficiaries face in getting optimal care for
chronic conditions.
Take for example my patient Mr. L, a wonderful gentleman
suffering from diabetes, heart failure, and kidney disease. Mr.
L has to manage his chronic conditions on his own, spending an
average of 2 hours a day coordinating his medications,
traveling to clinics, and attending appointments. He is one of
so many patients who would benefit from a more proactive
patient-centered model of care, a model that could have
prevented his recent hospitalization for kidney failure. In
reflecting upon Mr. L's situation, I would like to share three
key points.
First, chronic disease may be the single most important
challenge affecting the Medicare program. More than two-thirds
of the Medicare population has two or more chronic conditions.
The 15 percent of beneficiaries with six or more chronic
conditions cost Medicare more than three times the average.
Second, dramatic fragmentation plagues chronic disease
care. Medicare beneficiaries with chronic conditions see more
than five physicians concurrently. My colleague Matt Press
found that over just 3 months, it takes a PCP over 50
interactions--let me say that again--50 interactions with other
clinicians and the patient, to actively coordinate care for
just one important clinical condition. It is pretty astounding
how much time and effort this takes.
What does this have to do with physician payment? That
leads me to my third point. Unfortunately, the status quo fee-
for-service system is a key factor in producing fragmentation.
The focus is not on producing more health, just on producing
more health care. Each clinician has their head down, focused
on doing more visits and procedures, while the critical task of
coordinating care often gets overlooked.
With good intentions, CMS has attempted to fill this gap by
adding more billing codes. But reducing the important work of
clinicians to a list of codes is a fraught task. The result is
an administratively complex system of ticky-tack codes that are
underused because the cost of billing them is itself
unprofitable. For example, the administrative cost to bill for
a visit is about $20. That is more than the $15 physicians get
paid for a virtual check-in visit. I sometimes call this death
from a thousand codes.
So what is the path forward? Addressing fragmentation will
require a new way of delivering chronic disease care, which in
turn will require substantial changes to physician payment.
Simply adding more dollars to the current system will not be
enough. Physician groups need to be able to invest in new
capabilities; use technologies like telehealth when safe,
efficient, and effective; and staff practices differently.
A natural place to start is investing in primary care. One
promising path is to provide PCPs with steady monthly payments
per beneficiary, in addition to certain fee-for-service
payments. This would balance the roles of preserving access,
while enabling PCPs to practice more patient-centered care. An
additional benefit would be unshackling PCPs from a system that
requires billing for each and every task.
Another promising approach is to continue expansion of
alternative payment models, which place accountability for cost
and quality outcomes onto providers. This will require
continued support from the CMS Innovation Center. Alternative
payment models can improve care for patients with both high and
low burdens of chronic disease. A great example has been the
Accountable Care Organization model. However, alternative
payment models still rely on the Physician Fee Schedule,
creating conflicting incentives for some physicians. This leads
me to point out that CMS needs more tools to manage the fee-
for-service program effectively.
There are many factors to consider in improving physician
payment, and no single entity has all the required expertise.
This effort will benefit from the input of multidisciplinary
experts, who could be convened as an advisory panel to CMS.
Ultimately, CMS needs the ability to catalyze a new care model,
and that will require adapting the fee schedule to accommodate
new approaches, such as for primary care. This will require
action. Unlike in Medicare Advantage, where we have seen
substantial innovation to meet beneficiary needs on a near
real-time basis, traditional Medicare requires congressional
action to stay up to date. Hence, CMS needs more tools and
authorities to better address chronic disease among Medicare
beneficiaries.
Thank you.
[The prepared statement of Dr. Navathe appears in the
appendix.]
The Chairman. Dr. Navathe, we have had some jaw-dropping
testimony around here over the years, but to hear that one
patient had 50 interventions--was that your word, or
interactions?
Dr. Navathe. Interactions.
The Chairman. Yes. Fifty interactions over a 3-month
period. I am going to be replacing my jaw or something. That
was really extraordinary, and I think that also gives us a
wake-up call like we had years earlier when we started down
this path. And I thank you.
Dr. Furr?
STATEMENT OF STEVEN P. FURR, M.D., FAAFP, PRESIDENT, AMERICAN
ACADEMY OF FAMILY PHYSICIANS, JACKSON, AL
Dr. Furr. Good morning, Chairman Wyden, Ranking Member
Crapo, and members of the committee; I am Steve Furr. I am a
practicing family physician from Jackson, AL, population
slightly less than 5,000. I am the president of the American
Academy of Family Physicians. I am honored to be with you here
today, representing our 130,000 members, physicians, and
medical students who faithfully serve their patients and your
constituents.
I have delivered primary care in a rural community for more
than 35 years. In my time, I have seen firsthand how my
patients are getting sicker and more complex. Meeting the
current and future needs of our patients with chronic
conditions requires our Nation to better leverage primary care.
On March the 21st, Carolyn, my long-term patient, came to
my office complaining that she had a blister on her right great
toe. Carolyn and I were born in the very same year, but our
life paths are very different. But we have walked them together
as physician and patient. She is a diabetic on short- and long-
acting insulin, and between her diabetes and her hypertension,
her kidneys failed. She was on dialysis and then was fortunate
enough to get a kidney transplant. Now she is on chronic
immunosuppressive therapy. She comes to my office and as I
examine her, I can smell the putrid odor from her toe, and I
know that she has a necrotic foot.
I clean and debride the wound, get the x-ray confirming
infection has not moved into the bone. The vascular studies
showed what we suspected. She has no blood flow from the knee
down to the rest of her foot. She saw the vascular surgeon on
Tuesday this week, and will hopefully get a revascularization
procedure that will save that leg. If she is not treated in
time, she would get a very different procedure, a left above-
the-knee amputation, leaving more morbidity and mortality. One
of the most impactful aspects of primary care is the trusting
relationship we develop with our patients.
Evidence suggests that the longitudinal relationships that
I and other primary care physicians foster with our patients
lead to better control of chronic conditions, fewer emergency
department visits and hospital stays, and improved patient
outcomes. But traditional Medicare underinvests in primary care
and these relationships. Lower primary care payment rates and a
system that rewards volume over value means physicians are
pressured to see as many patients as possible.
Meanwhile, overwhelming administrative burden takes
significant time away from our patient care. This is leading
current primary care physicians to leave the field, and
discouraging medical students from pursuing primary care
specialties. This in turn is having severe impacts on patient
access. Among peer nations, the patients in our country are the
least likely to have a longstanding relationship with a primary
care physician. Our health-care system has steered people away
from high-value, low-cost services like preventive screenings
and primary care office visits.
By not investing more up-front dollars in primary care, we
are paying an even higher price, and we are not prioritizing
what really matters: patient outcomes and experience. One of
the major factors contributing to our national underinvestment
in primary care is a relative undervaluation of primary care in
fee-for-service payment. In general, Medicare values procedural
services higher than it does office visits and other cognitive
services most often delivered by primary care physicians. This
devaluation is not limited to Medicare. As mentioned earlier,
most payers tie their payment rates to Medicare or use
Medicare-relative values.
Fee-for-service does not just underinvest in primary care;
it also makes it hard to get paid. We must submit multiple
unique codes for each service we provide, documenting both what
we did and why we did it. That does not fit with the
continuous, comprehensive nature of the primary care that we
provide.
That is why we must accelerate the transition to value-
based payment for primary care, using alternative payment
models, or APMs, that provide prospective population-based
payments. However, it is important to realize APMs are often
designed based on fee-for-service payment rates. Therefore,
improving fee-for-service payment for primary care is one
essential strategy to support the transition into value-based
care.
I am encouraged by the recent policy changes to better
value primary care Medicare. Unfortunately, Medicare's budget-
neutrality requirements for physician payment are severely
undermining these investments. CMS is forced to offset
increases anywhere in the fee schedule with across-the-board
cuts to all services, including primary care. This means
Medicare cannot appropriately pay for all the services a
patient might need.
So, as a first step forward, I would ask that Congress
revise current budget-neutrality requirements. Additionally,
Congress should waive patient cost-sharing requirements for
chronic care management and other primary care services. In
closing, I urge Congress to prioritize policies that would
better support patients with chronic conditions and the family
physicians who care for them. We all have the same goal: to
improve the lives of the people we serve.
Thank you for the opportunity to provide this testimony. I
look forward to trying to answer your questions.
[The prepared statement of Dr. Furr appears in the
appendix.]
The Chairman. Doctor, thank you, and good for you for
taking the principles that you have advocated and putting them
into action there at home. Nice to have you.
Dr. Turner?
STATEMENT OF PATRICIA L. TURNER, M.D., MBA, FACS, EXECUTIVE
DIRECTOR AND CHIEF EXECUTIVE OFFICER, AMERICAN COLLEGE OF
SURGEONS, CHICAGO, IL
Dr. Turner. Chairman Wyden, Ranking Member Crapo, and
members of the committee, thank you for inviting the American
College of Surgeons to testify at this important hearing on
``Bolstering Chronic Care Through Medicare Payment.'' The ACS
and its 90,000 members remain committed to improving care for
all surgical patients, including those living with chronic
conditions, and to ensuring that Medicare beneficiaries receive
the highest quality of care.
Quality improvement in surgery has been the cornerstone of
the ACS since its founding 110 years ago, and with 13 quality
programs, the ACS has set the standards for high-quality
surgical care. In some cases, it has collaborated with other
specialty societies to develop others. Patients seek out our
programs for definitive quality measurement and evidence-based
practice. We believe that medicine should be advancing toward a
system that rewards high quality and enhances the value basis
of care. This transformation is underway and would benefit from
efficient investments in the partnerships between CMS and
subject matter experts committed to improving the way quality
is measured and incentivized, and by improving the calculus of
the Physician Fee Schedule.
The ACS envisions quality as a comprehensive program which
centers on the patient and is inclusive of the entire team
involved in providing care. Truly team-based care requires
coordination with our primary care colleagues and other
specialists to ensure that a patient's chronic conditions are
managed appropriately to achieve the best possible outcome.
This commitment to team-based care is evident in our
verification programs, which include standards related to
disease management. Most physicians in the current fee-for-
service system, however, are evaluated on measures that do not
necessarily reflect the care they deliver or the conditions
they treat. Unfortunately, the current model of individual,
disconnected measures is insufficient to achieve coordinated
patient-centered high-value care, and provides little
actionable information for continuous physician improvement or
patient decision-making autonomy at point of care.
Programmatic measures developed by the ACS exhibit
applicability to diverse care settings, cause a limited burden
on care providers, and deliver demonstrably better results. The
ACS believes that addressing the shortcomings of traditional
Medicare fee-for-service payments will require new types of
quality measures, facilitated by increased flexibility in the
facility-based scoring option in the Merit-based Incentive
Payment System.
However, Medicare cannot transform into a system which
functions to reward value without immediate and lasting
stability in the physician payment system. To create this
stability, Congress should immediately address the payment
reductions already anticipated in 2025. Under current law, it
would take decades for the fee schedule conversion factor to
return to adjusted 2000 levels. The implementation of positive
annual updates to the conversion factor reflecting the
inflation in practice costs is an essential step necessary to
enhance patient access to care and to improved quality.
Yearly reductions to the Medicare conversion factor
continue to be problematic for surgeons and physicians of all
specialties, due to the budget-neutrality requirements for any
change in the Physician Fee Schedule expected to increase
expenditure by as little as $20 million annually. This trigger
amount has remained the same since its implementation in 1992.
Updating the trigger for budget-neutrality adjustments would
help to ensure that comparatively minor changes to the fee
schedule do not always require across-the-board cuts. Congress
should, at a minimum, increase the budget-neutrality trigger
threshold from $20 million to $100 million and index it
annually to account for inflation. This will create a stable
base from which physicians can incorporate payment models
involving risk, and will reduce unhelpful competition between
specialties when other sectors of the health-care system have
none of the same constraints.
Finally, Congress can do more to make alternative payment
models available to physicians. Along with dozens of other
specialty societies, the ACS developed and submitted proposals
that were reviewed, revised, and evaluated by the Physician-
Focused Payment Model Technical Advisory Committee created by
MACRA. Fourteen were recommended for testing or implementation
by the PTAC, but CMS has not tested any as proposed. This
bottleneck has created a disincentive for stakeholder
investment into the development of APMs. These innovative and
value-driven proposals are some of the best ways to incorporate
data into this conversation in a way that enhances patient
outcomes and ultimately bends the cost curve.
Congress should require that at a minimum, some portion of
the Innovation Center's budget be dedicated to testing
physician- and specialist-developed APMs recommended by the
PTAC. These are relatively modest reform ideas that would
stabilize the Physician Fee Schedule and build upon MACRA to
focus on providing high-value care to our patients.
Surgeons are devoted to their patients, and we look forward
to working with you to solve these thorny problems. Thank you
for the opportunity to participate, and we look forward to
answering your questions.
[The prepared statement of Dr. Turner appears in the
appendix.]
The Chairman. You are going to get some momentarily. Thank
you.
Ms. Matthews, welcome.
STATEMENT OF MELANIE MATTHEWS, MSN, CHIEF EXECUTIVE OFFICER,
PHYSICIANS OF SOUTHWEST WASHINGTON; AND PRESIDENT, MULTICARE
CONNECTED CARE, OLYMPIA, WA
Ms. Matthews. Thank you, Chairman Wyden, Ranking Member
Crapo, and distinguished members of the committee. I appreciate
this opportunity to discuss ways to enhance care for
individuals with chronic conditions. My name is Melanie
Matthews, and I am honored to serve as the chief executive
officer, PSW, and the president of MultiCare Connected Care. I
have over 2 decades of experience in health care, and have
strong focus in value-based care.
PSW is an independent physician practice association formed
in 1995. We participate in Accountable Care Organizations,
including the Medicare Shared Savings Program and the ACO
Realizing Equity, Access, and Community Health (REACH) model.
Across our partnerships, we provide care to over 400,000 people
in Washington, Idaho, and Oregon. Collectively, our
partnerships have saved $120 million in Medicare by maintaining
an average quality score of 96 percent.
Accountable Care Organizations sit at the intersection of
today's topics of both physician payment and care coordination.
ACOs deliver strategies that are particularly important for
individuals with chronic conditions, who frequently see
numerous providers across multiple settings. To better care for
populations, Congress should lean into Accountable Care
Organizations, which offer the best pathway for health outcomes
at a lower cost.
I would like to share three themes with you today. First,
accountable care is working. It is working for patients, and it
is working for Medicare. Over the past decade, ACOs have
collectively saved $22 billion. While cost savings have been a
headline, the underlying strategies that we deploy to achieve
shared savings improve care for people.
Essentially, we wrap services around people to improve
their health-care delivery experience by expanding access to
care coordination and ensuring the right care at the right time
in the right care setting. While we call that accountable care,
you may think about that as the type of care that you would
want for yourself, your family, and your community.
Second, these strategies are particularly impactful for
chronically ill populations. For example, a registered nurse
plays a pivotal role in the care coordination by developing and
executing personalized care plans. These nurses collaborate
closely with their patients, their families, and the
interdisciplinary teams of physicians, social workers,
pharmacists, and other health-care professionals as needed.
These programs would not be possible under the fee-for-service
model.
Third, we are focused on greater engagement of
beneficiaries and communities. This includes providing
incentives for beneficiaries such as a cost-sharing relief to
increase access to services that otherwise may be avoided or
foregone. An example in our ACO is, a rural critical access
provider built a chronic care management program for Chronic
Obstructive Pulmonary Disease. Despite the potential benefits
of the program, there was low enrollment because of the
beneficiary coinsurance payment. This was a hurdle. Within our
ACO reach, we implemented a cost-sharing waiver to remedy the
issue. This flexibility was a game-changer in increasing access
and enhancing quality of life.
There are key policy levers to accelerate this
transformation, including creating clear and strong incentives
for participation in accountable care by extending Advanced
Alternative Payment Model bonuses, strengthening the data
infrastructure needed to facilitate information sharing, and
simplifying and supporting provider participation in
alternative payment models.
I would like to leave you with a story to help illustrate
the importance of this work. Many of you know firsthand--or at
least secondhand--how frightening and overwhelming it can be to
be discharged from the hospital or any other post-acute care
setting. Often when this happens in a fee-for-service
environment, people are alone with complex instructions, and
far too often this experience leads to readmissions that are
preventable.
The experience is different in ACOs. We had a patient who
was sent home from a skilled nursing facility with instructions
for wound care. After returning home, it became clear that the
health care home health provider did not have the proper
supplies. The patient was planning to return to the emergency
department to have the wound addressed. At our ACO, the nurse
care manager checked in with the patient on the phone,
identified the issue, and was able to refer her to another home
health provider who had the supplies and could get there
immediately. The patient's experience was far superior,
avoiding an unnecessary trip to the emergency department and
addressing her health-care needs at home. The health-care
system avoided the cost of the hospital. This is a win-win.
In conclusion, I extend my gratitude for the opportunity to
share these impactful stories and advocate for advancements in
health-care delivery. PSW and MultiCare Connected Care remain
steadfast in our commitment to collaborate with Congress to
achieve better outcomes for all patients.
Thank you.
[The prepared statement of Ms. Matthews appears in the
appendix.]
The Chairman. Thank you very much. And I am going to start
with you, Dr. Navathe, because I want to understand a bit more
about these 50 interactions that you talked about as it related
to one patient in a 3-month period. I sense what you are
talking about here--and I do not want to put words in your
mouth--is that if this patient was taken care of in a different
kind of way, that for example, Medicare would pay every month a
flat sum for this patient to a primary care doctor, that
primary care doctor would coordinate things. Is that something
resembling English in terms of what you are talking about here?
Dr. Navathe. Thank you, Senator, for the question. So, I
think there are two aspects. I think the first part is, some of
those 50 interactions, probably the majority honestly, would
need to happen regardless. This is just a PCP, a primary care
doctor, having to talk to a specialist, contact the patient,
make sure that everything is translated and coordinated, and
the patient is getting the right care.
The second point that you are making is absolutely right.
Some portion of those interactions would probably not need to
happen in a type of payment model that you are suggesting,
because the primary care practice would be able to staff nurse
practitioners and physician's assistants and pharmacists, and
change the way that it is caring for that patient in a more
effective and efficient way.
The Chairman. So, have you made a list of these
interactions in terms of, say two or three different patients?
I assume not in every case are there 50 interactions, but there
would be different numbers, and you would see different people,
and that sort of thing. But have you made a list that would be
sort of a representative model?
I mean, as you know, physician payment is discussed around
here like the weather. You know, everybody says, ``Physician
payment, oh my goodness, we have got to change it. It is not
doing what we need to do. We are not spending the money
effectively. We are not getting providers for this particular
field and that.''
So, I like your idea very much, because we have been
looking--I see my colleagues, particularly Senator Stabenow and
Senator Whitehouse, who have specialized in this. We have been
talking about what to do about traditional Medicare for ages
and ages, and in fact, the legendary New York Times journalist
Robert Pear, who was the most authoritative reporter on health
care, he did his last article on chronic care and our bill, and
he had been covering it forever. And we all walked away saying,
``We have to do more for traditional Medicare.'' And so, we
want to get more details from you about how to do that with
your idea of the per-month per-patient kind of payment for
coordination.
There is one other question. I have a little bit of time
left for the entire panel. So, apropos of that piece that
Robert Pear wrote--he went through grab bars and nutritional
assistance and all of this kind of stuff. What do you four
experts in the field think are the lessons learned from the
jump-start we had doing this for MA?
In other words, MA was better positioned at the beginning,
because it already coordinated services in a constructive kind
of fashion. But you cannot leave 50 percent of the elderly
population behind that is using traditional Medicare.
So let's just use my time, go right down the table. What do
you think the lessons are learned from the MA experience, which
has produced some examples that I have given, and what can we
apply to traditional Medicare now? Dr. Navathe, let us just go
right down the row.
Dr. Navathe. Thank you, Senator. I will try to keep my
comments brief. So, I think what we have learned is that there
is a big gap between what traditional Medicare provides and
patient needs, because Medicare Advantage plans have provided
supplemental benefits like transportation. They have
flexibility to reduce cost sharing. As we have heard, that can
be very important.
So, I think we have to meet the patients where they are,
and that has been a key lesson, right? And I think one of the
big challenges is, in Medicare Advantage they have the
flexibility to innovate their benefits. They have that
flexibility to do some of this on their own. In traditional
Medicare, there are a lot more constraints, and we need
Congress to give CMS the authorities to make that happen.
The Chairman. That is way too logical for government--meet
the patients where they are. Good for you.
Dr. Furr?
Dr. Furr. So, there are medical advantages of Medicare
Advantage, but I will say there are also some downsides. The
rise of prior authorization coincides with the rise of the
Medicare Advantage plans. It is a huge hassle for our doctors
trying to take care of patients. To give you an example, when I
try to send a patient and I need a stress test, my nurses tell
me it is easier for me to do the referral to the cardiologist
than it is to get the stress test set up. I do not need to
refer to the cardiologist; I just need the stress test.
It is not just tests; it is even the drugs--the change of
plan, doing a different formulary. I have a diabetic who is
completely controlled, hypertension is controlled. If I have to
change the medication, there are some hassles with that.
Medicare is much easier as far as getting services. They do not
have the umbrella services. As far as getting referrals and
taking care of them, there is ease there doing that.
The Chairman. Well, thank you also for mentioning the prior
authorizations, because a good chunk of these talented staffers
here on the podium are working on it now, because some of the
stuff is outrageous, just literally outrageous.
Dr. Turner, your thoughts, lessons learned?
Dr. Turner. Thank you for the question, Senator. I agree
that there are two sides to nearly everything, and when we
think about Medicare Advantage, there are some advantages. The
flexibility is encouraging. The additional burden of prior
authorization can be a problem.
But when we think about innovation, that allows us to
consider prehabilitation. What are the elements of that that
can help patients do better with chronic conditions before
their surgical procedures? We have a geriatric surgery program
that allows us to think about all of the elements that can be
incorporated to enhance the care of the older patient with
chronic conditions. What are the elements that can be
integrated into that so that their outcomes are better, so
there is minimal readmission to the hospital, minimal
recidivism, incorporating all of the members of the health-care
team and recognizing that there is a complexity to the care of
the chronic conditions of our patients that requires a holistic
approach to the patient, meeting them where they are and making
sure that they have the best outcome in an evidence-based
fashion?
The Chairman. Great. We will wrap up with you, Ms.
Matthews. I am over my time, but----
Ms. Matthews. Thank you. The only thing I would add would
be----
The Chairman. We want to be partial to people in the
Northwest.
Ms. Matthews [continuing]. Just engaging beneficiaries in
their plan of care. I think there is a lot of flexibility in
continuing to support those and both the alternative payment
models as well as Medicare Advantage programs. Thank you.
The Chairman. Thank you.
Senator Crapo?
Senator Crapo. Thank you, Mr. Chairman.
This will be a question for Dr. Furr and Dr. Turner.
Seniors with chronic conditions can face severe access
barriers, particularly for prescription medications. The Better
Act, which our committee advanced unanimously this year, would
help to bridge affordability gaps by dragging down out-of-
pocket costs for a wide range of chronic disease treatments.
That said, clinicians and patients report record-high
growth in the use of prior authorization, step therapy, and
other policies that risk imposing costly burdens on providers
and impeding care quality for patients. Recent studies have
shown a dramatic increase in the use of these restrictions,
which clinicians often cite as most pervasive in the context of
medicines.
Regulations finalized earlier this year aim to streamline
prior authorization timelines and processes for numerous
services, but the complete exclusion of both physician-
administered and pharmacy-dispensed prescription drugs seems
likely to limit the effects of the final rule.
Dr. Furr and Dr. Turner, how do prior authorization and
step therapy affect physicians' ability to address patient
needs, and what steps should policymakers take to improve these
processes?
Dr. Furr. The realization of how prior authorization
started out was that it was for high-cost things, such as a PET
scan or something like that. But now this has been ratcheted
down. First it was procedures. Then it was things like CAT
scans, and now it has gone down to drugs. And the first strange
thing is, when I have a patient who is controlled with their
diabetes or hypertension, we do not need to be changing their
drugs. But yet, if they move to another plan or the plan
changes their formulary, they are required to change their
plan.
Just to give you an example, the other day I had a diabetic
who came in. I had a better diabetic drug for him that he
needed, but he said, ``I want this drug, which has more side
effects, because I can get it for zero copay for a 90-day
supply.'' It is a diabetic drug, but not a better drug, and not
the best drug for him. But he chose that drug, because he did
not want to pay a little bit more.
And just out-of-pocket costs are a huge issue. Our patients
are having to decide between getting drugs and getting food.
And as I mentioned the patient earlier, she was on chronic care
management for 2 years, the lady with the foot. She stopped
doing chronic care management because of the $13 to $15 copay
per month, and she was no longer doing that.
Senator Crapo. Thank you.
Dr. Turner?
Dr. Turner. Thank you for the question. There is no
question that prior authorization can create a roadblock for
patients to get the evidence-based care that they need, and we
are concerned about the onerous burden that it also places on
the physicians, and it can delay access to care. So, one of the
significant concerns is that prior authorization, which adds a
tremendous administrative burden, requires lots of back and
forth between the physician's office trying to get approval for
what we know is the right thing to do for the patient.
The patient's care is delayed, and ultimately our goal is
to provide timely and evidence-based high-quality care. So, if
prior authorization creates these unreasonable burdens for the
physician and the patient, it can be incredibly complex to
deliver the care that we know that they deserve and they need.
So we would agree that anything that smooths that process,
that allows the evidence base to be an opportunity to provide
the care that we know that they need, an electronic interface
that minimizes the amount of time that physicians' offices have
to spend on the phone, that is time they are preparing for and
seeing the next patient.
It often adds to the expense, because their practices must
hire additional people whose entire job it is to stay on the
phone, trying to get the care approved for their patients.
Senator Crapo. Well, thank you.
And this question will be for you, Ms. Matthews. For many
Idahoans, especially in rural communities, small physician
practices provide a crucial lifeline for health-care services,
from medical imaging to chronic disease treatment.
Unfortunately, these providers often lack an accessible avenue
to participate in Medicare's value-based care programs. MIPS in
particular demands dozens of hours of administrative tasks for
every participating clinician. Low Medicare patient volumes
also make MIPS unworkable for many rural clinicians. According
to MedPAC, roughly 460,000 remain ineligible. How could CMS or
Congress help to promote participation by small rural practices
in MIPS or AAPMs?
Ms. Matthews. Thank you for the question, Senator. Our ACO
certainly provides support and resources to critical access in
rural communities. We appreciate the opportunity that we think
highly coordinated care is very likely in rural communities
because everyone knows each other, and they have a little bit
more opportunity to communicate among the health-care
providers.
I think that stability in the program is critical to ensure
that we are sending the message that this is a long-term
commitment to the investments that it takes. It is complex,
change is hard, and having a financial payment model that
supports the financial methodologies in rural communities, many
of which are based on cost-based reimbursement versus the
typical fee-for-service payment, is essential.
So, it requires a little special attention for the rural
communities. But in our several years of engaging with Critical
Access Hospitals in smaller communities, we have felt that they
have done an incredible job and are very committed to highly
coordinated care.
I think I would just leave you with this, Senator Crapo. I
think that value-based care is a dimmer switch and not a light
switch, and I think as we get going, we need to continue to
turn up the light volume on these models, and really crack the
code on how to best support critical access in rural
communities.
Senator Crapo. Thank you.
The Chairman. Senator Stabenow?
Senator Stabenow. Well, thank you so much, Mr. Chairman,
and to you and our ranking member for all of your efforts.
We have been talking about these issues for a long time,
and the importance of coordination, the importance of getting
the right incentives in place, and value-based care. I remember
all the discussions in the Affordable Care Act, talking about
ACOs and everything. We are making steps, but we certainly have
a lot more to do, as all of you are showing us, and thank you
for your testimony today. I really appreciate the Bipartisan
Working Group on Physician Payment Reform that we put together:
Senator Thune and I, Senators Cortez Masto, Blackburn, Warner,
and Barrasso. And so hopefully, working with all of you, we can
make some further steps here--obviously in the right direction.
I do want to also stress though--because we talk about
Medicare Advantage when we talk about traditional Medicare--
Medicare Advantage plans do get paid more, and so one of the
issues is, I mean, why is that happening versus traditional
Medicare? I understand the flexibilities, but we built this in
when we were doing--it has been there a long time--the
Affordable Care Act and so on. So that is really a question. If
they can do more but they are paid more, what does that say
about what we should be doing here overall?
I also just wanted to mention one bill that Senator
Marshall and I have. There are so many pieces of how we
coordinate care and comprehensive care and deal with all the
factors, all the social determinants, all the factors for
people, one being food, right? Food is medicine, and Senator
Marshall and I have a bill to authorize medically tailored
meals under Medicare, which is important if we are talking
about the health of people. Eating healthy and having access to
the capacity to do that is also very, very important.
So, we have a lot to do in this area, and, Dr. Turner, I
wanted to ask you a question about the Physician Fee Schedule.
I mean, obviously there are a lot of challenges here that we
are talking about. But when we talk about it from a specialist
standpoint, it is very important that we are looking at the
front end. But from a specialist standpoint, you have spoken
about the fact that support to some specialists has caused cuts
to other specialists due to the conversion factor.
You have talked about this already. But could you talk more
about changes to the current payment system that would support
all physicians? Obviously, primary care physicians are
incredibly important; so are specialists. And so, what would
you recommend?
Dr. Turner. Thank you for that question, Senator. Clearly,
we are all trying to provide great care for our patients. Our
primary care colleagues, surgeons, all specialists are trying
to provide the best care for patients. So it is incredibly
unhelpful to have the budget-neutrality trigger set so low that
when an appropriate enhancement to one area comes about, it
requires that some other area that may have nothing to do with
the evidence base is cut.
And as we focus on value, on improvement, on evidence-based
care, it really does not enhance patient care when we think
about it that way. So we would favor raising the trigger for
budget neutrality to the point that modest improvements and
modest enhancements do not necessarily trigger that sort of
intervention that requires some other specialty in an unrelated
fashion to lose.
We would like to think of it as a win-win, and when we
focus again on the value-based, on the evidence-based, we know
for example, with our geriatric surgery verification program,
that the care of the older patient is more complex, and it does
require integration and a holistic approach that meets the
patient with all of their comorbid factors, and allows us to
provide better-quality surgical care in the continuum of care
that enhances across the board.
And so, we would favor all of us benefiting by the rising
tide that raises all boats, so that we can enhance the care
that we are providing for the complex older patient who does
have more of the comorbidities and requires a more complex
approach.
Senator Stabenow. Thank you.
And, Mr. Chairman and Ranking Member, it seems to me the
budget-neutrality requirement--I understand what happened, why
that happened. But it does not make sense to me when we are in
the context of services for people, that in order to
incentivize certain services, we have to cut other services.
That does not make sense to me, and so I hope we are going to
really, really focus on that.
And then just very quickly, Dr. Furr, could you talk more
about the alternative payment models as a way to expand quality
for Medicare beneficiaries? You have talked about this, but
could you speak a little bit more about that?
Dr. Furr. I think for family physicians, and particularly
for rural family physicians in an underserved area, I think
there are a couple of things. One, we found out in the ones we
did before, that we need more time for those models to truly
work. Often, those are set up for 3 to 5 years, and that is not
enough time to at least show the cost savings and the
difference they can make.
Two, because so many of our practices are financially in
such a tough situation, there have got to be some up-front
payments. You cannot, if you are just barely making a living,
afford to invest in quality that you might get later on. So,
there's got to be some prospective payments that go along with
it. But the time and the up-front payment are the two biggest
things, and then of course the training that would go along
with that.
Senator Stabenow. Thank you very much, Mr. Chairman.
The Chairman. Thank you, Senator Stabenow. And I know that
you and Senator Thune are going to do good work with our
colleagues working on this effort to look at the payment issue.
Senator Grassley?
Senator Grassley. My first discussion will be with Dr. Furr
and Ms. Matthews. I frequently hear from Iowans about poor
access to health-care services, especially in rural areas. In
many States, pharmacists, audiologists, and more are licensed
and trained to perform certain medical services that Medicare
does not pay for.
Example: right now pharmacists cannot get paid under
Medicare Part B rules for providing wellness screenings,
immunization, or diabetes management. I support modernizing
Federal rules. Should modernizing Federal rules to match
licensing and training laws in the various States be a part of
strengthening and improving health-care outcomes for patients
with chronic conditions?
Dr. Furr. Thank you, Senator. And I know you are concerned
about rural areas and the importance of the geographic index
also, and that we are protected there. I think that the problem
in the rural areas is also, everybody is overworked, and my
pharmacists are doing everything they can to fill their
prescriptions. I do not know how they could even possibly
consider doing wellness visits if they had that time to do
that. But at this time, I mean, they are trying to do that and
do immunizations. So we are all overworked, and I do not know
how they could actually do that, personally.
Ms. Matthews. Thank you for the question, Senator. I would
just share that in the Advanced Alternative Payment Models,
that we have made investments, including in the rural
communities, to help support pharmacists' engagement with the
patients and the providers to help support that kind of work.
Those are the kinds of things that ACOs do without a
billing code, because they are responsible for the total cost
of care. So, wrapping their services around, the ACOs are
making investments to help bring additional access to these
communities. That is inherently baked into the models.
Senator Grassley. Dr. Furr and Dr. Navathe, I have
championed efforts to ensure Iowa physicians, and other rural
States as well, get paid fairly for health-care services.
Iowans pay the same amount of money in Medicare as everyone
else. So the physicians labor market is not local but national,
especially with the expansion of telehealth.
Through the end of this year, Congress has established the
Geographic Practice Cost Index--GPCI for short--that floor, to
ensure that rural State physicians receive a fair
reimbursement.
So to you two, is CMS using the more current and complete
input data for GPCI to determine physicians' payments?
Dr. Furr. The AFP has strongly endorsed that and keeping
that floor. The one thing we have learned from COVID is,
suddenly all of my nurses decided they could be travel nurses
and make two or three times what they could in rural Alabama.
So now we are having to compete with New York and California
and Georgia and everywhere else. So, if they are going to come
back and practice with us, they want to get the same rates. So
the labor costs do not reflect, I think, what actually is going
on, and inflation is the same everywhere. Our costs are just as
great in our State as they are anywhere else--and in rural
Iowa.
Dr. Navathe. Thank you, Senator, for that question. I think
it is correct that the way the labor markets are functioning
now is different, as Dr. Furr has highlighted, and there are
needs to update the data to reflect that. There is granular
data that is collected by other agencies across the U.S.
Federal Government that could be used to update the input data,
for example, for the GPCI, which I agree is so important.
Senator Grassley. A follow-up for you, Dr. Furr. Currently,
36 States have statewide areas for GPCI and do not distinguish
more urban areas within the rural States. Should there be more
geographic areas to account for this?
Dr. Navathe. I certainly think it is important that we have
the right geographic designations for us to be able to
categorize the way that labor markets work and the way that
individuals actually do, for example, commute from rural areas
into urban areas or vice versa. And so, I think as you are
highlighting, reexamining, so we are constantly up to date on
how the markets function, is absolutely correct.
Senator Grassley. To you too, I am going to shorten up my
introduction by just asking this question. Is Medicare
Advantage an effective model to expand and improve chronic care
management services for seniors, while also lowering Medicare
spending?
Dr. Navathe. So, I believe there are two sides to this. I
think on one hand Medicare Advantage, which is more generously
paid--you know, MedPAC for example has put out estimates that
Medicare Advantage payment is up to 20 percent, maybe even more
than that, more generous than the traditional Medicare program.
Those dollars are at least in part being deployed to
support things like transportation, which the traditional
Medicare program does not have any support for, which I can say
from my own personal experience has been critical at times.
Very, very important to get beneficiaries who have
disabilities, for example, to their appointments. Otherwise, it
can be very hard.
On the flip side, because there is such generous
overpayment, if you will, to the Medicare Advantage side, it is
hard to know whether we are really getting true value from all
of those dollars. Certainly, there is some value in the
supplemental benefits that are helping chronic disease care.
But are we really getting value from it? And I would say we do
not know the answer to that, and that is a very challenging
question for us to wrestle with. One thing is for sure: there
is no symmetry across traditional Medicare and Medicare
Advantage. It is very hard for us to deliver the same kind of
tailored care in traditional Medicare unless we do alternative
payment models like ACO, as Ms. Matthews has highlighted.
The Chairman. The time of the gentleman has expired.
Senator Johnson?
Senator Johnson. Thank you, Mr. Chairman. First of all,
thank you for this hearing. This is another one that I think is
highlighting the fact that we have a horribly broken medical
financing system, and I would argue that Medicare has not
helped that. And I think the testimony today pretty well proves
that, because we are talking about the payment schedule, how it
has distorted medicine.
Now, I do not even want to call it a market, because I do
not think we have a market in medicine anymore. And you know, I
listened to Senator Stabenow--so we have been talking about
this for a long time. Dr. Turner talked about innovation. I
think somebody else talked about being flexible. Well,
government does not really drive innovation very well.
Government is not particularly flexible, and that is the
problem we are all dealing with here.
So I really want to focus--I am sure you probably do not
want to be practicing for 80 years, but I will take 40. I wish
I could talk to a physician who was practicing 80 years ago.
But what I want to focus on, Dr. Furr, is, forget the
medical innovations, which have been unbelievable, what we have
been able to do in the last number of decades. I mean, what we
can do in medicine is truly remarkable. But just the practice
of medicine--is it better today or worse? I mean, would you
like the medical innovations while being able to practice in
the 1980 model? Do you know what I am trying to get at here?
Dr. Furr. It is better. I mean, years ago, we had people
die out of just benign infections. We did not have penicillin--
--
Senator Johnson. But again, set aside the medical advances.
Just about the practice. I mean, you are a primary care
physician. We aren't able to track them very well. I mean, it
seems like the solution here is a more primary-care-physician
model, which we were closer to in the 1980s, probably more so
in the 1950s and 1960s.
Dr. Furr. Yes. I think, we have gotten better, like you
say, in advances and all, but as far as the stress of
practicing, it is much more difficult now than it has ever
been. Physicians used to work hard, but they spent their time
taking care of patients. They do not feel like they are
spending time taking care of patients now. They are doing prior
authorizations and other things to get those innovations there.
But there is not as much enjoyment of it.
Senator Johnson. And again, you are doing those
authorizations because you have to do it for Medicare and
Medicaid. You have to do it for insurance. You have to do it
for a third-party payer system; correct?
You did not have to do that when you were actually billing
the patient directly, when you had consumerism in health care,
when you had patients making the decision, do I want to go to
10 different specialists, or do I really want to rely on a
primary care physician, kind of let him work with me to make
those decisions?
Dr. Furr. That is correct.
Senator Johnson. Again, the point I am making is--and I
have said this, whether we are talking about our overly complex
tax system or our completely broken health-care financing
system--we are talking in this committee about putting a band-
aid on a dying patient, and I am trying to figure out, how do
we revive the patient? How do we bring back consumerism?
I often say that two areas of our economy that we are very,
just habitually dissatisfied with, are education and health
care. What they have in common is, we have largely driven the
benefits of free market competition out of both areas, and in
particular in medicine. How do we get it back?
Again, we are not going to do it through changing the fee
schedule--and, Ms. Matthews, I know you have your own little
solution here. It is not a solution. It is really not fixing
things. It is maybe improving things marginally.
But we are paying what, double what world health-care costs
are, and we are getting, in many cases, worse outcomes. I mean,
this is not working. We need a paradigm shift here. We need to
think outside the box. Again, I just do not think putting a
band-aid on the Medicare payment system is going to do it.
I mean, does anybody have any ideas or just want to comment
on that? Dr. Turner, you look like you want to say something.
Dr. Turner. Well, thank you for that question and for that
comment, Senator. I do think that the opportunity for those
closest--the subject matter experts--to propose innovative ways
to provide better care and bend the cost curve, as was the
plan, we think, under MIPS, is probably a good idea.
Bringing some of those good ideas that came forward through
the PTAC and allowing them to actually be tested and
implemented, I think, will get at part of what you are
describing. One size does not fit all. Making sure that we are
centering the patient and that we have the subject matter
experts propose what could really be the innovation that could
help to change the conversation, that is part of the solution.
And so, thinking about some of those great ideas--you know,
we had one other specialty that brought forth smart,
innovative, thoughtful solution-oriented ideas to the PTAC, and
then they were not able to really be tested and then ultimately
implemented.
So that would be one possible of the many solutions that
might address what you are describing. But I agree with you
entirely, that when we talk about access, and in a rural
community, we have surgeons who are out there trying to keep
their practice doors open who want to provide care, but the
administrative burden is so onerous that in those Critical
Access Hospitals, where they are the only game in town, so to
speak, we want them to be able to provide the care that they
want, but the administrative burden is overwhelming them.
Senator Johnson. And it is the administrative burden that
is just a self-inflicted wound, and that is why we need to stop
doing it. I would love to talk about the prospects of using AI
and more expert systems in medicine. I have seen that debate
over the decades, but we do not have time for that as well.
But thank you, Mr. Chairman.
The Chairman. I thank my colleague. We will be doing a lot
of discussion about AI in the days ahead.
Senator Warner--we don't really do ``gangs'' here in the
Senate Finance Committee, but to the extent we do task forces
and coalitions, Senator Warner was my partner back when we got
this off the ground with the late Johnny Isakson and Orrin
Hatch. That was a good crowd to run with, and we welcome you.
Go ahead, please, with your questions.
Senator Warner. Well, thank you, Mr. Chairman. You took the
words right out of my mouth. I was going to actually start with
a compliment to both you and the ranking member for holding
this hearing, and the fact is, I do not fundamentally disagree
with my friend from Wisconsin. But I do not know how, with the
complexity of medicine, we reinstall this back into consumer
choices, when a consumer is going to have to figure out which
advertisement to believe about which promised drug or which
promised therapy might work.
I do think one of the things that, again with our dear
friends Johnny Isakson and Orrin Hatch--the whole notion of the
CHRONIC Care Act was recognizing that some of these diseases
are not going to be solved with a pill, but are going to have
to be managed over a long period of time. And getting that
right--I would agree with Senator Johnson that what we have
done generally here--gosh, this is hard, so let's just bump up
reimbursement rates across the board--is not going to be the
answer as well.
I do think some of the work a lot of us on this committee
have done beyond chronic care on things like telehealth, on
things like getting folks to be able to get more services in
the home, some of the prevention activities--we still do not
have a scorecard system that scores prevention. And you know, I
think about diabetes and the good work some of us have tried to
do on diabetes, but that does not get recognized in any way, at
least in terms of the scorecard.
But I am going to start with Dr. Furr. You know, I have
spent a long, long time on advanced care planning. I have done
it on Alzheimer's, and I think we are the only industrial
nation in the world that has not had an adult conversation
about end of life, and has not been able to sort that out in
any meaningful way.
Let me be clear: I think everyone should have all the
medical options available to them, but we just do not have that
kind of conversation. So for years, we have been trying to get
a Medicare reimbursement on advanced care planning. You know,
this is a conversation we have all got to have. It is a hard
conversation.
We got it in, and yet it appears to me that the take-up
rate, particularly for family physicians, outside that annual
wellness visit, has not really worked that well. Do you have
any idea on how we--when Congress tries to set, or CMS tries to
set a reimbursement schedule, that we do not so overburden it
that the physicians and providers themselves just find this is
too much hassle to use?
Dr. Furr. You know, I think that was a great advancement,
and we do use it in our office. It means a lot to have that
time to spend with the patient and look at that, and make sure
they do have a plan going forward. I think the problem is,
because of all the other hassles in medicine right now with the
prior authorization and the other things, there are just so
many hours in the day, and there are just not enough hours to
do that. That does take time----
Senator Warner. But I've got to--I want to just interrupt.
I mean, if we are talking about end-of-life kind of issues or
last stage--I know we are not supposed to use the politically
incorrect ``end of life'' anymore. But who do you have to get
prior authorization from, God? [Laughter.]
Dr. Furr. No, no. We do that, but----
Senator Warner. That was just too easy. I couldn't let you
get by on that one.
Dr. Furr. Yes. I mean, we do that, and we utilize that code
very much. But again, there are only so many hours in the day,
and your staff is doing prior authorizations. They cannot get
CT scans covered. You are now forced to do all these other
things that you should not have to do----
Senator Warner. Right.
Dr. Furr [continuing]. So you cannot get to the really
important things, and I think this is the problem with medicine
right now. We do not have time to do the important things like
you are mentioning because we have all these other hassles that
really should not be there, and we cannot do them. So our time
is spent doing unnecessary things, rather than doing the
necessary things that you are mentioning.
Senator Warner. Well, while I am on it--and maybe this
would be for the panel because, I mentioned my mom had
Alzheimer's for 11 years, 9 years of which she did not speak.
My father and sister took care of her in a remarkable way.
Hardest thing; I could never have done that.
But for Alzheimer's, how do we even think about
reimbursement? We just, I think--FDA just recently approved
another drug, $3.5 billion, and I think drug therapy makes
enormous sense. But there is a whole portion of caring.
How do we get it right in terms of chronic illness like
Alzheimer's, to give the providers the right incentives to do
the appropriate care, whether in-home or elsewhere, without all
the hassles? Let me just go quickly down, recognizing I only
have 25 seconds, and Senator Whitehouse has been very, very
patient.
Dr. Navathe. So, I think that the short answer is, in the
fee-for-service program we have to pursue alternative payment
models that force the provider entity and the clinicians to
internalize, balancing the health benefit with the cost. If we
cannot get there, it is going to be very hard to actually steer
that forward.
Senator Warner. And that is hard to do. Very quickly,
because my time has expired. But, Dr. Furr, and the balance of
the panel.
Dr. Furr. And the key is, I think, for all those patients
to have a family physician who coordinates their care and knows
their patient, and spends time with them and their family and
knows their needs. I think that makes all the difference in the
world.
Senator Warner. Dr. Turner?
Dr. Turner. I think this is an opportunity to highlight the
expansion of facility-based scoring in MIPS, to think about the
type of collaborative shared accountability measures that would
work for Alzheimer's and work for other chronic conditions. So,
thinking about the holistic approach would address that
concern.
Senator Warner. Ms. Matthews?
Ms. Matthews. I might just add that there is a new dementia
care model that goes into effect July 1st of this year called
the GUIDE model, and that is one of the models in which to
provide additional support for Alzheimer's intervention-related
care, and I applaud the work for this very vulnerable
population.
Senator Warner. And how we make sure that providers
understand this and do not get intimidated by this new process
is important. I know we have another--again, I will not use the
disparaging ``gang,'' although my first gang was with Mike
Crapo on the Simpson-Bowles effort. But I do think the working
group we put together on this, I look forward to trying to
participate on.
The Chairman. Well, thank you, Senator Warner. Good job as
always. And before you got here, I went through the history of
the fact that in our original chronic care bill, as you will
recall, we had major telemedicine provisions. I remember the
day--I will never forget it--when Donald Trump's head of CMS
called me and asked me would it be okay if they used the
bipartisan product of the Finance Committee.
I should have called you up and said, ``Mark, hold a party
for us,'' because this was a product of the Finance Committee
that really laid the foundation for expanding telemedicine
during COVID. What I would like to work with you on, as you go
through this task force, is expanding telemedicine, and one of
the areas we ought to start with is interstate coverage.
Because this idea, in this age when we talk so much about tech
and AI and the like, that you cannot have patients treated when
they are, you know, 10 minutes away from another place----
Senator Warner. I do wonder who that CMS director got prior
authorization from. [Laughter.]
The Chairman. That director--when the chair of the
committee recovered from his shock and forgot to ask you to
hold a party, it was amazing, because it was talked about again
and again. Out of all the horrors of COVID--of which there are
so many--one of the things that made a difference was
telemedicine. I appreciate all the good work.
Okay. In the order of appearance it would be Senator
Blackburn, but I know Senator Whitehouse has been waiting.
Senator Lankford has been waiting.
Next in order of appearance will be Senator Blackburn.
Senator Blackburn. Thank you so much, Mr. Chairman. And I
am glad we are talking about telehealth, because I had the
legislation in the House. And I think we were all pleased when
it was picked up during COVID, and we really felt its worth and
its impact.
I have to tell you, in February I had the opportunity to
sit down with members of the HIMSS chapter in Nashville, and as
you all know, they are so focused on this bucket of issues that
we are discussing today. They are innovators; they are forward
thinkers.
In Nashville, our health-care industry generates, every
year, $100 billion in revenue, and it is responsible for over
500,000 jobs. So it is important, and any of my committee
members or the witnesses who want to come to Nashville, we will
be more than happy to set up meetings and show it off. We think
it is pretty important.
But one of the things that came up in this meeting with
health-care innovators and physicians was the issue of
consistent reimbursement policies, and the need for that
transparency for physicians and for patients and providers, and
also for investors, to give them confidence. Because many of
them are investing in this new innovation and new technologies,
which are going to end up yielding better outcomes.
And one of the things I have witnessed in my years in the
House and here in the Senate is, before we passed MACRA in
2015, we voted 17 times--17 times--to delay the pay cuts, and
this was under the Sustainable Growth Rate formula. So that
inconsistency, that amount of nerve-wracking, that uncertainty
around compliance and being able to meet your compliance--you
know, this is why I think it is so important that we look at
stable physician payments as we look at MACRA. And it has been
mentioned by others on the committee, we do have a working
group that some of us are going to be a part of to try to find
some answers to this.
I know it would make your life easier, and physicians are
always talking to me about trying to cope with operational
cost, and the pressure that is there. What we have seen in
rural Tennessee is the closure of some practices, some early
retirements, consolidations in these independent practices. And
what I have noticed is, it has detrimental delays in care
delivery, in wait times, and in access to affordable health
care.
So, a ``yes'' or ``no'' from you all, and we will just go
right down the list. I would like to know if you agree that the
cost of providing care in practices has increased over the
years, and if you agree that payment has kept pace with that
rising cost. So ``yes'' or ``no,'' has cost increased and has
payment kept pace?
Dr. Navathe. So, I do believe that costs have increased,
particularly when you factor in inflation, and so I think that
is absolutely correct.
Senator Blackburn. Okay.
Dr. Furr. Yes, to the first question, no to the second.
Senator Blackburn. Okay.
Dr. Turner. Costs have absolutely increased, and the
payment has not kept up with that. The inflation has been
problematic and the reason.
Senator Blackburn. Okay.
Ms. Matthews. I have the same answer. Costs increased.
Senator Blackburn. Then you all are right in line with
Tennessee physicians.
I want to talk about MIPS. I know several others have
talked about this. Dr. Navathe, talk to me about your
experience with MIPS and the administrative burden that is
there with that, and then what you see should be the changes.
What lessons should we learn? What should we keep, and what
should we toss?
Dr. Navathe. So I think the experience that my colleagues
have had under MIPS has been one that, frankly, has not been
that effective. So you have rightfully pointed out the
operational administrative burden that comes along with that
type of reporting. And it is unclear that reporting the
measures that we are reporting on are actually in keeping with
what beneficiaries really care about. I think that is a
fundamental disconnect. I think approaches like MIPS, in
general, have been shown not to be very effective in improving
care.
One of the challenges getting toward what we can do is--
MIPS kind of presents this choose-your-own-adventure type of
approach, and that is kind of weird actually, right, in terms
of trying to get a standardized set of data. I think it is very
challenging to improve MIPS, to make marginal changes to it and
actually get to where we need to go.
I think most likely we need to reimagine it completely, and
potentially replace it.
Senator Blackburn. So you would say toss it and start over?
Dr. Navathe. I would say replace it; that is correct.
Senator Blackburn. Okay; that is great.
Dr. Turner, I have a question for you I will submit, and it
has to do with overestimating spending and the payment policies
of the Physician Fee Schedule. So let me do that, because we
need to talk about the forecast error adjustments.
But, Mr. Chairman, thank you.
The Chairman. I thank my colleague, and I am glad she is on
the working group that is going to tackle these issues.
Next is Senator Whitehouse.
Senator Whitehouse. Thanks very much.
I would like to talk about two pieces of legislation. One
is a primary care bill that Senator Cassidy and I are working
on, whose discussion draft is out and which provides for hybrid
payments for primary care, and creates a physician payment
expert panel to try to better organize the payment model.
Dr. Navathe, I believe you are familiar with that
discussion draft?
Dr. Navathe. Yes, Senator, I am.
Senator Whitehouse. And it seems to align quite well with
your testimony before the committee today.
Dr. Navathe. Yes, sir. I think I would highlight two
points. One, the hybrid payment model that is in the discussion
draft is part of the Physician Fee Schedule. So it is not a
single-model alternative payment model. I think that is very
important to scalability.
The second point I would highlight is, there is a provision
for establishment of an advisory committee that will not
reduplicate the important work that the RUC does, but really
add to it so CMS has appropriate tools to manage the fee
schedule.
Senator Whitehouse. And the resulting benefit if those were
to become law would be----
Dr. Navathe. So really, two things. One, as we have talked
about--Senator Wyden very nicely characterized how chronic care
is such an important challenge. I think for primary care
physicians, a hybrid payment could catalyze a completely new
payment model at scale across the Nation.
We have talked a lot about stability here. You know, one of
the challenges around alternative payment models has been that
they have tended to change maybe every 5 years. It is very hard
for practices to invest in something if the rules of the game
are going to change 5 years later.
So the stability of what you have proposed in that
discussion draft, I think, is fundamentally critical to
actually getting better chronic disease care in the long run.
That will necessitate adaptations to the fee schedule, and so
the advisory committee really then comes in to fill in the
additional needs there.
Senator Whitehouse. Thank you. And let me just take a
moment to thank Senator Cassidy for his work with me on that
legislation.
The other bill is the Value in Health Care Act that I am
doing with Senator Barrasso. Other members on this committee
who are cosponsors include Senators Tillis, Cassidy, Thune, and
Blackburn.
Among other things it, would extend the 5-percent incentive
payment. It will help address the cost issues that ACOs face
when they are trying to pay their way through a very expensive
and difficult transition to treatment that is consistent with
the new payment model. And I would like to ask Ms. Matthews how
those incentives relate to the ability of ACOs to improve and
invest in patient care?
Ms. Matthews. Thank you, Senator, for the question. First,
I want to thank the committee for supporting the advanced
alternative payment bonuses. They are really critical at
engaging the physician in ACOs, and encouraging stability and
engagement.
Second, I would say that those bonuses go directly to the
providers, and that allows them to make investments in care
coordination and technology.
I am reminded there was a previous question around MIPS and
reporting. We support independent physicians, and those
incentives were paramount for engaging in AAPMs and really
promoting the continuation of independent practice by helping
support the investments that are critical for this
transformation from fee-for-service to value.
And then also--just to make a quick comment for you,
Senator Whitehouse, on the work under the hybrid--under some of
these ACO models, we are testing and paying capitation to
primary care. I used to say that one of the reasons I knew that
we were being successful in value-based care was listening to
and watching my physicians take their phone calls to manage
their patients.
They were so engaged in their total care, and they were
aligned around all things for their patients. So at 5, if they
got a call, they said, ``Come on down, let me see you,'' and
they were not going to the ER, as an example. They were
completely accountable, and the hybrid capitation helps with
that.
Senator Whitehouse. It is the outcome we want.
Ms. Matthews. Yes.
Senator Whitehouse. My time is about to expire, so let me
ask a last question for any of you who choose to comment on it
for the record. So an answer in writing, so we are not
burdening the time of the committee further.
We are working on a bill to, in a nutshell, require prior
authorization by CMS before any prior authorizations can be
applied by insurance companies to providers. They would have to
really show that there is a medical justification for the prior
authorization, and we would be focusing on applying that to
providers that were under an alternative payment model,
incentivized value-based model, and had shown that they
succeeded.
So presumably, they have no interest in running up bills
that would raise their costs and diminish their payment at the
end of the day. It does not make sense to apply a prior
authorization to a provider who is successfully engaged in an
at-risk, value-based practice. And so, we are looking at trying
to get rid of that, just get rid of it, and/or make them at
least come in first to CMS and say, ``You have to authorize me
requiring prior authorization, otherwise, I cannot do it at
all,'' and put that kind of a check on the misuse of prior
authorization.
If you have any thoughts about that, I would be grateful to
hear. I do think that it probably needs to focus on those who
are participating in advanced payment models and have skin in
the game, and have shown themselves to be successful. But I
would be interested in your thoughts, and I thank the chairman.
The Chairman. I thank my colleague. And for those who are
guests of the Finance Committee, Senator Whitehouse has spent
an enormous amount of time over the years on these primary care
issues. I have enjoyed working with him, and we look forward to
doing a lot more in the days ahead.
Senator Lankford is next.
Senator Lankford. Mr. Chairman, thank you. Thank you all
for spending your time here. A lot of things you could be doing
today. Thanks for being here and being a part of it.
We have all talked about the Physician Fee Schedule and the
struggle with that. That is frustrating for all of us, but
especially for physicians on it. I am one of the folks who
thinks we need to incentivize more doctors coming into the
process, rather than the next generation of folks thinking, ``I
do not want to do that, to be able to deal with the hassle of
that all the time.''
I would like for more folks to be able to come into the
process with several things we have kind of highlighted, and I
am not going to go through them as well. But the Critical
Access Hospital piece has been a challenge in my State, a State
that is split evenly rural and urban, and trying to be able to
manage that.
We have a bill, the Rural Hospital Closure Relief Act,
which gives some States some flexibilities. We have not talked
about
physician-owned hospitals, but that continues to be an issue
long-term: allowing physician-owned hospitals to continue to be
able to grow and to be able to take care of their patients.
I do want to talk a little bit about this prior
authorization. Dr. Furr, you have mentioned this a couple of
times as well. We have hospitals in my State that are just no
longer taking Medicare Advantage because of the prior
authorization issue on that. How does that get resolved? What
do you see as the solution to that?
Dr. Furr. And you are seeing physicians refusing to take
them, along with that, and it is a huge hassle. It takes a huge
amount of time. I think physicians need to be able to practice.
And again, when it is for big-budget items, I do not have a
problem with prior authorization, but when it comes to basic
drugs and basic things we need to do----
Just to give you a perfect example, if I have a patient
with an acute abdomen, it is easier to send them to the
emergency room--because they do not have to get a prior
authorization to do their CT scan--than for me to do it in my
office because it could take me a day or 2 to get that done.
So the prior authorizations, which are meant to control
costs, in many ways are actually increasing cost. And sometimes
the best drug might be a more expensive drug, but it is better
for the patient because it might lower their cardiovascular
risk, along with taking care of their diabetes or their
hypertension.
So those are all issues with prior authorization that keep
us from providing the best care that we can, and actually drive
up cost.
Senator Lankford. Okay. That is helpful to be able to get
context.
Ms. Matthews, you have talked a lot about the value-based
care, and some of the issues and the innovations that are
there. With 34 ACOs that are operating in Oklahoma, they have
saved $50 million, the best we can guess, the last couple of
years on it.
But I do want to give an example of this. We have one ACO
in Oklahoma that saved almost $9 million just in 2022. But they
missed the minimum savings rate by .17 percent. So here is the
challenge. What recommendations would you make on making
changes to the Shared Savings Plan to make sure that we have
more ACOs and that we do not actually frustrate entities that
are trying to get into this?
Ms. Matthews. I think building in the stability for the
long-term commitment to the AAPM, and engaging with CMS and
Congress on the importance of accuracy around benchmarking. You
know we had, through COVID, very, very different utilization
patterns, and those were realized very differently depending on
the State that you lived in as well.
And so, when we look at creating national and regional
benchmarks, there is some implication in the benchmarks from
COVID, just because of the utilization and historical
expenditures. So that certainly created some of those
methodologies.
The other thing is, we are learning so much, and so I
applaud the work that we are doing to take a look at what we
called the lessons learned in the models, and how do we
continue to iterate on those to be more successful for the
models in the future.
Senator Lankford. Okay.
I want to ask about something that we have not talked a lot
about today, and that is hospice care and how it interacts with
Medicare, just for the care of patients and individuals. I know
that it is set up typically for the last 6 months of life; not
always. We have a rather famous example of that in President
Carter, who I think has been in hospice care 14 months at this
point or approaching that. The design of it is to be able to
help with end of life, to be able to help through not only
families, to increase some benefits in some areas and decrease
them in others.
I walked through this recently. I will not go through all
the story on this with my own mom, who was a Parkinson's
patient for years. She passed away a year and a half ago. But
some physicians toward the end would talk to me about hospice
care and were walking through that as a son and a mom and a
physician.
I was advised, well, you know what? If hospice care is not
working out and you want to come see a specialist or whatever
it may be, you can just drop it, go back into Medicare, be in
Medicare for a while, then drop that, go back into hospice
care. I suddenly understood there is loophole in the system
that is literally being built in, and it is being exploited. I
personally watched firsthand in that, other issues that are
like that.
What would you recommend on changes in hospice care and
ways that we can help families in those moments, whether that
be in the value of it or what needs to be done do be able to
improve hospice? I am open to anyone who wants to contribute.
Dr. Navathe. I am happy to contribute. Thank you so much
for the question.
So I think a couple of things to highlight here. I think
first, one thing that is actually quite interesting is another
Federal program. The Veterans Health Administration provides a
benefit to veterans where, when they opt into hospice, they
actually do not have to forego regular life-extending care.
And I believe the latest estimate from the VA is that that
is a cost-saving program for them still, because it allows
palliative care clinicians to come and educate patients and
align care with their preferences, without what might seem to a
family or a patient as a somewhat draconian thing, which is, I
have to walk away from opportunities for other care. So that is
one thing to contemplate.
The other thing is, our hospice payment system also has
opportunities for improvement. There are some peculiar
incentives, in that we have caps on sort of duration of care
that hospices can give. Those create distortions. So it is
unclear that those caps are actually doing well for our
beneficiaries, and that is something else that could be
contemplated.
Senator Lankford. Thank you for that.
The Chairman. And the time of my colleague has expired.
Senator Warren?
Senator Warren. Thank you, Mr. Chairman.
Physicians' practices are increasingly being gobbled up by
corporations and Wall Street. Today, nearly three out of four
physicians work for a hospital or a corporate owner rather than
for themselves. In between 2012 and 2021, private-equity
buyouts of physician groups increased over 500 percent. And
it's not just private equity. Insurance companies like
UnitedHealth, giant retailers like Amazon, and investor-backed
groups have all dramatically expanded their control over
physician practices.
Here is one to look at. The total capital raised for
private investment in primary care alone increased by over
1,000-fold in just a decade. It went from $15 million--with an
``m''--in 2010 to $16 billion--with a ``b''--in 2021. This is
an alarming trend, and corporate consolidation of health care
can increase costs, it can lower the quality of care, and it
can accelerate physician burnout. But to reverse the trend, we
need first to understand what is motivating physicians to sell
their practices.
So, Dr. Furr, you are the president of the American Academy
of Family Physicians. Why do you think independent private
physicians are increasingly willing to sell their practices and
work for a big corporation?
Dr. Furr. Thank you, Senator, and I do not think it is
their first choice. Physicians tend to be independent-minded,
and when I first had a practice 40 years ago, most of us did go
into practice for ourselves.
The cost of practice has just become overwhelming. It
started with the emergence of the EHRs and the amount of cost
that went into that, and even though there was some
reimbursement for that, it was still a cost expense. Now the
cost of running your practice--what you have to pay for your
staff to have good staff, what you have to pay to do all the
prior authorizations and all the other hassles that go along
with that--the cost has just become enormous. And then, you
have something like the Change Healthcare attack, where you
suddenly do not get payments for 6 weeks and you are having to
take money out of your bank account to fund your practice. And
of course, if you are an independent physician, what happens
is, you pay everybody else, and the way you make up the
difference is, you do not take any pay.
Senator Warren. So you are telling me it is about the
economics of this?
Dr. Furr. Yes.
Senator Warren. And----
Dr. Furr. And the complexity of the system.
Senator Warren. And the complexity of the system. But that
is a part of the economics too, right?
Dr. Furr. Yes, it is.
Senator Warren. So let's take a look at the Medicare part
of this. Seniors, people with disabilities, rely on Medicare
Part B to cover their doctor's office visits and other
physician services. But Medicare payment rates, for primary
care physicians in particular, are basically too low to cover
their costs.
Medicare payment rates are set through what is known as the
Physician Fee Schedule, which determines how much Medicare will
reimburse a doctor for, say providing a routine check-up or
performing knee surgery. The payment rate is determined in
large part by the ``relative value assigned to it.''
A secretive committee run by the American Medical
Association has played an out-sized role in recommending the
relative values of physician services, and it has
overwhelmingly recommended that specialty services are worth a
whole lot more than primary care.
So, Dr. Navathe, can you explain why this committee over-
values specialty services?
Dr. Navathe. The methodology the committee uses very much
heavily values inputs like time, differentiated skill,
intensity--and these are easier to estimate for concrete things
like doing a surgical procedure, more so than they are for a
cognitive activity like diagnosing a patient effectively.
Senator Warren. So that is interesting. So let me ask: the
committee itself for the AMA, is it dominated by specialists?
Dr. Navathe. I believe there is an overrepresentation of
specialists relative to primary care, yes.
Senator Warren. Well, the reason I ask about this is, many
organizations, including the National Academy of Medicine and
the GAO, have called for changes in structure, so that primary
care is adequately paid. I strongly agree with them, and so I
think this is a part of what we have to understand about why
physicians feel forced to sell their practices.
There is another reason, though, why primary care
physicians have been motivated to sell their practices, and it
is the growing administrative burdens that you talked about
earlier, Dr. Furr, where doctors are spending more time doing
paperwork and less time with patients, which has widened the
gap between primary care physicians and their Medicare patients
even more.
Now, we know that the number of independent physicians who
have chosen to sell their practices appears to have
significantly grown over the last 10 to 15 years. Dr. Furr,
what changed during that time period to make the administrative
burden so much worse?
Dr. Furr. As I mentioned earlier, one of the things is,
more of them are covered by Medicare Advantage plans, which
have a lot of prior authorization, even on drugs now, that we
used to not have to deal with----
Senator Warren. Okay. So prior authorization is part of it.
Anything more?
Dr. Furr. The prior authorizations, and then just even
admissions to the hospital, things like that. All of those have
to be prior authorized procedures--all of those things. And
then the complexity of coding continues to get more and more
complex, and so then you have to do additional codes, and if
you do not do one little thing, and you code it wrong, that
code gets kicked out.
Then your claim gets rejected, and you have to resubmit
again, and there is just all that continual cost of doing that.
Senator Warren. So, I had a doctor tell me last week, after
we had done a hearing, that it is now the case that you cannot
just do an animal bite as your code, that there is a different
code for a turtle bite, as opposed to a fish bite. And so, we
want to watch out for this going forward, right?
Look, my view is, we should reward high-quality care rather
than high-volume care. But to do this requires significant up-
front investments that existing payment rates for primary care
just do not cover. And I think this has created the perfect
environment for corporate investors to swoop in.
There are things we can do to make physicians less
vulnerable to corporate vultures. As this committee continues
to work on physician payment reform, it is critical that we
root out the conflicts of interest that assign more value to
specialist services than to primary care. But we must also
ensure that the transition to value-based care does not lead to
further consolidation and further corporatization.
Thank you, Mr. Chairman.
The Chairman. I thank my colleague for her remarks. Those
were very important issues. I am not going to get into all of
the animal species, but my colleague is making the key point,
which is, we have to stop the financial vultures. And one of
the things that I am going to do--and I look forward to working
with my colleague on the whole suite of issues she just went
into--is, we touched on it earlier, the $6 billion that goes
for marketing.
I think that money can be spent in a better place, and we
are going to be talking to these nice four witnesses, and our
working group, and the like, about whether we can find some
common ground on putting that money, as Senator Warren is
talking about, into patient care. Because right now, as she
just described, patients and taxpayers--because it is two sides
of one coin--are getting fleeced. So let me just offer a quick
comment, and we will be out the door.
At one point, I think one of our colleagues talked about,
well, is this going to be another band-aid on Medicare? No.
What we want to do is fundamental change. When we recognize
that Medicare has changed, that it is not just about a broken
ankle, it is about chronic care--and, Senator Warren, I think
you might not have been able to be here because it has been
such a busy day.
Dr. Navathe talked about 50 interactions for a particular
patient with all of these different kinds of people. And what
you are talking about is primary care and particularly focusing
on these chronic illnesses and patients rather than just
propping up the vultures. And what we began in 2018, when
Chairman Hatch was in charge of this committee, was CHRONIC
Care 1.0.
We have gotten good advice today about how to start closing
the gap between Medicare Advantage and traditional Medicare.
That is urgent business. And we certainly heard a lot about
reducing administrative hassles and letting doctors put their
time into patients rather than filling out forms and going
through all these bureaucratic hoops.
So this has been a good hearing of the Finance Committee.
This is about the future of Medicare. We started it in this
committee, and this is now moving to CHRONIC Care 2.0, and
getting more to patients and protecting taxpayers and not all
these rip-offs that Senator Warren just appropriately
described.
With that, the committee is adjourned.
[Whereupon, at 11:52 a.m., the hearing was concluded.]
A P P E N D I X
Additional Material Submitted for the Record
----------
Prepared Statement of Hon. Mike Crapo,
a U.S. Senator From Idaho
Across the country, more than 60 million Americans rely on Medicare
to meet their health-care needs. Over the next decade, this population
will grow by more than 20 percent. Medicare's coverage and payment
policies play a dominant role in setting benchmarks and baseline rules
of the road not just for the program itself, but also for countless
other payers, affecting hundreds of millions of working families.
In short, ensuring a resilient and robust Medicare program has
become more vital than ever. Unfortunately, our current policies seem
poised to fall short of that goal.
Today's hearing highlights the urgency of advancing durable
clinician payment reforms--both for front-line medical providers and,
more importantly, for patients. In the absence of proactive policy
changes, tens of millions of seniors will suffer the consequences. The
risks of inaction range from surges in wait times and delays--including
for critical care--to clinician office closures and cutbacks in
provider participation. Our committee has an obligation to strengthen
the Medicare program and avert these unacceptable outcomes.
A successful legislative initiative must reckon with a range of
challenges under the current paradigm, which has served to devalue and
distort payments for vital services, as well as to exacerbate
administrative burdens. In inflation-adjusted terms, Medicare Physician
Fee Schedule payments have declined by more than 25 percent over the
past 2 decades, even as clinicians continue to face skyrocketing costs
for overhead, equipment, supplies, and staffing needs.
As the Medicare trustees cautioned last year, the colossal gap
between stagnant fees and steep inflation poses a dire threat to long-
term patient access. The current conversion factor update schedule
cannot sustain an effective--or even adequate--clinical workforce
moving forward.
For many specialists, recent regulatory changes have further
intensified these issues, as new billing codes and valuation shifts
have triggered drastic cuts under the program's budget-neutrality
rules. Based on inflexible cost-containment measures, a payment bump
for primary care prompts payment reductions for entirely unrelated
procedures and services, from brain surgery to advanced cancer care.
From 2014 to 2023, for instance, even before adjusting for
inflation, the fees for chemotherapy administration and IV infusions
declined. Under these conditions, it should come as no surprise that
many physicians have opted to sell their practices, join health
systems, or limit new Medicare patients. Structural fee schedule
reforms should shift away from the status quo, which forces clinicians
to vie for ever-
dwindling resources, and move toward models that promote and reward
team-based, patient-centered approaches.
Nine years ago, Congress took concerted action to repeal the
draconian Sustainable Growth Rate (SGR) system, which had threatened
cascades of dramatic cuts. In enacting the Medicare Access and CHIP
Reauthorization Act (MACRA), policymakers sought to stabilize the fee
schedule and incentivize value-based care.
In practice, these reforms have largely failed. The Merit-based
Incentive Payment System aimed to establish an accessible on-ramp to
participation in quality-driven alternative payment models, or APMs.
Instead, this system has buried clinicians in dozens of hours of
paperwork each year, all in exchange for potential, marginal payment
bumps, based on ambiguous metrics that lack meaningful value for
patients.
A number of primary-care-focused APMs have shown promise, but
countless specialties lack access to any clinically relevant models at
all. While the MACRA-
established committee to translate clinician-developed APM concepts
into concrete policy options has worked through dozens of viable
proposals, the Centers for Medicare and Medicaid Services (CMS) has
largely rejected these opportunities.
Reforms to advance value-based care thus demand a focus not just on
financial incentives, but also on structural improvements that ensure
meaningful options, informed by clinical experience and aligned with
patient needs. I look forward to building on this committee's
bipartisan work to bolster and modernize our clinician payment systems.
The program's current and future enrollees depend on it.
Thank you to our witnesses for being here today, and thank you, Mr.
Chairman.
______
Prepared Statement of Steven P. Furr, M.D., FAAFP,
President, American Academy of Family Physicians
Chairman Wyden, Ranking Member Crapo, and distinguished members of
the committee, thank you for the opportunity to testify today. My name
is Steven Furr, M.D., FAAFP, and I am a practicing family physician
from Jackson, AL. I am a cofounder of Family Medical Clinic of Jackson,
a rural health clinic, a member of the medical staff of a small rural
hospital, and medical director of the local nursing home. As the
President of the American Academy of Family Physicians (AAFP), I am
honored to be here today representing the more than 130,000 physician
and student members of the AAFP.
As a family medicine specialist who has cared for patients for more
than 35 years, I can speak firsthand about how fee-for-service payment
in traditional Medicare, including its underinvestment in primary care
and associated administrative burden, are impeding the delivery of
high-quality, patient-centered, comprehensive primary care, which
encompasses chronic care management (CCM).
Family physicians provide continuing and comprehensive medical
care, health maintenance and preventive services to patients across the
lifespan regardless of age, gender, or type of problem. Through
enduring partnerships, family physicians help patients prevent,
understand, and manage illness; navigate the health system; and set
health goals. The defining features of primary care, including
continuity, coordination, and comprehensiveness, mean family physicians
are particularly well-suited to serve as the focal point of care for
patients with chronic conditions.
Nearly 95 percent of adults 60 years and older have at least one
chronic condition, and nearly 80 percent have two or more.\1\ This is
only projected to get worse in the coming years as the number of adults
50 years and older with at least one chronic disease is estimated to
increase by almost 100 percent from 71.522 million in 2020 to 142.66
million by 2050.\2\ Effectively meeting the current and future needs of
our patients with chronic conditions requires our Nation to better
leverage primary care as the foundation of our health-care system.
However, our current fee-for-
service payment structure favors and incentivizes work that is done to
a patient, rather than done with and for them. We need doctors who care
for people, not doctors to deliver services.
---------------------------------------------------------------------------
\1\ National Council on Aging. Chronic Inequities: Measuring
Disease Cost Burden Among Older Adults in the U.S. A Health and
Retirement Study Analysis. Page 5, Figure 2. April 2022. Accessed
online at: https://ncoa.org/article/the-inequities-in-the-cost-of-
chronic-disease-why-it-matters-for-older-adults.
\2\ Ansah JP, Chiu CT. Projecting the chronic disease burden among
the adult population in the United States using a multi-state
population model. Front Public Health. 2023 January 13;10:1082183. doi:
10.3389/fpubh.2022.1082183. PMID: 36711415; PMCID: PMC9881650.
I'm seeing how our failure to invest in and uplift the true value
of primary care is impacting my patients every day. Our physician
workforce skews heavily toward non-primary care specialists, and we
have fewer primary care physicians relative to the population than in
other countries. This is having severe impacts on patient access. In a
recent comparison of primary care access across 10 peer countries, U.S.
adults were the least likely (43 percent) to have a longstanding
relationship with a primary care provider and a growing number of
adults have reported not having any usual source of care over the past
decade.\3\ At the same time, three-quarters of U.S. adults (73 percent)
say the health-care system is not meeting their needs.\4\ This data is
telling. People are losing their trusted relationship with a primary
care physician and, in turn, their trust in the health-care system.
---------------------------------------------------------------------------
\3\ Gumas ED, et al. ``Finger on the Pulse: The State of Primary
Care in the U.S. and Nine Other Countries,'' March 28, 2024. The
Commonwealth Fund. Accessed online at: https://
www.commonwealthfund.org/publications/issue-briefs/2024/mar/finger-on-
pulse-primary-care-us-nine-countries.
\4\ The Harris Poll, ``The Patient Experience: Perspectives on
Today's Healthcare.'' 2023. Accessed online at: https://www.aapa.org/
download/113513/'tmstv=1684243672.
Evidence continues to suggest this type of longitudinal
relationship that I and other primary care physicians foster with our
patients leads to better control of chronic conditions, fewer emergency
department visits and hospital stays, and improved health
outcomes.\5\, \6\ Unfortunately, traditional Medicare
underinvests in these trusted relationships with patients. Low primary
care payment rates in a system that rewards volume over value means
physicians are pressured to see as many patients as possible.
Meanwhile, overwhelming administrative burden takes time away from
delivering patient care and often requires physicians to spend hours
outside of the office doing documentation.
---------------------------------------------------------------------------
\5\ Jennifer Arnold, ``Fostering Long-Term Doctor-Patient
Relationships to Improve Outcomes,'' Duke Health, January 17, 2017.
\6\ Cabana MD, Jee SH. Does continuity of care improve patient
outcomes? J Fam Pract. 2004 December;53(12):974-80. PMID: 15581440.
These factors are leading current primary care physicians to leave
the field and, when combined with the burden of student loan debt,
dissuading medical students from pursuing primary care specialties like
family medicine. At a time when Americans have more chronic conditions
than ever, we should be making strides to embed primary care physicians
in every community. Instead, we've created a policy framework that is
actively driving prospective physicians away from primary care and
---------------------------------------------------------------------------
perpetuating nationwide workforce shortages.
Decades of systemic underinvestment in primary care and prevention
have led to poorer population health and a greater emphasis on rescue
medical care, rather than health care. We as a Nation have worried
about increased up-front spending and implemented policies that have
wrongly steered people away from high-value, low-cost services like
preventive screenings and primary care office visits. By failing to
invest more up-front dollars in primary care, we're paying an even
higher price. We're spending more than ever on health-care costs, both
as a Nation and as consumers, because we have sicker patients receiving
later diagnoses and utilizing expensive settings like the emergency
room and hospital as their ``usual source of care.''
Establishing a health-care system that prioritizes primary care
will, among many other things, require a meaningful overhaul of
physician payment that will take time. However, as a starting point, I
urge Congress to consider policies that work toward the following
objectives:
More appropriately valuing the work of primary care within
the Medicare Physician Fee Schedule, which is the framework for
many value-based payment arrangements;
Reforming budget neutrality requirements that unnecessarily
pit physician specialties against one another while undermining
CMS's ability to invest in all the services a patient may need;
Addressing existing financial barriers that dissuade
patients' utilization of chronic care management and other
primary care services by waiving cost sharing responsibilities;
and
Providing primary care physicians and practices with more
prospective, sustainable revenue streams that allow them to
tailor the care they deliver to their patient's needs.
Reforming Fee-for-Service to Better Value Primary Care
As noted in my introduction, access to longitudinal, coordinated
primary care--which family physicians like me provide every day--has
been shown to increase utilization of preventive care, improve outcomes
for patients with chronic conditions, and reduce costly emergency
visits, hospitalizations, and unnecessary specialty outpatient visits.
Yet the United States has continuously underinvested in primary care
with only 5 to 7 percent of total health-care spending going to primary
care.\7\
---------------------------------------------------------------------------
\7\ Jabbarpour Y, Greiner A, Jetty A, et al. Investing in Primary
Care: A State-Level Analysis. Patient-Centered Primary Care
Collaborative and the Robert Graham Center; July 2019.
Last month, the AAFP's Robert Graham Center, in collaboration with
the Milbank Memorial Fund and the Physicians Foundation, released the
Nation's second primary care scorecard, which reported that national
spending on primary care decreased from 6.2 percent in 2013 to 4.7
percent in 2021. Primary care spending decreased for all payers between
2019 and 2021 with Medicare being the most pronounced with a 15 percent
drop.\8\ While some of this decrease could be due to a drop in office
visits during the pandemic, it is a trend worth noting.
---------------------------------------------------------------------------
\8\ Jabbarpour Y, Jetty A, Byun H, Siddiqi A, Petterson S, Park J.
The Health of U.S. Primary Care: 2024 Scorecard Report--No One Can See
You Now. The Milbank Memorial Fund and The Physicians Foundation.
February 28, 2024.
The impact of this long-term underinvestment is evidenced in our
Nation's health. When we look at health outcomes across the world,
we're not doing well by almost any measure. Compared to other high-
income, peer nations, the U.S. has higher rates of obesity, diabetes,
and heart disease, and a larger share of the population with multiple
chronic conditions.\9\ A common theme across countries with better
health outcomes and lower health-care costs is that they invest more in
their primary care system with estimates placing primary care spending
between 12 and 17 percent of total health-care spending for these high-
performing nations.\10\
---------------------------------------------------------------------------
\9\ Turner A, Miller G, and Lowry E. ``High U.S. Health Care
Spending: Where Is It All Going?'', The Commonwealth Fund. Published
October 4, 2023. Available online at: https://www.
commonwealthfund.org/publications/issue-briefs/2023/oct/high-us-health-
care-spending-where-is-it-all-going.
\10\ Baillieu R, Kidd M, Phillips R, et al. The Primary Care Spend
Model: A systems approach to measuring investment in primary care. BMJ
Global Health 2019;4:e001601.
One of the major factors contributing to this underinvestment is
the relative undervaluation of primary care in fee-for-service (FFS),
the predominant payment model. In general, the Medicare Physician Fee
Schedule (MPFS) values procedural services delivered by other
specialists higher than it does office visits and other cognitive
services, which are most delivered by primary care physicians. Primary
care and other cognitive services have been passively devalued over
time as many new procedural codes with higher values have been
added.\11\
---------------------------------------------------------------------------
\11\ Linzer M, Bitton A, Tu SP, et al. The End of the 15-20 Minute
Primary Care Visit. J Gen Intern Med. 2015;30(11):1584-1586.
doi:10.1007/s11606-015-3341-3.
This devaluation has led to lower compensation for primary care
physicians who specialize in treating the whole person compared to our
specialist peers, despite the vital role we play in managing chronic
conditions and coordinating patient care across a large team and
despite the fact evidence has shown that primary care
office/outpatient evaluation and management (E/M) visits are more
complex and comprehensive than those delivered by other
specialties.\12\ This devaluation is not limited to Medicare. Many
other private and public payers peg their payment rates to the MPFS
rates or use the relative values in the MPFS to set their rates.
---------------------------------------------------------------------------
\12\ Katerndahl D, Wood R, Jaen CR. Complexity of ambulatory care
across disciplines. Healthcare. 2015, Available at: https://doi.org/
10.1016/j.hjdsi.2015.02.002.
FFS doesn't just underinvest in primary care--it also makes it
extremely complex to get paid. We must submit unique codes for each and
every service we provide--documenting both what we did and why we did
it. This is incompatible with the continuous, comprehensive nature of
primary care which spans everything from basic preventive services to
more complex services involving chronic care management, integrated
behavioral health, and care coordination. For patients with chronic
conditions, these discrete services may include patient education, care
planning, and managing medications, all of which are ongoing and
continuous processes. Each of these services must be individually
documented to justify payment for typical, comprehensive primary care,
even though these services are all foundational aspects. Billing for
primary care under FFS is like trying to cut a roll of paper with a
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hole punch rather than a pair of scissors.
The retrospective, volume-based nature of FFS also fails to account
for the costs of longitudinally managing patients' overall health. It
does not provide practices with the time and flexibility to invest in
the care management staff and population health tools that enable
practices to efficiently and effectively meet patients' individual
evolving health needs. For example, FFS structures have not
historically paid for wraparound patient activities, such as community
health workers or care coordination, but these interventions enable
family physicians to better address a patient's identified health-
related social needs (HRSNs) within a patient's community context. This
disadvantages patients who require more support and the physicians who
care for them. While Medicare has implemented new codes for some of
these services in 2024, such as community health integration and social
drivers of health risk assessments, their utilization and effectiveness
is not yet known.
For these reasons, the AAFP has long advocated to accelerate the
transition to value-based care using alternative payment models (APMs)
that provide prospective, population-based payments to support the
provision of comprehensive, longitudinal primary care. We strongly
believe well-designed APMs provide primary care a path out of the
undervalued and overly burdensome FFS payment system that exists today,
and in turn will better enable the Medicare program to meet the needs
of its growing and aging beneficiary population in new and innovative
ways. Unfortunately, a dearth of primary care APMs and the inadequacy
of FFS payment rates that often underlie APMs are undermining the
transition to value-based care. Because most APMs are designed based on
FFS payment rates, modernizing FFS payment for primary care is one
essential strategy to support physicians' transition into value-based
care.
Therefore, while FFS is not the future the AAFP envisions for
primary care, it is the present. Federal policymakers must ensure the
current FFS system appropriately and sustainably compensates primary
care physicians to make more meaningful progress toward the future--one
that rewards value over volume of services.
We have been encouraged by recent regulatory policy changes aimed
at more appropriately valuing and paying for primary care and other
types of cognitive care in Medicare. The AAFP greatly appreciates that
CMS finalized and Congress supported implementation of the G2211 add-on
code in 2024, which can be billed alongside offices visits that are
part of an ongoing, longitudinal care relationship. G2211 is an
incremental but meaningful step in appropriately valuing primary care
and supporting longitudinal, holistic patient-physician relationships,
relative to other services in the fee schedule.
However, the zero-sum, budget-neutral nature of the MPFS is
undermining investments like G2211. Existing budget neutrality
requirements force CMS to offset increases or additions anywhere in the
MPFS with across-the-board cuts to all services in the MPFS, including
those most delivered by primary care physicians. In short, this means
Medicare cannot appropriately pay for all the services a patient might
need, and it perpetuates inequities in the fee schedule, which bleed
into and impact the success of primary care practices in VBP
arrangements and outside of Medicare.
For these reasons, the Academy has long called for reforms to
budget-neutrality requirements, which are unnecessarily pitting
physician specialties against one another. We strongly urge the
committee to consider proposals such as increasing the current budget
neutrality threshold, which has not been updated since the fee schedule
was created in 1992, correcting the impact of over- or under-
utilization assumptions by CMS on the availability of funds, and more
regularly updating the direct costs used to calculate practice expense
Relative Value Units (RVUs). I'd also like to raise the suggestion that
Federal policymakers should think of budget neutrality in broader terms
than it currently is. As I've discussed, proper investment in primary
care yields the potential to increase long-term cost savings through
outcomes such as reduced emergency department visits, hospitalizations,
and better management of chronic conditions. I would make the case that
those savings should be considered as part of the direct budgetary
impacts of increasing primary care investments in Medicare.
In terms of other opportunities to improve CCM in traditional
Medicare, I'd like to discuss the experience of family physicians and
their patients in utilizing some of the CCM codes. In 2015, Medicare
began paying physicians for delivering non-face-to-face CCM through
separate codes. Being able to bill for CCM has been an overall positive
experience for our practice. However, there remain some operational
challenges such as patient cost-sharing requirements that are limiting
uptake by patients who would truly benefit from this type of additional
support. A 2022 study found that MPFS billing codes for preventive
medicine and care management services are being underutilized even
though primary care physicians were providing code-appropriate services
to many patients. The median use of the preventive and care
coordination billing codes was 2.3 percent among eligible patients.\13\
---------------------------------------------------------------------------
\13\ Sumit D. Agarwal, Sanjay Basu, Bruce E. Landon The Underuse of
Medicare's Prevention and Coordination Codes in Primary Care: A Cross-
Sectional and Modeling Study. Ann Intern Med.2022;175:1100-1108. [Epub
28 June 2022]. doi:10.7326/M21-4770.
I've had patients in my practice opt out of receiving these
services simply because the $15 or so a month they faced in cost-
sharing was not financially feasible. In almost every case these were
the very patients that would most benefit from CCM. This rings true for
many of the other new codes Medicare has implemented, including G2211,
SDOH risk assessments, and community health integration services.
Patients are not used to paying for these services and, understandably,
are likely to be resistant to doing so. If we want to incentivize usage
---------------------------------------------------------------------------
of these high-value services, we must waive patient cost-sharing.
In many ways, CCM is a preventive service in that it reduces
emergency department and other outpatient visits. Removing cost sharing
for CCM and other primary care services increases access to these
services without increasing overall health care spending.\14\ The
available evidence indicates that reducing or removing cost barriers to
primary care increases utilization of preventive and other recommended
primary care services, which improves both individual beneficiary and
population health. For example, while cost sharing for most preventive
services is waived across payers, many patients don't access all the
preventive care recommended for them because they don't know what is or
isn't covered or they are concerned they might be charged for raising
other health issues in the same visit.
---------------------------------------------------------------------------
\14\ Ma Q, Sywestrzak G, Oza M, Garneau L, DeVries A. ``Evaluation
of Value-Based Insurance Design for Primary Care.'' (2019). The
American Journal of Managed Care. 25: 5. https://www.ajmc.com/view/
evaluation-of-valuebased-insurance-design-for-primary-care.
Therefore, the AAFP supports the Chronic Care Management
Improvement Act (H.R. 2829), which would waive patient cost sharing for
the CCM codes under traditional Medicare. We urge Congress to pass this
and other legislation to remove cost-sharing barriers to other primary
care services.
Supporting the Transition to Primary Care Value-Based Payment
Alternative payment models (APMs), when well-designed and
implemented to meaningfully support primary care, provide practices
with predictable, stable revenue streams that afford them the funding
and flexibility needed to build teams and implement technology and
infrastructure to deliver high-quality, patient-centered care--without
the administrative complexity of FFS.
Value-based payment (VBP) arrangements, such as population-based
payments or Accountable Care Organizations (ACOs), better support and
encourage physicians to deliver a more comprehensive set of services,
such as care coordination and addressing HRSN, through prospective
payment and flexibility. These types of arrangements invest in the
longitudinal, continuous relationships primary care physicians have
with their patients in ways that FFS has not historically and enable
practices to tailor their care to better support patients with chronic
conditions while improving related health outcomes. For example,
practices might host monthly diabetes group visits to improve A1C. The
frequent touches and support from these group visits can lead to better
health outcomes for patients with type 2 diabetes and help the practice
meet quality measure requirements.
In the Comprehensive Primary Care Plus (CPC+) model tested by the
Center for Medicare and Medicaid Innovation, participating practices
reported they used the model's prospective payments to invest in care
delivery transformation that would not have been possible if FFS was
their only source of revenue. Some of these transformations included
key CCM activities, such as: providing patients with after-hours access
to a physician or other clinical staff member who has real-time access
to the practice's EHR; using designated care managers, typically onsite
staff who are nurses or medical assistants, to deliver longitudinal
care management services; and co-location of a pharmacist at the
practice site to support comprehensive medication management. To be
clear, the primary difference that afforded practices the opportunity
to make these investments is that the payment was prospective; while
they are possible to make in FFS, the retrospective payment makes it
much more challenging for practices to do so.
Given these and other benefits, there is mounting multistakeholder,
cross-
industry support for a primary care payment system that rewards value
and holds promise for improving health, addressing disparities, and
slowing the overall growth of health-care costs. Federal policymakers
should increase participation opportunities in primary care models that
align with the AAFP's guiding principles for VBP and meet practices
where they are, allowing them to gain a foothold in and stay in VBP.
Congress tried to provide an on-ramp for more practices to
participate in APMs with the passage of the Medicare Access and CHIP
Reauthorization Act (MACRA) and implementation of the Merit-based
Incentive Payment System (MIPS), which was intended to provide
clinicians with experience being measured on their performance. The
AAFP supported the intent of fostering continuous performance
improvements that lead to better outcomes for patients. Unfortunately,
continuous cuts to Medicare FFS payments have inhibited most practices
from making the necessary investments that would allow them to
successfully move into APMs. Further, the current design of MIPS, which
focuses on individual clinician performance using largely process
rather than outcomes measures, does not appear to be driving care
improvements as much as it is adding administrative complexities that
detract from patient care while unfairly penalizing small and rural
practices.
MACRA requires CMS to apply payment adjustments to Medicare Part B
FFS payments based on an eligible clinician's (EC) performance in MIPS.
Clinicians with a MIPS final score above the performance threshold
receive a positive adjustment while those below the threshold receive a
negative adjustment. The adjustments must be budget neutral--meaning
the total value of annual positive adjustments are equal to the total
value of negative adjustments. As such, both the positive and negative
adjustments are made on a sliding scale with the exception that those
in the bottom quartile automatically receive the maximum penalty for
the year.
While most physicians have met or exceeded the MIPS performance
threshold in past performance years, physicians in small and rural
practices consistently have lower than average MIPS scores. As the
performance threshold increases, it will become more difficult for
small and rural practices to avoid a negative payment adjustment, which
can be up to 9 percent to their Medicare Part B services. Given these
challenges, I urge Congress to consider reforms to the MIPS program to
alleviate the administrative costs of reporting to the program, ensure
it drives meaningful quality improvement, and assist physician
practices in building the necessary competencies to transition into
alternative payment models.
Congressional action is also needed to ensure Federal policies
provide appropriate support and incentives to physician practices
moving into APMs. I appreciate that Congress passed legislation last
month to extend the advanced APM (AAPM) incentive payment through
performance year 2024, albeit at a lower amount.
These payments have served as an important tool for attracting
physicians to participate in AAPMs, which require significant up-front
(and often ongoing) investments in new staff, technology, and other
practice improvements. Primary care practices have also used the AAPM
bonus payments to offset the cost of investing in care delivery
transformation that drives success in these models by improving patient
outcomes and lowering spending. Expiration of the AAPM incentive
payment could institute an additional barrier to continued AAPM
participation for physician practices and further impede family
physicians' ability to transition value-based payment models.
Congress should also consider legislation to provide CMS with
authority to modify AAPM qualifying participant thresholds to ensure
independent practices are not left behind. The Value in Health Care Act
(S. 3503), which the AAFP has endorsed, is one piece of legislation
that would do so.
However, primary care physicians still face significant barriers to
entering and sustaining participation in VBP arrangements, even when
they align with AAFP's principles. Practices must comply with an ever-
increasing number of Federal and State regulations, negotiate contracts
with multiple payers, acquire and effectively aggregate and analyze
data to track patient utilization, treatment adherence, and identify
outstanding needs--all while doing our primary job of taking care of
patients. This creates an immediate and high barrier to entry,
particularly for independent practices that don't have the up-front
capital or resources.
To address this problem, Federal policymakers should increase
options for primary care practices to benefit from APMs that provide
up-front or advance payments and other supports to enable the
investments required to be successful. For example, practices
participating in CPC+ not only received population-based, per-member
per-month (PMPM) payments, but CMMI provided them with a robust data
dashboard and other technical assistance that enabled new practices to
join the model and successfully reduce emergency visits and
hospitalizations. CMMI also partnered with State Medicaid agencies and
commercial payers to drive alignment across payers in CPC+ regions,
which in turn provided practices with greater financial support across
their contracts and accelerated care delivery innovations.
We are encouraged by CMS's recent announcement of a new model, ACO
Primary Care Flex, which will heed our recommendations and provide low
revenue ACOs participating in the Medicare Shared Savings Program
(MSSP) with a one-time up-front shared savings payment and a
prospective PMPM payment. CMMI's forthcoming Making Care Primary (MCP)
model, which is set to launch in July, also builds upon lessons learned
from CPC+ and Primary Care First (PCF) and provides participants who
are new to value-based care with up-front payments to develop
infrastructure and build advanced care delivery capabilities. CMMI is
also working with State Medicaid agencies and other payers in the
selected States to align MCP and State programs, helping facilitate the
multi-payer alignment that has contributed to successful aspects of
earlier models.
Congress should also consider providing CMMI with additional
flexibility in how it evaluates the success of primary care models.
Currently, Federal statute only allows CMMI to expand models that
reduce health-care spending and maintain quality, or improve
performance on quality metrics without increasing spending.
Demonstrating savings in primary care often takes several years as
physicians build relationships with their patients, use data to better
manage their care, and increase utilization of preventive and other
high-value services, like care management.
The current statutory framework has prevented CMMI from making
important model improvements or continuing to test models that do not
show significant savings within a short model test period, ultimately
causing more complexity and financial instability for participating
physician practices. Further, all CMMI primary care model evaluations
have been done at the national level, which may be masking regional
successes. Congress should consider enabling and encouraging CMMI to
evaluate several other markers of success for primary care APMs, such
as whether they successfully bring new physicians into value-based
payment, improve patient experience measures, markedly improve care
delivery transformation, enable more beneficiaries to access the
behavioral health services they need, and when applicable, evaluate
models both nationally and regionally. These additional criteria would
allow CMMI to continue testing models that show early markers of
success and iterate upon them to meet current patient, clinician, and
market needs.
While value-based payment can and should be used to buoy primary
care practices, health systems, hospitals, payers, and other large
companies will continue to enter these models. Federal policymakers
should take steps to ensure value-based payment is being used as a tool
to significantly increase our Nation's investment in primary care, not
as a leverage point to increase profits in other business areas. In
other words, payments and financial rewards from APMs should be
reinvested into the primary care practice, not redirected to other
service lines or books of business.
In closing, thank you again for the opportunity to provide this
testimony. On behalf of the AAFP and as a family physician, I look
forward to working with the committee to advance policies that invest
in high-quality primary care, improve patients' outcomes and
experiences, and better support family physicians by more appropriately
paying for the work we do. We all have the same goal: to improve the
lives of the people we serve.
Founded in 1947, the AAFP represents 130,000 physicians and medical
students nationwide. It is the largest medical society devoted solely
to primary care. Family physicians conduct approximately one in five
office visits--that's 192 million visits annually or 48 percent more
than the next most visited medical specialty. Today, family physicians
provide more care for America's underserved and rural populations than
any other medical specialty. Family medicine's cornerstone is an
ongoing, personal patient-physician relationship focused on integrated
care. To learn more about the specialty of family medicine and the
AAFP's positions on issues and clinical care, visit www.aafp.org. For
information about health care, health conditions and wellness, please
visit the AAFP's consumer website, www.familydoctor.org.
______
Questions Submitted for the Record to Steven P. Furr, M.D., FAAFP
Questions Submitted by Hon. Mike Crapo
Question. As you noted in your testimony and responses during the
hearing, numerous features of the Physician Fee Schedule (PFS), as
currently structured, have resulted in volatility and uncertainty for
clinicians. Broad utilization overestimates for certain new billing
codes, for instance, have triggered draconian conversion factor (CF)
reductions across all specialties and subspecialties, and policy
changes aimed at ensuring appropriate reimbursement for certain
subgroups of clinicians necessitate, under budget neutrality rules,
sizable payment cuts for others, with no countervailing enhancements
for the latter groups.
What specific legislative steps should Congress consider taking in
order to provide long-term stability and sustainability for the PFS,
beyond modifying the current CF update schedule?
Answer. In addition to updating the conversion factor by applying
an annual inflationary update based upon the Medicare Economic Index,
the AAFP strongly urges Congress to make immediate reforms to existing
budget-neutrality requirements. As noted in my written testimony, the
zero-sum, budget-neutral nature of the MPFS is undermining investments
Medicare tries to make in primary care. Existing
budget-neutrality requirements force CMS to offset increases or
additions anywhere in the MPFS with across-the-board cuts to all
services in the MPFS, including those most delivered by primary care
physicians. In short, this means Medicare cannot appropriately pay for
all the services a patient might need, and it perpetuates inequities in
the fee schedule, which bleed into and impact the success of primary
care practices in VBP arrangements and outside of Medicare.
Budget neutrality is unnecessarily pitting physician specialties
against one another. We strongly urge the committee to consider
proposals such as increasing the current budget neutrality threshold,
which has not been updated since the fee schedule was created in 1992,
correcting the impact of over or underutilization assumptions by CMS on
the availability of funds, and more regularly updating the direct costs
used to calculate practice expense Relative Value Units (RVUs).
I'd also like to raise the suggestion that Federal policymakers
should think of and interpret budget neutrality in broader terms than
it currently is. As I've discussed, proper investment in primary care
yields the potential to increase long-term cost savings through
outcomes such as reduced emergency department visits, hospitalizations,
and better management of chronic conditions. I would make the case that
those savings should be considered as part of the direct budgetary
impacts of increasing primary care investments in Medicare.
Question. In the absence of these types of steps, what concrete
impacts will current and future beneficiaries most likely experience?
Answer. While I cannot predict the future, I can point to the past.
Over the last decade or so, we have seen more and more primary care
practices closing their doors or being bought up by a health system,
hospital, insurer, or private equity. This trend accelerated during
COVID, when primary care practices that were already operating on
razor-thin margins were hit with an unprecedented financial reckoning.
While we're on the other side of the pandemic now, insufficient
Medicare physician payment rates continue to exacerbate the difficult
financial environment for many practices. Costs for administrative and
clinical staff, medical supplies, and overhead all continue to rise
while payment rates go down through a combination of statutorily
required cuts and failure to keep pace with inflation. Absent any
meaningful reforms from Congress, more primary care physicians will
leave the field, practices will close, and most importantly, patients
will struggle to access all of the care that they need--particularly
preventive and primary care that keeps them from having to pursue more
expensive care in costlier settings.
Question. Regulations finalized earlier this year aim to streamline
and standardize prior authorization standards and requirements in
certain contexts, but the final rule expressly excludes outpatient
medications, whether administered by clinicians or dispensed to
beneficiaries via pharmacy. Both the American College of Surgeons (ACS)
and the American Academy of Family Physicians (AAFP) made note of this
omission in comments submitted in response to the proposed rule.
Specifically, ACS ``urge[d] CMS to apply its proposed policies to
all drugs covered by any of the impacted payers to align PA processes
and related implementation efforts with those for all other covered
items and services.'' Similarly, AAFP expressed concern and
disappointment that ``these proposals do not apply to prior
authorizations for prescription and outpatient drugs,'' and went on to
``strongly urge CMS to expand the proposals in this rule to Medicare
Part D plans and prescription drug coverage across other impacted
payers.''
Virtually all clinician organizations concurred with these
recommendations, including those focused on treating some of the most
onerous chronic conditions, such as cancer. The Community Oncology
Alliance, for instance, asserted, ``Addressing the drug treatment for a
person's cancer should clearly be part of any effective, comprehensive
regulatory initiative to streamline the current onerous prior
authorization processes.'' Patient advocates uniformly agreed with
these concerns, which a number of groups have cited as a key source of
delays and denials of potentially life-saving therapeutics, across both
the provider-administered setting and the retail pharmacy context.
Studies have found that physician-administered drugs and biologics
account for a large and growing share of all forms of prior
authorization and utilization management (UM) under Medicare Advantage
(MA) plans' medical benefits, and the application of various UM tools,
such as prior authorization, step therapy, and formulary exclusion, has
risen dramatically in recent years under Medicare Part D plans.
Analysts broadly project that these trends will accelerate, rather than
reverse, in the midst of Part D's benefit redesign.
What specific components should Congress, or CMS, consider
including in any effort to streamline and otherwise reform requirements
and standards for UM tool application to outpatient drugs (both
physician-administered and pharmacy-
dispensed)?
Answer. In a 2023 rule, CMS proposed requirements to adopt the
updated National Council for Prescription Drug Programs (NCPDP) SCRIPT
(standards used to exchange information for e-prescriptions) version
2023011 (and to retire version 2017071) for Part D e-prescribing
starting January 1, 2027. CMS also proposed to update other e-
prescribing related standards including the adoption of NCPDP Real-Time
Prescription Benefit (RTPB) standard version 13 for real-time benefit
transactions (RTBT) and the adoption of NCPDP Formulary and Benefit
(F&B) standard version 60. The AAFP supported these proposals.\1\ CMS
did not announce a final decision in the published rule and we assume
these proposals are still under consideration.
---------------------------------------------------------------------------
\1\ https://www.aafp.org/dam/AAFP/documents/advocacy/legal/
administrative/LT-CMS-MedicareAdvantageCY25-122123.pdf.
The AAFP also supported earlier proposals to adopt NCPDP RTPB
standards, which enable the real-time exchange of patient-specific
coverage (including restrictions and alternatives) and estimate cost-
sharing at the point of prescribing.\2\ We supported CMS's proposal,
which they finalized in the 2024 Part D rule, to adopt RTPB standard
version 13 because it would offer enhancements that would enable payers
to provide additional product-level details about coverage and
formulary status.
---------------------------------------------------------------------------
\2\ https://www.aafp.org/dam/AAFP/documents/advocacy/coverage/
medicare/LT-HHS-CMS-MedicareAdvantagePriorAuthorization-021323.pdf.
NCPDP F&B standards enable plans to share formulary and benefit
information at the plan level, as opposed to the patient-level
eligibility information offered by RTPB standards. These standards
allow payers to transmit information about formulary status, preferred
alternatives, and coverage restrictions consistent with each plan's
benefit design. F&B standards are the foundation of electronic prior
authorization (ePA) functionality and real-time benefit checks for
individual patients in Part D. We have previously urged CMS to require
plans (including Part D plans) to implement ePA standards, and we
support the adoption of the proposed F&B standards which will
facilitate the use of ePA in Part D plans.\3\ Currently, family
physicians spend a significant amount of time determining whether a
prior authorization is required, and if so, the documentation
requirements for approval. We believe this proposal is a foundational
step to require Part D plans to implement ePA and make prior
authorization requirements more transparent to physicians and their
staffs. CMS did not announce a final decision in the published rule and
we assume these proposals are still under consideration.
---------------------------------------------------------------------------
\3\ https://www.aafp.org/dam/AAFP/documents/advocacy/legal/
administrative/LT-CMS-PriorAuthorizationEHR-031023.pdf.
CMS requires Medicare Advantage plans to use coverage criteria that
is no more restrictive than Traditional Medicare coverage policies.
When there are no applicable Medicare statute, regulation, National
Coverage Determination (NCD) or Local Coverage Determination (LCD) that
establish coverage criteria, plans may only create internal coverage
criteria based on publicly available clinical literature or widely used
treatment guidelines. We urge CMS to apply this proposal to
---------------------------------------------------------------------------
prescription drugs and Part D plan sponsors.
Question. What benefits would these components offer to patients
and clinicians?
Answer. The NCPDP RTPB standards discussed above would allow family
physicians to understand formulary and prior authorization requirements
for patients when writing a prescription, which aligns with AAFP policy
stating physicians must have real-time information available about drug
formularies at the point of care.\4\ These more recent standards would
increase transparency of prior authorization requirements, formulary
design, and patient financial responsibility at the point of
prescribing. Having this data at the point of prescribing would allow
physicians to have a more robust discussion with patients about
treatment options. We continue to support the use of ePA standards in
Medicare Part D plans and urge Congress and CMS to apply these
standards to all other non-Part D prescription plans.
---------------------------------------------------------------------------
\4\ https://www.aafp.org/about/policies/all/patient-centered-
formularies.html.
Question. In the absence of reform efforts along these lines for
medications, what prior authorization and UM burdens and other effects
will clinicians and beneficiaries continue to experience, even after
---------------------------------------------------------------------------
CMS's final rule takes effect?
Answer. I experience--and frequently hear from other family
physicians who do as well--significant administrative burden associated
with PA requirements for prescription drugs. PA processes force
physicians to take time away from patient care to understand arbitrary
formulary changes and/or new PA requirements. Without access to plan
coverage details at the point of prescribing, physicians spend a
significant amount of time going back and forth with the pharmacy to
identify alternative medicines that meet coverage requirements. In
addition to the burden on physicians, these PA processes increase
burden on pharmacists and beneficiaries.
Question. On a number of fronts, CMS has leveraged subregulatory
guidance as a means of clarifying current-law and regulatory
requirements for plans, providers, and beneficiaries. In the context of
Part D, 42 CFR 423.272(b)(2) establishes regulatory requirements for
plan designs, noting that the agency will not approve a bid if ``the
design of the plan and its benefits (including any formulary and tiered
formulary structure) or its utilization management program are likely
to substantially discourage enrollment by certain Part D eligible
individuals under the plan.'' Notably, clause (iii) specifies that even
if a plan adheres to proper category/class inclusion requirements, such
a plan may still fall short of this standard by virtue of its exclusion
of certain drugs.
Patients, providers, and plans, however, have flagged uncertainty
as to the scope and practical implications of this language. Updates to
the regulations themselves, or else to the relevant sections of the
Medicare Prescription Drug Manual, could present a potential avenue for
clarifications, along with exemplary examples of compliant and
noncompliant formulary design and UM tool applications.
What types of clarifications or examples, in this context, could
CMS provide, either through guidance or regulations, to ensure adequate
and efficient medication access for Part D enrollees, many of whom take
multiple prescriptions for chronic diseases?
Answer. Part D, 42 CFR 423.272(b)(2) establishes regulatory
requirements for plan design including a prohibition on excluding
certain drugs that, if not included, might discourage sicker patients
from enrolling. Chapter 6 of the Medicare Prescription Drug Benefit
Manual,\5\ Part 30.2.5--Protected Classes requires plans to include
``substantially all'' drugs in certain classes, and CMS notes this
policy was established to ``ensure that Medicare beneficiaries reliant
upon these drugs would not be substantially discouraged from enrolling
in certain Part D plans, as well as to mitigate the risks and
complications associated with an interruption of therapy for these
vulnerable populations.'' Guidance in the same section further states,
``Part D sponsors may not implement PA or ST requirements that are
intended to steer beneficiaries to preferred alternatives within these
classes for enrollees who are currently taking a drug.'' The policy
includes ``all drugs in the immunosuppressant (for prophylaxis of organ
transplant rejection), antidepressant, antipsychotic, anticonvulsant,
antiretroviral, and antineoplastic classes.)
---------------------------------------------------------------------------
\5\ https://www.cms.gov/medicare/prescription-drug-coverage/
prescriptiondrugcovcontra/
downloads/part-d-benefits-manual-chapter-6.pdf.
We encourage CMS to consider whether this policy or list of
conditions should be expanded. There may be more categories of
conditions or drugs that support their intent of reducing harms and
complications associated with an interruption of therapy. For example,
the CMS Innovation Center is developing a model that establishes a list
of 150 commonly filled generics and sets their copay at two dollars.\6\
Many chronic diseases can be managed with low-cost prescription drugs,
and establishing a formulary standard for commonly prescribed, low-cost
generics used to treat chronic disease would help patients with
multiple chronic diseases by reducing their total copays, and by
preventing patients from being forced to change prescriptions due
formulary changes, despite the fact that their disease is currently
well controlled.
---------------------------------------------------------------------------
\6\ https://www.cms.gov/blog/cms-innovation-centers-one-year-
update-executive-order-lower-prescription-drug-costs-americans.
Question. In some cases, formularies exclude or disadvantage lower-
cost alternatives to branded medications with higher list prices while
charging beneficiaries coinsurance tied to said inflated sticker-price
figures. The Part D statute directs pharmacy and therapeutic (P&T)
committees to ``base clinical decisions on the strength of scientific
evidence and standards of practice,'' but it remains unclear to what
extent these committees or the Part D plans themselves factor cost
sharing, UM hurdles, or lower-priced alternatives (and the role of
---------------------------------------------------------------------------
rebates) in making these types of determinations.
How does cost-sharing burden affect medication adherence and
clinical outcomes for patients, and how should plans (and their P&T
committees) incorporate these types of considerations into their
recommendation and review processes?
Answer. Cost sharing has very tangible, and often negative, impacts
on patients' medication adherence and clinical outcomes. In my
practice, I have experienced patients requesting a certain medication
for the sole reason that it had a lower cost-sharing amount, regardless
of whether it was the best treatment or what I would recommend. I have
had patients stop taking medication or ration doses because of the
costs. Research has backed up my anecdotal experiences, as well.
Studies have consistently shown that, regardless of disease area,
increased cost sharing was associated with worse adherence,
persistence, or discontinuation, with data suggesting that the more
significant the cost sharing, the worse the treatment or medication
adherence.\7\ For example, one study found that a low copayment for
generic statins is the strongest factor influencing their utilization
and eliminating the copay altogether has an even larger effect.\8\
---------------------------------------------------------------------------
\7\ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10394195/
#::text=The%20majority%20
of%20publications%20found,sharing%2C%20the%20worse%20the%20adherence.
\8\ https://www.healthaffairs.org/doi/10.1377/
hlthaff.2012.0019?url_ver=Z39.88-2003&rfr
_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub++0pubmed.
The AAFP's policy on patient-centered formularies provides several
recommendations to inform these recommendation and review processes,
including:\9\
---------------------------------------------------------------------------
\9\ https://www.aafp.org/about/policies/all/patient-centered-
formularies.html.
Formulary design should be patient-centered, fiscally
responsible, and
evidence-based. Drug selection should be based on clinical
outcomes, clinical comparability, safety, patient ease of use,
and bioequivalancy with drug unit cost being a secondary
consideration.
Formularies should be designed to offer patients multiple
levels of drug choice (from more to less restrictive) with
accompanying patient cost-sharing levels to account for
variables including patient preferences (e.g., ``direct
marketing-induced'' demand).
Formularies should be designed to reduce or eliminate out-
of-pocket costs for patients with chronic conditions to
increase medication adherence and improve patient well-being.
Health plans and PBMs should provide drug utilization and
cost information to physicians in clear and understandable
reports that are useful for physicians in affecting positive
change in their prescribing behavior.
Sufficient information concerning PBM design should be
provided by health plans to physicians and patients in a clear
and useful format. (Note: this includes information concerning
generic drug and therapeutic substitution policies, deductibles
and copays, appeal process for adverse decisions, formulary
choices, product information, contractual arrangements with a
PBM, et cetera).
Question. What formulary review mechanisms or reporting
requirements could CMS implement in order to ensure effective and
meaningful oversight of formulary design, UM tool application, and the
clinical basis for these decisions?
Answer. A 2019 analysis found that 72 percent of the formularies
reviewed placed at least one branded drug in a more favorable (lower-
cost) tier than its generic, and the price of the branded drug was
nearly four times the cost of the generic.\10\ We believe CMS should
consider the impact of this type of cost sharing when evaluating the
adequacy of a formulary. A 2023 GAO report, ``CMS Should Monitor
Effects of Rebates on Plan Formularies and Beneficiary Spending''\11\
noted similar findings: ``rebate practices may influence formulary
design in ways that could affect beneficiary access for certain Part D
drugs and may not be identified by a clinical formulary review.''
Reviewing plan rebate structures during the clinical plan design and
benefits review could enable CMS staff to assess whether a drug may be
at risk for lower adherence rates due to patient cost sharing, and help
to identify when copays might discourage certain beneficiaries from
enrollment.
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\10\ https://jamanetwork.com/journals/jamainternalmedicine/
fullarticle/2728446.
\11\ https://www.gao.gov/assets/gao-23-105270.pdf.
Question. Artificial intelligence (AI) has the potential to
mitigate administrative burden and enhance health-care quality,
including in the context of Medicare. That said, some clinicians have
raised concerns around the program's inability to keep pace with AI-
enabled tool development through its coverage and payment policies,
---------------------------------------------------------------------------
undercutting access, especially for smaller practices.
What use cases for AI-enabled tools and technologies seem most
promising in the context of clinician care?
Answer. AI-enabled tools that focus on administrative burden
reduction have the most promise today for supporting clinicians. Five
key areas of administrative burden are documentation, prior
authorization, EHR inbox management, quality measurements, and chart
review. We have seen how AI assistants can dramatically reduce
documentation time and cognitive burden of chart review, while
supporting more timely and empathetic responses to inbox messages. We
have also seen how AI assistants can reduce the burden of coding for
billing and risk-based adjustments under value-based care. The AAFP is
hopeful for additional AI-powered solutions to help with prior
authorization and quality measurement.
In the near future, there is promise for AI to power technologies
that help primary care be more comprehensive, provide better continuity
and coordination of care, and improve patient access. Work is still
needed to address the issues of trustworthiness and safety as AI moves
more into the clinical realm.
Question. What steps should CMS and Congress take to ensure
adequate coverage and reimbursement for appropriate AI-enabled tools in
this context?
Response: For the administrative burden reduction use cases,
coverage and reimbursement are not the key barriers; rather, issues of
interoperabilty with EHRs and willingness for health-care systems to
invest are key to further adoption. There is clear evidence that
investments in primary care result in lower total costs and improved
patient outcomes. So, as the investment in primary care more generally
happens to align payments with the value generated, this could also
incentivize health-care systems to invest in primary care
infrastructure, including AI solutions.
On the near future clinical applications, it is important for
coverage to allow for primary care physicians to practice to the top of
their training and not have coverage tied to a particular specialty.
This is due to the opportunity AI has to empower primary care
physicians to be more comprehensive.
The biggest potential driver of responsible AI-powered solutions
for clinical care is the alignment of payment to high-quality primary
care and to pay prospectively. This alignment incentivizes the adoption
and use of AI that improves outcomes and lowers total cost.
Furthermore, additional fee-for-service payments can be used to
accelerate adoption of newer solutions.
______
Questions Submitted by Hon. Chuck Grassley
Question. In 2005, this committee held a hearing that I chaired
titled, ``Improving Quality in Medicare: The Role of Value-Based
Purchasing.'' I said at the time that we do not want to overburden
providers with reporting requirements. I went on to say that it is
important to develop these health care quality measures by consensus.
Do you feel reporting requirements are developed by consensus and
do not overburden providers? If not, what actions should we take to
reduce the burden?
Answer. We support the goal to implement health care quality/
performance measures that do not overburden physicians. We appreciate
HHS's and CMS's efforts to improve the measurement landscape by
recommending a ``Universal Foundation,''\12\ which is one step toward
measure alignment across programs. We also appreciate the ability to
participate in annual, multistakeholder, measure review processes to
make recommendations for measures that should be implemented in Federal
programs like Medicare, as well as measures that should be removed from
use in Federal program. That said, there's still a tremendous amount of
work that must be done to decrease the significant burden created by
the current measurement landscape. While quality measurement is
essential to moving toward a value-based health-care system, our
current approach fails to measure what matters to patients and
clinicians or drive meaningful improvement. The eagerness to measure
has burdened family physicians with the onerous task of capturing
structured electronic data to feed an excessive number of measures,
taken time away from patients, and led to loss of joy in practice.
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\12\ https://www.cms.gov/medicare/quality/cms-national-quality-
strategy/aligning-quality-measures-across-cms-universal-foundation.
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To further reduce burden, we recommend the following actions:
Use fewer measures overall and implement only those measures
focused on improving outcomes that matter to patients and/or
improve health equity.
Align performance measures and other aspects of value-based
payment models across all payers and programs.
Continue to involve physicians and patients in selection of
measures to be used in Federal programs and allow their
feedback to help determine which measures are used.
Ensure physicians are measured according to patients who
truly are under their care, and provide physicians and clinics
with rosters of patients for whom they are accountable on a
timely basis and in an easy-to-use format.
Optimize health information exchanges and allow primary care
physicians easy access to real-time health information showing
care provided to their patients outside their clinic.
Ensure all electronic health record (EHR) systems are
equipped to discretely capture and electronically report
performance measures before implementation without any added
administrative burden or cost.
Ensure Federal payment programs provide coverage for care
where physicians are held accountable via performance measures
(e.g., physicians should be able to administer the shingles
vaccine in their offices if they are being measured on it).
Question. According to the Medicare Payment Advisory Commission
(MedPAC), Medicare's Physician Fee Schedule updates have grown more
slowly than input cost growth in recent years. Yet Medicare spending on
an annual basis is up 30 percent over 5 years and the Congressional
Budget Office (CBO) just revised Medicare spending for benefits--for
this year and last year--up another $272 billion. MedPAC explains this
is due to an increase in the volume and intensity of Medicare services.
Can you explain the root cause for higher Medicare spending while
at the same time, physicians are receiving less in reimbursement?
Answer. By law and with some exceptions, Medicare generally covers
only the diagnosis and treatment of illness or injury rather than
prevention. Thus, part of the root cause for higher Medicare spending
is the program's inclination to pay for a pound of cure rather than an
ounce of prevention.
Beyond that, Medicare spends less than 5 percent of its total
spending on primary care. Between 2019 and 2021, there was a 15 percent
drop in Medicare spending on primary care.\13\ When we look at health
outcomes across the world, we're not doing well by almost any measure.
Compared to other high-income peer nations, the U.S. has higher rates
of obesity, diabetes, and heart disease, and a larger share of the
population with multiple chronic conditions.\14\ We know from extensive
evidence that other countries and even U.S. States that invest a
greater percentage of spending in primary care reap the benefits in
reduced overall spending. Thus, the biggest root cause for higher
Medicare spending is the program's failure to invest in primary care
and over-investment in other facets of the health-care system.
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\13\ https://www.milbank.org/publications/the-health-of-us-primary-
care-2024-scorecard-report-no-one-can-see-you-now/.
\14\ https://www.commonwealthfund.org/publications/issue-briefs/
2023/oct/high-us-health-care-spending-where-is-it-all-going.
Question. There are an estimated 8,000 medical services codes that
---------------------------------------------------------------------------
physicians bill for a range of health-care services.
How many are typically used in a primary care setting? Are the
suite of primary care codes overly burdensome or complicated? If so,
how? How does this compare to billing under Medicare Advantage or other
commercial insurance?
Answer. The number of codes by themselves is not overly burdensome
or complicated. What is burdensome and complicated are the myriad rules
(some associated with the code set(s) and others created by Medicare
and other payers) that govern when codes may be reported either
independently or in conjunction with other codes. This is true in
almost any fee-for-service payment system, whether traditional
Medicare, Medicare Advantage, or commercial insurance. Research has
concluded that creating additional billing codes for distinct
activities in the MPFS may not be an effective strategy for supporting
primary care,\15\ due to the burden associated with billing each one.
This is part of the reason the AAFP advocates for prospective, risk-
adjusted per-patient per-month payments for the continuous,
comprehensive care delivered by primary care physicians.
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\15\ https://www.acpjournals.org/doi/10.7326/M21-4770.
______
Questions Submitted by Hon. Maria Cantwell
Question. Health plans are legally required to offer to pay medical
practices through standardized electronic payments, similar to the
direct deposit system through which many Americans receive their
paychecks. These payments are known as electronic fund transfers, or
EFTs. Receiving payments electronically is convenient, but there's a
catch. Health plans use vendors to process EFTs that charge physicians
processing fees of 2 percent to 5 percent of the claims payment. Under
this egregious system, physicians are essentially ``paying to get
paid'' and receiving less than the fully contracted payment amount for
care that they already provided.
In a survey conducted by the Medical Group Management Association,
nearly 60 percent of physician practice respondents said they are
forced to pay these
percentage-based fees without ever having agreed to them. These fees
are particularly burdensome for small practices, which may not have the
margins or administrative support to cope with them.
To address this problem, Senator Cassidy and I introduced the No
Fees for EFTs Act earlier this year. Our bill would prohibit health
plans from imposing these unnecessary fees for electronic transfers on
providers. Doctors should be focused on providing care, not dealing
with burdensome EFTs.
Are your members or you personally subjected to these fees? Could
you comment on how they affect the financial outlook for practices who
treat a high portion of patients with complex chronic care needs?
Answer. Yes, I hear from family physicians who are subjected to
these fees. The AAFP has previously expressed concerns to CMS about
physicians incurring fees for electronic payments from health
plans.\16\ Family medicine practices report that they are increasingly
forced to pay mandatory, percentage-based fees for the receipt of
electronic payments made from health plans via the electronic funds
transfer (EFT) transaction standard. These fees are adding to
practices' already overwhelming administrative burden and ongoing
financial strain. Practices cannot afford to lose a percentage of each
claim payment due to EFT fees. Disenrolling in EFT payments is often
not permitted by payers, but when allowed it leads to additional
administrative tasks that take time away from patient care.
---------------------------------------------------------------------------
\16\ https://www.aafp.org/dam/AAFP/documents/advocacy/legal/
administrative/LT-CMS-EFTFees-102221.pdf.
Question. Do you agree that the No Fees for EFTs Act would help
---------------------------------------------------------------------------
protect providers from unfair processing fees?
Answer. Yes. The AAFP is proud to have endorsed your
legislation,\17\ the No Fees for EFTs Act, to help protect family
physicians and other clinicians from these fees, as you note.
---------------------------------------------------------------------------
\17\ https://www.aafp.org/dam/AAFP/documents/advocacy/legal/
administrative/LT-Senate-NoFeesEFTsAct-032524.pdf.
______
Questions Submitted by Hon. John Cornyn
Question. In 2015, Medicare began reimbursing providers for chronic
care management under a separate code in the Medicare Physician Fee
Schedule. This code was supposed to compensate providers for the
additional time needed outside of a typical visit to coordinate care
for patients with chronic diseases, but only a fraction of eligible
Medicare beneficiaries have received these services.
Under current CMS guidelines, eligible chronic care management
beneficiaries must have two or more chronic conditions. This can
include mental health conditions like depression or a substance use
disorder.
What is preventing better utilization of these services?
Answer. Although CCM helps prevent hospitalizations and emergency
department visits, it is subject to beneficiary cost sharing, unlike
most preventive services. For monthly services, such as CCM, this means
patients must pay cost sharing each month. This cost sharing prevents
better utilization, especially among beneficiaries who are financially
disadvantaged and those without a supplemental policy (e.g., Medigap).
Another barrier to better utilization is the way CCM codes are
structured and paid under fee-for-service. The code descriptors and
payers require a certain number of minutes of clinical staff or
physician (or qualified health professional) time to be documented
before the codes may be submitted and claimed. This necessitates
tracking individual interactions with the patient or on the patient's
behalf over the course of a calendar month before a claim can be
submitted. Tracking and documenting that information over the course of
a month to claim payment in a fee-for-service environment is cumbersome
and sometimes deters use of services, especially as compared to a
payment model where such services are paid on a prospective, per-
patient per month basis for attributed beneficiaries.
Question. For the estimated 1.7 million Medicare beneficiaries with
a substance use disorder, can using this code improve outcomes for this
more vulnerable patient population? For example, how might this reduce
patient emergency room visits?
Answer. I don't know of any research that specifically looks at use
of the CCM code for Medicare beneficiaries with SUD, but some research
has indicated that CCM more broadly has the potential to be a
successful model for treating patients with SUD.\18\ However, I do
believe that one of the remaining and significant barriers that may
prevent the full benefits of CCM being realized for this population is
the insufficient number of behavioral health clinicians, particularly
those that are trained in CCM.
---------------------------------------------------------------------------
\18\ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3902022/
#::text=CCM%20is%20
multidisciplinary%20patient%2Dcentered,(a%20substance%20use%20disorder).
Question. Do CCM services reduce overall health-care costs for
---------------------------------------------------------------------------
chronic care patients when used?
Answer. Data has indicated that the answer to your question is yes.
CMMI released a report showing that CCM was associated with lower
growth in Medicare costs,\19\ reduced hospital admissions and increased
connections with community-based resources for patients. Over an 18-
month period, it reduced costs by $74 per beneficiary per month. CMS
claims data has shown that if a patient is in the program for at least
a year,\20\ Medicare achieves $888 per patient, per year in gross
savings. Additionally, patients in CCM had lower hospital, ED, and
nursing home costs and CCM was linked with a reduced likelihood of
hospital admission for people with diabetes, chronic obstructive
pulmonary disease, congestive heart failure, urinary tract infection,
dehydration, and pneumonia.
---------------------------------------------------------------------------
\19\ https://www.cms.gov/priorities/innovation/files/reports/
chronic-care-mngmt-finalevalrpt.pdf.
\20\ https://www.chartspan.com/blog/effectivity-of-chronic-care-
management-programs/.
______
Questions Submitted by Hon. John Thune
Question. As part of the Merit-based Incentive Payment System
(MIPS), physicians must be compliant in promoting interoperability as
part of their reimbursement, which helps to facilitate the sharing of
data between various providers.
I have long been an advocate for health IT initiatives that can
improve efficiencies and reduce costs in the health-care system, and I
believe that sharing information between providers through an
interoperable network has immense upside, so long as there are
safeguards to protect patient privacy and ensure taxpayer funds are
spent appropriately.
However, there continue to be challenges to physicians meeting
interoperability metrics, like information blocking for example in
which an individual or entity impedes the delivery or utilization of an
electronic health record, making interoperability impossible.
In your view, how have practices been impacted by information
blocking?
Answer. Practices have been impacted both by information blocking
itself, as well as by information blocking regulations. The AAFP has
long supported efforts to advance the interoperability of health IT,
including through the Office of the National Coordinator (ONC) for
Health IT's development of information blocking regulations. Despite
ONC's longstanding efforts to reach and educate the health-care
community about information blocking, significant knowledge gaps still
exist regarding the implementation and enforcement of information
blocking regulations. Several independent, small, rural, and solo
medical practices are still unaware or underinformed about information
blocking requirements. The AAFP has urged HHS,\21\ ONC, CMS, and other
agencies to develop an intraagency communications plan and educational
outreach program specifically designed to reach physicians in
underserved communities and small practices. Family physicians want to
follow regulations and appropriately share information with their
patients and other members of their patients' care team, and
significantly more education is needed for practices to be able to
achieve those goals.
---------------------------------------------------------------------------
\21\ https://www.aafp.org/dam/AAFP/documents/advocacy/health_it/
ehr/LT-HHS-ONC-InformationBlocking-122223.pdf.
Question. Are you aware of instances in which the timeliness or
quality of the care physicians are able to provide patients has been
impacted by a limited ability or complete inability to access
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electronic health records?
Answer. Yes. My family physician peers have shared several
examples.
A clinical example is medication reconciliation. One family
physician shared that they use a different EHR than their local
hospital system, and the ER and inpatient services cannot see
the physician practice's updated medication list despite both
organizations being connected through Epic's Care Everywhere.
When patients are discharged from the hospital, they are
routinely discharged on a medication list that has no
reflection of their home medications because the medication
list in the hospital system was wrong in the ER, stayed wrong
upon admission, was never corrected during the hospitalization,
and was of course all wrong upon discharge.
Another physician stated that consulting subspecialists in
their two main systems assume that ``everyone'' can see their
notes and no longer send chart notes in response to referrals.
The practice's referral coordinator spends time every day
trying to track down consult notes from subspecialists who
think their notes are visible throughout the system due to
their ``connected'' systems. When notes do come in as an
electronic ``Record of Care,'' they are not tied back to the
referral order to close the loop automatically. Instead, they
must be manual labeled as a consult note and attached to the
order that generated the initial referral by a staff person or
the physician.
A physician stated that they are unable to get the data from
outside laboratories to know if the patient got the test. They
must resort to having the patient follow up with another
appointment to ensure the labs were completed and where, so
they can request the results.
Finally, a physician stated that they are unable to get data
from an urgent care center and are forced to call the center
and request the information be faxed to them. These are not
isolated events, but rather we hear these types of stories all
the time. The lack of interoperability increases costs, delays
care, and adds burden to primary care to find and get the
needed data.
Question. Furthermore, beyond information blocking, what other
challenges persist in physicians accessing patients' health information
electronically despite the billions of dollars spent to implement
electronic health IT and interoperability?
Answer. See above for examples that also respond to this question.
______
Question Submitted by Hon. Robert P. Casey, Jr.
Question. Your testimonies and discussions at the hearing noted
that the Merit-based Incentive Payment System (MIPS) is cumbersome for
clinicians. The intention of MIPS is to foster performance
improvements, leading to better outcomes for patients. You all
mentioned that MIPS is burdensome and may not accurately capture the
quality of care physicians provide.
Are there policy proposals that could be implemented to make MIPS
more accurate and less burdensome?
Answer. MIPS uses four siloed performance categories--all with
different measures and reporting requirements. Despite multiple calls
for consolidation and cross-category credit, CMS argues that they do
not have the statutory authority to alter the program in that regard.
One significant step toward reducing burden would be to give CMS the
flexibility to provide cross-category credit. For example, a physician
who reports a quality measure related to depression screening should
automatically receive credit for the corresponding improvement
activity.
The AAFP has also repeatedly advocated that CMS allow practices to
attest to using CEHRT rather than requiring multiple burdensome
measures for the promoting interoperability category. Again, CMS does
not have the authority to offer such an option. As we noted in our
comments on the 2024 MPFS NPRM, years of policy changes to the legacy
Meaningful Use program and now the promoting interoperability category
have failed to move the needle on health information exchange. It is
beyond time to move away from such burdensome requirements--doing so
would be an important step toward reducing the burden of the MIPS
program.
______
Question Submitted by Hon. Sheldon Whitehouse
Question. I am working on a bill to relieve providers excelling in
the Medicare Shared Savings Program (MSSP), from prior authorization
(PA) requirements in MA. The bill rewards providers in Accountable Care
Organizations (ACOs) that generate savings for Medicare by granting an
exemption from PA requirements for their MA beneficiaries. If an
insurer believes there is a rationale for maintaining PA in such
instances, this bill would require them to seek prior approval from the
Centers for Medicare and Medicaid Services (CMS). I would welcome your
thoughts and comments on this idea.
Answer. AAFP policy supports the concept that family physicians
that contract with health plans to participate in a financial risk-
sharing agreement should be exempt from prior authorizations.\22\
---------------------------------------------------------------------------
\22\ https://www.aafp.org/about/policies/all/prior-
authorizations.html.
______
Question Submitted by Hon. Maggie Hassan
Question. I am working with my colleagues on the Finance Committee
to address discrepancies in Medicare reimbursement that disadvantage
independent doctors. Older adults, and the Medicare program, often pay
a huge markup for basic services if their provider's office is owned by
a hospital.
If a patient on Medicare with arthritis received a routine steroid
injection from an independent doctor, Medicare would pay $50 and the
patient would pay about $15. For the same injection at an office owned
by a hospital, Medicare would pay $250, and the patient would pay $60.
What impact does this huge price differential have for patients in
rural areas, and how can we level the playing field so that we are not
disadvantaging physician-led care?
Answer. The AAFP has been strongly calling for Congress to advance
policies that will meaningfully address site-of-service payment
differentials for the reasons you identified in your question:\23\ they
are creating an uneven playing field for independent practices across
the country and patients are quite literally paying the price for it,
without getting anything in return.
---------------------------------------------------------------------------
\23\ https://www.aafp.org/dam/AAFP/documents/advocacy/payment/
medicare/LT-HouseEC-HealthCareSpending-013124.pdf.
There is little evidence that these additional payments hospitals
are able to charge are reinvested in the acquired physician practice,
many of which are primary care practices. Thus, the hospital increases
its revenue by acquiring physician practices and beneficiaries are
---------------------------------------------------------------------------
forced to pay higher coinsurance.
Medicare's increased payments for services performed in HOPDs does
not just impact the Medicare program and beneficiaries, however.
Private health plans generally use Medicare's payment system as a basis
for how much they pay physicians and hospitals, meaning that this
influences and directs spending and resources among commercial plans
and patients. Therefore, adopting comprehensive site-
neutral payment policies in Medicare would have significant impacts in
saving money across the health-care sector, with one study estimating
that it would lead to $471 billion in savings over the next 10
years.\24\
---------------------------------------------------------------------------
\24\ https://www.bcbs.com/sites/default/files/file-attachments/
affordability/Phil_Ellis_
Site_Neutral_Payment_Cost_Savings_Report_BCBSA_Feb_2023.pdf.
In terms of direct patient costs, Medicare patients collectively
would save about $67 billion on Part B premiums and $67 billion on cost
sharing. Premiums for private health insurance plans would be about
$107 billion lower over that period, which would amount to a reduction
in aggregate premiums of 0.75 percent. Privately insured patients would
---------------------------------------------------------------------------
also save about $18 billion on cost sharing due to lower payment rates.
Therefore, the AAFP continues to encourage Congress to extend
payment parity for all clinically appropriate services to off-campus
HOPDs established before 2015. We have also supported more incremental
policies such as requiring that payment for physician drug
administration services be the same in an off-campus HOPD as in a
physician's office.
______
Questions Submitted by Hon. Marsha Blackburn
Question. Medicare physician pay and its impact on patient access
to care remains a significant issue for my constituents. Adjusted for
inflation in practice costs, Medicare physician pay plummeted 29
percent from 2001 to 2024. Although Congress did act in the March 8th
government funding package to reduce the 3.37-percent cut that went
into effect on January 1, 2024, by an additional 1.68 percent, the 29-
percent reduction in Medicare payments over the last 2 decades is
reflective of this most recent congressional action. Plus, physicians
are now set up for another steep payment cut at the end of this year.
Nonpartisan government stakeholders recognize the damaging impact these
cumulative payment cuts have on patient access to care. Multiple
Medicare trustee reports stated that ``absent a change in the delivery
system or level of update by subsequent legislation, the trustees
expect access to Medicare-participating physicians to become a
significant issue in the long term.''
Can you discuss some of the impacts of this pressing financial
instability on physician practices, including consolidation, difficulty
retaining staff, and trouble keeping their doors open amid rising
costs?
Answer. Your question includes much of the answer. Insufficient
payment rates, particularly for small, independent primary care
practices that are already operating on thin margins, make it extremely
difficult for them to compete with hospitals, health systems, plans,
and other corporate entities who are recruiting for the same staff with
more attractive salaries and more significant resources (such as access
to advanced tools and technology, additional administrative support,
and other experts). For the physician, increasingly high rates of
student loan debt have a clear impact on the decision for many to
choose employment with a well-resourced system or plan. All of these
factors together, in addition to having to comply with an extremely
burdensome regulatory environment, are accelerating consolidation
within primary care.
Question. What available mechanisms do Congress and HHS have within
current statutory authority to help provide adequate Medicare payments
to physicians and ensure continued patient access to care? For example,
alleviating the administrative burden on practices through reforms to
the Merit-based Incentive Payment System?
Answer. As noted in a response above, we have made several
recommendations on ways to improve MIPS and alleviate associated
administrative burden on practices--however, CMS has indicated their
statutory authority to do so is limited. Absent congressional action,
CMS and HHS do not have much existing authority that allows them to
provide adequate Medicare payments to all physicians. For example,
efforts made by CMS to try and better value primary care within their
existing authority have required them to also offset these investments
by cutting payment for all Medicare fee schedule services (including
all of the other primary care services). Congress must lead the charge
on providing adequate Medicare payments to physicians by first
reforming budget-neutrality requirements and implementing an annual
inflationary update for physician payment based upon the MEI, as two
important starting points.
Question. Do these cuts disproportionately impact access to care in
underserved areas?
Answer. As a rural family physician, I can attest that the answer
is ``yes.''
Question. As a value-based purchasing program, MIPS was supposed to
reward physicians who achieved quality and cost-efficient care.
However, for years physicians have raised concerns about the program,
including that it increases administrative burden and does not
accurately capture quality.
What has been your experience with MIPS and the administrative
burden that it entails?
Answer. I have heard from many family physicians that MIPS has not
supported them in the transition to alternative payment models but
rather it has only contributed to significantly more time spent on
administrative tasks. A 2021 study in JAMA \25\ of the time and
financial costs to practices to participate in MIPS found that small
and medium primary care practices had mean per-physician costs of
$18,466 and $13,631. It also found that physicians, clinical staff
members, and administrators spent 201.7 hours annually per physician to
participate in the MIPS program. Physicians alone spent more than 53
hours per year on MIPS activities. These statistics are even more
significant when you consider that they only apply to MIPS, and family
physicians often participate with 7-10 different payers.
---------------------------------------------------------------------------
\25\ https://jamanetwork.com/journals/jama-health-forum/
fullarticle/2779947.
Question. Is it time to consider replacing the program with a more
valuable alternative? If so, what are some of the program's benefits
---------------------------------------------------------------------------
that should be considered when designing its replacement?
Answer. Whether it's complete replacement or a significant
overhaul, it is clear that the current program is not working as
intended.
The MACRA statute included funding for technical assistance.
However, this funding expired, and the Small, Underserved, and Rural
Support (SURS) program ended in 2022. The SURS Extension Act (H.R.
6576) would have authorized additional funding, but it has yet to move.
The SURS program provided valuable and direct assistance to practices
through tools and resources to help them navigate the complex MIPS
reporting requirements. Under the current structure, the performance
threshold will continue to increase. We've already seen that these
practices are more likely to face difficulties in meeting the
performance threshold, which will lead to significant payment
adjustments.
Without continued technical support as well as other program
reforms, the disproportionate financial impact may accelerate
consolidation and exacerbate access issues. We believe technical
support for practices is just as important as program design and
critical to ensuring practices can succeed under value-based payment
arrangements. We urge Congress to provide additional funding for such
support.
While the statute requires the Secretary to provide performance
feedback data to physicians, CMS has not been able to develop a
mechanism that provides timely and actionable information to
physicians. Feedback reports often include data that is 2 years old--
making it outdated and significantly limiting its utility.
Question. How have your practices been impacted by information
blocking?
Answer. See above responses to the questions posed by Senator
Thune.
Question. Have you had experiences where your ability (or
inability) to access health records has impacted the timeliness or
quality of the care you are able to provide your patients?
Answer. See above responses to the questions posed by Senator
Thune.
Question. Do existing Federal quality and payment incentive
programs under Medicare, like ``Promoting Interoperability'' under the
Merit-based Incentive Payment System, enable up-to-date, consolidated
longitudinal health records accessible without special effort?
Answer. No.
Question. With over $40 billion spent and nearly 2 decades of
effort put into implementing electronic health information technology,
fax machines remain widely used for sharing health data in our health-
care system.
Why is this the case, and what challenges persist in accessing
patients' health information electronically?
Answer. Fax machines are reliable, easy to use, and HIPAA-
compliant. They also have a single, standard way to send information to
many entities. For small and underresourced practices in particular,
fax machines can be a straightforward way to securely exchange health
information. Additionally, lack of technological literacy and lack of
access to reliable broadband Internet are two significant obstacles to
patients' health information being electronically accessible.
AAFP members have shared stories of their EHR vendor blocking
access to records during billing negotiations or disputes, examples of
previous EHR vendors refusing to share records that should have been
transferred during EHR transitions, and instances of hospitals refusing
to send an admission, discharge, and transfer (ADT) or to provide
access to summary of care documents for physicians without staff
privileges. These are just a few of many challenges that persist today
when attempting to access patients' health information electronically.
______
Prepared Statement of Melanie Matthews, MSN, Chief Executive Officer,
Physicians of Southwest Washington; and President, MultiCare Connected
Care
Thank you, Chairman Wyden, Ranking Member Crapo, and members of the
committee, for the opportunity to testify today about how to improve
care for people with chronic conditions. My name is Melanie Mathews,
and I serve as the chief executive officer of PSW and president of
MultiCare Care Connected. I have over 20 years of health-care
experience with a focus on the delivery of value-based care.
Founded by independent physicians, PSW has led health-care
innovation with the guiding principle of supporting the physician-
patient relationship to improve the quality of care since its inception
in 1995. Committed to the value of innovation, PSW's approach is to
meet our partners ``where they are.'' We seek to find the complementary
balance of organizational experience and operational strength to
support our partner's success. PSW's diversified business portfolio
includes payer network operations, accountable care models, and
advisory and management solutions; this collective work accounts for
more than 400,000 member lives with a clientele of hospital systems,
payers, vendors, and provider practices.
In 2017, PSW created its first Accountable Care Organization (ACO):
NW Momentum Health Partners (NWMHP). NWMHP was created to give our
partner providers the ability to join a single network and engage in
new innovative Federal payment models. Since then, NWMHP has
participated in several CMS Innovation Center models: the Next
Generation ACO Model, the Bundled Payments for Care Improvement
Advanced (BPCI) Model, Global and Professional Direct Contracting
(GPDC) Model, and the ACO Realizing Equity, Access, and Community
Health (REACH) Model.
In 2018, PSW began its partnership with MultiCare Health System and
MultiCare Connected Care (MCC). MCC was developed to be the Clinically
Integrated Network (CIN) for MultiCare Health System and participate as
an ACO in the Medicare Shared Savings Program (MSSP). MCC's ACO
includes all MultiCare Health System hospitals and several other
provider organizations throughout Washington State.
accountable care is improving care delivery and lowering costs
Through our vast experience, we have seen how accountable care
(also called alternative payment models) delivers coordinated care that
best meet the needs of people, particularly those with chronic
conditions. Accountable care delivery holds providers responsible for
the cost of care and health outcomes. As opposed to a fee-for-service
system where the incentives are aligned toward greater volume,
accountable care focuses on healthier populations and people.
Accountable care efforts have shown that holding clinicians
responsible for total cost of care and patient outcomes improves care,
expands access, and saves money for Federal programs:
Accountable care improves care experiences by holding
providers responsible for patient outcomes and creating cash
flow through up-front or population-based payments that
providers can use to invest in tailored care management
programs, including for the chronically ill. Accountable care
strategies including care coordination, care transitions
programs (smoothing the transition from hospital to home for
example) and care management for medically complex patients
improve people's care experiences.\1\
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\1\ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7347295/.
Accountable care expands access to care, for example,
increasing weekend and evening hours appointments, using data
to identify gaps in care, and developing relationships with
community providers and social needs organizations to improve
health outcomes and address social determinants of health.\2\
---------------------------------------------------------------------------
\2\ https://accountableforhealth.org/wp-content/uploads/2024/02/
BRG_ImprovingAccess
ThroughValueBasedCare2024.pdf.
By incentivizing preventative care and reducing wasteful
spending, accountable care saves money. Advanced APM
Accountable Care Organization (ACO) portfolio (ACOs that take
on two-sided risk, including two-sided risk Medicare Shared
Savings Program and CMS Innovation Center ACOs) saved $4.2
billion in traditional Medicare in 2022,\3\ and a total of $8.4
billion in gross savings after taking into account spillover
effects in Medicare Advantage.
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\3\ https://www.naacos.com/assets/docs/pdf/2023/
NAACOS2022ACOSavingsResource.pdf.
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chronic care management successes in accountable care delivery
PSW's Chronic Care Management (CCM) program, overseen by the chief
medical officer (CMO) and chief nursing officer (CNO), is specifically
designed to enhance the quality of life for patients dealing with
chronic health conditions. Its primary objectives are to reduce health
disparities, minimize unnecessary health-care costs, and align with
value-based reimbursement systems. This initiative places a strong
emphasis on empowering patients to take charge of their health through
active engagement with primary care services.
The CCM program is particularly geared towards individuals with
chronic diseases who require support for self-management to improve
health outcomes. It operates within home settings, where patients or
their designated representatives assume responsibility for self-care
under professional guidance. Notably, the program takes a proactive
approach by identifying patients with poorly controlled chronic
conditions or significant negative impact of social determinants of
health, with the overarching goal of enhancing patient well-being and
health outcomes.
One of the program's core strategies is to foster long-term
positive outcomes by ensuring patients and their caregivers possess the
necessary knowledge and skills to identify and address health concerns
promptly. A registered nurse plays a pivotal role in this process by
developing and executing personalized care plans. This nurse
collaborates closely with a multidisciplinary team comprising
physicians, licensed practitioners, social workers, discharge planners,
pharmacists, and other health-care professionals as needed.
Services provided through the CCM program are highly
individualized, tailored to support patients with chronic conditions in
improving their overall health and well-being. The program places a
strong emphasis on patient education and empowerment for effective
chronic disease management and self-care. Through a collaborative team
approach involving the patient, nurse care manager (NCM), and primary
care provider (PCP), the program strives to achieve the patient's
specific health goals.
Additionally, comprehensive documentation of services follows
stringent National Committee for Quality Assurance (NCQA) requirements.
Participation in the Complex Care Management Program is voluntary, with
patients having the option to opt out at any time, provided they meet
the established enrollment criteria. This comprehensive approach
ensures that patients with complex health issues receive holistic care
tailored to their individual needs, ultimately aiming for improved
health outcomes and quality of life.
Patient Example
A patient with multiple health issues, including congestive heart
failure, experienced setbacks due to hospitalizations for sepsis and
pneumonia. Despite adhering to prescribed medications, their symptoms
worsened at home. After enrolling into a PSW ACO care management
program, a PSW nurse care manager began engaging with the patient and
recognized critical signs. The nurse care manager immediately took
action by contacting the primary care physician and recommending daily
monitoring of weight and blood pressure. With the remote monitoring and
PCP's adjusted medication regimen, the patient rapidly improved within
2 days, avoiding further complications. This success highlights the
vital role of ACO care management programs in providing timely support
and interventions for patients dealing with complex health issues,
enabling them to recover at home.
ACO Successes
NWMHP and MCC have played a pivotal role in transforming health-
care delivery and improving patient outcomes in Washington State,
resulting in significant cost savings for Medicare. Through their
innovative and patient-centered approaches, these ACOs have
collectively saved $120 million for Medicare while maintaining an
impressive average quality score of 96 percent and an average savings
rate of 4.5 percent from 2017 to 2022.
NWMHP's emphasis on accountable care has led to notable
advancements in patient outcomes across the State. By prioritizing
coordinated care initiatives, they have streamlined care transitions,
reduced hospital readmissions, and bolstered preventive care services.
NWMHP has partnered with independent providers and Critical Access
Hospitals alike to expand access to care and benefits to Medicare
beneficiaries. Moreover, NWMHP's proactive approach to preventive care
has resulted in increased utilization of wellness visits and
recommended screenings, fostering early detection and management of
health conditions.
Similarly, MCC's commitment to accountable care has yielded
positive outcomes for patients throughout Washington State. Through
targeted programs focusing on chronic disease management, MCC has
empowered patients to better manage their conditions, leading to
improved health outcomes and reduced health-care expenditures. The
emphasis on preventive screenings, including mammograms and flu
vaccines, has promoted proactive health management and wellness among
beneficiaries. Additionally, MCC's efforts in care coordination have
facilitated smooth transitions for patients navigating different care
settings, ensuring continuity of care and optimal patient experiences.
The combined achievements of NWMHP and MCC underscore their
dedication to delivering high-quality care while driving cost savings
for Medicare. Their success stories exemplify the transformative impact
of accountable care models in enhancing care coordination, promoting
preventive services, optimizing chronic disease management, and
ultimately, improving patient outcomes and health-care affordability in
Washington State.
federal policy can drive better care for chronically ill people
The Medicare Access and CHIP Reauthorization Act (MACRA) has been
instrumental in driving participation in accountable care that improves
care for people. MACRA included incentives for participation in two-
sided risk models, where providers can share in savings if they beat
spending targets while improving quality or repay losses if they exceed
those targets. Participants also received an incentive payment for
participating in a two-sided risk arrangement, known as the advanced
APM bonus. Those incentives served as a powerful motivator to grow
accountable care and allowed participants to reinvest into the health
care delivery system to expand access, improve care, and support our
clinical network. As a result, substantially more clinicians today,
including specialists, are participating in accountable care as
compared to before MACRA was enacted. ACO participation in the Medicare
Shared Savings Program has more than doubled, from 220 ACOs providing
care to fewer than 5 million Medicare beneficiaries in 2012,\4\ to 480
ACOs providing care to nearly 11 million aligned beneficiaries in
2024.\5\
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\4\ https://www.federalregister.gov/documents/2014/12/08/2014-
28388/medicare-program-medicare-shared-savings-program-accountable-
care-organizations.
\5\ https://www.cms.gov/newsroom/press-releases/participation-
continues-grow-cms-accountable-care-organization-initiatives-2024.
While accountable care has shown progress toward the goals of
better outcomes and lower costs, additional work is necessary to drive
change to the way care is delivered in Medicare and for other payers.
Now, nearly 10 years after MACRA's passage and over a decade into our
ACO and APM experience, we know more about what incentives work to
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drive participation in APMs. Specifically, we would recommend:
Extend the advanced APM bonus in the short term to
demonstrate Congress's bipartisan continued commitment to
ensuring better care for patients in traditional Medicare.
Restructure the bonus in the longer term to strengthen that
commitment, delinking advanced APM bonuses from volume of
services provided and shortening the time between payment and
performance (which is currently a 2-year delay).
Focus on advanced APM policies that simplify and support
provider participation and create clear advantages for
participating in an advanced APM.
Strengthen the data infrastructure to support accountable
care and population health.
incentives for beneficiaries to engage
Creating incentives for beneficiaries to engage with ACOs is
crucial to ensuring that the intended programs developed by ACOs have a
true impact on the population. Cost sharing incentives, for example,
can increase access services that otherwise might be avoided or
forgone. In Washington State, Columbia County Health System saw this as
they embarked on a journey to provide greater support to their patients
at risk of or diagnosed with chronic obstructive pulmonary disease
(COPD). Recognizing the challenges faced by these individuals, Columbia
County Health System developed a comprehensive program in collaboration
with their chronic care management efforts.
This program was designed to offer additional support and
resources, including regular nurse consultations, enhanced care
coordination, increased primary care visits, and facilitated access to
community-based and State-funded services to address social
determinants of health. However, despite the immense potential of this
program to improve patient outcomes and quality of life, Columbia
County Health System encountered a significant obstacle: low enrollment
among Medicare beneficiaries.
The primary deterrent to enrollment was the financial burden
imposed by coinsurance payments, rendering many beneficiaries unable to
afford these health-care services. It was evident that without
addressing this barrier, the program's impact would be severely
limited, denying vulnerable populations access to the care they
desperately needed.
In response to this challenge, Columbia County Health System, with
the support of our ACO, implemented the ACO REACH cost-sharing waiver.
This strategic decision to waive coinsurance payments proved to be a
game-changer. By alleviating the financial burden on beneficiaries, we
witnessed a remarkable surge in program enrollment.
The waiver not only facilitated greater participation but also
translated into tangible improvements in patient outcomes. Patients
with COPD who previously struggled to access care now had the means to
engage proactively in managing their health. This translated into
increased use of primary care, improved disease management, and
ultimately, enhanced quality of life for these individuals.
The success story of Columbia County Health System's COPD program
underscores a fundamental principle: when we remove financial barriers
and create incentives for engagement, we unlock the full potential of
ACO initiatives to deliver transformative health-care solutions. It is
imperative that we continue to explore and implement innovative
strategies, such as cost-sharing waivers, to ensure equitable access to
quality care for all beneficiaries.
support provider participation in sustainable, effective accountable
care
ACOs have supported and improved care for chronically ill
individuals for over a decade. Through two main avenues, the Medicare
Shared Savings Program and the ACO portfolio at the CMS Innovation
Center, participants in these total cost of care models, where
providers are accountable for population health and cost, have
consistently demonstrated savings and care improvements.
More can be done to support these models as well. In the Medicare
Shared Savings Program, CMS can continue to develop options with
greater levels of financial risk and reward, such as a full risk ACO
that was included in the Value in Health Care Act, introduced earlier
this year. In addition, Congress and CMS should work to ensure that
there are clear advantages under MACRA to participating in MSSP,
disentangling MSSP participants from burdensome MIPS requirements.
The ACO portfolio at the CMS Innovation Center has been a mainstay
of that portfolio since the Innovation Center's creation and continuing
across administrations with bipartisan support. Congress should support
continued operation of ACO models at the CMS Innovation Center that
support the transition to population-based payments, experiment with
new waiver flexibilities, and allow greater pursuit of coordinated care
strategies that support patent care.
conclusion
I thank the Committee for the opportunity to testify today. On
behalf of PSW and MultiCare Care Connected, we look forward to
continuing to work with you to advance the United States health care
delivery system to get better outcomes for patients.
Melanie's Affiliations
Accountable for Health (A4H)--board member
National Association of ACOs (NAACOS)--board member and chair-elect
America's Physician Groups (APG)--board member
Health Care Transformation Task Force (HCTTF)--board member
______
Questions Submitted for the Record to Melanie Matthews, MSN
Questions Submitted by Hon. Mike Crapo
Question. Advanced Alternative Payment Models (AAPMs) hold
significant promise as a means of driving improved value while ensuring
appropriate and targeted stewardship of Federal Medicare dollars for
both beneficiaries and taxpayers.
What specific steps should Congress or CMS take in order to improve
uptake of these models, including for specialties with low
participation rates?
Answer. To improve uptake of these models, Congress should pass
legislation that provides clear, strong incentives for the move to
accountable care. For example, Congress should extend the alternative
payment model (APM) incentive payment which helps providers address the
start up costs and ongoing costs associated with participating in these
models, including hiring staff, investing in health IT and standing up
care management programs. Congress should also make clear that the
Merit-based Incentive Payment System (MIPS) is less attractive than APM
participation. Today, the maximum MIPS potential bonus is 9 percent
while the advanced alternative payment model bonus is 1.88 percent.
These programs are reversed if the goal is to increase uptake in
alternative payment models.
Congress should also review the qualifying thresholds to obtain APM
status. MACRA established revenue/performance thresholds--known as
Qualifying APM Participant (QP) thresholds--that APM participants must
meet to qualify for incentives. These statutory levels, which increase
over time, have proven unrealistic relative to the real-life
experiences of clinicians. Congress has previously adjusted the QP
thresholds in 2020, 2022, and 2024.
The Value in Health Care Act ensures that qualifying thresholds
remain attainable to promote program growth by freezing them at 50
percent for 2 years and giving the Centers for Medicare and Medicaid
Services (CMS) authority to adjust thresholds through rulemaking and
set varying thresholds for more targeted models where participants
(e.g., specialists) cannot meet the existing one-size-fits-all
thresholds.
Last year, CMS also proposed making QP determinations at the
individual NPI level instead of the APM entity. This policy was not
finalized due to broad stakeholder concerns, but CMS has expressed
interest in revisiting this change.
While the current QP thresholds can make it difficult for some ACOs
to include specialists, there is concern that only making QP
determinations at the individual level would further discourage
specialist participation in ACOs.
As uptake of APMs continues to underperform original projections
the agency should use a determination process that will maximize the
number of QPs and promote growth in APMs.
Question. What specific flexibilities would help Accountable Care
Organizations to improve patient care quality and reduce costs, and
what steps could Congress take to advance these types of flexibilities?
Answer. MIPS--Reduce program complexity by ensuring that clinicians
in APMs are not required to engage in duplicative quality reporting
efforts. Emphasize that MIPS should prepare clinicians for and
encourage adoption of APMs.
Interoperability and use of CEHRT--CMS should repeal policies
changing the CEHRT requirements for MSSP ACOs and other APM
participants in 2025. In April, over 100 ACOs and dozens of health-care
associations wrote to CMS outlining how PI changes finalized in the
2024 Medicare Physician Fee Schedule will result in significant
increases in burden, especially for small practices.\1\
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\1\ https://www.naacos.com/assets/docs/pdf/2024/
AMASignonLetter_PICEHRTChangesAPMs
041024.pdf.
Digital Quality--Direct CMS to pilot test new digital quality
measurement to identify key challenges and unintended consequences.
Congress should provide incentives to participate in pilot tests, such
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as exemptions from existing reporting requirements.
MSSP--(1) Remove the high or low revenue-based designation in MSSP
that penalizes certain ACOs, especially those including rural and
safety net providers, (2) establish guard rails for CMS to ensure that
the process to set financial benchmarks is transparent and
appropriately accounts for regional variations in spending, to prevent
arbitrary winners and losers, (3) direct CMS to establish a voluntary,
full-risk track MSSP, and (4) expand the ACO Primary Care Flex model to
all ACOs to ensure that more clinicians can take advantage of
prospective population-based payments for primary care.
Waivers--Direct CMS to establish a common set of waivers for APMs,
incorporating successful waivers from the Next Generation ACO Model and
the ACO REACH Model into MSSP.
Chronic Care Management (CCM)--While APMs offer opportunity to
allow providers to reduce beneficiary cost sharing to ensure patients
receive enhanced care management, we encourage the committee to look at
legislative options to waive the beneficiary coinsurance related to
CCM.
GAO Report on Parity--Evaluate the potential of parity between APMs
and Medicare Advantage (MA) so policymakers can seek greater alignment
between the programs to ensure that both models provide attractive,
sustainable options for innovating care delivery, and to ensure that
APMs do not face a competitive disadvantage.
CMMI--Ensure that promising aspects of innovative models have a
more predictable pathway for becoming permanent.
Question. Artificial intelligence (AI) has the potential to
mitigate administrative burden and enhance health-care quality,
including in the context of Medicare. That said, some clinicians have
raised concerns around the program's inability to keep pace with AI-
enabled tool development through its coverage and payment policies,
undercutting access, especially for smaller practices.
What use cases for AI-enabled tools and technologies seem most
promising in the context of clinician care?
Answer. AI-enabled tools and technologies offer numerous promising
use cases in the context of clinician care. One area is quality gap
closure, where AI systems can efficiently communicate with patients and
schedule appointments on their behalf, ensuring timely and seamless
health-care delivery. This not only improves patient experience but
also optimizes clinic workflows.
Another valuable application is in annual wellness visits, where AI
tools can streamline the process, making it more comprehensive and
personalized. This ensures that preventive care measures are
effectively implemented, leading to better health outcomes.
Chronic disease monitoring is another promising area where AI
shines. By continuously monitoring patients and sending reminders about
necessary tests and visits, AI tools empower patients to manage their
conditions more effectively while providing clinicians with real-time
data for proactive intervention.
Additionally, AI can support clinicians in providing accurate and
timely differential diagnoses through clinical decision support and
chart review functionalities. This not only enhances diagnostic
accuracy but also aids in treatment planning.
One of the notable benefits of AI-enabled tools is the potential
for reducing administrative expenses significantly. The automation of
administrative tasks frees up resources that can be redirected towards
patient care, ultimately improving the overall quality of health-care
delivery.
Lastly, AI has the potential to enhance documentation practices by
providing more robust and accurate documentation of patient encounters.
This not only improves the quality of medical records but aids in
research and analysis for improvement in health-care practices.
Question. What steps should CMS and Congress take to ensure
adequate coverage and reimbursement for appropriate AI-enabled tools in
this context?
Answer. To ensure adequate coverage and reimbursement for
appropriate AI-
enabled tools in the context of clinician care, both CMS and Congress
can take several proactive steps.
Establish programs and incentives: Implement programs and
incentives that encourage the use of AI-enabled tools in health-care
settings. These programs can be tracked through auditing processes to
ensure proper utilization and effectiveness. Incentives could include
financial rewards, performance-based bonuses, or accreditation benefits
for clinics and providers adopting AI tools effectively.
Develop specific billing codes: Work collaboratively to develop
specific billing codes that reflect services leveraging AI
technologies. For example, for tools used in completing assessments
like the PHQ-9 (Patient Health Questionnaire-9) with patients, there
could be dedicated billing codes that allow for appropriate
reimbursement. These codes should be designed to accurately capture the
value and complexity of AI-enabled services provided.
Collaborate with industry stakeholders: Engage with industry
stakeholders, including AI developers, healthcare organizations, and
professional associations, to gather insights and best practices for
integrating AI tools into clinical care. This collaboration can help
identify opportunities for coverage and reimbursement improvements and
address any regulatory or policy barriers hindering the adoption of AI
technologies.
Regular review and updates: Establish a framework for regular
review and updates of coverage and reimbursement policies related to
AI-enabled tools. This ensures that policies remain current with
advancements in technology and health-care practices, allowing for
agile adjustments to support appropriate reimbursement for innovative
AI solutions.
______
Questions Submitted by Hon. Chuck Grassley
Question. The Center for Medicare and Medicaid Innovation (CMMI)
receives $10 billion in mandatory funding every decade. The nonpartisan
Congressional Budget Office (CBO) has found that CMMI has not lowered
Medicare spending. Separately, CBO has found the Medicare Shared
Savings Program (MSSP) was not a factor in the slower growth of Federal
health-care spending.
Are the spending impacts on Medicare from CMMI and MSSP each
validated by an independent, third-party organization? If not, why
would that be important?
Answer. There have been limited independent, third-party
organizations who have assessed the impact of MSSP. Studies conducted
by MedPAC,\2\ the National Association of ACOs,\3\ and researchers at
Harvard University,\4\ have all concluded net savings to Medicare. In
fact, in MedPAC's 2020 report to Congress the Commissioners estimated
that ACO models accounted for a 1- or 2-percent slower growth rate in
spending. The report from the commission goes on to say, ``Although the
estimated savings from these models are modest, they surpass those
achieved by a wide variety of care coordination models Medicare has
tried.''
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\2\ https://www.medpac.gov/wp-content/uploads/import_data/
scrape_files/docs/default-source
/reports/jun20_ch2_reporttocongress_sec.pdf.
\3\ https://www.naacos.com/assets/docs/pdf/
ExecutiveSummaryStudyMSSPSavings2012-2015.
pdf.
\4\ https://www.nejm.org/doi/full/10.1056/NEJMsa1803388.
It is important to bolster the ability for independent third-party
organizations to evaluate the impact of CMMI and MSSP. The current
approaches that CBO and CMMI uses to assess programs may not capture
the full impact of the model. For example, current approaches are
ineffective in quantifying the impact of health-care delivery changes.
Providers in APMs deliver care management improvements for their
patient populations, not just the patients aligned to the APM. This
``spillover effect'' creates savings accrued to non-model patients.
Similarly, it is increasingly challenging to evaluate models against a
population that is not in any value model. This counterfactual is
difficult with Medicare alternative payment models because so many
traditional Medicare patients are in at least one, if not multiple,
models. It's hard to find a population on which to make a true
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comparison of no value-based care interventions.
The proliferation of value, while a testament to its success, will
create challenges in assessing its impact. Providers in Medicare APMs
have been engaging in value-based arrangements with Medicaid, Medicare
Advantage, and commercial payers. This ultimately drives system-wide
changes that are not captured by single model evaluations.
In this vein, CBO has previously testified that ACOs may not have
been the primary driver of lower health-care spending. However, a
recent CBO report cited reductions in the growth of health-care
spending is due to reductions in spending on patients with
cardiovascular diseases due to better care management and increased use
of technology.\5\ To those of us working to improve patient care, these
findings are a direct result of value-based care. Care management and
leveraging technology to support population health management are two
core components of all APMs, yet these aspects are not measured as part
of CBO reports or CMMI evaluations.
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\5\ https://www.cbo.gov/system/files/2023-10/59660-testimony.pdf.
To support more independent, third-party organization research and
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to better demonstrate the impact of value, we recommend the following:
CMMI should release more granular data on providers
participating in these models. Even CBO has had to rely on the
formal, published evaluations for its conclusions about CMMI
models.
CMMI and CBO should include a broader set of model aspects
in its evaluation reports--such as provider satisfaction,
beneficiary satisfaction, overlap with other models, potential
spillover to practice change, and additional benefits or
services provided to beneficiaries because of inclusion in the
model.
CMMI and CBO should consider how to assess quality
improvements. As outlined by Congress, CMMI models should lower
costs without sacrificing quality, improve quality without
raising spending, or both lowering costs and improving quality.
CMMI models should be deemed successful if they improve quality
of care, even if they don't lower Medicare spending.
Question. In 2005, this committee held a hearing that I chaired
titled, ``Improving Quality in Medicare: The Role of Value-Based
Purchasing.'' I said at the time that we do not want to overburden
providers with reporting requirements. I went on to say that it is
important to develop these health-care quality measures by consensus.
Do you feel reporting requirements are developed by consensus and
do not overburden providers? If not, what actions should we take to
reduce the burden?
Answer. MACRA created pathways for reducing provider burden by
excluding all clinicians in advanced APMs from MIPS. This has been a
strong nonfinancial incentive for providers to join APMs; however, we
are concerned that CMS has removed some of this burden reduction. In an
effort to align ACOs and APMs reporting approaches with MIPS, CMS is
now requiring:
Advanced APMs to report the Promoting Interoperability (PI)
category of MIPS instead of attesting to CEHRT use by
clinicians in the APMs. This adds burden as it will require
reporting of metrics that are not indicative of improved care.
ACOs must be committed to information sharing to be successful
in the model, so these requirements are duplicative and
unnecessary.
ACO reporting requirements to align with MIPS. The MIPS
reporting requirements and scoring rules were created with a
focus on individuals and small groups and have therefore caused
a number of problems when applying to ACOs who are a collection
of clinicians, hospitals, and other providers. This has
resulted in expensive data aggregation and de-duplication work
to report quality measures at the ACO level using MIPS
measures, specifications and reporting types.
ACOs to report electronic clinical quality measures (eCQMs)
ahead of industry readiness, with a lack of full adoption of
standards and interoperability impeding this effort.
Additionally, quality measures have not been designed to measure
the care delivered in value arrangements. The quality measures that
have been developed since the passage of MACRA have been focused on
implementation in a fee-for-service system. Measures for APMs are then
selected from the available FFS measures. For value-based care
entities, the measure sets vary across programs and models, there are
multiple reporting methods, and a misalignment with the measures sets
used in MA and commercial value arrangements.
Fundamentally, we believe that this approach is flawed. Reporting
for ACOs and other APMs should be the gold standard with MIPS
structured to prepare clinicians for adopting APMs. To accomplish this,
Congress should:
Exclude all APMs from all MIPS, this will reduce program
complexity by removing duplicative efforts.
Direct CMS structure MIPS to prepare clinicians for
transitioning to APMs.
Direct CMS to exclude advanced APMs from all MIPS reporting
categories, repealing the recently finalized rule requiring
advanced APMs to report PI. Instead, CMS could require advanced
APMs to attest to additional needed elements such as
information blocking. Over 100 ACOs and dozens of stakeholders
recently sent a letter to CMS requesting this change.\6\
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\6\ https://www.naacos.com/assets/docs/pdf/2024/
AMASignonLetter_PICEHRTChangesAPMs
041024.pdf.
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Direct CMS to develop measures specifically for APMs.
Direct CMS to pilot test eCQMs and other digital quality
measure approaches ahead of required implementation.
Question. In CBO's report on pilot programs supported through CMMI,
only six of the 49 pilot program models saved money.
Are CMMI models effective at lowering total Medicare spending? Did
the Comprehensive Primary Care Plus model save money?
Answer. The Innovation Center has been successful in testing
innovative payment arrangements and increasing adoption of APMs. The
successes of the Innovation Center are not always captured within
current evaluation approaches. For example, CBO estimates that CMMI's
activities increased direct spending by $5.4 billion in the first 10
years and another $1.3 billion by 2030.\7\ However, CBO's report
focuses only on savings achieved and does not account for many aspects
of value-based payment models such as provider burden relief, patient
experience, clinical transformation, and the spill-over effect that
occurs when providers apply value principles across all patient
populations. The Innovation Center's evaluation criteria and criteria
for model expansion have similar challenges. Congress should work with
CMS to ensure that promising models have a more predictable pathway for
being implemented and becoming permanent and are not cut short due to
overly stringent criteria. Specifically, Congress should:
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\7\ https://www.cbo.gov/system/files/2023-09/59274-CMMI.pdf.
Broaden the criteria by which CMMI models qualify for Phase
2 expansion. The criteria should consider if the model reduces
provider burden, increases patient satisfaction, offers
additional benefits and services to patients that are not
billed to Medicare, expands participation to more provider
types, results in clinical care transformation, or is adopted
---------------------------------------------------------------------------
in private sector value arrangements.
Direct CMMI to engage stakeholder perspectives during APM
development. The Innovation Center could leverage the
Physician-Focused Payment Model Technical Advisory Committee
(PTAC) to provide input on models in development.
The Comprehensive Primary Care Plus (CPC+) model evaluation \8\
demonstrated that practices simultaneously participating in MSSP did
achieve reductions in total expenditures even though the model did not
reduce total Medicare expenditures after accounting for enhanced
payments. CPC+ practices in the MSSP cohort were also found to have
reduced acute inpatient expenditures by over 2 percent during the
course of the model.
---------------------------------------------------------------------------
\8\ PY4 evaluation: https://www.cms.gov/priorities/innovation/data-
and-reports/2022/cpc-plus
-fourth-annual-eval-report.
Summary: https://www.cms.gov/priorities/innovation/data-and-
reports/2022/cpc-plus-fourth
-annual-report-findings.
PY5 (final) evaluation: https://www.cms.gov/priorities/innovation/
data-and-reports/2023/cpc-plus-fifth-annual-eval-report.
Summary: https://www.cms.gov/priorities/innovation/data-and-
reports/2023/cpc-plus-fg-fifth-annual-eval-report.
Given the positive interaction of CPC+ and MSSP, it is important to
replicate this approach for all ACOs. Currently, ACOs in the REACH
model can offer primary care capitation. The new ACO Primary Care Flex
(PC Flex) Model, which will provide monthly, prospective, population-
based payments for primary care practices in participating MSSP ACOs
will replicate the success of CPC+ and MSSP together. However, it is
disappointing that the model is limited to ACOs that are designated as
``low revenue,'' have selected prospective assignment, and begin a new
agreement period beginning in 2025. This will significantly limit
participation in the model since the majority of primary care providers
currently participating in MSSP are in ``high revenue'' ACOs, including
67 percent of primary care physicians, 68 percent of NPs, 72 percent of
PAs, 87 percent of RHCs, and 25 percent of FQHCs. To build on known
---------------------------------------------------------------------------
successes, CMS should open the PC Flex model to all ACOs in MSSP.
Question. You stated in your written testimony that the ``advanced
APM Accountable Care Organization portfolio (ACOs that take on two-
sided risk, including two-sided risk Medicare Shared Savings Program
and CMS Innovation Centers ACOs) saved $4.2 billion in traditional
Medicare in 2022, and a total of $8.4 billion in gross savings after
taking into account spillover effects in Medicare Advantage.''
Are these figures validated by an independent, third-party
organization? If so, by whom?
Answer. These savings numbers are derived from public use files CMS
makes available and reflect the difference between CMS-generated
benchmarks for a given year and an ACOs' collective spending compared
to those benchmarks.\9\
---------------------------------------------------------------------------
\9\ https://www.cms.gov/medicare/payment/fee-for-service-providers/
shared-savings-program-ssp-acos/data.
Recently, CBO released an updated report highlighting how several
counterfactual studies have shown ACOs in the MSSP program are
associated with net budgetary savings for the Medicare program.\10\
Many of CBO's recommendations to increase ACO savings--increasing and
extending current provider incentives, ensuring accurate financial
benchmarks, improving patient engagement, and offering tools like
primary care hybrid payments--are options that PSW and other
stakeholders have previously discussed with Congress. We hope this
report spurs additional interest in these topics from Capitol Hill.
---------------------------------------------------------------------------
\10\ https://www.cbo.gov/publication/60213#footnote-038-backlink.
Question. A common concern from Iowa providers is the lack of
preparation and notice for final payment rules from CMS. When final
payment rules are set a couple of months or less from the start of the
payment rule's implementation date, providers do not have time to
prepare or adjust to new payment policies and administrative
---------------------------------------------------------------------------
requirements. This includes changes to value-based care efforts.
Should there be a longer preparation period (e.g., 6 months, 1
year) for providers to adjust to new payment policies and
administrative requirements under Medicare? What effect would that
have? Alternatively, should payment policies and administrative
requirements remain consistent for more than 1 year except for newer
input data (e.g., inflationary or economic factors)?
Answer. There should be longer preparation periods for some new
policies. Certain small changes or changes in response to ACO
participant challenges could be implemented more rapidly, while other
significant changes or payment cuts have at least a year-long
preparation period before they are put in place. This would allow
provider organizations a reasonable amount of time to implement
necessary operational changes or carefully consider strategic decisions
that would impact their participation in Advanced Alternative Payment
Models (AAPM).
One example of this is the impact of participation in the Medicare
Shared Savings Program (MSSP) based on the timing of the Medicare
Physician Fee Schedule rule. Currently, MSSP ACOs must submit to CMS
their list of participating providers who have signed an agreement to
participate in MSSP by the beginning of August. This submission
ultimately determines the decision for the AAPM that a provider
organization will participate in for the upcoming year. However, the
final Medicare Physician Fee Schedule rule is typically not released
until November with policy changes that often affect MSSP for the
upcoming year.
This can be a challenge for provider organizations looking to
participate in AAPMs as these late policy changes make projections for
potential performance highly unpredictable. Creating a sufficient
preparation period before new policies are finalized will ensure that
provider organizations are given a proper amount of time to evaluate
the effects of those policies on their operations and financial
stability.
Question. A 2023 RAND study of the Medicare Advantage Value-Based
Insurance Design Model found the first 2 years of the model did not
result in improved health outcomes or costs, but there was an
improvement in the quality of care. This is similar to independent
analyses of fee-for-service value-based models.
What is the scope of value-based contracts in Medicare Advantage
and their effectiveness in reducing costs and improving outcomes?
Answer. Adoption of value-based contracts between Medicare
Advantage plans and providers are reported informally to the Health
Care Payment Learning and Action Network. Summary reports on the
adoption of alternative payment model contracts for the past several
years are available here: https://hcp-lan.org/apm-measurement-effort/
2023-apm/.
Their effectiveness in reducing costs and improving outcomes would
be accessible via the individual health plans--that data is not
currently publicly available as far as we are aware.
In our experience, we are fully delegated for risk in Medicare
Advantage, allowing us to support our providers across Medicare
Advantage and Medicare ACOs. We are able to synthesize measures and
operational workflows to ease the provider burden when participating in
multiple programs. We have been successful in this space in reducing
costs and improving outcomes for Medicare Advantage and Medicare ACO
beneficiaries alike.
______
Questions Submitted by Hon. Maria Cantwell
Question. The Medicare program accounts for about 20 percent of
national health-care spending, and Medicare physician payments account
for 26 percent of all national payments for physician and clinical
services. Despite the enormous amount we spend on health care, health
outcomes, especially for our seniors, are not better than comparable
wealthy countries. In fact, the United States has the highest rate of
people with multiple chronic conditions out of all high-income
countries.
As the baby boomer generation ages, Medicare expenditures will
only continue to rise. We must be looking at innovative ways to reduce
costs for the government while improving health outcomes at the same
time. One of these innovations is Accountable Care Organizations, or
ACOs. An ACO is a group of health-care providers who voluntarily come
together to provide coordinated, high-quality care for Medicare
patients. By increasing coordination, ACOs help reduce duplication of
services and prevent medical errors, leading to higher health outcomes.
ACOs also help reduce costs by reinvesting a portion of the savings
they generate into the Medicare trust fund. In Washington State, there
are 44 ACOs serving more than 260,000 Medicare beneficiaries. These
ACOs saved $104.5 million for Medicare in 2021 and 2022, which amounted
to $235 in savings per beneficiary.
This is the type of innovation that we need to consider as we
tackle the problem of ballooning medical expenditures. We need to start
moving away from volume-based care that prioritizes the quantity of
services provided, to value-based care that prioritizes quality of care
and increased health outcomes.
Do you agree that Medicare could see even more savings and improve
the quality of care for seniors by encouraging more providers to join
ACOs?
Answer. Yes. ACOs have demonstrated the ability to generate savings
for Medicare and improve the health outcomes for the populations that
they serve. By adopting policies, such as extending the Advanced
Alternative Payment Model (AAPM) bonus, that encourage greater provider
participation in ACOs, Medicare could see exponential growth in the
savings generated by these programs.
Question. Are there any issues or roadblocks that are preventing
more providers from joining ACOs?
Answer. There are several roadblocks to increased provider
participation in ACOs. Some of the biggest roadblocks are:
Infrastructure and resources: Participating in an ACO often
requires robust infrastructure and resources to manage data,
track performance metrics, and coordinate care effectively.
Smaller practices or those with limited technological
capabilities may find it challenging to meet these
requirements, making ACO participation less feasible.
Regulatory and compliance burdens: ACOs comply with complex
regulatory requirements, including those related to data
reporting, quality measures, and beneficiary communications
Navigating these regulatory requirements can be time-consuming
and resource-intensive for providers, acting as a barrier to
participation.
Incentive alignment: Ensuring that incentives are aligned is
essential for the success of ACO Models. Misaligned incentives
or conflicting policy changes can create challenges in
achieving shared goals and may discourage providers from
joining or remaining actively engaged in an ACO.
Rural and underserved: To improve access to health care in
rural and underserved settings, Congress should create more
pathways for providers in rural settings to adopt APMs. There
are significant barriers to providers who are currently paid
via cost-based reimbursement to be able to successfully
participate in ACOs. In the last decade we have seen
significant adoption among rural providers, with more than
4,400 Federally Qualified Health Centers (FQHCs), 2,200 Rural
Health Clinics (RHCs), and 460 Critical Access Hospitals
participating in MSSP or ACO REACH.
Question. What types of policies or programs should we be promoting
to incentivize more providers to join ACOs?
Answer. There are many policy changes that would encourage greater
participation in ACOs such as the Value in Healthcare Act, which would
implement numerous policies that would incentivize greater
participation in ACOs. These policies include the extension of the APM
incentive payment, establishes guardrails for CMS to ensure that the
process to set financial benchmarks is transparent and appropriately
accounts for regional variations in spending, and removes the revenue-
based designation in the Medicare Shared Savings Program (MSSP) that
penalizes certain ACOs, especially those including rural and safety net
providers.
______
Questions Submitted by Hon. John Cornyn
Question. Too often our health-care system looks at patients'
medical needs as separate and unrelated issues rather than looking at
the full picture of someone's health.
Value-based care recognizes the importance of coordinating
patients' care for better health outcomes. It both holds providers
accountable for their services and rewards good patient care. Patient
heath-care services are not just boxes to be checked.
Accountable Care Organizations provide this type of care to over
593,000 Medicare beneficiaries in Texas. You have extensive experience
in value-based care.
Can you elaborate on how alternative payment models like ACOs
incentivize more personalized care for patients?
Answer. Alternative payment models like Accountable Care
Organizations promote personalized care for patients through various
strategies.
ACOs establish financial incentives based on performance against
quality metrics, encouraging providers to deliver high-quality,
personalized care to improve patient outcomes. By aggregating data and
providing performance scorecards, ACOs enable providers to track their
performance and make data-driven improvements, fostering a culture of
continuous quality improvement.
Moreover, many ACO models offer benefit enhancements to patients,
such as extended services or to support improved access to care. These
can be in the form of beneficiary incentives to engage in care
programs. This further supports personalized care initiatives by
addressing specific patient needs and preferences.
Additionally, the Advanced Alternative Payment Model (AAPM) bonus
allows for investment in infrastructure enhancements, such as
additional staff or technology improvements. This investment supports
personalized care initiatives like care management programs and
interdisciplinary care teams, which work collaboratively to develop
specific care plans tailored to individual patient needs.
Through these mechanisms, ACOs create an environment that
incentivizes and supports personalized care delivery, leading to better
health outcomes and enhanced patient satisfaction.
Question. How does coordinating care both improve the patient
experience and reduce wasteful spending?
Answer. Coordinating care plays a vital role in improving the
patient experience and reducing wasteful spending by optimizing health-
care delivery and addressing Social Determinants of Health (SDOH).
Firstly, through ACOs, care management programs can identify trends
within practice groups, such as the overutilization of emergency
departments (ED) for conditions like urinary tract infections (UTIs).
By providing information on these trends, ACO care teams collaborate
with providers to implement strategies that reduce ED visits. For
instance, educating patients on alternatives like telehealth for non-
emergency conditions can redirect care to more appropriate and cost-
effective settings, reducing wait times, improving patient
satisfaction, and reducing unnecessary health-care expenditures.
Additionally, coordinating care involves addressing SDOH, such as
housing instability, food insecurity, and lack of access to
transportation. These factors significantly impact health outcomes and
health-care utilization. By implementing programs that target SDOH,
health-care organizations can improve patient health outcomes, reduce
the need for acute care services, and ultimately lower health-care
costs.
Coordinating care enhances the patient experience by ensuring
timely and appropriate access to care while also curbing wasteful
spending through targeted interventions that address both health-care
utilization trends and SDOH.
______
Questions Submitted by Hon. John Thune
Question. As part of the Merit-based Incentive Payment System
(MIPS), physicians must be compliant in promoting interoperability as
part of their reimbursement, which helps to facilitate the sharing of
data between various providers.
I have long been an advocate for health IT initiatives that can
improve efficiencies and reduce costs in the health-care system, and I
believe that sharing information between providers through an
interoperable network has immense upside, so long as there are
safeguards to protect patient privacy and ensure taxpayer funds are
spent appropriately.
However, there continue to be challenges to physicians meeting
interoperability metrics, like information blocking for example in
which an individual or entity impedes the delivery or utilization of an
electronic health record, making interoperability impossible.
In your view, how have practices been impacted by information
blocking?
Answer. Information blocking has had a profound impact on health-
care practices, particularly smaller provider organizations that lack
robust information technology (IT) resources. The burden of achieving
interoperability often falls heavily on these entities as larger
systems prioritize their own operational efficiencies. This dynamic can
result in significant challenges and increased costs for smaller
providers who must rely on outsourcing for building and managing
interoperability solutions.
One of the key issues is the absence of dedicated programs to
support smaller, community-based provider organizations. These
entities, often consisting of independent primary care practices, face
the dual challenge of meeting stringent reporting and data sharing
requirements while lacking adequate funding to invest in the necessary
IT infrastructure. This imbalance can lead to suboptimal patient care
outcomes and hinder the ability of these providers to fully leverage
digital tools for improved health-care delivery.
For instance, in communities primarily composed of small,
independent primary care providers, the strain is palpable. These
providers are essential pillars of local health-care ecosystems but are
often constrained by financial limitations when it comes to adopting
and maintaining interoperable IT systems. Consequently, they may
struggle to meet regulatory demands, share patient data seamlessly, and
offer high-quality, coordinated care.
To address these challenges effectively, it's crucial to establish
a supportive program that provides funding and resources specifically
tailored to the needs of smaller provider organizations. By offering
financial assistance and guidance for IT investments, such a program
can empower these providers to enhance their interoperability
capabilities, streamline data sharing processes, and ultimately improve
patient outcomes across communities.
Question. Are you aware of instances in which the timeliness or
quality of the care physicians are able to provide patients has been
impacted by a limited ability or complete inability to access
electronic health records?
Answer. The limited ability or complete inability to access
electronic health records (EHRs) can indeed impact the timeliness and
quality of care that physicians are able to provide to patients.
Specifically, instances regarding Rural Health Clinics (RHCs) and their
inability to submit CPT II codes in traditional Medicare can have a
substantial impact.
When RHCs are restricted from submitting these codes for quality
metrics, it creates a skewed perception that their outcomes are poorer
compared to non-RHC groups. However, this discrepancy doesn't
accurately reflect the care provided. It leads to duplicated efforts
and adds a significant overhead and administrative burden on these
rural systems, diverting valuable resources away from patient care.
Moreover, these limitations in funding and resources can have
broader repercussions. Patients may perceive a lack of comprehensive
care in rural areas and feel compelled to seek treatment in urban
centers where access to advanced health-care services may be perceived
as better. This migration of patients towards urban areas due to
perceived gaps in care further strains the health-care system and can
result in individuals who cannot afford such travel opting to forgo
necessary medical attention altogether.
This situation underscores the critical importance of addressing
barriers to EHR accessibility and interoperability, particularly for
rural health-care settings. Investing in technology infrastructure,
providing adequate funding and support for rural providers to implement
and maintain EHR systems, and ensuring standardized reporting
mechanisms can all contribute to improving the timeliness and quality
of care delivered to patients in these underserved areas. Such efforts
can also help mitigate the administrative burdens that currently hinder
optimal patient care in rural healthcare settings.
Question. Furthermore, beyond information blocking, what other
challenges persist in physicians accessing patients' health information
electronically despite the billions of dollars spent to implement
electronic health IT and interoperability?
Answer. Several challenges persist in physicians accessing
patients' health information electronically despite significant
investments in electronic health IT and interoperability.
One major challenge is the exorbitant cost associated with
electronic medical records (EMRs). While EMRs are essential for digital
health information management, their initial implementation and ongoing
maintenance expenses can be high and difficult to maintain.
Additionally, the need for customization to suit specific workflows or
requirements further drives up costs, creating financial barriers for
smaller providers.
In rural communities, another significant challenge emerges due to
reliance on larger health systems to purchase the technology. This
reliance can create a monopoly in the market, where rural providers are
limited to the options and functionalities offered by the dominant
systems. As a result, these providers may not have access to tailored
solutions that address their unique patient population or operational
needs, impacting their ability to effectively leverage electronic
health information for better patient care.
Addressing these challenges requires a multifaceted approach.
Initiatives aimed at reducing the cost of EMRs, such as incentivizing
standardized systems or providing subsidies for implementation, could
make these technologies more accessible to a broader range of
providers. Investments could also be made in this area by developing
programs that provide a greater level of funding to small and rural
providers attempting to meet the interoperability requirements.
______
Question Submitted by Hon. Sheldon Whitehouse
Question. I am working on a bill to relieve providers excelling in
the Medicare Shared Savings Program (MSSP), from prior authorization
(PA) requirements in MA. The bill rewards providers in Accountable Care
Organizations (ACOs) that generate savings for Medicare by granting an
exemption from PA requirements for their MA beneficiaries. If an
insurer believes there is a rationale for maintaining PA in such
instances, this bill would require them to seek prior approval from the
Centers for Medicare and Medicaid Services. I would welcome your
thoughts and comments on this idea.
Answer. There has been great discussion as to the administrative
burden that the prior authorization process imposes on providers. We
recognize the burden imposed to the providers as well as to the
beneficiaries who see the process as a potential impediment or barrier
to timely access to care. In the worst case scenario, prior
authorization requirements can sometimes lead to the delay or denial of
medically necessary care that compromises the outcome of a patient.
The Medicare Advantage program utilizes prior authorizations as a
means to ensure that certain designated services meet established
criteria before approval. This allows the Medicare Advantage
Organization to safeguard against unnecessary procedures and
treatments, reduce the risk of inappropriate or ineffective care, and
encourage providers to explore equally effective but less costly
alternative treatment options. By ensuring that efficacious quality
care is being approved for delivery, Medicare Advantage plans help
improve beneficiary outcomes--but only if the prior authorization
process is efficient and effective.
We view the proposal to exempt well performing MSSP providers from
all Medicare Advantage prior authorizations as ambitious and
innovative, but potentially harmful to operations. The burden of
knowing who is in or who is out of the program at the provider level at
any given time provides additional abrasion and could consume resources
that could otherwise be spent on investments in interoperability of the
prior authorization process. Also, this approach would exempt a
provider from all prior authorization requirements which may not be the
most effective approach. A provider may be a successful MSSP
participant without having made the same cost-effective, high-quality
decisions for treating all conditions across the board. This exemption
may be more effective at reducing provider burden while still managing
cost by building an structure where a provider must apply for this
exemption that is approved by a decision-making body. The decision-
making body could then review the provider's practices and determine if
an exemption should be offered for certain conditions or for the
provider's entire range of practice.
If carried out effectively, this exemption would be an additive,
nonfinancial incentive for providers to join ACOs and offer more
streamlined access to their practices that meet care coordination and
utilization standards. Tying the qualification to advanced APM
eligibility could also help to standardize some of the nonfinancial
incentives available for clinicians that choose to participate in APMs.
______
Questions Submitted by Hon. Marsha Blackburn
Question. It is important that Congress continue to promote
policies that accelerate the movement toward alternative payment models
(APMs). The Consolidated Appropriations Act of 2024 included a 1-year
extension of the incentive payments for participation in eligible APMs
at a reduced rate of 1.88 percent.
How will the continuation of the APM incentive payments help
promote the movement toward value-based care? What can Congress or CMS
do to encourage more physicians, especially specialists, to adopt APMs?
Answer. The continuation of the APM incentive payments will help
providers invest in infrastructure that will allow them to be
successful in an APM. Many of our small, independent providers used the
APM incentive to help them pay staff wages and keep their doors open
throughout the pandemic. Now, providers who have been able to stabilize
their revenue can use the incentive payment to invest in new technology
or additional resources that help them care for the community.
Congress and CMS could encourage greater APM participation by
reinstating the full APM incentive payment and promoting policies that
integrate specialists into ACOs. These policies would also need to
redesign the requirements to achieve the APM incentive to account for
specialists. Currently, ACOs with specialists in their network are
unable to meet the thresholds required for the APM incentive payment.
By developing a long-term APM incentive solution that accounts for
specialists alongside primary care, Congress and CMS would see an
increase in participation and in investments toward improving the
health outcomes of patients.
Question. Every year, we see an alarming decline in physicians
offering essential care services. This trend is partly fueled by
soaring costs for practices, already high yet constantly increasing
administrative burden, and low reimbursement rates, often well below
the cost of providing care.
How has the cost of providing lifesaving care changed over the
years for your practice, and how has the payment for those services
caught up or not caught up?
Answer. The cost to provide lifesaving care has continued to
increase over the years. The years following the pandemic have been
especially challenging with the combination of increased pricing and
struggle to maintain resources. The payment for these services have not
kept up, causing numerous independent providers to close their doors or
sell to a larger organization. Without a payment system that maintains
pace with increasing costs and incentives such as the APM incentive
payment to drive provider participation in APMs, we will continue to
see a high rate of closure among independent providers. Many of our
providers have relied on the APM incentive payment to keep their doors
open through the pandemic. It is crucial to support the Value in
Healthcare Act to extend important policies such as the APM incentive
payment.
Question. How does the yearly scramble to delay or reduce CMS
payment cuts to the PFS impact your ability to plan for the future?
What would it mean for you and practices like you if these cuts were
fully implemented and not scaled back?
Answer. The yearly scramble to mitigate CMS payment cuts to the
Medicare Physician Fee Schedule has a substantial impact on our ability
to plan for the future. The changes in the Medicare Physician Fee
Schedule often dictate if a provider's participation in an ACO will be
financially viable and impacts the resources that a provider must
invest in to participate. With how late in the year these policy
changes are released, providers are forced to have already signed
contracts to participate in ACOs or made the decision to not
participate for the upcoming year by the time the changes are released.
This makes it near impossible to accurately project the financial
viability of ACO participation and poses a substantial barrier to
increased provider participation. Also, if many of these large proposed
cuts are not scaled back due to our efforts, independent providers
would not be able to maintain pace with rising costs and would be
forced to shut their doors. Our organization spends a great deal of
time with our advocacy groups to mitigate the payment cuts, but this
takes time and resources away from our original mission to enhance the
patient experience and improve the quality of care for those that we
serve.
Question. As a value-based purchasing program, MIPS was supposed to
reward physicians who achieved quality and cost-efficient care.
However, for years physicians have raised concerns about the program,
including that it increases administrative burden and does not
accurately capture quality.
What has been your experience with MIPS and the administrative
burden that it entails?
Answer. Due to its complexity, one of the many advantages to
participating in APMs is the opportunity to be excluded from MIPS
reporting. We believe it is essential that APM providers continue to
have the opportunity to be excluded from MIPS. However, recent policy
changes in the Physician Fee Schedule rule are attempting to impose
burdensome MIPS reporting elements, such as reporting Promoting
Interoperability, onto APM providers. This increased burden has no
impact on the quality of care that is provided to patients.
Question. Is it time to consider replacing the program with a more
valuable alternative? If so, what are some of the program's benefits
that should be considered when designing its replacement?
Answer. A valuable alternative to MIPS already exists in the form
of APMs. We support reducing program complexity by mitigating the
duplicative work that providers engage in when participating in an APM.
This would be accomplished by maintaining that APM providers be
excluded from MIPS reporting and ensuring that new policy changes do
not impose elements of MIPS reporting onto APM providers. Future
reforms to MIPS should be used to prepare providers for participation
in APMs and encourage them to transition from MIPS to APMs. A clear
direction with clear incentives must be outlined for the pathway from
MIPS to APM participation for providers, allowing them to adjust their
efforts accordingly.
Question. Part of the Physician Fee Schedule's MIPS program
measures interoperability, which is impeded by information blocking by
providers, vendors, or others wanting to hoard patient data, which can
affect MIPS performance and reduce reimbursement to providers.
How have your practices been impacted by information blocking?
Answer. Information blocking has had a profound impact on our
health-care practices, particularly smaller provider organizations that
lack robust information technology (IT) resources. The burden of
achieving interoperability often falls heavily on these entities as
larger systems prioritize their own operational efficiencies. This
dynamic can result in significant challenges and increased costs for
smaller providers who must rely on outsourcing for building and
managing interoperability solutions.
One of the key issues is the absence of dedicated programs to
support smaller, community-based provider organizations. These
entities, often consisting of independent primary care practices, face
the dual challenge of meeting stringent reporting and data sharing
requirements while lacking adequate funding to invest in the necessary
IT infrastructure. This imbalance can lead to suboptimal patient care
outcomes and hinder the ability of these providers to fully leverage
digital tools for improved health-care delivery.
For instance, in communities primarily composed of small,
independent primary care providers, the strain is palpable. These
providers are essential pillars of local health-care ecosystems but are
often constrained by financial limitations when it comes to adopting
and maintaining interoperable IT systems. Consequently, they may
struggle to meet regulatory demands, share patient data seamlessly, and
offer high-quality, coordinated care.
To address these challenges effectively, it's crucial to establish
a supportive program that provides funding and resources specifically
tailored to the needs of smaller provider organizations. By offering
financial assistance and guidance for IT investments, such a program
can empower these providers to enhance their interoperability
capabilities, streamline data sharing processes, and ultimately improve
patient outcomes across communities.
Question. Have you had experiences where your ability (or
inability) to access health records has impacted the timeliness or
quality of the care you are able to provide your patients?
Answer. The limited ability or complete inability to access
electronic health records (EHRs) can indeed impact the timeliness and
quality of care that physicians are able to provide to patients.
Specifically, instances regarding Rural Health Clinics (RHCs) and their
inability to submit CPT II codes in Traditional Medicare can have a
substantial impact.
When RHCs are restricted from submitting these codes for quality
metrics, it creates a skewed perception that their outcomes are poorer
compared to non-RHC groups. However, this discrepancy doesn't
accurately reflect the care provided. It leads to duplicated efforts
and adds a significant overhead and administrative burden on these
rural systems, diverting valuable resources away from patient care.
Moreover, these limitations in funding and resources can have
broader repercussions. Patients may perceive a lack of comprehensive
care in rural areas and feel compelled to seek treatment in urban
centers where access to advanced health-care services may be perceived
as better. This migration of patients towards urban areas due to
perceived gaps in care further strains the health-care system and can
result in individuals who cannot afford such travel opting to forgo
necessary medical attention altogether.
This situation underscores the critical importance of addressing
barriers to EHR accessibility and interoperability, particularly for
rural health-care settings. Investing in technology infrastructure,
providing adequate funding and support for rural providers to implement
and maintain EHR systems, and ensuring standardized reporting
mechanisms can all contribute to improving the timeliness and quality
of care delivered to patients in these underserved areas. Such efforts
can also help mitigate the administrative burdens that currently hinder
optimal patient care in rural health-care settings.
Question. Do existing Federal quality and payment incentive
programs under Medicare, like ``Promoting Interoperability'' under the
Merit-based Incentive Payment System, enable up-to-date, consolidated
longitudinal health records accessible without special effort?
Answer. Existing Federal quality and payment incentive programs
under Medicare, such as the ``Promoting Interoperability'' initiative
under the Merit-based Incentive Payment System (MIPS), do not
necessarily enable up-to-date, consolidated longitudinal health records
that are easily accessible without special effort.
The challenge lies in the practical implementation of these
programs, especially for single-provider practices with limited
technical expertise among their office staff. These practices often
operate under tight budget constraints, making it difficult to allocate
additional resources towards building and maintaining sophisticated
health record systems that meet interoperability standards.
The costs associated with implementing and sustaining such systems
can be prohibitive for small practices, preventing them from fully
participating in Federal incentive programs aimed at promoting
interoperability. As a result, these practices may struggle to achieve
the level of data integration and accessibility necessary for seamless
patient care coordination and quality reporting.
To address this issue, it's crucial for Federal incentive programs
to consider the unique challenges faced by small practices and provide
adequate support, both in terms of funding and technical assistance.
Simplifying the requirements, offering subsidies or grants specifically
tailored to smaller providers, and facilitating partnerships with
technology vendors or regional health information exchanges can all
help bridge the gap and make longitudinal health records more
accessible without imposing overwhelming financial burdens on these
practices.
Question. With over $40 billion spent and nearly 2 decades of
effort put into implementing electronic health information technology,
fax machines remain widely used for sharing health data in our health-
care system.
Why is this the case and what challenges persist in accessing
patients' health information electronically?
Answer. The persistent reliance on fax machines can be attributed
to several factors, and challenges in accessing patients' health
information electronically play a significant role in this dynamic.
One key reason for the continued use of fax machines is the
financial and technological barriers faced by small providers. Many
smaller practices lack the necessary funding and technical expertise to
implement advanced Health Information Technology (HIT) solutions. The
upfront investment required for transitioning to electronic data
sharing platforms, such as secure messaging systems or interoperable
electronic medical records (EMRs), can be substantial for these
practices. As a result, fax machines remain a more manageable and
familiar communication tool, especially when considering the limited
resources available to small providers.
Additionally, the complexity and fragmentation of electronic health
information systems pose ongoing challenges in accessing patients'
health information electronically. Interoperability issues between
different EMR systems, varying data formats, and inconsistent data
standards can hinder seamless data sharing and integration across
health-care entities. This lack of standardized processes and
interoperable technologies contributes to the continued reliance on fax
machines as a relatively simple and universally compatible means of
exchanging health information.
Furthermore, regulatory and privacy concerns, such as HIPAA
compliance requirements and concerns about data security breaches, also
impact the adoption and utilization of electronic data sharing
solutions. Small providers may be hesitant to embrace new technologies
without assurances of data privacy and security, further contributing
to the persistence of fax-based communication methods.
Addressing these challenges requires a concerted effort to support
small providers in overcoming financial, technical, and regulatory
barriers to adopting electronic health information technologies. This
may involve providing financial incentives, offering technical
assistance and training programs, promoting interoperability standards,
and enhancing data security measures to foster a more seamless and
secure electronic data sharing environment in health care.
______
Prepared Statement of Amol S. Navathe, M.D., Ph.D., Professor of Health
Policy, Medicine, and Healthcare Management, Perelman School of
Medicine and The Wharton School, University of Pennsylvania
To really help address the needs of patients with chronic
diseases, we need information systems and teams that can help
patients in between office visits, and we need financial
incentives that reward providers for adopting them.
--Dr. Thomas Lee, M.D., M.Sc., Network President for Partners
Healthcare System and Chief Executive Officer, Partners
Community HealthCare, Inc.
Chairman Wyden, Ranking Member Crapo, and distinguished members of
the committee, thank you for the opportunity to testify today. My name
is Dr. Amol Navathe. I am a primary care-trained internal medicine
physician and a Ph.D.-trained health economist. I would like to
highlight why the Medicare program needs to better address chronic care
for its beneficiaries and how changes to physician payment can support
improvements. As a practicing physician, I have a front row seat in
witnessing the challenges that Medicare beneficiaries face in receiving
optimal care for chronic conditions.
Take for example, my patient Mr. L. He is a wonderful, elderly
gentleman suffering from diabetes, heart failure, kidney disease, and a
concern for kidney cancer. Most notably, he lives alone with no living
spouse or children to help care for him. While I do my best to help Mr.
L get his medications on time and make it to his specialist
appointments, our fragmented system does not make it easy. Mr. L has to
manage his chronic conditions on his own, spending up to an average of
2 hours a day coordinating his medications, traveling to appointments,
and interacting with the health system.\1\ He is an archetypal Medicare
patient who would benefit from a more proactive and supportive model of
care, ensuring that he gets his routine care to avoid long, avoidable,
and expensive hospitalizations, like the one he had last month for
acute kidney failure. In learning from Mr. L's situation, I would like
to share three key points.
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\1\ Jowsey T, Yen L, W PM. Time spent on health related activities
associated with chronic illness: A scoping literature review. BMC
Public Health. 2012 Dec 3;12:1044. doi: 10.1186/1471-2458-12-1044.
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i. chronic diseases may be the single most important challenge
affecting medicare beneficiaries and thus the medicare program
The U.S. has the highest rate of individuals with multiple chronic
conditions.\2\ Some of the most common conditions include heart
disease, cancer, dementia, diabetes, and chronic kidney disease. More
than two-thirds (69 percent) of the Medicare population is diagnosed
with two or more chronic conditions, with one in seven beneficiaries
(15 percent) having six or more conditions.\3\ These 15 percent alone
account for $92 billion in emergency visits, hospitalizations, and
post-acute care, with their overall care resulting in over $150 billion
dollars of Medicare spend.\4\ Across the entire U.S. adult population,
27 percent are estimated to have multiple chronic conditions, costing
the American health-care system more than $1 trillion
annually.\5\, \6\ When incorporating the costs associated
with lost economic productivity, this number balloons to $3.7
trillion.\7\ The overall financial impact is likely to increase moving
forward, given projections related to an aging U.S. population.
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\2\ Munira Z. Gunja, Evan D. Gumas, and Reginald D. Williams II,
U.S. Health Care from a Global Perspective, 2022: Accelerating
Spending, Worsening Outcomes (Commonwealth Fund, Jan. 2023). https://
doi.org/10.26099/8ejy-yc74.
\3\ Centers for Medicare and Medicaid Services. Medicare Multiple
Chronic Conditions 2015 data. https://www.cms.gov/research-statistics-
data-and-systems/statistics-trends-and-reports/
chronic-conditions/MCC_Main.html.
\4\ Centers for Medicare and Medicaid Services. Chronic Conditions
among Medicare Beneficiaries, Chartbook, 2012 Edition. Baltimore, MD.
2012. https://www.cms.gov/research-statistics-data-and-systems/
statistics-trends-and-reports/chronic-conditions/downloads/2012chart
book.pdf.
\5\ Boersma P, Black LI, Ward BW. Prevalence of multiple chronic
conditions among U.S. adults, 2018. Prev Chronic Dis. 2020;17:E106.
\6\ Waters H, Graf M, editors. The costs of chronic disease in the
U.S. 1st ed. Milken Institute; 2018. https://milkeninstitute.org/sites/
default/files/reports-pdf/ChronicDiseases-HighRes-FINAL_2.pdf.
\7\ Ibid.
This financial impact also affects patients directly. For example,
patients with chronic disease have increased adverse financial outcomes
compared with healthier patients.\8\ Of individuals with medical debt,
those with 7 or more conditions owed an estimated $1,252 compared with
$784 for those with no chronic diseases.\9\ Patients experiencing
chronic diseases face additional difficulties, such as the inability to
work due to symptoms, managing their disease, and other health
implications.\10\ The experiences of beneficiaries living with chronic
conditions, as well as the experiences of the clinicians caring for
them, convey a compelling case for why the Medicare program must
address the challenges of chronic disease care in a timely fashion.
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\8\ Becker NV, Scott JW, Moniz MH, Carlton EF, Ayanian JZ.
Association of Chronic Disease With Patient Financial Outcomes Among
Commercially Insured Adults. JAMA Intern Med. 2022;182(10):1044-1051.
doi:10.1001/jamainternmed.2022.3687.
\9\ Slomski A. Chronic Disease Burden and Financial Problems Are
Intertwined. JAMA. 2022;328(13):1288-1289. doi:10.1001/jama.2022.15440.
\10\ Boersema HJ, Hoekstra T, Abma F, Brouwer S. Inability to Work
Fulltime, Prevalence and Associated Factors Among Applicants for Work
Disability Benefit. J Occup Rehabil. 2021 Dec;31(4):796-806. doi:
10.1007/s10926-021-09966-7. Epub 2021 Mar 12. PMID: 33710457; PMCID:
PMC8558289.
---------------------------------------------------------------------------
ii. dramatic fragmentation in care makes
addressing chronic disease a burden
One of the most important challenges in managing chronic conditions
is the extremely fragmented nature of the U.S. health-care system. As
an illustrative fact, over a third of Medicare beneficiaries (35
percent) received care from five or more physicians in 2019, a number
likely to be higher among beneficiaries with chronic conditions.\11\
That reflects not only a substantial number of physician visits,
diagnostic tests, treatments, and prescriptions that beneficiaries have
to keep track of, but also the many opportunities for care details to
slip through the cracks. For a primary care physician (PCP) to
effectively coordinate care for a single medical condition it can
require upwards of 50 interactions in a 3-month period (through various
modes of communication) between patient, primary care physician, and
other physicians.\12\ Moreover, there has been a substantial increase
in the total number of other clinicians a PCP's Medicare panel of
patients saw between 2000 and 2019, from a median of 52 to 1 of 95
physicians.\13\ While having multiple physicians can tailor treatment
to the needs of a patient's condition, it can also increase the
likelihood of medical errors, redundant visits, preventable
hospitalizations, and substandard care due to incomplete communication
and differing treatment strategies. Each individual interaction adds
complexity. This demonstrates the challenging role of a PCP,
highlighting a structural complexity in managing care for those with
chronic conditions amidst a backdrop of increasing specialization and
resulting fragmentation.
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\11\ Barnett ML, Bitton A, Souza J, Landon BE. Trends in Outpatient
Care for Medicare Beneficiaries and Implications for Primary Care, 2000
to 2019. Ann Intern Med. 2021 Dec;
174(12):1658-1665. doi: 10.7326/M21-1523. Epub 2021 Nov 2. Erratum in:
Ann Intern Med. 2022 Oct;175(10):1492. PMID: 34724406; PMCID:
PMC8688292.
\12\ Press MJ. Instant Replay--A Quarterback's View of Care
Coordination. New England Journal of Medicine. 2014;371:489-491. doi:
10.1056/NEJMp1406033.
\13\ Barnett ML, Bitton A, Souza J, Landon BE. Trends in Outpatient
Care for Medicare Beneficiaries and Implications for Primary Care, 2000
to 2019. Ann Intern Med. 2021 Dec;
174(12):1658-1665. doi: 10.7326/M21-1523. Epub 2021 Nov 2. Erratum in:
Ann Intern Med. 2022 Oct;175(10):1492. PMID: 34724406; PMCID:
PMC8688292.
A study involving patients with diabetes and chronic kidney disease
revealed significant repercussions of fragmented care on emergency
department (ED) utilization. Every 0.1-unit increase in the
fragmentation of care (encompassing number of different providers
visited, the proportion of attended visits to each of those providers,
and the total number of visits) was associated with a 15-percent
increase in the number of ED visits (incidence rate ratio, 1.15; 95
percent CI, 1.09-1.21).\14\ Another study, specifically focused on
Medicare beneficiaries with chronic conditions, similarly reported that
incremental and heightened fragmentation significantly increased the
risk of both ED visits and hospital admissions (by 14 percent for each;
adjusted P < .05 for each comparison).\15\
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\14\ Liu CW, Einstadter D, and Cebul RD. ``Care fragmentation and
emergency department use among complex patients with diabetes.'' The
American journal of managed care 16.6 (2010): 413-420.
\15\ Kern LM, et al. ``Fragmented ambulatory care and subsequent
healthcare utilization among Medicare beneficiaries.'' Am J Manag Care
24.9 (2018): e278-e284.
Beneficiaries with chronic conditions face the burden of
fragmentation across the care continuum. Among patients with 5 or more
chronic conditions, patients experiencing the highest degree of care
fragmentation underwent roughly twice as many radiology and other
diagnostic procedures as those experiencing the lowest level of
fragmentation, translating to an additional 284 tests per 100 patients,
or an increase of 110 percent (adjusted p < 0.01).\16\ A study from the
Harvard Chan School of Public Health assigned patients a fragmentation
index based on their PCP's practice style, measured by the number of
other physicians seen by their PCP's panel. The authors found increased
departures from clinical best practice, higher rates of preventable
hospitalizations, and higher health-care spending in the highest
fragmentation quartile versus the lowest fragmentation quartile
($10,396 versus $5,854, p < 0.001) (Exhibit 1).\17\
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\16\ Kern LM, et al. ``Healthcare fragmentation and the frequency
of radiology and other diagnostic tests: A cross-sectional study.''
Journal of general internal medicine 32 (2017): 175-181.
\17\ Frandsen BR, et al. ``Care fragmentation, quality, and costs
among chronically ill patients.'' Am J Manag Care 21.5 (2015): 355-362.
[GRAPHIC] [TIFF OMITTED] T1124.001
.epsiii. the american care system prioritizes producing more
health care, rather than producing more health
The prevailing fee-for-service (FFS) reimbursement system is a key
driver in producing such a fragmented system. FFS reimbursement pays
physicians and other health-care providers based on volume of
activities, creating a system that incentivizes each clinician to focus
on increasing the number of visits and procedures.\18\ The complex task
of coordinating care, especially for beneficiaries with chronic
conditions, is not directly reimbursed and therefore gets
overlooked.\19\
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\18\ Zyzanski SJ, Stange KC, Langa D, Flocke SA. Trade-Offs in
High-Volume Primary Care Practice. J Fam Pract. 1998;46:397-402.
\19\ Young RA, Burge S, Kumar KA, Wilson J. The Full Scope of
Family Physicians' Work Is Not Reflected by Current Procedural
Terminology Codes. J Am Board Fam Med. 2017 Nov-Dec;30(6):724-732. doi:
10.3122/jabfm.2017.06.170155.
With good intentions, the Centers for Medicare and Medicaid
Services (CMS) have tried to fill this gap by adding more billing codes
in an attempt to more comprehensively tie payment to effort.
Unfortunately, it is a fraught effort to reduce the important work of
physicians and other health-care providers to a list of codes. This has
resulted in an administratively burdensome system of ``ticky tack''
codes that get underused because the cost of submitting the bill
exceeds the payment doctors receive. I sometimes call this ``death by a
thousand codes.'' For example, the billing cost for a visit has been
estimated to be $20.49,\20\ exceeding CMS's initially proposed $15 FFS
payment for a phone call or other ``virtual check-in'' visit. This
places PCPs in a difficult situation: shoulder substantial
administrative burden to deliver and bill for these services, deliver
but do not bill for these services, or do not provide these services at
all. Either of the first two options is financially perverse and the
third is clinically perverse. Consequently, the core issue of
fragmentation does not get systematically addressed.\21\
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\20\ Tseng P, Kaplan RS, Richman BD, Shah MA, Schulman KA.
Administrative costs associated with physician billing and insurance-
related activities at an academic health care system. JAMA.
2018;319(7):691-697. doi:10.1001/jama.2017:19148.
\21\ Berenson R, Shartzer A. The Mismatch of Telehealth and Fee-
for-Service Payment. JAMA Health Forum. 2020;1(10):e201183.
doi:10.1001/jamahealthforum.2020.1183.
Adding billing code upon billing code increases administrative
complexity while failing to appropriately pay primary care practices
for all the services they provide off of the fee schedule, an estimated
25 percent of their activities.\22\ Studies show that 60 percent of
primary care visits deliver services that are not reportable in CPT
(Current Procedural Terminology) codes.\23\ Examples of these services
include checking insurance coverage for patients, addressing social
determinants of health during visits, and discussing medication
options. All of these are critical for effective delivery of medical
care, but providers are not compensated for them.
---------------------------------------------------------------------------
\22\ Young RA, Burge S, Kumar KA, Wilson J. The Full Scope of
Family Physicians' Work Is Not Reflected by Current Procedural
Terminology Codes. J Am Board Fam Med. 2017 Nov-Dec;30(6):724-732. doi:
10.3122/jabfm.2017.06.170155.
\23\ Ibid.
What can we do to fix this? Despite the challenge facing
beneficiaries, doctors, and policymakers, there are some potential
---------------------------------------------------------------------------
options we can consider.
Any effort to improve chronic disease care will require a change in
the way health care is delivered, a different ``model of care'' to
address fragmentation. It will require physician groups to be able to
invest in new capabilities; use technologies like telehealth when they
are safe, efficient, and effective; and expand the role of staff
practices, including care coordinators and case managers. For example,
there is a growing workforce of nurse practitioners in primary care who
help bolster access and improve care coordination, demonstrating
successful care model shifts. A crucial element to enable a new model
of care, however, is substantial change to physician payment. Simply
adding more dollars to the current system is unlikely to address the
chronic care crisis in Medicare. Instead, thoughtful care redesign is
needed.
A natural place to start is to invest more in primary care,
empowering PCPs to act as the ``quarterback'' or ``point guard'' of a
patient's care team. Robust primary care has consistently demonstrated
an improvement in population health and reduction in health
disparities.\24\ Despite this, the United States systemically
underinvests in primary care. Expenditure on primary care in the U.S.
has declined over the past decade, ranging from 6.2 percent in 2013 to
4.6 percent in 2020 across all insurance types. Medicare spends an
estimated 4 percent of its total spending on primary
care,\25\, \26\, \27\ about $15 billion per year,
which is half that of many other developed countries.\28\ In contrast,
we spend more on inpatient care and hospitalizations than other
nations. Within the U.S., primary care is systematically underinvested
relative to other specialties,\29\, \30\ despite the fact
that PCPs play the central role in a patient's health and face the
cognitively and logistically complex task of care coordination and
integration. Procedural specialties are compensated significantly more
than primary care and other office-based specialties.\31\,
\32\, \33\ Changing fee schedule weights alone will not fix
this; studies demonstrated that a recent upweighting of reimbursement
for office visits led to only a 2-percent decrease in the Medicare
payment gap between primary care and specialty physicians (from a gap
of $40,259.80 to one of $39,434.70).\34\
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\24\ Jabbarpour Y, Petterson S, Jetty A, Byun H, Robert Graham
Center. The Health of US Primary Care: A Baseline Scorecard Tracking
Support for High-Quality Primary Care. Milbank Quarterly. 2023 Feb.
https://www.milbank.org/wp-content/uploads/2023/02/Milbank-Baseline-
Scorecard_final_V2.pdf.
\25\ New ``Scorecard'' Finds Primary Care Funding and Physician
Workforce Are Shrinking. AA of Family Physicians. February 24, 2023.
https://www.aafp.org/pubs/fpm/blogs/inpractice/entry/primary-care-
scorecard.html.
\26\ Jabbarpour Y, Petterson S, Jetty A, Byun H, Robert Graham
Center. The Health of US Primary Care: A Baseline Scorecard Tracking
Support for High-Quality Primary Care. Milbank Quarterly. 2023 Feb.
https://www.milbank.org/wp-content/uploads/2023/02/Milbank-Baseline-
Scorecard_final_V2.pdf.
\27\ Reid R, Damberg C, Friedberg MW. Primary Care Spending in the
Fee-for-Service Medicare Population. JAMA Intern Med. 2019 Jul
1;179(7):977-980. doi: 10.1001/jamainternmed.2018.
8747.
\28\ OECD Country Health Profiles, 2023. https://www.oecd.org/els/
health-systems/primary-care.htm.
\29\ Reid R, Damberg C, Friedberg MW. Primary Care Spending in the
Fee-for-Service Medicare Population. JAMA Intern Med. 2019;179(7):977-
980. doi:10.1001/jamainternmed.2018.8747v.
\30\ Zuckerman S, Merrell K, Berenson RA, Cafarella Lallemand N,
and Sunshine J. 2015. Realign Physician Payment Incentives in Medicare
to Achieve Payment Equity Among Specialties, Expand the Supply of
Primary Care Physicians, and Improve the Value of Care for
Beneficiaries. Washington, DC: Urban Institute, Social & Scientific
Systems Inc.
\31\ Hsiao WC, Braun P, Yntema D, Becker ER. Estimating Physicians'
Work for a Resource-Based Relative-Value Scale. N Engl J Med. 1988;
319:835-41.
\32\ Katz S, Melmed G. How Relative Value Units Undervalue the
Cognitive Physician Visit: A Focus on Inflammatory Bowel Disease.
Gastroenterol Hepatol (NY). 2016 Apr;12(4):240-4.
\33\ Bodenheimer T, Berenson RA, Rudolf P. The Primary Care-
Specialty Income Gap: Why It Matters. Ann Intern Med. 2007 Feb
20;146(4):301-6. doi: 10.7326/0003-4819-146-4-200702200-00011.
\34\ Neprash HT, Golberstein E, Ganguli I, Chernew ME. Association
of Evaluation and Management Payment Policy Changes with Medicare
Payment to Physicians by Specialty. JAMA. 2023;329(8):662-669.
doi:10.1001/jama.2023.0879.
Beyond mobilizing more dollars into primary care, we need to enable
PCPs to invest in new capabilities and grant them more flexibility. One
potential path would be to provide PCPs with consistent per-beneficiary
per-month (PBPM) payments in addition to certain fee-for-service
payments.\35\ These PBPM payments would be designed to cover the
estimated 25 percent of PCP activities that are not currently captured
in the Medicare Physician Fee Schedule, such as care coordination,
communication with other providers, addressing social determinants of
health, and improving patient and caregiver health literacy.
Consequently, a benefit of such an approach is that it would unshackle
PCPs from a system that tries to capture every activity across
thousands of codes, since the litany of codes would no longer be
necessary (since the associated clinical activities would be included
in the monthly payment). This would also balance the goals of
preserving access through FFS payments while enabling PCPs to practice
more patient-centered, rather than visit-
centered, care. The PBPM payments would allow PCPs to invest in
sustainable practice infrastructure transformation such as hiring case
managers and care coordinators or integrating technology and team-based
care. Such care model redesign is of particular importance for
improving the health of patients with multiple chronic conditions while
reducing wasteful administrative complexity.
---------------------------------------------------------------------------
\35\ Berenson RA, Shartzer A, Pham HH. Beyond demonstrations:
Implementing a primary care hybrid payment model in Medicare. Health
Affairs Scholar. 2023 Aug;1(2):qxad024.
Hybrid primary care payments cannot be implemented at scale without
congressional action. The Centers for Medicare and Medicaid Services
(CMS) have conducted several demonstration projects implementing hybrid
payments (e.g., Comprehensive Primary Care Plus). It also has the
authority to--and should--implement hybrid payments in the Medicare
Shared Savings Program (MSSP),\36\ the largest accountable care program
in Medicare. The ACO Primary Care Flex Model is a step in that
direction.\37\ However, moving past demonstrations to impact Medicare
beneficiaries nationwide will require Congressional action to grant CMS
the appropriate authority.
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\36\ Commonwealth Fund. Response to Request for Information on HHS
Initiative to Strengthen Primary Health Care from the Office of the
Assistant Secretary for Health, Department of Health and Human
Services. https://www.commonwealthfund.org/sites/default/files/2022-08/
TO%20ATTACH%20AS%20DOWNLOAD_Commonwealth%20Fund_OASH%20Primary%20Care
%20RFI_7.29.22.pdf.
\37\ https://www.cms.gov/priorities/innovation/innovation-models/
aco-primary-care-flex-model.
The evidence for hybrid payments is promising. Blue Cross Blue
Shield of Hawaii, or Hawaii Medical Services Association (HMSA), has
conducted what is perhaps the most rigorous test of hybrid payments for
primary care to date in its Population-based Payments for Primary Care
(3PC) model. The 3PC model is a hybrid model that shifted the majority
of payments to PCPs to a risk-adjusted per-member per-month payment,
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while continuing to pay some services as FFS.
The transformative elements of HMSA's 3PC model relate to its large
market share; across its commercial, Medicare Advantage, and Managed
Medicaid lines of business, HMSA retains large shares of patients and
revenue for most of its PCPs. The model led to marked improvements in
quality, greater use of telehealth that predated the COVID-19 pandemic,
and fewer low-value imaging tests.\38\ This included increased rates of
cost-effective prevention such as blood pressure control among patients
with diabetes (2.7-percent differential increase), as well as greater
cost-saving care such as a 5.5-percent differential increase in advance
care planning (Exhibit 2).\39\ In fact, unlike other states where
primary care practice finances were massively disrupted by the COVID-19
pandemic, practices in Hawaii were protected financially, as PCPs were
well-equipped to care for patients effectively in a remote fashion
because they had already made such infrastructure investments. The
experience and transformative successes in Hawaii underscore the
stability and ability to invest that hybrid payments can impart to
primary care practices.
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\38\ Dinh CT, Linn KA, Isidro U, Emanuel EJ, Volpp KG, Bond AM,
Caldarella K, Troxel AB, Zhu J, Yang L, Matloubieh SE, Drye E, Bernheim
S, Lee EO, Mugiishi M, Endo KT, Yoshimoto J, Yuen I, Okamura S, Tom J,
Navathe AS. Changes in Outpatient Imaging Utilization and Spending
Under a New Population-Based Primary Care Payment Model. J Am Coll
Radiology. 2020 Jan;17(1 Pt B):101-109. doi: 10.1016/
j.jacr.2019.08.013. PMID: 31918865.
\39\ Navathe AS, Emanuel EJ, Bond A, Linn K, Caldarella K, Troxel
A, Zhu J, Yang L, Matloubieh SE, Drye E, Bernheim S, Lee EO, Mugiishi
M, Endo KT, Yoshimoto J, Yuen I, Okamura S, Stollar M, Tom J, Gold M,
Volpp KG. Association Between the Implementation of a Population-Based
Primary Care Payment System and Achievement on Quality Measures in
Hawaii. JAMA. 2019 Jul 2;322(1):57-68. doi: 10.1001/jama.2019.8113.
Notes: Significant differential improvement in blood pressure
control among patients with diabetes and advance care planning in
hybrid payment group versus control group. Source: Navathe AS et al.
Association Between the Implementation of a Population-Based Primary
Care Payment System and Achievement on Quality Measures in Hawaii.
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JAMA. 2019 Jul 2;322(1):57-68.
Beyond private payers in Hawaii, CMS has been testing ``advanced
primary care models'' at a national level using hybrid payments in
Medicare for over a decade with promising ``leading indicator''
results. These models led to fewer emergency department visits and
hospitalizations, while producing modest gains in chronic disease
management and prevention. In Comprehensive Primary Care (CPC, 2012-
2016), hospitalizations and emergency department visits increased by 2
percent less among participating practices.\40\ This represented a
statistically significant relative reduction of 8,150 hospitalizations
and 15,472 outpatient emergency department (ED) visits over the 4 years
of the program. Importantly, practices with greater access to resources
or more experience with care delivery transformation were more likely
to reduce growth in expenditures (2 percent). This highlights the
importance of providing practices with resources for successful and
sustainable transformation.
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\40\ Evaluation of the Comprehensive Primary Care Initiative:
Fourth Evaluation Report. Mathematica. 2018 May. https://
downloads.cms.gov/files/cmmi/CPC-initiative-fourth-annual-report.pdf.
[GRAPHIC] [TIFF OMITTED] T1124.002
.epsComprehensive Primary Care Plus (CPC+, 2017-2021) similarly saw
a 2-percent reduction in ED visits that emerged early and persisted
across the 5 program years.\41\ A 2-percent reduction in
hospitalizations emerged in program years 3 and 4 and was driven by
reductions in medical admissions, suggesting that these admissions were
prevented by improved outpatient care. Furthermore, over the 5 years of
the program, the percentages of beneficiaries who received all
recommended services for diabetes increased by about 1 percentage point
and of females who received breast cancer screening increased by about
1 percentage point. CPC+ had more favorable effects among concurrent
MSSP participants, again suggesting that practices can build experience
with care transformation with time and proper investment. These
demonstrations suggest that transforming primary care payment can have
important implications for beneficiaries with multiple chronic
conditions, such as decreasing emergency department visits and
hospitalizations while improving the delivery of robust well-integrated
and well-coordinated primary care.
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\41\ Independent Evaluation of Comprehensive Primary Care Plus
(CPC+): Final Evaluation Report. Mathematica. 2023 Dec. https://
www.cms.gov/priorities/innovation/data-and-reports/2023/cpc-plus-fifth-
annual-eval-report.
Another approach would be to continue expansion of alternative
payment models (APMs), which increase accountability for cost and
quality outcomes onto providers, shifting provider focus to value. This
will require continued support for the CMS Innovation Center. There is
some evidence that APMs can improve care for beneficiaries with both
high and low burdens of chronic disease. A great example has been the
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Accountable Care Organization (ACO) model.
The ability of ACOs to improve quality measures and drive savings
is particularly evident through their performance in the MSSP. Notably,
physician-led ACOs are more successful than other ACOs. An evaluation
studying differential changes in annual per-beneficiary utilization and
total Medicare spending found that physician-led ACOs demonstrated
significant improvements and growing savings for Medicare over a 3-year
period in the MSSP.\42\ Among the physician-group led ACOs, the study
reported statistically significant reductions (differential change) for
annual per-
beneficiary any-cause hospitalization (-0.008), ED visits (-0.018), and
post-acute facility stays. In contrast, hospital-led ACOs showed
statistically significant reductions in ED visits (-0.009) only. Per-
beneficiary spending reductions were significant in both ACO types, but
larger for physician-led ACOs.\43\ The spending reductions observed in
ACOs led by physicians resulted in a net savings of $256.4 million for
Medicare in 2015, while the corresponding spending reductions in ACOs
integrated with hospitals were offset by bonus payments.\47\ The
integration facilitated by ACOs, particularly those led by physicians,
can be important among beneficiaries with chronic conditions, as
fragmented management of these conditions is known to drive a
significant portion of overall Medicare spending.
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\42\ McWilliams JM, et al. Medicare Spending After 3 Years of the
Medicare Shared Savings Program. New England Journal of Medicine 379.12
(2018): 1139-1149.
\43\ Ibid.
Another evaluation analyzed outcomes of ACOs entering MSSP in 2012
through 2014, stratifying beneficiaries as either low-risk or high-risk
based on the number of chronic conditions. The authors identified
improvements in quality measures such as a reduction in annual
hospitalizations, with statistically significant reductions among the
high-risk patients in 2012 only and reductions for low-risk patients in
both 2012 and 2013. Among hospitalizations for ambulatory care-
sensitive conditions in the 2012 cohort, participation in MSSP was
linked with a decrease in the proportion of patients hospitalized for
chronic obstructive pulmonary disease or asthma (-0.05 percentage
points, or 4.8 percent of the precontract mean). However, there were
significant increases in the proportion hospitalized for congestive
heart failure (0.05 percentage points, or 3.6 percent) and
cardiovascular disease or diabetes (0.07 percentage points, or 3.5
percent).\44\ High-risk patients experienced a substantially greater
absolute decrease in spending (-$686 versus -$207), while relative
reductions were similar between the two groups (-3.0 percent versus
-2.9 percent). The notable decrease in spending and admissions observed
in the 2013 cohort predominantly stemmed from reductions among patients
classified as low-risk.
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\44\ McWilliams, JM, Chernew ME, and Landon BE. Medicare ACO
program savings not tied to preventable hospitalizations or
concentrated among high-risk patients. Health Affairs 36.12 (2017):
2085-2093.
In another evaluation of nearly a dozen ACOs, PCP clinical staffing
type played a pivotal role in influencing financial gains within
ACOs.\45\, \46\ An increase of one primary care visit per
beneficiary-year administered by PCPs resulted in significant average
gains of $49.65, $40.84, and $27.31 in earned shared savings per
beneficiary for hybrid, hospital-led, and physician-led ACOs,
respectively (p < 0.001). These findings underscore the impact of
primary care providers within the ACO framework, especially for
managing chronic conditions.
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\45\ Lemaire N and Singer SJ. Do Independent Physician-Led ACOs
Have a Future? NEJM Catalyst 4.1 (2018).
\46\ Coyne J, et al. Financial Performance of Accountable Care
Organizations: A 5-Year National Empirical Analysis. Journal of
Healthcare Management 69.1 (2024): 74-86.
To date, the MSSP has saved CMS $1.8 billion by its own
estimates.\47\ When advanced primary care models have overlapped with
ACOs, the synergies have yielded even larger savings, up to 3 percent
lower Medicare spending per beneficiary or about $300 in annual savings
per beneficiary.\48\ This provides supportive evidence for CMS using
its existing authority to implement hybrid primary care payment in
MSSP.
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\47\ Medicare Shared Savings Program Saves Medicare More Than $1.8
Billion in 2022 and Continues to Deliver High-quality Care. CMS. 2023
Aug 24. https://www.cms.gov/newsroom/press-releases/medicare-shared-
savings-program-saves-medicare-more-18-billion-2022-and-continues-
deliver-high.
\48\ Independent Evaluation of Comprehensive Primary Care Plus
(CPC+): Final Evaluation Report. Mathematica. 2023 Dec. https://
www.cms.gov/priorities/innovation/data-and-reports/2023/cpc-plus-fifth-
annual-eval-report.
ACOs are an exemplar of the positive shifts in care that APMs can
create for Medicare beneficiaries. Other APMs have also been successful
in changing practice patterns toward greater quality and cost-
efficiency. However, we should also note that most, if not all, APMs
still rely on the Medicare Physician Fee Schedule. This can create
complexities and conflicts in the financial incentives for many
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physicians.
This leads me to point out that CMS needs additional tools to
manage the FFS program more effectively. The FFS system is only getting
more complicated as new technologies and drugs emerge and as clinical
care becomes increasingly specialized and sub-specialized.\49\ There
are many factors to consider in improving physician payment, and no
single entity has all of the required expertise. Payment changes will
require multidisciplinary experts to provide input to CMS who could be
convened as a panel.\50\ Ultimately, CMS needs the ability to catalyze
a new care model and that will require adapting the fee schedule to
accommodate approaches like a PBPM payment.
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\49\ Hunter K, Kendall D, Ahmadi L. ``The Case Against Fee-for
Service Health Care,'' September 9, 2021. https://thirdway.imgix.net/
pdfs/the-case-against-fee-for-service-health-care.pdf.
\50\ National Academy of Medicine; Finkelman EM, McGinnis JM,
McClellan MB, et al., editors. Vital Directions for Health & Health
Care: An Initiative of the National Academy of Medicine. Washington
(DC): National Academies Press (U.S.); 2017. 9, Payment Reform for
Better Value and Medical Innovation. Available from: https://
www.ncbi.nlm.nih.gov/books/NBK595162/.
A recent effort to address the undervaluation of primary and
outpatient care led to evaluation and management (office visit) weights
being increased in 2021 by up to 20 percent. This also resulted in a
corresponding decrease in weights to other services to maintain budget
neutrality. However, this was a refinement in the current payment
structure rather than enablement of a shift. Looking forward, it will
be important to give CMS the ability to scale payment approaches that
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support better care for beneficiaries with chronic diseases.
Telehealth represents one example of an opportunity for improved
care management of patients with multiple chronic conditions. When so
much of patients' time is spent traveling to and from office visits,
capitalizing on technological advancements could offer one means by
which this burden can be reduced, and health outcomes can be improved.
For example, one care coordination approach using telehealth for
chronically ill Medicare beneficiaries demonstrated significant savings
of approximately 7.7-13.3 percent ($312-$542) per person per
quarter.\51\ Reforms to primary care payment, which enable investment
in practice-transforming programs such as telehealth in this study, can
improve the care of beneficiaries with multiple chronic conditions.
While telehealth is a great potential area of opportunity, implications
of accessibility and feasibility must be taken into consideration given
the nuances of supporting an aging population. Furthermore, telehealth,
like other services, may be susceptible to overuse if paid for in the
usual FFS structure.
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\51\ Baker LC, Johnson SJ, Macaulay D, Birnbaum H. Integrated
telehealth and care management program for Medicare beneficiaries with
chronic disease linked to savings. Health Aff (Millwood). 2011
Sep;30(9):1689-97. doi: 10.1377/hlthaff.2011.0216. PMID: 21900660.
Primary care practices can also improve the health of patients with
multiple chronic conditions by hiring community health workers (CHWs).
A CHW is a ``front-line public health worker who is a trusted member of
the community served, which enables the worker to serve as a liaison
between health/social services and the community to facilitate access
and improve the quality and cultural competence of service
delivery.''\52\ CHW visits can help patients improve their self-
efficacy and health literacy in managing multiple chronic conditions.
Randomized controlled trials of CHWs have demonstrated improvements in
hospital admissions, hospital length of stay, chronic disease control,
and mental health for patients with chronic conditions.\53\ These
programs have also improved measurable health outcomes such as
hemoglobin A1C, Body Mass Index, cigarettes per day, and blood
pressure.\54\ In Medicaid, CHWs have been estimated to return an annual
$2.47 for every dollar invested.\55\ Hospital-based health systems
across the country have begun to incorporate CHW programs, such as the
IMPaCT (Individualized Management for
Patient-Centered Targets) program at the University of Pennsylvania.
Reforming primary care payment can enable practices to invest in CHW
programs, one such innovation in care management to improve the care of
patients with chronic disease.
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\52\ ``Community Health Workers.'' American Public Health
Association. https://www.apha.org/apha-communities/member-sections/
community-health-workers/.
\53\ Kangovi S, Mitra N, Grande D, et al. Patient-Centered
Community Health Worker Intervention to Improve Posthospital Outcomes:
A Randomized Clinical Trial. JAMA Intern Med. 2014;174(4):535-543.
doi:10.1001/jamainternmed.2013.14327.
\54\ Kangovi S, Mitra N, Grande D, Huo H, Smith RA, Long JA.
Community Health Worker Support for Disadvantaged Patients With
Multiple Chronic Diseases: A Randomized Clinical Trial. Am J Public
Health. 2017 Oct;107(10):1660-1667. doi: 10.2105/AJPH.2017.303985.
\55\ Kangovi S, Mitra N, Grande D, Long JA, Asch DA. Evidence-Based
Community Health Worker Program Addresses Unmet Social Needs and
Generates Positive Return on Investment. Health Aff (Millwood). 2020
Feb;39(2):207-213. doi: 10.1377/hlthaff.2019.00981.
Acting now is paramount to improve the landscape of chronic
condition care management and payment. Unlike in Medicare Advantage,
where we have seen substantial innovation to meet beneficiary needs on
a near real-time basis, traditional Medicare requires Congressional
action to stay up to date. It is imperative to give CMS the tools and
authorities it requires to address chronic diseases among Medicare
beneficiaries. Thank you for the opportunity to share my testimony with
you today.
Acknowledgements
I would like to express sincere thanks to Vrushabh P. Ladage, Aidan
Crowley, Maura Boughter-Dornfeld, and Torrey Shirk for research
assistance in preparing my testimony.
Disclosures
I report grants from Hawaii Medical Service Association, grants
from Commonwealth Fund, grants from Robert Wood Johnson Foundation,
grants from Donaghue Foundation, grants from the Veterans Affairs
Administration, grants from Arnold Ventures, grants from United
Healthcare, grants from Blue Cross Blue Shield of NC, grants from
Humana, personal fees from Navvis Healthcare, personal fees from
Elsevier Press, personal fees from Medicare Payment Advisory
Commission, personal fees from Analysis Group, personal fees from
Advocate Physician Partners, personal fees from the Federal Trade
Commission, personal fees from Catholic Health Services Long Island,
equity from Clarify Health, personal fees and board membership for The
Scan Group, and non-compensated board membership for Integrated
Services, Inc. outside the submitted work in the past 3 years.
Disclaimer: This testimony does not necessarily represent the views
of the U.S. Government, Medicare Payment Advisory Commission,
Department of Veterans Affairs, or the University of Pennsylvania
Health System and Perelman School of Medicine.
______
Questions Submitted for the Record to Amol S. Navathe, M.D., Ph.D.
Questions Submitted by Hon. Mike Crapo
Question. Advanced Alternative Payment Models (AAPMs) hold
significant promise as a means of driving improved value while ensuring
appropriate and targeted stewardship of Federal Medicare dollars for
both beneficiaries and taxpayers.
What specific steps should Congress or CMS take in order to improve
uptake of these models, including for specialties with low
participation rates?
Answer. Alternative payment models (APMs) serve as a form of value-
based payment (VBP) that continues to demonstrate promise as a
potential avenue forward for the American health-care system,
particularly within care model delivery and financing. Over the past
few decades, APMs have evolved as a key model to drive value while
saving Federal dollars, with programs using two-sided risk creating the
greatest impact.\1\ While there have been concerns and challenges
throughout the development of various attempts testing APMs
implementation, the two that have shown the most promise are those that
are population-based and episode-based.\2\ The transition to value-
based systems requires substantial time, research, and effort to best
determine methodology; as such, seeing additional potential within both
care transformation and improved value in the form of savings will
support further success.\3\
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\1\ Final Rule Creates Pathways to Success for the Medicare Shared
Savings Program. [Press release]. U.S. Centers for Medicare and
Medicaid Services. Retrieved from https://www.cms.
gov/newsroom/fact-sheets/final-rule-creates-pathways-success-medicare-
shared-savings-program.
\2\ Liao JM, Navathe AS, Werner RM. (2020). The Impact of
Medicare's Alternative Payment Models on the Value of Care. Annual
Review of Public Health, 41(1), 551-565. doi:10.1146/annurev-
publhealth-040119-094327.
\3\ McWilliams JM, Hatfield LA, Landon BE, Hamed P, Chernew ME.
(2018). Medicare Spending after 3 Years of the Medicare Shared Savings
Program. N Engl J Med, 379(12), 1139-1149. doi:10.1056/NEJMsa1803388.
Advanced Alternative Payment Models (AAPMs) are models that are
exemplary and can demonstrate most clearly the potential ability for
these programs to be spread more widely. If CMS dedicates additional
resources to encourage the uptake of these models, particularly in
areas where low participation has been observed, further development is
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likely for such models in diverse sectors and climates.
Along with my peers at Leonard Davis Institute, we developed a
suggested roadmap for CMS to bolster efforts needed to evolve VBP
systems, including APMs and AAPMs, suggesting the following:
I. CMS must articulate a clear vision for the future of
value-based payment.
II. CMS must dramatically simplify the current value-based
payment landscape and engage late-adopting providers.
III. For health systems already participating in value-based
payment, CMS must accelerate the movement from upside-only
shared savings to risk-bearing, population-based alternative
payment models while curtailing the ability of providers to opt
out of value-based payment altogether.
IV. CMS must not only pull providers toward Advanced
Alternative Payment Models, but also structure incentives to
push providers away from fee-for-service payment.
V. Achieving health equity must be a central feature and
goal of value- based payment.\4\
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\4\ Werner RM, Emanuel EJ, Pham HH, Navathe AS. (2021). The Future
of Value-Based Payment: A Road Map to 2030. Leaonard Davis Institute.
https://ldi.upenn.edu/our-work/research-updates/the-future-of-value-
based-payment-a-road-map-to-2030/.
These suggestions still hold true, with an evident need for
concerted effort and improved coordination across model design to
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further the potential ability for continued success.
Additional key lessons building upon that we propose for improving
current systems in place include modification of design flaws in
existing programs and how to address implementation challenges to
encourage further participation in CMS's VBP programs.
Regarding design flaws, we review the following three as most
problematic:\5\
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\5\ Navathe AS, Emanuel EJ, Shenfeld DK. Expanding VBP: Fixing
Design Flaws. Health Affairs Forefront, April 23, 2024. DOI: 10.1377/
forefront.20240418.617238.
1. Many VBP incentive designs require participants to forgo
revenue for the opportunity to earn just a fraction of it back
as shared savings. To address the issue of forgone revenue, VBP
designs must target wasteful or inefficient spending outside
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the intended participant.
2. Many VBP models are vulnerable to ``ghost savings,''
savings that occur when calculated on a risk-adjusted basis due
to more intense coding but that are not present on a nominal
(raw or unadjusted) basis.\6\ To address the issue of ghost
savings, payers should require ``real savings'' to earn shared
savings.
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\6\ Shenfeld DK, Navathe AS, Emanuel EJ. The Promise and Challenge
of Value-Based Payment. JAMA Internal Medicine. Forthcoming May 2024.
3. Most VBP experimental models are voluntary. To address the
issues of voluntariness, the presumption for every new VBP
model should be mandatory participation. In cases where
mandatory enrollment is not feasible, building on regionalized
demonstrations such as Medicare's Comprehensive Primary Care
Plus model, voluntary models should be deployed in reasonably
small geographic areas using randomization to offer
participation in the model, preserving the ability to examine
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population-level effects.
To encourage further participation in VBP programs tailored to
difficulty within implementation, we review the following areas and
propose potential solutions for each: (1) consolidation and use of
management service organizations; (2) paucity of data and modeling for
actuarial risk; and (3) experimentation and protection from failure.\7\
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\7\ Shenfeld DK, Navathe AS, Emanuel EJ. Expanding VBP: Overcoming
Implementation Barriers. Health Affairs Forefront, April 24, 2024. DOI:
10.1377/forefront.20240422.791880.
Specific steps that Congress or CMS should take to improve the
uptake of these models include ongoing conversations with stakeholders
and participants about reasons for participation to further improve and
strengthen considerations from the aforementioned highlighted lessons.
Up-front investment is also crucial, as changing care patterns to
conform with these models often requires initial transformation such as
hiring care coordinators and altering practice workflow if change is to
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be sustainable.
Question. What specific flexibilities would help Accountable Care
Organizations to improve patient care quality and reduce costs, and
what steps could Congress take to advance these types of flexibilities?
Answer. ACOs are a strong example of value-based care (VBC) models
that have seen success with investment from CMS in testing various
structures and dedication effort to revise as needed. The CMS Medicare
Shared Savings Program (MSSP) has selected the most high-performing
ACOs to evaluate the factors leading to increased success of these
models on improving quality and reducing cost. We suggest that by
allowing for further ACO-led innovation, without a ``one-size-fits-
all'' approach, fitting the needs of each population served per ACO
will be more attainable.
The newly announced ACO Primary Care Flex model beginning in
January 2025 is one example of a well-designed model that offers
increased flexibility for primary care. It includes a prospective
primary care payment (PPCP) that will shift payment for primary care
away from visit-based FFS payment to enhance the predictability and
amount of primary care funding for low revenue ACOs, increasing their
flexibility to meet the needs of people with Medicare.\8\ It also
includes a one-time up-front advanced shared savings payment to cover
onboarding practice transformation costs of joining the model.
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\8\ ACO Primary Care Flex Model. https://www.cms.gov/priorities/
innovation/innovation-models/aco-primary-care-flex-model.
Another flexibility to help ACOs improve quality and reduce costs
is improving their overlap with episode-based models through
hierarchical payment structures.\9\ Creating flexibility for patients
in ACOs to still be treated through episode-based payments as proposed
in the new TEAM model is one example of how this can be accomplished,
as well as by facilitating improved data sharing between ACOs and
specialists.
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\9\ Shrank WH, Chernew ME, Navathe AS. Hierarchical Payment
Models--A Path for Coordinating Population- and Episode-Based Payment
Models. JAMA. 2022 Feb 1;327(5):423-424. doi: 10.1001/jama.2021.23786.
Lastly, additional flexible support should be directed toward ACOs
serving beneficiaries who face higher social burden. This approach is
seen in ACO REACH with its Health Equity Benchmark Adjustment. However,
these approaches will require empirical justification beyond solely
conceptual support.\10\
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\10\ Navathe AS, Liao JM. Embedding Equity in Financial Benchmarks:
Changes to the Health Equity Benchmark Adjustment. Health Affairs
Forefront. 28 Sep 2023. https://www.
healthaffairs.org/content/forefront/embedding-equity-financial-
benchmarks-changes-health-equity-benchmark-adjustment.
Question. Artificial intelligence (AI) has the potential to
mitigate administrative burden and enhance health-care quality,
including in the context of Medicare. That said, some clinicians have
raised concerns around the program's inability to keep pace with AI-
enabled tool development through its coverage and payment policies,
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undercutting access, especially for smaller practices.
What use cases for AI-enabled tools and technologies seem most
promising in the context of clinician care?
Answer. AI-enabled tools have the potential to handle more menial
and repetitive tasks for clinicians. There is a lot of promise in
imaging specifically, with tools trained to detect signs of disease to
be flagged for a more detailed review by clinicians. This type of
technology is already being introduced to interpret imaging for
pulmonary nodules, intracranial hemorrhage risk, diabetic retinopathy,
cardiac ultrasound, and others.\11\, \12\ This type of AI-
enabled tools supplement physician practice and create efficiencies
which allow clinicians to spend more time performing higher-level
tasks.
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\11\ Gonzalez-Smith J, Shen H, Silcox C. Moving Ahead of the Pack:
Understanding Health System Priorities on AI-Enabled Clinical Decision
Support. Biomedical Instrumentation & Technology. 2022;56(4):119-23.
\12\ Halabi, SS. Artificially Practical in Every Way. Journal of
the American College of Radiology. Volume 17, Issue 11. 2020, Pages
1361-1362. ISSN 1546-1440. https://doi.org/10.1016/j.jacr.2020.09.063.
Beyond established uses for imaging, AI is currently being piloted
in primary care settings to draft responses to patient portal messages
and draft clinic notes with ambient listening technology. This can
enable physicians to spend less time on the computer and more time with
their patients, a win-win for the system, clinician well-being, and
patient satisfaction. Furthermore, AI can be used to streamline
administrative requirements such as billing and documentation as well
as prior authorization requirements. However, it is imperative to train
these algorithms on a representative dataset with continual monitoring
of outcomes to promote equity. These topics were discussed in an
executive order from President Biden as well as a Health Plan
Management System memorandum from CMS.\13\, \14\
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\13\ Executive Order on the Safe, Secure, and Trustworthy
Development and Use of Artificial Intelligence. 30 Oct 2023. https://
www.whitehouse.gov/briefing-room/presidential-actions/2023/10/30/
executive-order-on-the-safe-secure-and-trustworthy-development-and-use-
of-artificial-intelligence/.
\14\ Frequently Asked Questions Related to Coverage Criteria and
Utilization Management Requirements in CMS Final Rule (CMS-4201-F).
CMS. 6 Feb 2024. https://www.aha.org/system/files/media/file/2024/02/
faqs-related-to-coverage-criteria-and-utilization-management-
requirements-in-cms-final-rule-cms-4201-f.pdf.
Question. What steps should CMS and Congress take to ensure
adequate coverage and reimbursement for appropriate AI-enabled tools in
---------------------------------------------------------------------------
this context?
Answer. Value-based models create incentives to use new AI
technologies that improve efficiency. Rather than adding new codes for
each new technology, a hybrid payment with a population-based payment
would enable practices to decide which AI technologies best fit their
needs and those of their patients. The use of AI-
enabled tools can in some contexts be self-funding, as the efficiencies
they create will allow clinicians to provide more care to more
patients, drawing in more reimbursement without major changes in
funding structure. Appropriately designing incentives outside of value-
based models can be much more challenging.
______
Questions Submitted by Hon. Chuck Grassley
Question. The Center for Medicare and Medicaid Innovation (CMMI)
receives $10 billion in mandatory funding every decade. The nonpartisan
Congressional Budget Office (CBO) has found that CMMI has not lowered
Medicare spending. Separately, CBO has found the Medicare Shared
Savings Program (MSSP) was not a factor in the slower growth of Federal
health-care spending.
Are the spending impacts on Medicare from CMMI and MSSP each
validated by an independent, third-party organization? If not, why
would that be important?
Answer. While no independent organization has been formally
commissioned to conduct an evaluation of MSSP outside of CBO, many
academic scholars have independently evaluated the effects of MSSP and
found favorable results concentrated among physician-led ACOs.\15\ What
appears to be a lack of contribution by MSSP to the growth of Federal
health spending may actually be created by a measurement challenge.
Practice change among clinicians both within and outside of
demonstration projects, as well as overlapping demonstrations, creates
``control group contamination,'' making it look like demonstration
projects did not save money when in reality they catalyzed broader
systemwide transformation observed in the flattening of national health
spending.\16\
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\15\ McWilliams JM, Hatfield LA, Landon BE, Hamed P, Chernew ME.
Medicare Spending after 3 Years of the Medicare Shared Savings Program.
N Engl J Med. 2018 Sep 20;379(12):1139-1149. doi: 10.1056/
NEJMsa1803388. Epub 2018 Sep 5. PMID: 30183495; PMCID: PMC6269647.
\16\ Navathe AS, Boyle CW, Emanuel EJ. Alternative Payment Models--
Victims of Their Own Success? JAMA. 2020;324(3):237-238. doi:10.1001/
jama.2020.4133.
While the spending impacts of CMMI as a whole were measured by CBO,
CMMI itself commonly commissions government-contracted entities such as
the Lewin Group and Mathematica to evaluate its demonstration projects.
Furthermore, it is important to note that the purpose of CMMI is not
solely to lower spending, but also to improve quality.\17\ Growth in
spending is only a problem if it is not accompanied by commensurate
gains in outcomes. For example, while some of CMMI's demonstration
projects may not have decreased spending overall, they did decrease
hospitalizations and emergency department visits,\18\ suggesting that
we are realizing quality gains for those dollars spent.
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\17\ Innovation Center Strategy Refresh. 2021. CMMI. https://
www.cms.gov/priorities/innovation/strategic-direction-whitepaper.
\18\ Independent Evaluation of Comprehensive Primary Care Plus
(CPC+): Final Evaluation Report. Mathematica. 2023 Dec. https://
www.cms.gov/priorities/innovation/data-and-reports/2023/cpc-plus-fifth-
annual-eval-report.
Question. Congress and the Centers for Medicare and Medicaid
Services (CMS) have access to several advisory committees to inform us
on how to move Medicare's fee-for-service payment system to a more
outcomes-based model. These committees include the American Medical
Association's RVS Update Committee, the Medicare Payment Advisory
Commission--which you serve on--and the Physician-Focused Payment Model
---------------------------------------------------------------------------
Technical Advisory Committee.
Are these committees effective at providing actionable
recommendations to move our health-care system to be outcomes-based? If
not, what reforms should be made to them?
Answer. Each of these committees have an important role to play in
advising Congress and CMS. I believe that the roles of the RVS Update
Committee, the Medicare Payment Advisory Commission are well defined,
and that they are able to be effective in their mission. The Physician-
Focused Payment Model Technical Advisory Committee (PTAC) role has been
less clear as their recommendations have not been implemented. To
implement the recommendations of PTAC there needs to be a greater
ability to create Value Based Models which are designed to engage
specialists. By having a more proactive system CMS will have a greater
ability to get reforms into practice.
Further, in order to be more effective, CMS requires a
reexamination of the fee-for-service weights, but also the methodology
and process by which the weights are created. I propose an independent
group, comprised of experienced representatives from many specialties,
and free of any interest in the results themselves. A group of this
kind will be well suited to the task of creating weights which
incentivize the form of practice which will achieve the greatest
outcomes most efficiently.
Question. CMS has the authority to add additional procedure codes,
which can allow for additional medical services to be covered under
Medicare. Data shows that CMS rulemaking expanded annual Medicare
spending by $6 billion in 2016, $10 billion in 2017, and $6 billion in
2018.
Should Congress be concerned about these regulatory spending
increases? How does this impact Medicare's long-term solvency?
Answer. CMS's introduction of procedural codes with the intent of
improving care coordination--especially among beneficiaries with
chronic conditions--has unfortunately resulted in additional
administrative burden for physicians and other health-care providers;
thereby affecting care quality and worsening fragmentation. Adding
billing code upon billing code increases administrative complexity
while failing to appropriately pay primary care practices for all the
services they provide off of the fee schedule, an estimated 25 percent
of their activities. Studies show that 60 percent of primary care
visits deliver services that are not reportable in CPT (Current
Procedural Terminology) codes.\19\ Examples of these services include
checking insurance coverage for patients, addressing social
determinants of health during visits, and discussing medication
options.
---------------------------------------------------------------------------
\19\ Young RA, Burge S, Kumar KA, Wilson J. The Full Scope of
Family Physicians' Work Is Not Reflected by Current Procedural
Terminology Codes. J Am Board Fam Med. 2017 Nov-Dec;30(6):724-732. doi:
10.3122/jabfm.2017.06.170155. 23.
In the short term, the deferred depletion of the Hospital Insurance
(HI) trust fund coming at within 6 years of project depletion
(projected depletion at 2026 in 2020, 2026 in 2021, and 2028 in 2022)
can, in part, be attributed to the COVID-19 pandemic.\20\ However, the
Medicare trustees reported that the pandemic led to a significant rise
in unemployment, causing a decline in payroll tax revenue to the HI
trust fund. Spending grew due to expenses for COVID-19 treatment,
testing, and vaccine distribution, along with advance payments to
providers. Trustees project that the spending effects of the pandemic
will not have a large effect on the financial status of the Medicare
program beyond 2028.
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\20\ #s from--https://www.kff.org/medicare/issue-brief/what-to-
know-about-medicare-spending-and-financing/.
In the long run, Medicare faces financial strain from rising
health-care costs, increasing beneficiary enrollment, and an aging
population. This growth in Medicare spending stresses the Federal
budget, hastens the depletion of the Part A trust fund, and raises
Medicare premiums, deductibles, and cost sharing for beneficiaries.\21\
Various changes have been suggested to tackle Medicare's fiscal issues.
Proposals include raising the Medicare eligibility age and shifting to
a premium support model. Additionally, the Inflation Reduction Act of
2022 seeks to limit Medicare's prescription drug spending by having the
Federal Government negotiate drug prices in Medicare and requiring drug
companies to provide rebates for price hikes that exceed inflation. CBO
projects that the drug price negotiation measures in the Inflation
Reduction Act will save Medicare $98.5 billion over a decade (2022-
2031).\22\
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\21\ Ibid. [KFF].
\22\ Explaining the Prescription Drug Provisions in the Inflation
Reduction Act--KFF.
In summary, it is understandable to be concerned about spending
increases and to assess the value. The spending that increases value to
beneficiaries and taxpayers may be warranted. These spending increases
have not resulted in big impacts to the HI trust fund but rather come
from general revenue from Medicare. Of note, however, is the need for
CMS to have authority to bring new technologies and services into
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Medicare, as this the only way that Medicare FFS can evolve.
Question. You stated in your written testimony that ``simply adding
more dollars to the current system is unlikely to address the chronic
care crisis in Medicare. Instead, thoughtful design is needed.''
Can you point to an example where less Medicare outlays produced
better health outcomes? How was that efficiency achieved?
Answer. Investing in a robust primary care infrastructure may be
crucial for a cost-efficient system that produces more health for each
dollar spent. The U.S. already systematically underinvests in primary
care, declining from 6.4 percent in 2013 to 4.6 percent in 2020.
Medicare spends an estimated 4 percent of its total spending on primary
care.\23\ Despite this, geographic regions within the U.S. that have
more primary care providers achieve greater health with lower total
spending. For example, Medicare spends 25 percent less per beneficiary
in states with many primary care providers compared to those with
few.\24\ There are examples of State-level investments in primary care
that yielded overall savings. For example, Oregon's Primary Care Home
Program produced $13 in savings for every $1 increase in primary care
expenditures, saving $240 million during its first 3 years.\25\
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\23\ Reid R, Damberg C, Friedberg MW. Primary Care Spending in the
Fee-for-Service Medicare Population. JAMA Intern Med. 2019 Jul
1;179(7):977-980. doi: 10.1001/jamainternmed.2018.
8747.
\24\ Baicker K, Chandra A. Medicare Spending, the Physician
Workforce, and Beneficiaries' Quality of Care. Health Affairs
(Millwood). 2004 Jan-Jun; Suppl Web Exclusives: W4-184-97. doi:
10.1377/hlthaff.w4.184.
\25\ Gelmon S, Wallace N, Sandber B, Petchel S, Bouranis N. 2016
September. Implementation of Oregon's PCPCH Program: Exemplary Practice
and Program Findings. https://www.
oregon.gov/oha/HPA/dsi-pcpch/Documents/PCPCH-Program-Implementation-
Report-Sept2016.
pdf.
CMS's Medicare Shared Savings Program (MSSP) saved Medicare $1.8
billion in 2022 compared to spending targets for the year. The program
has generated savings for a substantial number of years. In 2022, an
estimated 63 percent of MSSP participating ACOs earned payments for
their performance, with low-revenue ACOs (with at least 75 percent
primary care clinicians) had $294 per capita in net savings. These
promising results emphasize achieved efficiency, showing the ability
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for saved dollars to align and bolster improved care outcomes.
Question. In your written testimony, you stated, ``the billing cost
for a visit has been estimated to be $20.49, exceeding CMS's initially
proposed $15 FFS payment for a phone call or other `virtual check-in'
visit.''
Is it possible to lower the cost burden of submitting a bill for a
provider? How do we make the billing more efficient and cost less?
Answer. The most efficient way to lower the cost burden of
submitting a bill is by eliminating the need to submit a bill at all.
This is the approach of population-based payments (PBP), the capitated
portion of hybrid payments. Folding payments for selected fee-based
activities into a PBP can relieve providers of the time and effort
required to submit a bill for reimbursement. They can instead be
reimbursed for that same activity through a stable and predictable
population-based payment and spend that extra time on direct patient
care.
Beyond folding fees for certain services into a population-based
payment, the PBP itself can support a physician practice to hire an
administrator whose job it is to submit claims to Medicare or purchase
an AI technology system which can streamline bill submission. A portion
of the estimated cost of billing is in the opportunity cost of spending
time with patients.\26\, \27\ PBPs may free up physicians to
practice at the top of their license and spend their time with
patients, hiring administrators to focus on streamlining billing for a
given practice. However, this approach is less than ideal, because it
is still spending Medicare's dollars on administrative costs. Other
approaches may include a single transparent set of payment rules with
clear explanations and descriptions, a single claim form, and standard
rules of submission.\28\, \29\
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\26\ Tseng P, Kaplan RS, Richman BD, Shah MA, Schulman KA.
Administrative Costs Associated With Physician Billing and Insurance-
Related Activities at an Academic Health Care System. JAMA.
2018;319(7):691-697. doi:10.1001/jama.2017.19148.
\27\ Gottlieb JD, Shapiro AH, Dunn A. The Complexity of Billing and
Paying for Physician Care. Health Aff (Millwood). 2018 Apr;37(4):619-
626. doi: 10.1377/hlthaff.2017.1325. PMID: 29608348.
\28\ Blanchfield BB, Heffernan JL, Osgood B, Sheehan RR, Meyer GS.
Saving billions of dollars--and physicians' time--by streamlining
billing practices. Health Aff (Millwood). 2010 Jun;29(6):1248-54. doi:
10.1377/hlthaff.2009.0075. Epub 2010 Apr 29. PMID: 20430822.
\29\ Young RA, Bayles B, Hill JH, Kumar KA. Family physicians'
opinions on the primary care documentation, coding, and billing system:
a qualitative study from the residency research network of Texas. Fam
Med. 2014 May;46(5):378-84. PMID:24915481.
Question. A common concern from Iowa providers is the lack of
preparation and notice for final payment rules from CMS. When final
payment rules are set a couple of months or less from the start of the
payment rule's implementation date, providers do not have time to
prepare or adjust to new payment policies and administrative
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requirements. This includes changes to value-based care efforts.
Should there be a longer preparation period (e.g., 6 months, 1
year) for providers to adjust to new payment policies and
administrative requirements under Medicare? What effect would that
have? Alternatively, should payment policies and administrative
requirements remain consistent for more than 1 year except for newer
input data (e.g., inflationary or economic factors)?
Answer. Continual consideration for improvements to current payment
rules and concurrent regulations will benefit stakeholders across
Medicare. CMS should continue efforts to balance providing sufficient
time for notice while also allowing for the ability for modifications
to best evolve the program and meet beneficiaries needs.
______
Questions Submitted by Hon. John Cornyn
Question. There are approximately 700,000 Texans and 12.2 million
Americans who are jointly enrolled in Medicaid and Medicare. This
includes many people with multiple chronic conditions. Medicare and
Medicaid currently often don't coordinate care for these individuals.
This can lead to poorer outcomes for patients and a more costly and
ineffective health-care system overall.
I introduced the Delivering Unified Access to Lifesaving Services
(or DUALS) Act with Senators Cassidy, Carper, Warner, Scott of South
Carolina, and Menendez last month. This bill would require States to
develop a unified health plan for these beneficiaries to help
streamline our health-care system. The DUALS Act would also ensure this
vulnerable patient population receives comprehensive care for their
chronic health conditions.
Can you speak to how improving care coordination for dual eligible
beneficiaries will help those with chronic conditions in particular?
Answer. Chronic conditions, like diabetes and hypertension, require
consistent care to prevent acute hospitalizations. Barriers to primary
care reduce consistency in the provision of care, and may lead to an
acute hospitalization. Beneficiaries with chronic conditions, and those
who are dual eligible, encounter more barriers to primary care.\30\
Improving care coordination has the potential to reduce these barriers
by shifting some of the burden of managing their care from the patient
to care providers. Coordinated care also fosters collaboration between
specialists. Coordinated care has been shown to reduce ED and acute
care hospitalizations in beneficiaries generally,\31\, \32\
and in chronic care beneficiaries specifically.\33\, \34\
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\30\ Chatterjee P, Liao JM, Wang E, Feffer D, Navathe AS.
Characteristics, utilization, and concentration of outpatient care for
dual-eligible Medicare beneficiaries. Am J Manag Care. 2022 Oct
1;28(10):e370-e377. doi: 10.37765/ajmc.2022.89189. PMID: 36252177;
PMCID: PMC100
84394.
\31\ Tessa van Loenen, Michael J van den Berg, Gert P Westert,
Marjan J Faber. Organizational aspects of primary care related to
avoidable hospitalization: A systematic review, Family Practice, Volume
31, Issue 5, October 2014, Pages 502-516. https://doi.org/10.1093/
fampra/cmu053.
\32\ Aldo Rosano, Christian Abo Loha, Roberto Falvo, Jouke van der
Zee, Walter Ricciardi, Gabriella Guasticchi, Antonio Giulio de Belvis.
The relationship between avoidable hospitalization and accessibility to
primary care: A systematic review, European Journal of Public Health,
Volume 23, Issue 3, June 2013, Pages 356-360. https://doi.org/10.1093/
eurpub/cks053.
\33\ Oh NL, Potter AJ, Sabik LM, et al. The association between
primary care use and
potentially-preventable hospitalization among dual eligibles age 65 and
over. BMC Health Serv Res 22, 927 (2022). https://doi.org/10.1186/
s12913-022-08326-2.
\34\ R.J. Wolters, J.C.C. Braspenning, M. Wensing. Impact of
primary care on hospital admission rates for diabetes patients: A
systematic review, Diabetes Research and Clinical Practice, Volume 129,
2017, Pages 182-196, ISSN 0168-8227. https://doi.org/10.1016/
j.diabres.2017.
05.001.
Question. How does streamlining care coordination support providers
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in addition to patients?
Answer. Streamlining care coordination has the potential to reduce
administrative burden on providers. Physicians spend a significant
amount of time performing administrative tasks which drains mental
energy and draws time away from patients.\35\ Streamlining these
burdens can reduce physician burnout.\36\ Less time spent in
administrative tasks can also increase physician throughput, allowing
physician to attend to more patients but also earn more dollars for
their practice while providing useful care.\37\
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\35\ J. Marc Overhage, David McCallie. Physician Time Spent Using
the Electronic Health Record During Outpatient Encounters: A
Descriptive Study. Ann Intern Med.2020;172:169-174. [Epub 14 January
2020]. doi:10.7326/M18-3684.
\36\ Kelly J. Thomas Craig, Van C. Willis, David Gruen, Kyu Rhee,
Gretchen P. Jackson, The burden of the digital environment: A
systematic review on organization-directed workplace interventions to
mitigate physician burnout, Journal of the American Medical Informatics
Association, Volume 28, Issue 5, May 2021, Pages 985-997. https://
doi.org/10.1093/jamia/ocaa301.
\37\ Youn S, Geismar HN, Pinedo M. (2022). Planning and scheduling
in healthcare for better care coordination: Current understanding,
trending topics, and future opportunities. Production and Operations
Management, 31(12), 4407-4423. https://doi.org/10.1111/poms.13867.
______
Questions Submitted by Hon. John Thune
Question. In your testimony, you emphasize that in order to improve
chronic disease outcomes, there must be changes in the way physicians
deliver care. Specifically, you highlight issues with fragmentation
within the fee-for-service reimbursement system that places overly
burdensome administrative challenges onto providers.
I know you allude to this in your testimony, but can you just
expand on some of these fragmentation issues and, specifically, some of
the day-to-day effects of seemingly endless new billing codes being
added by CMS and how that affects providers and their ability to care
for their patients?
Answer. Some of these fragmentation issues emerge because of the
sheer number of physicians that each patient with chronic disease sees
per year. Over one-third of all Medicare beneficiaries saw 5 or more
different physicians in 2019, a number that is likely higher among
patients with chronic disease.\38\ As the clinical workforce becomes
increasingly subspecialized, a patient with diabetes, chronic
obstructive pulmonary disease (COPD), and chronic kidney disease may
see a primary care physician, endocrinologist, dietitian,
pulmonologist, and nephrologist. The PCP is tasked with serving as a
``quarterback,'' communicating with multiple different physicians. This
can require upwards of 50 distinct interactions between a PCP and other
providers to manage one condition for one patient over a 3-month
period.\39\ Each of these interactions risks information falling
through the cracks. Despite the fact that this communication is one of
the most important roles of the PCP, it is something they cannot
directly bill for in the current FFS system. Implementing a population-
based hybrid payment would compensate the PCP for spending time on
these critical activities as well as financially support them to hire a
care coordinator or case manager to smooth these interactions.
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\38\ Barnett ML, Bitton A, Souza J, Landon BE. Trends in Outpatient
Care for Medicare Beneficiaries and Implications for Primary Care, 2000
to 2019. Ann Intern Med. 2021 Dec;
174(12):1658-1665. doi: 10.7326/M21-1523. Epub 2021 Nov 2. Erratum in:
Ann Intern Med. 2022 Oct;175(10):1492.
\39\ Press MJ. Instant Replay--A Quarterback's View of Care
Coordination. New England Journal of Medicine. 2014;371:489--491. doi:
10.1056/NEJMp1406033.
Beyond fragmentation between multiple specialists, fragmentation
also arises because of the increasing number of billing codes. CMS
continues to add new codes in a valiant effort to compensate PCPs for
their work. While this is well-intentioned, simply adding more dollars
and more billing codes to the existing system will not address the
challenge of fragmentation; rather, it will exacerbate it. Adding more
billing codes places a band-aid on the problem of primary care
compensation--namely, that it is a fee-for-service system operating in
a health-care environment that is increasingly fast-paced, technology
dependent, subspecialized, and complex. Instead, the system must be
reimagined with a new type of compensation altogether to account for
the rapidly changing demands of modern care delivery for patients with
chronic disease. Hybrid payments offer a promising approach to increase
financial stability and reverse fragmentation and administrative burden
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created by ``ticky tack'' codes.
Question. As part of the Merit-based Incentive Payment System
(MIPS), physicians must be compliant in promoting interoperability as
part of their reimbursement, which helps to facilitate the sharing of
data between various providers.
I have long been an advocate for health IT initiatives that can
improve efficiencies and reduce costs in the health-care system, and I
believe that sharing information between providers through an
interoperable network has immense upside, so long as there are
safeguards to protect patient privacy and ensure taxpayer funds are
spent appropriately.
However, there continue to be challenges to physicians meeting
interoperability metrics, like information blocking for example in
which an individual or entity impedes the delivery or utilization of an
electronic health record, making interoperability impossible.
In your view, how have practices been impacted by information
blocking?
Are you aware of instances in which the timeliness or quality of
the care physicians are able to provide patients has been impacted by a
limited ability or complete inability to access electronic health
records?
Furthermore, beyond information blocking, what other challenges
persist in physicians accessing patients' health information
electronically despite the billions of dollars spent to implement
electronic health IT and interoperability?
Answer. The 21st Century Cures Act, enacted in 2016, had an
important component to improve the exchange of electronic health
information by promoting interoperability, preventing information
blocking, and enhancing the usability, accessibility, privacy, and
security of health information technology.\40\ Yet, interoperability
remains a challenge in health care, impacting the efficiency and
quality of care. A recent observational study revealed a significant,
positive, and cyclic relationship among three capabilities of health
information exchange, interoperability, and medication reconciliation,
suggesting that a decline in one could lead to declines in the others,
highlighting the need for policies to address these gaps to ensure
improved medication reconciliation and overall patient safety.\41\
Policy measures targeting key elements of high-functioning EHRs, like
interoperability, could have broad impacts on other system
capabilities.
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\40\ The Office of the National Coordinator for Health Information
Technology (ONC)'s Cures Act Final Rule. Federal Register as 85 FR
25642, May 1, 2020.
\41\ Gerald E, Herrin J, and Horwitz LI. An Observational Study of
the Relationship Between Meaningful Use-Based Electronic Health
Information Exchange, Interoperability, and Medication Reconciliation
Capabilities. Medicine 96.41 (2017): e8274.
Hindered access to electronic health records leads to delays in
patient care while limiting a physician's ability to make timely
informed decisions. However, the expense of implementing EHRs continues
to be a significant obstacle to their adoption. According to the
Michigan Center for Effective IT Adoption, initial and ongoing annual
costs for EHR implementation can vary from $15,000 to $70,000 per
provider, influenced by whether the deployment is server-based or web-
based.\42\
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\42\ Reisman M. EHRs: The Challenge of Making Electronic Data
Usable and Interoperable. Pharmacy and Therapeutics 42.9 (2017): 572.
______
Questions Submitted by Hon. Robert P. Casey, Jr.
Question. In your testimony, you noted that Medicare spends an
estimated 4 percent of its total spending on primary care, which is
about half of what other developed countries spend. You also noted,
more than two-thirds of the Medicare population is diagnosed with two
or more chronic conditions, and 15 percent of the Medicare population
has six or more conditions.
Can you expand on why increased and more functional investments in
primary care could result in better outcomes for patients, especially
for older adults? How is this likely to result in long-term costs
savings?
Answer. Increased and more functional investments in primary care
could result in better outcomes for patients by focusing on prevention
to keep them healthy and out of the hospital. Any effort to improve
chronic disease care will require a change to the way health care is
delivered, a different ``model of care'' to address fragmentation. It
will require physician groups to be able to invest in new capabilities;
use technologies like telehealth when they are safe, efficient, and
effective; and expand the role of staff practices, including care
coordinators and case managers. For example, there is a growing
workforce of nurse practitioners in primary care who help bolster
access and improve care coordination, demonstrating successful care
model shifts. A crucial element to enable a new model of care, however,
is substantial change to physician payment. Simply adding more dollars
to the current system is unlikely to address the chronic care crisis in
Medicare. Instead, complete care redesign is needed.
A natural place to start is to invest more in primary care,
empowering PCPs to act as the ``quarterback'' or ``point guard'' of a
patient's care team. Robust primary care has consistently demonstrated
an improvement in population health and reduction in health
disparities.\43\ Despite this, the United States systemically
underinvests in primary care. Expenditure on primary care in the U.S.
has declined over the past decade, ranging from 6.2 percent in 2013 to
4.6 percent in 2020 across all insurance types. Medicare spends an
estimated 4 percent of its total spending on primary
care,\44\, \45\, \46\ about $15 billion per year,
which is half that of many other developed countries.\47\ In contrast,
we spend more on inpatient care and hospitalizations than other
nations. Within the U.S., primary care is systematically underinvested
relative to other specialties,\48\, \49\ despite the fact
that PCPs play the most central role in a patient's health and face the
cognitively and logistically complex task of care coordination and
integration. Procedural specialties are compensated significantly more
than primary care and other office-based specialties.\50\,
\51\, \52\ Changing fee schedule weights alone will not fix
this; studies demonstrated that a recent upweighting of reimbursement
for office visits led to only a 2 percent decrease in the Medicare
payment gap between primary care and specialty physicians (from a gap
of $40,259.80 to one of $39,434.70).\53\
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\43\ Jabbarpour Y, Petterson S, Jetty A, Byun H, Robert Graham
Center. The Health of US Primary Care: A Baseline Scorecard Tracking
Support for High-Quality Primary Care. Milbank Quarterly. 2023 Feb.
https://www.milbank.org/wp-content/uploads/2023/02/Milbank-Baseline-
Scorecard_final_V2.pdf.
\44\ New ``Scorecard'' Finds Primary Care Funding and Physician
Workforce Are Shrinking. AA of Family Physicians. February 24, 2023.
https://www.aafp.org/pubs/fpm/blogs/inpractice/entry/primary-care-
scorecard.html.
\45\ Jabbarpour Y, Petterson S, Jetty A, Byun H, Robert Graham
Center. The Health of US Primary Care: A Baseline Scorecard Tracking
Support for High-Quality Primary Care. Milbank Quarterly. 2023 Feb.
https://www.milbank.org/wp-content/uploads/2023/02/Milbank-Baseline-
Scorecard_final_V2.pdf.
\46\ Reid R, Damberg C, Friedberg MW. Primary Care Spending in the
Fee-for-Service Medicare Population. JAMA Intern Med. 2019 Jul
1;179(7):977-980. doi: 10.1001/jamainternmed.2018.
8747.
\47\ OECD Country Health Profiles, 2023. https://www.oecd.org/els/
health-systems/primary-care.htm.
\48\ Reid R, Damberg C, Friedberg MW. Primary Care Spending in the
Fee-for-Service Medicare Population. JAMA Intern Med. 2019;179(7):977-
980. doi:10.1001/jamainternmed.2018.8747v.
\49\ Zuckerman S, Merrell K, Berenson RA, Cafarella Lallemand N,
and Sunshine J. 2015. Realign Physician Payment Incentives in Medicare
to Achieve Payment Equity Among Specialties, Expand the Supply of
Primary Care Physicians, and Improve the Value of Care for
Beneficiaries. Washington, DC: Urban Institute, Social & Scientific
Systems Inc.
\50\ Hsiao WC, Braun P, Yntema D, Becker ER. Estimating Physicians'
Work for a Resource-Based Relative-Value Scale. N Engl J Med. 1988;
319:835-41.
\51\ Katz S, Melmed G. How Relative Value Units Undervalue the
Cognitive Physician Visit: A Focus on Inflammatory Bowel Disease.
Gastroenterol Hepatol (NY). 2016 Apr;12(4):240-4.
\52\ Bodenheimer T, Berenson RA, Rudolf P. The Primary Care-
Specialty Income Gap: Why It Matters. Ann Intern Med. 2007 Feb
20;146(4):301-6. doi: 10.7326/0003-4819-146-4-200702200-00011.
\53\ Neprash HT, Golberstein E, Ganguli I, Chernew ME. Association
of Evaluation and Management Payment Policy Changes with Medicare
Payment to Physicians by Specialty. JAMA. 2023;329(8):662-669.
doi:10.1001/jama.2023.0879.
Beyond mobilizing more dollars into primary care, we need to enable
PCPs to invest in new capabilities and grant them more flexibility. One
potential path would be to provide PCPs with consistent per-beneficiary
per-month (PBPM) payments in addition to certain fee-for-service
payments.\54\ These PBPM payments would be designed to cover the
estimated 25 percent of PCP activities that are not currently captured
in the Medicare Physician Fee Schedule, such as care coordination,
communication with other providers, addressing social determinants of
health, and improving patient and caregiver health literacy. This would
balance the goals of preserving access through FFS payments while
enabling PCPs to practice more patient-centered, rather than visit-
centered, care. Ultimately, it would unshackle PCPs from a system that
tries to capture every activity across thousands of codes. PBPM
payments enable PCPs to invest in sustainable practice infrastructure
transformation such as hiring case managers and care coordinators or
integrating technology and team-based care. This care model redesign is
of particular importance for improving the health of patients with
multiple chronic conditions while reducing wasteful administrative
complexity.
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\54\ Berenson RA, Shartzer A, Pham HH. Beyond demonstrations:
Implementing a primary care hybrid payment model in Medicare. Health
Affairs Scholar. 2023 Aug;1(2):qxad024.
Hybrid primary care payments cannot be implemented at scale without
congressional action. The Centers for Medicare and Medicaid Services
(CMS) have conducted several demonstration projects implementing hybrid
payments (e.g., Comprehensive Primary Care Plus). It also has the
authority to--and should--implement hybrid payments in the MSSP \55\
the largest accountable care program in Medicare. However, moving past
demonstrations to impact Medicare beneficiaries nationwide will require
congressional action to grant CMS the appropriate authority.
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\55\ Commonwealth Fund. Response to Request for Information on HHS
Initiative to Strengthen Primary Health Care from the Office of the
Assistant Secretary for Health, Department of Health and Human
Services. https://www.commonwealthfund.org/sites/default/files/2022-08/
TO%20ATTACH%20AS%20DOWNLOAD_Commonwealth%20Fund_OASH%20Primary%20Care
%20RFI_7.29.22.pdf.
The evidence for hybrid payments is promising. Blue Cross Blue
Shield of Hawaii, or Hawaii Medical Services Association (HMSA), has
conducted what is perhaps the most rigorous test of hybrid payments for
primary care to date in its Population-based Payments for Primary Care
(3PC) model. The 3PC model is a hybrid model that shifted the majority
of payments to PCPs to a risk-adjusted per-member per-month payment,
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while continuing to pay some services as FFS.
The transformative elements of HMSA's 3PC model relate to its large
market share; across its commercial, Medicare Advantage, and Managed
Medicaid lines of business, HMSA retains large shares of patients and
revenue for most of its PCPs. The model led to marked improvements in
quality, greater use of telehealth that predated the COVID-19 pandemic,
and fewer low-value imaging tests.\56\ This included increased rates of
cost-effective prevention such as blood pressure control among patients
with diabetes (2.7 percent differential increase), as well as greater
cost-saving care such as a 5.5-percent differential increase in advance
care planning (Exhibit 2).\57\ In fact, unlike other States where
primary care practice finances were massively disrupted by the COVID-19
pandemic, practices in Hawaii were protected financially, as PCPs were
well equipped to care for patients effectively in a remote fashion
because they had already made such infrastructure investments. The
experience and transformative successes in Hawaii underscore the
stability and ability to invest that hybrid payments can impart to
primary care practices.
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\56\ Dinh CT, Linn KA, Isidro U, Emanuel EJ, Volpp KG, Bond AM,
Caldarella K, Troxel AB, Zhu J, Yang L, Matloubieh SE, Drye E, Bernheim
S, Lee EO, Mugiishi M, Endo KT, Yoshimoto J, Yuen I, Okamura S, Tom J,
Navathe AS. Changes in Outpatient Imaging Utilization and Spending
Under a New Population-Based Primary Care Payment Model. J Am Coll
Radiology. 2020 Jan;17(1 Pt B):101-109. doi: 10.1016/
j.jacr.2019.08.013. PMID: 31918865.
\57\ Navathe AS, Emanuel EJ, Bond A, Linn K, Caldarella K, Troxel
A, Zhu J, Yang L, Matloubieh SE, Drye E, Bernheim S, Lee EO, Mugiishi
M, Endo KT, Yoshimoto J, Yuen I, Okamura S, Stollar M, Tom J, Gold M,
Volpp KG. Association Between the Implementation of a Population-Based
Primary Care Payment System and Achievement on Quality Measures in
Hawaii. JAMA. 2019 Jul 2;322(1):57-68. doi: 10.1001/jama.2019.8113.
Beyond private payers in Hawaii, CMS has been testing ``advanced
primary care models'' at a national level using hybrid payments in
Medicare for over a decade with promising ``leading indicator''
results. These models led to fewer emergency department visits and
hospitalizations, while producing modest gains in chronic disease
management and prevention. In Comprehensive Primary Care (CPC, 2012-
2016), hospitalizations and emergency department visits increased by 2
percent less among participating practices.\58\ This represented a
statistically significant relative reduction of 8,150 hospitalizations
and 15,472 outpatient emergency department (ED) visits over the 4 years
of the program. Importantly, practices with greater access to resources
or more experience with care delivery transformation were more likely
to reduce growth in expenditures (2 percent). This highlights the
importance of providing practices with resources for successful and
sustainable transformation.
---------------------------------------------------------------------------
\58\ Evaluation of the Comprehensive Primary Care Initiative:
Fourth Evaluation Report. Mathematica. 2018 May. https://
downloads.cms.gov/files/cmmi/CPC-initiative-fourth-annual-report.pdf.
Comprehensive Primary Care Plus (CPC+, 2017-2021) similarly saw a
2-percent reduction in ED visits that emerged early and persisted
across the 5 program years.\59\ A 2-percent reduction in
hospitalizations emerged in program years 3 and 4 and was driven by
reductions in medical admissions, suggesting that these admissions were
prevented by improved outpatient care. Furthermore, over the 5 years of
the program, the percentages of beneficiaries who received all
recommended services for diabetes increased by about 1 percentage point
and of females who received breast cancer screening increased by about
1 percentage point. CPC+ had more favorable effects among concurrent
MSSP participants, again suggesting that practices can build experience
with care transformation with time and proper investment. These
demonstrations suggest that transforming primary care payment can have
important implications for beneficiaries with multiple chronic
conditions, such as decreasing emergency department visits and
hospitalizations while improving the delivery of robust well-integrated
and well-coordinated primary care.
---------------------------------------------------------------------------
\59\ Independent Evaluation of Comprehensive Primary Care Plus
(CPC+): Final Evaluation Report. Mathematica. 2023 Dec. https://
www.cms.gov/priorities/innovation/data-and-reports/2023/cpc-plus-fifth-
annual-eval-report.
Another approach would be to continue expansion of alternative
payment models (APMs), which increase accountability for cost and
quality outcomes onto providers, shifting provider focus to value. This
will require continued support for the CMS Innovation Center. There is
some evidence that APMs can improve care for beneficiaries with both
high and low burdens of chronic disease. A great example has been the
---------------------------------------------------------------------------
Accountable Care Organization (ACO) model.
Question. Your testimony highlighted how fractured our current
health-care system is and demonstrated that patients, especially those
with chronic conditions, spend a lot of time trying to navigate that
system. We also know that individuals who are dually eligible for
Medicare and Medicaid often experience even more fragmented care due to
poor care coordination. Additionally, average Medicare spending is
higher for dual-eligibles across all services.
How could changes to how primary care services are delivered and
paid benefit dually eligible beneficiaries?
Answer. Dual-eligible beneficiaries face a disproportionately high
burden of chronic conditions compared to non-dual Medicare
enrollees.\60\ As a result, they seek a higher volume of specialty
care. Therefore, they would get an outsized benefit from improvements
in coordination.
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\60\ Kasper J, Watts MO, Lyons B. Chronic Disease and Co-Morbidity
Among Dual Eligibles: Implications for Patterns of Medicaid and
Medicare Service Use and Spending. Kaiser Family Foundation, 2010.
https://www.kff.org/wp-content/uploads/2013/01/8081.pdf.
Question. Today's patients navigate a complex health system, while
also facing the complexities of their own lives. We need a health
workforce that can meet people where they are and address their
specific barriers to good health. Community health workers have long
filled this need by providing health-care navigation and social support
in diverse communities across the Nation. They are versatile problem
solvers who take the time to understand each client's situation and
help restore them to their best possible health. But despite the
significant value they bring to our health system, community health
worker programs often rely on a patchwork of funding that comes and
goes. In your testimony, you discussed how primary care practices can
improve care for patients with multiple chronic conditions by hiring
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community health workers.
What are some barriers primary care providers currently face in
hiring and sustaining these workers? How could a shift in payment
models decrease these barriers?
Answer. CHWs can significantly improve the outcomes of their
patients, especially those with multiple chronic conditions.\61\
Barriers that PCPs currently face in hiring CHWs are the lack of
sustainable funding to support these staff members. Medicare began
reimbursing for CHW activities effective January 1, 2024, but this
merely added codes to the existing FFS system to allow CHWs to bill for
their services. Unfortunately, this will be of no help to practices who
do not have the capital to invest in these team members in the first
place. primary care practices do not have the capital to invest in
these team members. A shift in payment models to hybrid payments could
decrease these barriers by providing practices with a steady flow of
population-based payments to support hiring lay health workers.
---------------------------------------------------------------------------
\61\ Knowles M, Crowley AP, Vasan A, Kangovi S. Community Health
Worker Integration with and Effectiveness in Health Care and Public
Health in the United States. Annu Rev Public Health. 2023 Apr 3;44:363-
381. doi: 10.1146/annurev-publhealth-071521-031648. PMID: 37010928.
As of 2022, 19 States do not allow Medicaid payment for services
provided by Community Health Workers (CHWs).\62\ Without this funding,
CHWs must be funded through other means, often times by grants or
community organizations.\63\ This lack of funding is a barrier to
utilizing these workers in those States. Value-based care models which
incentivize providers to keep costs low through preventative care and
practices will likely find value in hiring and sustaining these
workers. A study by Penn's own IMPaCT program found that for every $1
invested in a CHW program $2.47 of savings were generated.\64\
Additional programs like this could be implemented by providers
searching for savings through better care coordination.
---------------------------------------------------------------------------
\62\ Sweta Haldar and Elizabeth Hinton. State Policies for
Expanding Medicaid Coverage of Community Health Worker (CHW) Services,
KFF, Jan 23, 2023. https://www.kff.org/medicaid/issue-brief/state-
policies-for-expanding-medicaid-coverage-of-community-health-worker-
chw-services/.
\63\ Ibid.
\64\ Kangovi S, Mitra N, Grande D, Long JA, and Asch DA. Evidence-
Based Community Health Worker Program Addresses Unmet Social Needs and
Generates Positive Return on Investment. Health Affairs 2020 39:2, 207-
213.
Question. Your testimonies and discussions at the hearing noted
that the Merit-based Incentive Payment System (MIPS) is cumbersome for
clinicians. The intention of MIPS is to foster performance
improvements, leading to better outcomes for patients. You all
mentioned that MIPS is burdensome and may not accurately capture the
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quality of care physicians provide.
Are there policy proposals that could be implemented to make MIPS
more accurate and less burdensome?
Answer. Currently, MIPS requires reporting of quality metrics that
may be out of touch with what providers find best for their patients or
are excessively burdensome to monitor and report. While monitoring
quality is important for patient safety and delivering high-quality
care, the current approach designed by MIPS may create costs that
outweigh its benefits. One study in JAMA Health Forum of 30 physician
practice leaders across the U.S. found that an average of $12,811 per
physician was spent to participate in MIPS in 2019, and clinicians and
administrators spent more than 200 hours per physician on MIPS-related
activities.\65\ In its 2018 report to Congress, the Medicare Payment
Advisory Commission (MedPAC) recommended eliminating MIPS and replacing
it with a more streamlined quality system that is synergistic and
supportive of physician effort.\66\ Our own research highlights that
MIPS may disproportionately negatively impact safety-net and rural
providers.\67\
---------------------------------------------------------------------------
\65\ Khullar D, Bond AM, O'Donnell EM, Qian Y, Gans DN, Casalino
LP. Time and Financial Costs for Physician Practices to Participate in
the Medicare Merit-based Incentive Payment System: A Qualitative Study.
JAMA Health Forum. 2021 May 14;2(5):e210527. doi: 10.1001/
jamahealthforum.2021.0527. PMID: 35977308; PMCID: PMC8796897.
\66\ The Medicare Payment Advisory Commission. Moving beyond the
Merit-based Incentive Payment System, chapter 15. Report to Congress,
2018. Accessed April 24, 2024. https://www.medpac.gov/wp-content/
uploads/import_data/scrape_files/docs/default-source/reports/
mar18_medpac_ch15_sec.pdf.
\67\ Liao JM, Navathe AS. Does the Merit-based Incentive Payment
System disproportionately affect safety-net practices? JAMA Health
Forum. 2020;1(5):e200452. doi: 10.1001/jamahealth
forum.2020.0452.
Beyond reforming MIPS, Congress and HHS may have statutory
authority to reform physician payment in other ways, including by
establishing hybrid payments. Congress should clarify CMS's authority
to broadly implement population-based payment through the Medicare
Physician Fee Schedule (MPFS). In the meantime, MSSP offers an
immediate opportunity for this to occur. Section 3022 of the ACA
established that providers participating in an MSSP ACO are reimbursed
according to standard Parts A and B payments, including the MPFS.
However, according to Berenson et al., 2023, any provision of Medicare
title 18 of the Social Security Act can be waived to carry out the MSSP
under statutory waiver authority. This statute specifically mentions
the possibility of implementing new payment methods.\68\
---------------------------------------------------------------------------
\68\ Berenson RA, Shartzer A, Pham HH. Beyond demonstrations:
implementing a primary care hybrid payment model in Medicare, Health
Affairs Scholar, 1(2). August 2023. https://doi.org/10.1093/haschl/
qxad024.
MedPAC suggested in 2018 that Congress eliminate MIPS to instead
attempt an alternative approach to incentivize high-quality care for
traditional Medicare beneficiaries, due to the belief that within it's
current structure, MIPS will not achieve such a goal. believes that
MIPS, as currently structured, will not achieve this goal.\69\
---------------------------------------------------------------------------
\69\ MedPAC, March 2018 Report to the Congress: Medicare Payment
Policy. https://www.medpac.gov/document/http-www-medpac-gov-docs-
default-source-reports-mar18_medpac_
entirereport_sec_rev_0518-pdf/.
Payment policy can help to rebalance quality versus quantity
incentive for physicians and provider organization motivation. There is
potential through policy reform to support clinicians' ``intrinsic
motivation'' by encouraging systematic feedback provided to clinicians
tied with opportunities for collaboration to improve care; CMS has
programs such as Partnership for Patients and Conditions of
Participation that demonstrate existing models that support providers
to improve quality while avoiding substandard care for
beneficiaries.\70\
---------------------------------------------------------------------------
\70\ Berenson RA, Rice T. Beyond Measurement and Reward: Methods of
Motivating Quality Improvement and Accountability. Health Serv Res.
2015 Dec;50 Suppl 2(Suppl 2):2155-86. doi: 10.1111/1475-6773.12413.
Epub 2015 Nov 10. PMID: 26555346; PMCID: PMC5114714.
______
Question Submitted by Hon. Sheldon Whitehouse
Question. I am working on a bill to relieve providers excelling in
the Medicare Shared Savings Program (MSSP), from prior authorization
(PA) requirements in MA. The bill rewards providers in Accountable Care
Organizations (ACOs) that generate savings for Medicare by granting an
exemption from PA requirements for their MA beneficiaries. If an
insurer believes there is a rationale for maintaining PA in such
instances, this bill would require them to seek prior approval from the
Centers for Medicare and Medicaid Services (CMS). I would welcome your
thoughts and comments on this idea.
Answer. Prior authorization is used by insurers to constrain costs
created by potentially unnecessary or low-value treatment. However,
providers participating in ACOs should already face incentives to keep
costs low and would therefore only be using expensive medications if
they were truly beneficial for patient care. Consequently, prior
authorization should be less necessary among ACOs who are succeeding in
MSSP, because they would already be containing costs through the
incentives created by accountable care arrangements. PA would only add
to their administrative burden, likely raising costs rather than saving
them because physicians should already be optimizing prescriptions due
to ACO incentives.
One national survey of 49 ACOs found that they accomplish this by
involving pharmacists directly in care, expanding the use of generics,
and educating patients on therapeutic alternatives.\71\ Another survey
of 46 ACOs identified strengths including the ability to integrate
medical and pharmaceutical data into a single database and maintaining
a formulary that encourages generic use when appropriate.\72\ However,
this study found that ACOs will need more support to quantify the
magnitude of cost offsets and therefore demonstrate the value of
appropriate medication, use as well as create protocols to avoid
medication duplication and polypharmacy. Regardless, the most
successful ACOs are likely those who are most prepared to assume
accountability for medication costs and optimize prescription value
without the added burden of PA. Therefore, a bill limiting PA for top
performers in MSSP could relieve providers of this additional
administrative work and allow them to focus more on caring for their
patients.
---------------------------------------------------------------------------
\71\ Wilks C, Krisle E, Westrich K, Lunner K, Muhlestein D, Dubois
R. Optimization of Medication Use at Accountable Care Organizations. J
Manag Care Spec Pharm. 2017 Oct;23(10):1054-1064. doi: 10.18553/
jmcp.2017.23.10.1054. PMID: 28944730; PMCID: PMC10397795.
\72\ Dubois RW, Feldman M, Lustig A, Kotzbauer G, Penso J, Pope SD,
Westrich KD. Are ACOs Ready to be Accountable for Medication Use? J
Manag Care Spec Pharm. 2020 Nov;26(11):1446-1451. doi: 10.18553/
jmcp.2020.26.11.1446. PMID: 33119446; PMCID: PMC10390926.
______
Question Submitted by Hon. Maggie Hassan
Question. I am working with my colleagues on the Finance Committee
to address discrepancies in Medicare reimbursement that disadvantage
independent doctors. Older adults, and the Medicare program, often pay
a huge markup for basic services if their provider's office is owned by
a hospital.
For example, for a routine allergy test, a patient on traditional
Medicare will pay around $40 at an independent doctor's office, but
would pay almost $200 if that office is owned by a hospital, even if
the actual hospital is miles away. Similarly, the Medicare program
would pay the doctor around $170 for the allergy test, but would pay a
hospital-owned practice more than $700 for the same exact service.
How do these imbalanced payments hold the Medicare program back
from investing in high-quality, office-based care?
Answer. In 2021 and again more recently as of June of 2023, MedPAC
recommended that Congress adopt more site-neutral payment policies for
certain outpatient services to redistribute these dollars in a more
balanced fashion.\73\ The Commission recommended more closely aligning
Medicare payment rates across ambulatory settings--hospital outpatient
departments, ambulatory surgical centers, and freestanding physician
offices--for selected services. These imbalanced payments hold the
Medicare program back from investing in high quality, office-based care
by setting up wrong incentives, leading to arbitrage as opposed to
prioritizing access.
---------------------------------------------------------------------------
\73\ MedPAC, June 2023 Report to the Congress: Medicare Payment
Policy. https://www.
medpac.gov/document/june-2023-report-to-the-congress-medicare-and-the-
health-care-delivery-system/.
______
Questions Submitted by Hon. Marsha Blackburn
Question. As CMS begins implementing the Inflation Reduction Act's
price-setting scheme, I am concerned about the impact on patient access
for Part B drugs subjected to price controls beginning in 2028. As
currently written, CMS will reimburse providers for negotiated Part B
drugs based on the Maximum Fair Price plus 6 percent rather than the
standard Average Sales Price (ASP) plus 6 percent. In the words of the
Community Oncology Alliance, this change will ``drastically cut
reimbursement for Part B drugs, making it increasingly challenging for
community oncology practices to administer drugs and keep their doors
open.'' An analysis conducted by Avalere Health found that the IRA
would lead to a minimum 49.5-percent Part B reimbursement cut for
providers.
Additionally, depending on how CMS implements IRA price controls on
Part B drugs, these payment cuts in Medicare could also affect the ASP
of the drug, which is often used by private insurance companies for
reimbursement to providers.
Have you examined the potential impact that IRA price controls for
Part B drugs, if allowed to proceed in 2028, would have on your
providers, practices, and the Medicare patients you serve?
Have you assessed the impact it could have on quality of care and
patient outcomes?
Answer. This is a new focus area for our research center, and is an
important topic. We hope to assess this in a more robust fashion to be
able to report back in the future. Thank you for highlighting this
relevant and emerging topic area.
Question. Medicare physician pay and its impact on patient access
to care remains a significant issue for my constituents. Adjusted for
inflation in practice costs, Medicare physician pay plummeted 29
percent from 2001 to 2024. Although Congress did act in the March 8th
government funding package to reduce the 3.37-percent cut that went
into effect on January 1, 2024, by an additional 1.68 percent, the 29-
percent reduction in Medicare payments over the last 2 decades is
reflective of this most recent congressional action. Plus, physicians
are now set up for another steep payment cut at the end of this year.
Nonpartisan government stakeholders recognize the damaging impact
these cumulative payment cuts have on patient access to care. Multiple
Medicare trustee reports stated that ``absent a change in the delivery
system or level of update by subsequent legislation, the trustees
expect access to Medicare-participating physicians to become a
significant issue in the long term.''
Can you discuss some of the impacts of this pressing financial
instability on physician practices, including consolidation, difficulty
retaining staff, and trouble keeping their doors open amid rising
costs?
Answer. Rising costs in Medicare are in part due to a combination
of an aging population with rising rates of chronic disease as well as
increasing administrative and technological burden. Our health system
in the United States invests much more in hospital and acute care than
it does in outpatient care, a ratio opposite that of other high-income
nations such as Denmark and Norway.\74\, \75\ As a result,
primary care practices may find themselves underfunded and unable to
deliver the care they aspire to provide, especially in rural and
underserved areas.
---------------------------------------------------------------------------
\74\ Denmark: Country Health Profile 2023, State of Health in the
EU, OECD Publishing, https://doi.org/10.1787/e4f0bee3-en.
\75\ Norway: Country Health Profile 2023, State of Health in the
EU, OECD Publishing, https://doi.org/10.1787/256fd7cf-en.
A fee-for-service (FFS) payment system causes PCPs to be dependent
upon visit volume for revenue to keep their practices afloat. Shifting
to a hybrid payment model can provide PCPs with stable, predictable
population-based payments that can support their practices through
fluctuations in visit volume and enable them to increase after-hours,
virtual, or weekend care to best meet the needs of their
population.\76\
---------------------------------------------------------------------------
\76\ National Academy of Sciences, Engineering, and Medicine.
Implementing High-Quality Primary Care Consensus Study Report, 2021.
Accessed April 24, 2024. https://www.
nationalacademies.org/our-work/implementing-high-quality-primary-care.
Consolidation of primary care practices has been shown to reduce
total patient health-care spending by 16 percent.\77\ While this
reduction in spending is primarily driven by a 21-percent reduction in
inpatient admissions, it is also due to a 13-
percent reduction in primary care visits. This demonstrates how
consolidation may decrease access to primary care. Increasing funds
through population-based payment mechanisms may provide practices with
the stable financial cash flow to keep their doors open, increasing
access for Medicare patients with chronic conditions.
---------------------------------------------------------------------------
\77\ Zhang J, Chen Y, Einav L, Levin J, Bhattacharya J.
Consolidation of primary care physicians and its impact on healthcare
utilization. Health Econ. 2021 Jun;30(6):1361-1373. doi: 10.1002/
hec.4257.
Of note, accounting for inflation in input costs is important, but
we should be sure to distinguish between keeping pace with inflation
versus adding more dollars to create better access and outcomes for
---------------------------------------------------------------------------
beneficiaries.
Question. What available mechanisms do Congress and HHS have within
current statutory authority to help provide adequate Medicare payments
to physicians and ensure continued patient access to care? For example,
alleviating the administrative burden on practices through reforms to
the Merit-based Incentive Payment System?
Answer. Reforms to the Merit-based Incentive Payment System (MIPS)
represent one mechanism to reduce administrative burden on practices.
It is unclear in the current framework if MIPS can be reformed to be
effective. Currently, MIPS requires reporting of quality metrics that
may be out of touch with what providers find best for their patients or
are excessively burdensome to monitor and report. While monitoring
quality is important for patient safety and delivering high-quality
care, the current approach designed by MIPS may create costs that
outweigh its benefits. One study in JAMA Health Forum of 30 physician
practice leaders across the U.S. found that an average of $12,811 per
physician was spent to participate in MIPS in 2019, and clinicians and
administrators spent more than 200 hours per physician on MIPS-related
activities.\78\ In its 2018 Report to Congress, the Medicare Payment
Advisory Commission (MedPAC) recommended eliminating MIPS and replacing
it with a more streamlined quality system that is synergistic and
supportive of physician effort.\79\ Our own research highlights that
MIPS may disproportionately negatively impact safety-net and rural
providers.\80\
---------------------------------------------------------------------------
\78\ Khullar D, Bond AM, O'Donnell EM, Qian Y, Gans DN, Casalino
LP. Time and Financial Costs for Physician Practices to Participate in
the Medicare Merit-based Incentive Payment System: A Qualitative Study.
JAMA Health Forum. 2021 May 14;2(5):e210527. doi: 10.1001/
jamahealthforum.2021.0527. PMID: 35977308; PMCID: PMC8796897.
\79\ The Medicare Payment Advisory Commission. Moving beyond the
Merit-based Incentive Payment System, chapter 15. Report to Congress,
2018. Accessed April 24, 2024. https://www.medpac.gov/wp-content/
uploads/import_data/scrape_files/docs/default-source/reports/
mar18_medpac_ch15_sec.pdf.
\80\ Liao JM, Navathe AS. Does the Merit-based Incentive Payment
System disproportionately affect safety-net practices? JAMA Health
Forum. 2020;1(5):e200452. doi: 10.1001/jamahealth
forum.2020.0452.
Congress and HHS may also need to enable statutory authority to
reform physician payment in other ways, including by establishing
hybrid payments. Congress should clarify CMS's authority to broadly
implement population-based payment through the Medicare Physician Fee
Schedule (MPFS). In the meantime, MSSP offers an immediate opportunity
for this to occur. Section 3022 of the ACA established that providers
participating in an MSSP ACO are reimbursed according to standard Parts
A and B payments, including the MPFS. However, according to Berenson et
al. (2023), any provision of Medicare title 18 of the Social Security
Act can be waived to carry out the MSSP under statutory waiver
authority. This statute specifically mentions the possibility of
implementing new payment methods.\81\
---------------------------------------------------------------------------
\81\ Berenson RA, Shartzer A, Pham HH. Beyond demonstrations:
Implementing a primary care hybrid payment model in Medicare, Health
Affairs Scholar, 1(2). August 2023. https://doi.org/10.1093/haschl/
qxad024.
Question. Do these cuts disproportionately impact access to care in
---------------------------------------------------------------------------
underserved areas?
Answer. Reductions in Medicare payments may affect access to care
in rural and underserved areas. Because providers are currently
dependent on volume, they may be forced to close or be acquired when
payment rates or visit volumes fall. Establishing a stable population-
based payment may help rural practices invest in sustainable practice
transformation and remain open during periods of visit instability. For
example, a population-based payment in Hawaii enabled them to transform
their practice to increase the provision of telehealth, improving their
practice stability when many others faced difficulty during the COVID-
19 pandemic.\82\
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\82\ Dinh CT, Linn KA, Isidro U, Emanuel EJ, Volpp KG, Bond AM,
Caldarella K, Troxel AB, Zhu J, Yang L, Matloubieh SE, Drye E, Bernheim
S, Lee EO, Mugiishi M, Endo KT, Yoshimoto J, Yuen I, Okamura S, Tom J,
Navathe AS. Changes in Outpatient Imaging Utilization and Spending
Under a New Population-Based Primary Care Payment Model. J Am Coll
Radiology. 2020 Jan;17(1 Pt B):101-109. doi: 10.1016/
j.jacr.2019.08.013.
Question. Many patients have chronic heart conditions, and studies
have shown how better cardiac care and rehabilitation after events
reduces hospital readmissions. However, uptake for cardiac
rehabilitation services remains low, which was affirmed by MedPAC's
March 2024 report showing 1-3 percent across Medicare Advantage and
---------------------------------------------------------------------------
Special Needs Plans, and 5-8 percent in Medicare fee-for-service.
Can we leverage more strategies focused on adherence and prevention
to reduce health-care costs, such as the home care model used in
Sustainable Cardiopulmonary Rehabilitation Services in the Home Act?
Answer. Some evidence (although limited) suggests an association
between increased cost sharing and more inpatient care and less
outpatient care; studies found in evaluating reducing or eliminating
cost-sharing total costs did not rise.\83\ The Medicare Advantage
Value-Based Insurance Design (VBID) Model aims to remove certain
obstacles to optimal health and health care. Examples include offering
patients supplemental benefits such as lower costs for prescription
drugs; grocery assistance to help ensure their unmet medical needs and
nutrition needs are met; transportation services to make sure they can
attend medical appointments; and support managing chronic health
conditions.\84\
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\83\ Fusco N, Sils B, Graff JS, et al. Cost-sharing and adherence,
clinical outcomes, health care utilization, and costs: A systematic
literature review. Journal of Managed Care & Specialty Pharmacy 2023
29:1, 4-16.
\84\ CMS, Medicare Advantage Value-Based Insurance Design Model.
https://www.cms.gov/priorities/innovation/innovation-models/vbid.
Behavioral economics serve to provide insight within developing
effective incentives for physicians to deliver high-value care, through
structured incentives with thoughtful design; several principles of
behavioral economics, such as inertia, loss aversion, choice overload,
and relative social ranking can be applied to physician incentive
programs.\85\
---------------------------------------------------------------------------
\85\ Emanuel EJ, Ubel UA, Kessler JB, et al. Using Behavioral
Economics to Design Physician Incentives That Deliver High-Value Care.
Annals of Internal Medicine, November 2015. https://doi.org/10.7326/
M15-1330.
Question. In Tennessee, our hospital emergency department staff
grapple with the fourth highest rate of ED utilization in the country.
It shouldn't be this way. For seniors on Medicare and for all
Tennesseans, we know an ounce of prevention is worth a pound of care. A
2022 report by AAFP's Robert Graham Center and Primary Care
Collaborative provides evidence that access to a usual source of care
---------------------------------------------------------------------------
is associated with fewer ED visits and more preventive services.
What are your recommendations for reforming Medicare payment to
connect every Tennessee senior to primary care and prevention--giving
our EDs some relief and ultimately improving patient health while
reducing costs?
Answer. A natural place to start is to invest more in primary care,
empowering PCPs to act as the ``quarterback'' or ``point guard'' of a
patient's care team. Robust primary care has consistently demonstrated
an improvement in population health and reduction in health
disparities.\86\ Despite this, the United States systemically
underinvests in primary care. Expenditure on primary care in the U.S.
has declined over the past decade, ranging from 6.2 percent in 2013 to
4.6 percent in 2020 across all insurance types. Medicare spends an
estimated 4 percent of its total spending on primary
care,\87\, \88\, \89\ about $15 billion per year,
which is half that of many other developed countries.\90\ In contrast,
we spend more on inpatient care and hospitalizations than other
nations. Within the U.S., primary care is systematically underinvested
relative to other specialties,\91\, \92\ despite the fact
that PCPs play the most central role in a patient's health and face the
cognitively and logistically complex task of care coordination and
integration. Procedural specialties are compensated significantly more
than primary care and other office-based specialties.\93\,
\94\, \95\ Changing fee schedule weights alone will not fix
this; studies demonstrated that a recent upweighting of reimbursement
for office visits led to only a 2-percent decrease in the Medicare
payment gap between primary care and specialty physicians (from a gap
of $40,259.80 to one of $39,434.70).\96\
---------------------------------------------------------------------------
\86\ Jabbarpour Y, Petterson S, Jetty A, Byun H, Robert Graham
Center. The Health of US Primary Care: A Baseline Scorecard Tracking
Support for High-Quality Primary Care. Milbank Quarterly. 2023 Feb.
https://www.milbank.org/wp-content/uploads/2023/02/Milbank-Baseline-
Scorecard_final_V2.pdf.
\87\ New ``Scorecard'' Finds Primary Care Funding and Physician
Workforce Are Shrinking. AA of Family Physicians. February 24, 2023.
https://www.aafp.org/pubs/fpm/blogs/inpractice/entry/primary-care-
scorecard.html.
\88\ Jabbarpour Y, Petterson S, Jetty A, Byun H, Robert Graham
Center. The Health of US Primary Care: A Baseline Scorecard Tracking
Support for High-Quality Primary Care. Milbank Quarterly. 2023 Feb.
https://www.milbank.org/wp-content/uploads/2023/02/Milbank-Baseline-
Scorecard_final_V2.pdf.
\89\ Reid R, Damberg C, Friedberg MW. Primary Care Spending in the
Fee-for-Service Medicare Population. JAMA Intern Med. 2019 Jul
1;179(7):977-980. doi: 10.1001/jamainternmed.
2018.8747.
\90\ OECD Country Health Profiles, 2023. https://www.oecd.org/els/
health-systems/primary-care.htm.
\91\ Reid R, Damberg C, Friedberg MW. Primary Care Spending in the
Fee-for-Service Medicare Population. JAMA Intern Med. 2019;179(7):977-
980. doi:10.1001/jamainternmed.2018.8747v.
\92\ Zuckerman S, Merrell K, Berenson RA, Cafarella Lallemand N,
and Sunshine J. 2015. Realign Physician Payment Incentives in Medicare
to Achieve Payment Equity Among Specialties, Expand the Supply of
Primary Care Physicians, and Improve the Value of Care for
Beneficiaries. Washington, DC: Urban Institute, Social & Scientific
Systems Inc.
\93\ Hsiao WC, Braun P, Yntema D, Becker ER. Estimating Physicians'
Work for a Resource-Based Relative-Value Scale. N Engl J Med. 1988;
319:835-41.
\94\ Katz S, Melmed G. How Relative Value Units Undervalue the
Cognitive Physician Visit: A Focus on Inflammatory Bowel Disease.
Gastroenterol Hepatol (NY). 2016 Apr;12(4):240-4.
\95\ Bodenheimer T, Berenson RA, Rudolf P. The Primary Care-
Specialty Income Gap: Why It Matters. Ann Intern Med. 2007 Feb
20;146(4):301-6. doi: 10.7326/0003-4819-146-4-200702200-00011.
\96\ Neprash HT, Golberstein E, Ganguli I, Chernew ME. Association
of Evaluation and Management Payment Policy Changes with Medicare
Payment to Physicians by Specialty. JAMA. 2023;329(8):662-669.
doi:10.1001/jama.2023.0879.
Beyond mobilizing more dollars into primary care, we need to enable
PCPs to invest in new capabilities and grant them more flexibility. One
potential path would be to provide PCPs with consistent per-beneficiary
per-month (PBPM) payments in addition to certain fee-for-service
payments.\97\ These PBPM payments would be designed to cover the
estimated 25 percent of PCP activities that are not currently captured
in the Medicare Physician Fee Schedule, such as care coordination,
communication with other providers, addressing social determinants of
health, and improving patient and caregiver health literacy. This would
balance the goals of preserving access through FFS payments while
enabling PCPs to practice more patient-centered, rather than visit-
centered, care. Ultimately, it would unshackle PCPs from a system that
tries to capture every activity across thousands of codes. PBPM
payments enable PCPs to invest in sustainable practice infrastructure
transformation such as hiring case managers and care coordinators or
integrating technology and team-based care. This care model redesign is
of particular importance for improving the health of patients with
multiple chronic conditions while reducing wasteful administrative
complexity.
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\97\ Berenson RA, Shartzer A, Pham HH. Beyond demonstrations:
Implementing a primary care hybrid payment model in Medicare. Health
Affairs Scholar. 2023 Aug;1(2):qxad024.
Hybrid primary care payments cannot be implemented at scale without
congressional action. The Centers for Medicare and Medicaid Services
(CMS) have conducted several demonstration projects implementing hybrid
payments (e.g., Comprehensive Primary Care Plus). It also has the
authority to--and should--implement hybrid payments in the Medicare
Shared Savings Program (MSSP),\98\ the largest accountable care program
in Medicare. However, moving past demonstrations to impact Medicare
beneficiaries nationwide will require Congressional action to grant CMS
the appropriate authority.
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\98\ Commonwealth Fund. Response to Request for Information on HHS
Initiative to Strengthen Primary Health Care from the Office of the
Assistant Secretary for Health, Department of Health and Human
Services. https://www.commonwealthfund.org/sites/default/files/2022-08/
TO%20ATTACH%20AS%20DOWNLOAD_Commonwealth%20Fund_OASH%20Primary%20
Care%20RFI_7.29.22.pdf.
The evidence for hybrid payments is promising. Blue Cross Blue
Shield of Hawaii, or Hawaii Medical Services Association (HMSA), has
conducted what is perhaps the most rigorous test of hybrid payments for
primary care to date in its Population-based Payments for Primary Care
(3PC) model. The 3PC model is a hybrid model that shifted the majority
of payments to PCPs to a risk-adjusted per-member per-month payment,
while continuing to pay some services as FFS; underlining a value-based
payment (VBP) approach and it's proven success. Continued VBP can
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incentivize additional investment in primary care.
______
Prepared Statement of Patricia L. Turner, M.D., MBA, FACS, Executive
Director and Chief Executive Officer, American College of Surgeons
The American College of Surgeons (ACS) thanks the Senate Finance
Committee for convening a hearing on the challenges of the Medicare
physician payment system. The ACS remains committed to improving the
care for all surgical patients, including those living with chronic
conditions, and to ensuring that Medicare beneficiaries receive the
highest quality of care. We appreciate the opportunity to describe some
of the recent work the ACS has undertaken in improving surgical quality
and value. We hope to continue partnering with Congress on potential
reforms to the current system to ensure that improving care and access
for the surgical patient stays at the forefront.
The ACS and our more than 90,000 members recognize the impact that
chronic conditions can have on surgical patient outcomes. These
conditions have a distinct impact on the finances of Federal health
programs and create additional challenges for providing high-quality
care. In the United States, more than 130 million adults suffer from at
least one chronic condition.\1\ These patients often require additional
preparations or more intensive post-acute care after surgery is
performed. ACS is focused on improving the quality of care provided and
achieving the optimal outcome for all our patients.
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\1\ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5876976/.
Our surgeon members have firsthand experience with the challenges
posed by the lack of an inflationary update and more recently the
continued reductions to fee-for-service Medicare payments. Centers for
Medicare and Medicaid Services (CMS) policies have resulted in broad
and arbitrary cuts. These reductions are often the unintended
consequence of statutory budget neutrality requirements for the
Physician Fee Schedule. One aspect of budget neutrality falls on the
Medicare Physician Fee Schedule conversion factor. These conversion
factor reductions create a strain on physicians working towards value-
based care and fail to incentivize quality or care coordination. This
results in the Medicare program taking resources away from certain
physician specialties in order to finance priorities in other areas. A
payment model designed in such a way that different specialties are
pitted against one another is counterproductive, since all specialties
are doing their best to provide quality care to their patients with
ever-scarcer resources. Since 2001, physicians have seen their Medicare
physician payments decrease by 13 percent in real terms between 2001
and 2024 before indexing for inflation. In addition to these cuts, the
impact of inflation has raised the overall cost to provide care as
costs for rent, equipment, staffing and utilities have increased.
Surgeons and other physicians have also seen an increase in financial
pressures to meet new bureaucratic barriers such as increased use of
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prior authorization in Medicare Advantage.
Since the enactment of the Medicare Access and CHIP Reauthorization
Act of 2015 (MACRA), ACS has made significant investments to translate
what we have learned about improving quality of care and outcomes into
proposals to increase value for surgical patients. Our efforts have
included:
The submission and approval of one of the first Advanced
Alternative Payment Model (APM) proposals to the MACRA-enacted
Physician-Focused Payment Model Technical Advisory Committee,
or PTAC, which is the ``first stop'' for adoption of a
stakeholder-developed APM;
Ongoing work to increase transparency in pricing through
standardization of episode definitions; and
Proposing novel quality measures that incentivize evidence-
based, team-based care organized around the geriatric hospital
patient.
Yet today, many physicians still struggle with the same barriers to
improving outcomes and transitioning to modern payment systems that
they did a decade ago:
Surgeons are faced with a Medicare Physician Fee Schedule
(PFS) conversion factor for 2024 that remains below the 1998
level;\2\
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\2\ https://www.ama-assn.org/system/files/cf-history.pdf.
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The combination of inflation and a lack of Physician Fee
Schedule updates to account for the increasing cost of
providing care means that it costs more to deliver care while
payments are declining;
Most physicians in fee-for-service (FFS) are still evaluated
based on measures that do not assess care delivered to their
patients or the conditions they treat, meaning no information
is available for improvement efforts or for patients and
referring physicians to make care choices; and
Surgeons wishing to move beyond FFS will find few physician-
focused alternative payment models are available for them,
since none of the models submitted to the PTAC have been tested
as proposed.
To create stability in the Medicare physician payment system,
Congress should immediately address cuts already expected in 2025. A
foundational step necessary to maintain access and improve quality for
patients is the implementation of positive annual updates reflecting
the inflation in practice costs. Under current law, and assuming no
additional cuts result from budget neutrality or other policy
decisions, it would take decades for the PFS conversion factor to
return to the same amount it was in the year 2000. Over that same
period, inflation will have significantly eroded the value of payments.
Clearly this is not tenable.
stabilizing medicare physician payment
The ACS is committed to working together with Congress to ensure
the stability of the Medicare PFS through both short- and long-term
policy improvements. The Medicare PFS suffers from multiple
shortcomings that have negatively impacted the care provided to our
patients. It is unique in its lack of a meaningful mechanism to account
for inflation and is currently in a multiyear window until 2026 where
any positive updates to physician payment must be legislated. Once the
positive updates begin in 2026, current law only provides a 0.25-
percent conversion factor update for non-APM participants and a 0.75-
percent update for qualified Advanced APM participants, still failing
to adequately offset the effects of inflation and account for rising
medical and staff costs. Without congressional action, continued cuts
will challenge physicians to provide adequate services and high-quality
care. Additionally, without an annual update for the PFS, it is
unlikely that future payments will keep pace with medical cost
inflation. This concerning combination of high inflation and a lack of
any update for expenses results in a need to deliver expected high-
quality care while payments are rapidly declining.
While Congress has taken action to address some of these fiscal
challenges by mitigating part of the recent PFS cuts, Medicare payment
continues to decline year after year. The recent 1.68-percent positive
adjustment only partially offsets the 3.37-percent cut that went into
effect in early 2024, and further cuts are expected in 2025. These
yearly compounding cuts, combined with a broad lack of viable
alternative payment models for surgeons, demonstrate that the Medicare
payment system is broken and falling short of the goals of MACRA. As a
starting point to create a more stable foundation for value-based care
initiatives, ACS supports building an update into the Medicare
Physician Fee Schedule, comparable to other Medicare payment programs,
to account for the effects of inflation on the cost of providing care
to seniors. This inflationary update should be separate and distinct
from incentives for quality and from the budget-
neutral Merit-based Incentive Payment System (MIPS) incentives.
The impact of the lack of inflationary adjustments is further
compounded by the overly strict nature of the budget-neutrality
trigger. The budget-neutrality requirement in a system with no
inflationary updates results in across-the-board cuts for any changes
to the PFS expected to increase expenditure by as little as $20 million
annually. This trigger amount has remained the same since its
implementation in 1992. Updating the trigger for budget-neutrality
adjustments would help to ensure that comparatively minor changes to
relative values or the addition of limited new service codes do not
always require across the board cuts. Congress, at a minimum, should
amend 42 U.S.C. 1395w-4(c)(2)(B)(ii) to increase the current $20-
million budget-neutrality adjustment trigger and index it for inflation
going forward.
Adjusting the budget-neutrality trigger is an example of a small,
but important, concrete step Congress could take to improve the
functioning of the current system. Without meaningful adjustments to
account for the increased cost of staff, office space, and other
resources, surgeons will find it increasingly difficult to continue to
improve care and outcomes. Beyond this, it will be necessary to
counteract the effects of inflation to help provide stability while
Congress and the administration provide support to facilitate the
transition to value-based payment models.
The ACS supports building a more modern and equitable care
environment for patients, rewarding value and innovation. Addressing
well-documented health disparities and ensuring the availability of
high-quality care across all settings are imperative, and medicine
should be moving steadily toward a system that truly rewards the value
of care provided rather than data entry that may not be relevant to the
patients treated. This could partially be achieved through testing and
expansion of alternative payment models developed by and for
specialists. These models should complement primary care focused
models, not compete with them, and could include primary care
physicians and other specialists focused on chronic conditions in the
fiscal attribution model and rewards to encourage care coordination.
Congress should encourage innovation by incentivizing the testing and
implementation of physician-developed, value-based payment models.
Models developed by subject matter experts such as specialty societies
will be better structured to provide and utilize timely, actionable
data and allow physicians to improve care.
facilitating the transition value-based care
The ACS believes that medicine should be moving steadily toward a
system that truly rewards the value of care provided. APMs can
facilitate better care and could also be used to incentivize physicians
to practice in rural or underserved areas. Unfortunately, efforts at
implementing an Advanced APM were hindered by a breakdown of the
process envisioned in MACRA. Along with dozens of other groups, ACS
developed and submitted proposals that were reviewed, revised, and
evaluated by the PTAC. Fourteen proposals have been recommended for
testing or implementation by the PTAC, but CMS has not tested a single
model through the Center for Medicare and Medicaid Innovation (CMMI or
Innovation Center) as proposed. This bottleneck has created a
disincentive for stakeholder investment into the development of APMs,
as witnessed by the lack of new proposals on the PTAC website since
2020.
The ACS-Brandeis Advanced APM proposal included shared
accountability for cost and quality for defined episodes of surgical
care and allowed for the entire care team, including the primary care
physician, to work together toward shared goals. Information on the
comprehensiveness of a quality program, along with comparable
information on the price of that care, are prerequisites for a valid
depiction of the value of care. The ACS has supported the development
of standardized episode definitions to foster alignment of both price
and quality measurement and create shared accountability for the team
of providers. Our proposal would provide the data and incentives
necessary to drive value improvement in specialty care. While it is our
impression that Congress has provided the resources to CMS and the
Innovation Center that are necessary to stand up and test PTAC
recommended APMs, there is nothing within the law to compel CMS to try
out new programs. This creates further barriers to those seeking to
move to value-based care. Congress should require that at a minimum,
some portion of the CMS Innovation Center's budget be dedicated to
testing physician and specialist-developed APMs recommended by the
PTAC.
improving macra to ensure meaningful quality
measurement and reduce reporting burden
The ACS sees quality as a comprehensive program built around the
patient, and inclusive of the entire team involved in providing care
for patients with a given condition or diagnosis. The current model of
individual, disconnected measures is insufficient to achieve
coordinated, patient-centered, high-value care and provides little
actionable information for physician improvement or patient decision-
making when it is time to seek care. This is especially true in rural
and underresourced areas where regional shortages in surgeons and other
care providers can lead to reduced access and fewer choices for care.
Most physicians in the current FFS system are currently evaluated
on measures that do not reflect the care they deliver to patients or
the conditions they treat. Further, the payment update associated with
the reported data applies 2 years after the data has been reported.
This means that no actionable, recent information is available for
improvement or to help patients choose the best care for them. In
contrast, ACS has designed quality programs to overcome barriers faced
by surgeons and other physicians who want to work together to
coordinate and improve care. Based on these efforts and the more than
100-year history of ACS working to improve the quality and value of
care for surgical patients, the ACS believes addressing the
shortcomings of traditional Medicare FFS payments will require new
types of quality measures, facilitated by increased flexibility in the
facility-based scoring option in MIPS. As described below, such a
combination will improve care coordination and reduce surgical
complications.
The ACS believes that surgical patients deserve to have the right
structures, processes, and personnel in place to provide optimal care
and that information should be available to allow them to find and
access such care. Verification programs like the Quality Verification
Program (QVP) or the Geriatric Surgery Verification program (GSV) could
be used as the basis of programmatic measures that more accurately
assess the ability of a system to provide high-quality care to
patients. Programmatic quality measures do the following: align
multiple structure, process, and outcome measures; target condition- or
population-specific care; apply to multiple quality domains; address
the continuum of care; and create actionable information for care teams
and patients.
Our experience with programmatic measures exhibits applicability to
diverse care settings, limited burden on care providers, and
demonstrably better results. Applied correctly, programmatic measures
will address the quality gaps created by the current measures.
In early 2023, the ACS submitted a programmatic measure, the Age
Friendly Hospital Measure, to the CMS Measures Under Consideration
(MUC) list to demonstrate how programmatic measures could be
implemented in CMS programs. We are optimistic this measure will be
included in the Fiscal Year 2025 Inpatient Prospective Payment System
(IPPS) proposed rule and will hopefully be available for hospital
reporting in future years. This measure considers the full program of
care needed for geriatric patients. It incentivizes hospitals to take a
holistic approach to the provision of care for older adults by
implementing multiple data-driven modifications to the entire clinical
care pathway spanning the emergency department, the operating room, the
inpatient units, and beyond. The measure puts an emphasis on the
importance of defining patient (and caregiver) goals, not only from the
immediate treatment decision, but also for long-term health and
functional status. The measure underscores the importance of aligning
care with what the patient values. It acknowledges certain processes,
outcomes, and structures that are necessary for providing high-quality,
holistic care for older adults across five domains:
Domain 1: Eliciting Patient Health-care Goals: This domain
focuses on obtaining patient's health-related goals and
treatment preferences to inform shared decision-making and goal
concordant care.
Domain 2: Responsible Medication Management: This domain
aims to optimize medication management through monitoring of
the pharmacological record for drugs that may be considered
inappropriate in older adults due to increased risk of harm.
Domain 3: Frailty Screening and Intervention (i.e. Mobility,
Mentation, and Malnutrition): This domain aims to screen
patients for geriatric issues related to frailty including
cognitive impairment/delirium, physical function/mobility, and
malnutrition for the purpose of early detection and
intervention where appropriate.
Domain 4: Social Vulnerability (social isolation, economic
insecurity, ageism, limited access to health care, caregiver
stress, elder abuse): This domain seeks to ensure that
hospitals recognize the importance of social vulnerability
screening of older adults and have systems in place to ensure
that social issues are identified and addressed as part of the
care plan.
Domain 5: Age Friendly Care Leadership: This domain seeks to
ensure consistent quality of care for older adults through the
identification of an age friendly champion and/or
interprofessional committee tasked with ensuring compliance
with all components of the measure.
If adopted and implemented, the Age Friendly Hospital Measure could
be further enhanced through an expansion of the facility-based scoring
option of the Quality Payment Program to make the same measure directly
applicable to physicians.
Facility-based scoring opportunities are currently limited to very
specific circumstances. This scoring method should be expanded to cover
more physicians, more facility settings and reporting programs, and to
apply it to all four Merit-based Incentive Payment System (MIPS)
categories (to include Promoting Interoperability and Improvement
Activities, in addition to Quality and Cost as currently in statute).
In such a scenario, the score would be determined automatically unless
physicians prefer to submit additional data and be scored through a
different scoring option. Then, like in other cases, they would have
the option of reporting data of their choice.
The ACS developed programs like GSV and QVP have demonstrated
marked improvements in patient care in trauma, cancer, bariatric
surgery, geriatric surgery, and other areas all of which involve the
clinical team and facilities coming together to improve the delivery of
care. Alignment with facility reporting is critical for care centering
the patient. We believe a voluntary expansion of facility-based scoring
to additional physicians, sites of service, and to all MIPS categories
could greatly reduce reporting burden while creating the environment
necessary for meaningful quality programs to be recognized and
incentivized in the payment environment.
surgical quality and impact on chronic care
The ACS recognizes the impact of chronic conditions on both
surgical patient outcomes and the finances of Federal health programs.
Chronic conditions also have a huge impact on the quality of life of
patients and in many cases, surgeons are best positioned to intervene
to fix longstanding problems. Patients with chronic, comorbid
conditions often face additional challenges in surgery and may need
additional preparation or more intensive post-acute care after surgery.
ACS's Strong for Surgery initiative provides checklists, tools, and
resources that can be used to ensure patients are controlling blood
sugar, managing medications, and stopping tobacco use to reduce the
risk of adverse events and improve outcomes from surgery. Additionally,
surgical procedures often play a role in the prevention of chronic
condition progression or can even serve as curative treatment of some
chronic conditions. Surgical intervention to address chronic conditions
comes in many forms and continues to grow with the introduction of
innovative technologies and procedures, such as groundbreaking work in
the area of xenotransplantation, which will help save even more lives
in the future and overcome shortages of viable donor organs for
transplantation. Curative interventions include orthopaedic surgery for
chronic joint pain, transplantation for organ failure, and bariatric
surgery, which can be an effective treatment for obesity, diabetes,
hypertension, and osteoarthritis. Reducing obesity can further treat or
prevent other conditions such as cancer etc.\3\
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\3\ https://asmbs.org/for-patients/explore-conditions-procedures/.
Even the effects of a traumatic injury can be considered a chronic
condition, and surgeons play a key role in helping those affected
emerge from trauma and re-enter normal life, both through surgical
skill to address the immediate injury, and by being part of a team-
based approach to managing the injury from stabilization through
rehabilitation. Simply put, surgery lets people get back to work and
live fuller, more productive lives. ACS is focused on improving the
quality of surgical care for all patients and avoiding or managing
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chronic conditions is an important aspect of this.
Quality has been the cornerstone of the American College of
Surgeons since its founding more than a century ago. Through the Power
of Quality campaign, ACS is on a mission to improve surgical quality
and patient care for every patient and in every setting across the
country. This includes expanding the reach of ACS Quality Programs to
more hospitals, enlisting more surgeons in quality improvement efforts,
encouraging adoption of quality metrics into public policy, and
expanding patient recognition of the important role these programs play
in health care. At the ACS, we believe a strong, united voice for
surgery is essential to effective advocacy in service of our patient
and surgeon community. With 13 ACS Quality Programs, the ACS has set
the standard for high quality, evidence-based surgical care and is the
definitive marking of quality patients should seek.
Achieving optimal outcomes for the surgical patient must include a
highly qualified surgeon and must involve an entire well-functioning
team. This focus on team-based care includes coordination with primary
care physicians and other specialists to ensure that the patient's
chronic conditions are managed to help patients achieve the best
possible outcomes. This commitment to team-based care is witnessed by
our verification programs, which include standards related to disease
management. For example, the ACS Surgical Quality Verification Program
or QVP includes a standard on ``Disease-Based Management Programs and
Integrated Practice Units.'' The purpose of this standard is to ensure
that the surgical management of diseases, procedures, and patient
populations requiring multispecialty care is integrated, organized, and
standardized. Another standard on team-based processes in the five
phases of surgical care requires facilities to document processes to
optimize patients for surgery through review of medications and
glycemic controls and processes to ensure continuity of care
postoperatively. The standard also looks specifically at the unique
needs of geriatric patients, including management of prescriptions for
multiple chronic conditions frequently found in this population. ACS
recognizes hospitals that successfully meet these standards through our
Power of Quality campaign.
This focus is not new and was also demonstrated in the ACS-Brandeis
Advanced APM, where the entire care team including primary care and
other specialists managing chronic conditions could participate to
improve value. Unfortunately, the model was never advanced by CMS.
Team-based APMs with patient-focused measurement represent an
opportunity to both improve patient outcomes and lower costs for
Medicare through increased efficiency.
congressional action is needed to reform medicare payment: in summary
The value transformation is underway but could greatly benefit and
accelerate through a combination of improving the foundation of the
Physician Fee Schedule and efficient investments in the partnership
between CMS and stakeholders interested in improving the way quality is
measured and incentivized. Congress has the power to provide CMS with
direction, flexibility, and additional authority to help achieve the
goal of improving value. ACS proposes the following specific action
items for Congress to consider:
First, prevent pending cuts and implement an update
mechanism in the Physician Fee Schedule to account for
inflation. This will create a stable base from which physicians
can make the leap to models involving risk;
Eliminate the Medicare PFS budget-neutrality requirement or
increase the trigger threshold from $20 million to $100 million
and index it annually to account for inflation;
Expressly direct that, at a minimum, a portion of the
Innovation Center's budget be devoted to testing APMs
recommended by the PTAC; and
Expand facility-based scoring in MIPS to accommodate the
type of collaborative measure proposed by ACS. This should
include expanding the program to additional settings such as
hospital outpatient departments and ambulatory surgical
centers.
These are relatively modest reform ideas that would stabilize the
Physician Fee Schedule and build upon MACRA to squarely focus on
providing high-value care to our patients. Surgeons are devoted to
being part of the solution and to continue to work with Congress to
advance these critical and necessary reforms. The ACS thanks you for
convening this important hearing and for the committee's attention to
improving quality and value, particularly for those with chronic
conditions. We share this commitment and look forward to working
collaboratively with the committee to achieve the goal of safe,
affordable care for all Americans.
______
Questions Submitted for the Record to Patricia L. Turner, M.D., MBA,
FACS
Questions Submitted by Hon. Mike Crapo
Question. As you noted in your testimony and responses during the
hearing, numerous features of the Physician Fee Schedule, as currently
structured, have resulted in volatility and uncertainty for clinicians.
Broad utilization overestimates for certain new billing codes, for
instance, have triggered draconian conversion factor (CF) reductions
across all specialties and subspecialties, and policy changes aimed at
ensuring appropriate reimbursement for certain subgroups of clinicians
necessitate, under budget-neutrality rules, sizable payment cuts for
others, with no countervailing enhancements for the latter groups.
What specific legislative steps should Congress consider taking in
order to provide long-term stability and sustainability for the PFS,
beyond modifying the current CF update schedule?
Answer. First, the American College of Surgeons urges Congress to
correct the unique problem of a lack of a meaningful inflation
adjustment by implementing an annual update to account for increases in
the cost of providing care to seniors. The rampant inflationary
pressure in recent years has exacerbated the underlying problem and has
damaged physicians' ability to continue to provide the high-quality
care expected by Medicare beneficiaries in a timely manner. The cost of
staff salaries, rent, technology upgrades, medical supplies and other
resources have continued to rise while the per-unit reimbursement to
physicians has not kept pace and has decreased. This is problematic in
and of itself, but the effect is compounded by how payments are set
across the health-care system. Facilities incur many of the same costs
as physician practices with similar inflation dynamics, particularly
when it comes to labor costs. But because facilities receive
inflationary adjustments, it becomes a severely distorted employment
market for the same staff and labor where facilities receive money from
Medicare to hire staff in recognition of inflation while physician
practices do not. This places a greater burden on physician practices
than on all other providers, making this problem a unique Medicare
Physician Fee Schedule problem that requires a unique Medicare
Physician Fee Schedule solution. At a minimum, an annual inflationary
index to mitigate these increases in costs should be adopted.
Beyond modifications to the update schedule, ACS also believes that
it is time to adjust the estimated change in spending that triggers a
budget-neutrality adjustment. Under current statute, when there is an
increase annually of $20 million to the fee schedule, it automatically
requires CMS to implement across-the-board cuts for physicians. This
dollar amount is not indexed for inflation and has not been updated
since implementation of the fee schedule in 1992. Increasing this
amount to $100 million and indexing it for inflation moving forward
would help to increase stability in Medicare physician payment by
eliminating the need for cuts when necessary but minor changes are
implemented to the fee schedule.
Question. In the absence of these types of steps, what concrete
impacts will current and future beneficiaries most likely experience?
Answer. If Congress does not take the steps necessary to ensure
long-term stability, there will be several damaging developments to
those providing and receiving care. Due to the increasing financial
strain faced by self-employed physicians, many of whom are less able to
make up for the insufficient Medicare payment updates there will be an
increased likelihood of more providers selling their practices or
possibly even leaving the practice of medicine. Not only will this lead
to increased consolidation in health care, but it will also create gaps
in access, particularly in underserved and rural communities.
Another foreseeable consequence of failure to stabilize physician
payments will be to further delay the needed transition to value-based
care and alternative payment models (APMs). The Medicare Access and
CHIP Reauthorization Act of 2015 (MACRA) was designed to create a
``period of stability'' during which new models and measures would be
created. Unfortunately, due to the lack of regular updates and the
budget-neutral nature of the PFS, this period of stability was
punctuated by a series of cuts to many physicians. Some of these cuts
were delayed or reversed, but not all. This has created an uncertain
playing field where it is difficult to make the investments necessary
in care models and technology for the value transformation to be
successful. Furthermore, the expected physician developed models and
quality measures have not materialized, further harming efforts to
modernize and improve care models.
Question. Regulations finalized earlier this year aim to streamline
and standardize prior authorization standards and requirements in
certain contexts, but the final rule expressly excludes outpatient
medications, whether administered by clinicians or dispensed to
beneficiaries via pharmacy. Both the American College of Surgeons (ACS)
and the American Academy of Family Physicians (AAFP) made note of this
omission in comments submitted in response to the proposed rule.
Specifically, ACS ``urge[d] CMS to apply its proposed policies to
all drugs covered by any of the impacted payers to align PA processes
and related implementation efforts with those for all other covered
items and services.'' Similarly, AAFP expressed concern and
disappointment that ``these proposals do not apply to prior
authorizations for prescription and outpatient drugs,'' and went on to
``strongly [urge] CMS to expand the proposals in this rule to Medicare
Part D plans and prescription drug coverage across other impacted
payers.''
Virtually all clinician organizations concurred with these
recommendations, including those focused on treating some of the most
onerous chronic conditions, such as cancer. The Community Oncology
Alliance, for instance, asserted, ``Addressing the drug treatment for a
person's cancer should clearly be part of any effective, comprehensive
regulatory initiative to streamline the current onerous prior
authorization processes.'' Patient advocates uniformly agreed with
these concerns, which a number of groups have cited as a key source of
delays and denials of potentially lifesaving therapeutics, across both
the provider-administered setting and the retail pharmacy context.
Studies have found that physician-administered drugs and biologics
account for a large and growing share of all forms of prior
authorization and utilization management (UM) under Medicare Advantage
(MA) plans' medical benefits, and the application of various UM tools,
such as prior authorization, step therapy, and formulary exclusion, has
risen dramatically in recent years under Medicare Part D plans.
Analysts broadly project that these trends will accelerate, rather than
reverse, in the midst of Part D's benefit redesign.
What specific components should Congress, or CMS, consider
including in any effort to streamline and otherwise reform requirements
and standards for UM tool application to outpatient drugs (both
physician-administered and pharmacy-
dispensed)?
Answer. First and foremost, ACS would urge that it be made clear
that PA should never be required for maintenance drugs that patients
have been on for an extended period of time as part of an evidence-
based form treatment plan for their chronic condition or conditions.
Such requirements, including for periodic prior authorization for
insulin for a diabetic patient, add significant burden on the care team
and create the potential for harmful disruptions in needed medications
for patients while providing no measurable benefit in the quality and
appropriateness of care.
Question. What benefits would these components offer to patients
and clinicians?
Answer. Reducing unnecessary burdens would have far-reaching
benefits for patients and their physicians including reduced stress and
potentially better adherence to treatment plans as unnecessary
disruptions in care could be avoided.
Question. In the absence of reform efforts along these lines for
medications, what prior authorization and UM burdens and other effects
will clinicians and beneficiaries continue to experience, even after
CMS's final rule takes effect?
Answer. ACS believes that PA adds little value in most cases while
adding substantial cost and burden. PA requirements should be limited
to instances where a clear need can be demonstrated. As highlighted by
the question, these concerns also extend beyond PA to other forms of
UM, including step therapy, nonmedical switching, and restrictive
formularies.
Question. On a number of fronts, CMS has leveraged subregulatory
guidance as a means of clarifying current-law and regulatory
requirements for plans, providers, and beneficiaries. In the context of
Part D, 42 CFR 423.272(b)(2) establishes regulatory requirements for
plan designs, noting that the agency will not approve a bid if ``the
design of the plan and its benefits (including any formulary and tiered
formulary structure) or its utilization management program are likely
to substantially discourage enrollment by certain Part D eligible
individuals under the plan.'' Notably, clause (iii) specifies that even
if a plan adheres to proper category/class inclusion requirements, such
a plan may still fall short of this standard by virtue of its exclusion
of certain drugs.
Patients, providers, and plans, however, have flagged uncertainty
as to the scope and practical implications of this language. Updates to
the regulations themselves, or else to the relevant sections of the
Medicare Prescription Drug Manual, could present a potential avenue for
clarifications, along with exemplary examples of compliant and
noncompliant formulary design and UM tool applications.
What types of clarifications or examples, in this context, could
CMS provide, either through guidance or regulations, to ensure adequate
and efficient medication access for Part D enrollees, many of whom take
multiple prescriptions for chronic diseases?
Answer. The ACS has previously submitted comments to CMS detailing
our concerns with the use of utilization management tools in Part D
that have the potential of disrupting the patient-physician
relationship and overruling physician judgment in terms of which
treatment is best for a patient. Physicians prescribe drugs based on
clinical judgment, patient needs, and evidence-based medicine--not on
profit incentives.
One specific area where we have expressed concern would be the use
of step therapy requirements on immunosuppressive drugs, which are
often prescribed for transplant patients. The ACS believes that any
perceived savings that might be achieved by expanding utilization
management to these drugs would be far outweighed by the potential harm
both to patients and the Medicare program should changes to coverage
for immunosuppressants lead to unnecessary hospitalizations, organ
rejection, or other serious health consequences.
Question. In some cases, formularies exclude or disadvantage lower-
cost alternatives to branded medications with higher list prices while
charging beneficiaries coinsurance tied to said inflated sticker-price
figures. The Part D statute directs pharmacy and therapeutic (P&T)
committees to ``base clinical decisions on the strength of scientific
evidence and standards of practice,'' but it remains unclear to what
extent these committees or the Part D plans themselves factor cost
sharing, UM hurdles, or lower-priced alternatives (and the role of
rebates) in making these types of determinations.
How does cost-sharing burden affect medication adherence and
clinical outcomes for patients, and how should plans (and their P&T
committees) incorporate these types of considerations into their
recommendation and review processes?
Answer. Medication adherence before and after surgery is important
in ensuring optimal outcomes. Excessive cost sharing can have an
adverse effect on patients being able to afford their medications and
therefore on adherence. As noted previously with the immunosuppressive
example above, this can have the opposite effect, costing more rather
than less while also having dire consequences for patients and their
health.
Question. What formulary review mechanisms or reporting
requirements could CMS implement in order to ensure effective and
meaningful oversight of formulary design, UM tool application, and the
clinical basis for these decisions?
Answer. As mentioned above, ACS strongly maintains that physicians
should be able to use their clinical judgment in prescribing the most
appropriate medication for their patient. Expanding UM for drugs can
have adverse effects on patient care. One specific area where we have
expressed concern would be the use of step therapy requirements on
immunosuppressive drugs, which are often prescribed for transplant
patients. The ACS believes that any perceived savings that might be
achieved by expanding utilization management to these drugs would be
far outweighed by the potential harm both to patients and the Medicare
program should changes to coverage for immunosuppressants lead to
unnecessary hospitalizations, organ rejection, or other serious health
consequences. If CMS implements UM, these requirements should be made
clear to the prescriber in real time.
Question. Artificial intelligence (AI) has the potential to
mitigate administrative burden and enhance health-care quality,
including in the context of Medicare. That said, some clinicians have
raised concerns around the program's inability to keep pace with AI-
enabled tool development through its coverage and payment policies,
undercutting access, especially for smaller practices.
What use cases for AI-enabled tools and technologies seem most
promising in the context of clinician care?
Answer. One promising case for AI-enabled tools would be the
potential application towards reducing the administrative burden that
many providers face. This could range from typical administrative
tasks, insurance related correspondence, record maintenance, and even
note taking while consulting with a patient. Generative AI has the
potential to greatly increase the overall productivity of providers and
create a more efficient health-care sector for our patients. This could
lead to providers having more time and energy to focus on improving and
developing the highest possible quality of care. AI tools should always
be used to aid physicians in their decision-making, not to replace
them, as regardless of the sophistication of the algorithm used, they
still lack physician judgment and training.
Question. What steps should CMS and Congress take to ensure
adequate coverage and reimbursement for appropriate AI-enabled tools in
this context?
Answer. CMS should ensure that approved AI-enabled tools receive
coverage commensurate with the value that they provide to patients, and
reflective of the costs associated with acquiring, implementing, and
updating the tools as well as any costs associated with integrating
such tools into electronic health records (EHRs).
______
Questions Submitted by Hon. Chuck Grassley
Question. According to the Medicare Payment Advisory Commission
(MedPAC), Medicare's Physician Fee Schedule updates have grown more
slowly than input cost growth in recent years. Yet Medicare spending on
an annual basis is up 30 percent over 5 years and the Congressional
Budget Office (CBO) just revised Medicare spending for benefits--for
this year and last year--up another $272 billion. MedPAC explains this
is due to an increase in the volume and intensity of Medicare services.
Can you explain the root cause for higher Medicare spending while
at the same time, physicians are receiving less in reimbursement?
Answer. There are numerous factors that account for the increased
Medicare spending. As you point out, Medicare spending is up 30 percent
over 5 years. Over that period an additional 2 million Americans have
entered the program, and CPI increased by approximately 23 percent.
When these factors are taken into account this increase seems more
reasonable. Over that same period, updates to the Physician Fee
Schedule have actually been a net negative. Virtually all the growth in
overall Part B spending can be accounted for due to increased spending
on facilities and prescription drugs. The following table, created from
data in the 2023 Annual Report of the Boards of Trustees of the Federal
Hospital Insurance and Federal Supplemental Medical Insurance Trust
Funds, shows the growth in Part B spending from 2013 to 2022 was driven
largely by spending in hospital outpatient services and Part B drugs
and virtually none of the growth is attributable to physician services
(from Table IV.B6.--Aggregate Part B Reimbursement Amounts on an
Incurred Basis).
[GRAPHIC] [TIFF OMITTED] T1124.003
.eps__
Questions Submitted by Hon. Maria Cantwell
Question. Adjusted for inflation in practice costs, the American
Medical Association estimates that Medicare physician payments
plummeted by 29 percent from 2001 to 2024. As one of the only provider
groups without an automatic inflation-based update to their Medicare
payments, physicians are falling farther and farther behind. Medicare
physician payments and their impact on patient access to care is a
major issue for my constituents.
As a gastroenterologist in Vancouver, WA told me, it's become
increasingly hard for physicians to maintain their practices because
the costs of labor, equipment, and technology have spiked while
Medicare payments have remained largely stagnant. One radiologist in
Seattle told me that her income has effectively stayed the same for her
entire career, despite inflation and other changes, because of flat
Medicare reimbursements. A rehab therapy provider in Anacortes, WA said
that unless physicians get relief, her practice and others like it
might have to close.
Nonpartisan government stakeholders are recognizing the damaging
impact these cumulative payment cuts have on patient access to care.
Multiple Medicare trustee reports have stated that access to Medicare-
participating physicians will become a significant issue in the long
term.
This access is especially important for people with chronic
conditions. Care for chronic diseases is expensive: the CDC estimates
that spending on individuals with chronic disease accounts for about 90
percent of all health-care spending in the U.S. Providers caring for
Medicare patients take on a disproportionate amount of that burden
because older adults have a higher risk of living with or developing
chronic conditions. A 2022 study found that 66 percent of people aged
65 and older have at least two common chronic conditions. That means
that Medicare physician payment relief is directly tied to ensuring
that chronic care patients can access the care they need.
What impact does the financial instability from low Medicare
payments have on access to care for patients with chronic diseases?
Answer. If Congress does not take the steps necessary to ensure
long-term stability there will be several damaging developments to
those providing and receiving care. This includes the more than 130
million adults that suffer from at least one chronic condition. These
patients often require additional preparations or more intensive post-
acute care once the surgery is performed. If long-term stability to the
Medicare payment system is not achieved there would be several impacts
to chronic care patients. One immediate impact would be the increased
barrier to care. Providers that can no longer keep their lights on
would either opt out of Medicare or worse would close their office.
Either situation would be increasingly damaging, especially to those in
underserved areas or care deserts. In other circumstances, the
practices might fight to continue providing care but be forced into
ownership models that increase negative consolidation in the market or
lead to ownership of health-care providers by nonhealth-care entities.
Question. A recent MedPAC report to Congress recommends that
Congress increase the 2025 Medicare physician payment rate above
current law with an
inflation-based payment update because physician practices cannot
absorb the increasing costs to practice medicine. Do you agree that
this policy would help with inadequate reimbursements?
Answer. Yes, the American College of Surgeons strongly believes
that the implementation of an inflationary index would help to
strengthen and stabilize the Medicare payment system. Without some
acknowledgement of the adverse impact of inflation on a physician's
ability to care for patients, we will continue to struggle to adapt to
the need to do more with less, jeopardizing our ability to provide the
highest quality care to American seniors. However, unlike the MedPAC
recommendation, the American College of Surgeons believes the Medicare
Physician Fee Schedule should be updated by a full inflationary update
factor (and not half of the Medicare Economic Index (MEI) as put
forward by MedPAC).
______
Questions Submitted by Hon. John Thune
Question. As part of the Merit-based Incentive Payment System
(MIPS), physicians must be compliant in promoting interoperability as
part of their reimbursement, which helps to facilitate the sharing of
data between various providers.
I have long been an advocate for health IT initiatives that can
improve efficiencies and reduce costs in the health-care system, and I
believe that sharing information between providers through an
interoperable network has immense upside, so long as there are
safeguards to protect patient privacy and ensure taxpayer funds are
spent appropriately.
However, there continue to be challenges to physicians meeting
interoperability metrics, like information blocking for example in
which an individual or entity impedes the delivery or utilization of an
electronic health record, making interoperability impossible.
In your view, how have practices been impacted by information
blocking?
Answer. Based on feedback from our surgeon members, surgical
practice has been less impacted by information blocking and more from
the lack of comprehensive interoperable data standards to allow for
easy repurposing of clinical data to aid in clinical decision-making at
the point of care. Further, the sometimes-excessive cost of updating or
upgrading EHR products to meet certification requirements is burdensome
and at times prohibitive, especially for small or rural practices.
Question. Are you aware of instances in which the timeliness or
quality of the care physicians are able to provide patients has been
impacted by a limited ability or complete inability to access
electronic health records?
Answer. While the flow of clinical data is far from effortless, and
interoperability and lack of easy access to clinical data remain at
times problematic for care coordination efforts and long term tracking
of patients journeys, our surgeon Fellows express greater concern at
the delays in care created by unnecessary prior authorization
requirements.
Question. Furthermore, beyond information blocking, what other
challenges persist in physicians accessing patients' health information
electronically despite the billions of dollars spent to implement
electronic health IT and interoperability?
Answer. The substantial investment in HIT was well meaning and
important, but as noted, has struggled to meet its full promise. From
the outset, the focus on specific technology rather than on the
standardization and use of data to inform and improve clinical care has
limited the benefit to patients.
Question. In your testimony, you allude to the issue of Congress
being consistently relied upon to take certain action to address
payment adjustments to the Physician Fee Schedule.
As you continue to advocate for more stability to the Physician Fee
Schedule to ensure providers have the certainty they need to continue
providing high-quality care to their patients, in addition to ensuring
the fee schedule accounts for the impacts of inflation, could you
expand on a few other policies referenced in your testimony that you
believe Congress should consider that could also result in greater
stability for providers through the fee schedule?
Answer. There are several steps that Congress can take to ensure
the long-term stability of Medicare physician payments. First, Congress
should prevent any future cuts and implement a mechanism into the
Physician Fee Schedule to account for inflation. Eliminating across-
the-board cuts, not intended to incentivize higher-
quality care, as well as implementing a regular update mechanism are
critical first steps in creating a stable FFS payment system. This
stability is a prerequisite for physicians to be able to evaluate and
invest in value-based payment models involving financial risk.
Second, Congress should eliminate the Medicare PFS budget-
neutrality threshold requirement or increase the trigger from $20
million to $100 million annually and index it for inflation moving
forward. This will help ensure that small but necessary corrections to
the relative values of services will not necessarily result in harmful
cuts for others.
Regarding the transition to value-based care, ACS strongly believes
that any changes to existing FFS payment programs should ensure that
they are designed to help further this goal. That is, they should
provide patients and their physicians with the data on quality and
price necessary to make decisions based on value as well as for efforts
to improve outcomes and efficiency. One example of a change that would
further this goal would be to expand the facility-based scoring option
in MIPS to accommodate measures explicitly designed to foster team-
based coordinated care. ACS has developed a geriatric surgery focused
measure called the Age Friendly Hospital measure, which is included in
the FY 2025 IPPS proposed rule.
Furthermore, to ensure that physicians have options when they
decide to make the leap to advanced APMs, Congress should specify that
a portion of the CMS Innovation Center's budget be devoted to testing
advanced alternative payment models (APMs) developed by physicians and
evaluated by the Physician-Focused Payment Model Technical Advisory
Committee (PTAC).
Question. Another issue you touch on in your testimony pertains to
the frustrations that the Physician Fee Schedule today does not
adequately reflect the quality of care that physicians provide due to
certain shortcomings in existing evaluation metrics and data lags.
To address this, you suggest that new quality measures need to be
built into fee-for-service payments.
Could you outline for the committee what some of those quality
measures are and how you think implementation of them could, in
practice, improve the quality of care that is provided to patients?
Answer. The ACS has a more than 110-year history of measuring and
improving the quality for the surgical patient. Over that time, we have
come to recognize the importance of shared goals and evaluation in
spurring quality improvement. We have also used this knowledge to
develop a number of quality programs aimed at verifying that the
people, resources, structures, and processes necessary for optimal
outcomes are in place. Recently, the ACS, in collaboration with the
American College of Emergency Physicians and the Institute for
Healthcare Improvement, developed a programmatic measure that builds on
the successes of the ACS Geriatric Surgery Verification Program and
incentivizes hospitals to take a holistic approach to care delivery for
older adults. The measure highlights the importance of implementing a
clinical framework, using evidence-based best practices, which provides
goal-centered, clinically effective care for older patients.
The Age Friendly Hospital Measure is a ``focused-composite'' metric
that comprises a handful of structural metrics (such as staffing and
roles specific to geriatrics), process metrics (such as frailty
assessments and delirium screening), and outcomes focused on activities
that are essential for effective care in this demographic. If
finalized, the measure would be a positive step toward incentivizing
team-based care organized around the geriatric patient.
As noted previously, expanding the facility-based scoring method in
MIPS and specifically allowing care teams to be scored on measures such
as this would go a long way toward improving physician quality
measurement in surgery.
______
Question Submitted by Hon. Robert P. Casey, Jr.
Question. Your testimonies and discussions at the hearing noted
that the Merit-based Incentive Payment System (MIPS) is cumbersome for
clinicians. The intention of MIPS is to foster performance
improvements, leading to better outcomes for patients. You all
mentioned that MIPS is burdensome and may not accurately capture the
quality of care physicians provide.
Are there policy proposals that could be implemented to make MIPS
more accurate and less burdensome?
Answer. Any time that a physician is asked to report on something
that is not perceived as important to improving patient care it will be
perceived as burdensome, and this is the case with many of the
requirements in MIPS. As passed, it appeared that MIPS would be
developed as an on-ramp to value-based payment, with funding for new
quality measures to fill in caps and a pathway for creation of APMs.
Unfortunately, MIPS has proven in many ways to be more of a reshuffling
of the deck than a transformation, with little progress in developing
and moving to more meaningful measures and no progress in testing or
implementing physician developed APMs. Recent proposals to reform the
program seem to promise more of the same, with the MIPS Value Pathway
(MVP) proposal being built from the same pieces. ACS has previously
proposed and submitted an Advanced APM and worked with CMS to explain
how we would make a more meaningful MVP for surgery. Unfortunately, CMS
lacks the authority and/or the will to implement novel approaches.
Within the current MIPS framework, ACS would support implementing
and expansion of the facility-based scoring method in conjunction with
new programmatic quality measures. An example of a programmatic measure
is the Age Friendly Hospital measure developed by ACS, in collaboration
with the American College of Emergency Physicians and the Institute for
Healthcare Improvement. This measure builds on the successes of the ACS
Geriatric Surgery Verification Program and incentivizes hospitals to
take a holistic approach to care delivery for older adults. The measure
highlights the importance of implementing a clinical framework, using
evidence-based best practices, which provides goal-centered, clinically
effective care for older patients.
The Age Friendly Hospital Measure is a ``focused-composite'' metric
that comprises a handful of structural metrics (such as staffing and
roles specific to geriatrics), process metrics (such as frailty
assessments and delirium screening), and outcomes focused on activities
that are essential for effective care in this demographic. If
finalized, the measure would be a positive step toward incentivizing
team-based care organized around the geriatric patient.
The ACS believes that components of this measure, and of
comprehensive verification programs in general, meet many of the goals
of the four MIPS categories and that facility-based scoring should be
expanded beyond quality and cost to include Promoting Interoperability
and Improvement Activities, and that the program should be expanded to
other facility types. Such measures show great promise in bringing the
entire care team together to center the patient.
______
Question Submitted by Hon. Sheldon Whitehouse
Question. I am working on a bill to relieve providers excelling in
the Medicare Shared Savings Program (MSSP), from prior authorization
(PA) requirements in MA. The bill rewards providers in Accountable Care
Organizations (ACOs) that generate savings for Medicare by granting an
exemption from PA requirements for their MA beneficiaries. If an
insurer believes there is a rationale for maintaining PA in such
instances, this bill would require them to seek prior approval from the
Centers for Medicare and Medicaid Services (CMS). I would welcome your
thoughts and comments on this idea.
Answer. While the ACS would want to review legislative text of such
a proposal prior to taking a position, we do see a certain logic in
waiving PA requirements for health systems that have demonstrated
appropriateness and adherence to best practices through achievement of
savings to the Medicare program. By achieving savings to the program,
physicians have shown that they are not inappropriately or excessively
utilizing care. In addition to savings, the ACS would caution that such
an exemption should also require that quality benchmarks are attained
to show that patient outcomes are not adversely affected in efforts to
achieve shared savings. Achieving the patients' goals of care and
optimal outcomes should be our ultimate objective. Whether or not
savings are achieved, PA requirements should not be allowed to get
between physicians and patients as they strive for this goal. The ACS
would welcome the opportunity to review and comment on this legislative
proposal when it becomes available.
Questions Submitted by Hon. Marsha Blackburn
Question. CMS has a track record of overestimating spending
associated with payment policy changes. For example, in 2013, the
introduction of Transitional Care Management codes led to a reduction
of over $700 million in fee schedule payments. This was due to the
agency projecting utilization of around 5.6 million claims, whereas
actual claims fell below 300,000 in the first year.
A similar scenario unfolded with Chronic Care Management codes. CMS
made budget-neutrality adjustments based on an assumed utilization of
4.7 million claims, yet actual claim volume totaled less than 1
million. These assumptions, among others, perpetually reduce the
aggregate dollars available under the fee schedule, with no mechanism
for reconciling overestimates or underestimates.
Do you believe the Physician Fee Schedule should incorporate
forecast error adjustments to rectify over- and underestimations
exceeding a certain threshold through subsequent payment modifications?
Answer. Lacking information on how frequently forecasting errors
occur and how often they are overestimates versus underestimates, the
ACS has not taken a formal position on this proposal. However, it is
important to take steps to ensure that cost and utilization estimates
are as accurate as possible. While reversing cuts due to overestimates
of utilization would be beneficial, the ACS also does not believe that
it makes sense to penalize all providers through budget-neutrality
adjustments in the first place. If small but necessary adjustments are
made to the Physician Fee Schedule these changes should not require
patients with other care needs to sacrifice access or quality of care
due to unjustified cuts.
Question. Medicare physician pay and its impact on patient access
to care remains a significant issue for my constituents. Adjusted for
inflation in practice costs, Medicare physician pay plummeted 29
percent from 2001 to 2024. Although Congress did act in the March 8th
government funding package to reduce the 3.37-percent cut that went
into effect on January 1, 2024, by an additional 1.68 percent, the 29-
percent reduction in Medicare payments over the last 2 decades is
reflective of this most recent congressional action. Plus, physicians
are now set up for another steep payment cut at the end of this year.
Nonpartisan government stakeholders recognize the damaging impact these
cumulative payment cuts have on patient access to care. Multiple
Medicare trustee reports stated that ``absent a change in the delivery
system or level of update by subsequent legislation, the trustees
expect access to Medicare-participating physicians to become a
significant issue in the long term.''
Can you discuss some of the impacts of this pressing financial
instability on physician practices, including consolidation, difficulty
retaining staff, and trouble keeping their doors open amid rising
costs?
Answer. As with any business, independent physicians must have
enough income and revenue to pay for rent, utilities, and staff as well
as their own income. In addition, physicians must spend an increasing
amount of time and money in meeting burdensome mandates both from the
government and private insurers, including an increasing amount of time
spent dealing with prior authorization and other utilization
restricting techniques that interfere in the patient-physician
relationship. The impact of higher-than-average inflation in recent
years has contributed greatly to the overall cost to provide care as
costs to staff these facilities continue to increase year after year.
Lacking any mechanism within the PFS to account for these increases,
they contribute to a growing financial strain that may force them to
make difficult decisions related to staff retention, patient access or
even whether or not to remain in private practice. These decisions may
be even more difficult in rural areas, where it is difficult for
physicians to increase volume to make up for decreasing payments. Loss
of a practice in a rural area may jeopardize access to care for
patients without other reasonable alternatives. Further, physician
practices are often hiring staff in direct competition with hospitals
and other facilities. When physician practices are not compensated for
inflationary increases, but hospitals and other facilities are, the
ability to recruit and retain physician practice staff becomes
untenable.
Question. What available mechanisms do Congress and HHS have within
current statutory authority to help provide adequate Medicare payments
to physicians and ensure continued patient access to care? For example,
alleviating the administrative burden on practices through reforms to
the Merit-based Incentive Payment System?
Answer. The Merit-based Incentive Payment System (MIPS) as
implemented falls far short of the goals of tying payment more closely
to quality and value, while creating the potential for significant
additional burden or even steep payment reductions, particularly for
those in small, independent practices.
Most surgeons currently evaluated in MIPS are employed by a health
system or large group practice that reports measures on their behalf,
many of which may be completely unrelated to the care they provide.
Physicians in such employment situations are statistically more likely
to score well in MIPS even though the measures reported add little to
improve patient care.
Smaller independent practices on the other hand would face the full
burden of reporting on quality, promoting interoperability, and
improvement activities. While the measures they select are likely to be
more meaningful, the burden is also higher and many may choose not to
fully report or not to participate at all, calculating that the cost of
compliance is greater than the reduction mandated.
The ACS believes that the burden on physicians could be greatly
alleviated by an expansion of the facility-based scoring option.
Currently, facility-based scoring only applies to quality and cost and
only measures in very specific circumstances. In order to incentivize
team-based care and greater coordination of effort toward shared goals,
this option could be expanded to a larger array of physician
specialties and to all four categories of the MIPS program. While some
of these changes would require legislative authority, we think they are
worthwhile improvements that would reduce burden and improve patient
experience and outcomes.
Question. Do these cuts disproportionately impact access to care in
underserved areas?
Answer. Cuts to the Medicare physician payment system have led to
increased instability for physicians that aim to provide high-quality
care in underserved communities. While finding adequate care in these
areas can already present a challenge, stagnation in Medicare payments
has led to an even larger burden. Many of these providers are the only
care in the area. When they are forced to close their offices, it can
lead to an immense barrier to care. Patients in these communities are
then forced to either forgo the care they need or travel immense
distances to receive care.
Question. Are there enough APMs approved by CMMI for all physician
practices to participate? In other words, are all practices ready to
move to value-based care models? If not, what steps can Congress and/or
the administration take to promote the value-based care pathway?
Answer. The current options for participation in Advanced APMs are
limited to programs developed by CMS, and exclude models proposed and
developed by physician experts and approved by the PTAC because CMS
never implemented a single one of them. Existing models may be limited
in scope, specialty, or geographic location, leaving some physicians
without access to a model or with too few eligible patients to meet
participation thresholds. The ACS continues to advocate for a portion
of the CMMI budget to be dedicated to testing physician stakeholder-
developed models approved by the PTAC to expand the options available
to physicians.
Question. Do you think the Physician-Focused Payment Model
Technical Advisory Committee (PTAC) has an important role to play in
the creation of new APMs? Do you know why CMMI to date has not accepted
any of the PTAC-approved models?
Answer. ACS in conjunction with Brandeis University developed and
submitted proposals that were reviewed, revised, and evaluated by the
PTAC. We found the process of revising and improving the proposal in
response to PTAC questions and evaluation helpful and in the end our
proposal was recommended for limited scale testing. In total, at least
14 proposals have been recommended for testing or implementation by the
PTAC, but CMS has not tested a single model through the CMMI as
proposed. This bottleneck has created a glaring disincentive for
stakeholder investment, as witnessed by the lack of new proposals on
the PTAC website since 2020. While ACS does believe that there is a
role for PTAC to play, unfortunately there is no current law to compel
action from CMS once proposals have been reviewed and recommended.
Congress should require that at a minimum, some portion of the CMS
Innovation Center's budget be dedicated to testing physician- and
specialist-developed APMs recommended by the PTAC.
Question. Every year, we see an alarming decline in physicians
offering essential care services. This trend is partly fueled by
soaring costs for practices, already high yet constantly increasing
administrative burden, and low reimbursement rates, often well below
the cost of providing care.
How has the cost of providing lifesaving care changed over the
years for your practice, and how has the payment for those services
caught up or not caught up?
Answer. Unfortunately, the cost of providing care has continued to
rise through several factors while the level of compensation has been a
consistent target to offset other costs. Our surgeon members have
firsthand experience of the financial challenges posed by the lack of
an inflationary update as costs for rent, equipment, staffing, and
utilities have increased. On top of this, surgeons have faced payment
reductions due to the budget neutrality threshold requirement in the
MPFS. These conversion factor reductions create a strain on physicians
working towards value-based care and fail to incentivize quality or
care coordination. This results in the Medicare program taking
resources away from certain physician specialties in order to finance
priorities in other areas. A payment model designed in such a way that
different specialties are pitted against one another is
counterproductive, since all specialties are doing their best to
provide quality care to their patients with ever-scarcer resources.
Since 2001, physicians have seen their Medicare physician payments
decrease by 13 percent in real terms before indexing for inflation.
Question. How does the yearly scramble to delay or reduce CMS
payment cuts to the PFS impact your ability to plan for the future?
What would it mean for you and practices like you if these cuts were
fully implemented and not scaled back?
Answer. These reoccurring cuts make it incredibly difficult for
providers and physicians to take a long-term approach and improve the
care they deliver. Due to the ambiguity in payments, it has led to a
yearly source of frustration for physicians that still own and operate
their own practices. While we appreciate Congress stepping in to
mitigate the cuts, the annual and ongoing uncertainty of whether
physicians will see relief makes it extremely difficult to operate a
business. If this trend of yearly cuts continues more often than not,
privately owned small business providers will continue to either close
their doors or refuse to accept new Medicare patients. The impact this
would have on our health-care system and the lifesaving care that is
performed would be detrimental for patients in these communities.
Question. As a value-based purchasing program, MIPS was supposed to
reward physicians who achieved quality and cost-efficient care.
However, for years physicians have raised concerns about the program,
including that it increases administrative burden and does not
accurately capture quality.
What has been your experience with MIPS and the administrative
burden that it entails?
Answer. The ACS experience with MIPS has been punctuated by missed
opportunities. As envisioned, MIPS would have provided an on-ramp to
value-based payment models through development of novel quality
metrics, greater reliance on clinical data from registries and other
improvements. However, most of the important reforms were lost in
implementation and the experience of many surgeons has been one of
increased administrative burden, quality measures nonreflective of the
care they provide, stagnant or falling reimbursement and lack of
meaningful data for quality improvement in patient care.
Question. Is it time to consider replacing the program with a more
valuable alternative? If so, what are some of the program's benefits
that should be considered when designing its replacement?
Answer. CMS has sought to address some of the shortcomings of the
MIPS program through implementation of MIPS Value Pathways or MVPs.
When this was first announced, ACS envisioned what we thought a
surgical MVP should look like. Based on the more than 110 years of
experience in measuring surgical quality, ACS has developed a number of
quality programs in both broad and targeted areas of surgery. If ACS
were to develop a surgical MVP, the core of the payment model would be
based on evidence-based verification programs that assure that all of
the resources, structures, processes, and personnel necessary for
optimal outcomes are present. Such a model would build in the use of
digital clinical information, improvement efforts, and patient
experience and outcomes, meeting the key requirements of MIPS. While
the requirements of such a program would be as intensive or perhaps
even further reaching than the current program, we believe that they
would be less burdensome because each component of the program is
explicitly designed to improve care to the patient and ensure their
safety.
If Congress considers reforms to MIPS, it is critical to address
the core shortcomings with the current FFS payment system. Chief among
these shortcomings are its lack of a regular payment update mechanism
to create a stable environment, as well as its current failure to
create an onramp toward more integrated payment models centered on the
patient.
Question. Part of the Physician Fee Schedule's MIPS program
measures interoperability, which is impeded by information blocking by
providers, vendors, or others wanting to hoard patient data, which can
affect MIPS performance and reduce reimbursement to providers.
How have your practices been impacted by information blocking?
Answer. Surgical practice has been less impacted by information
blocking and more from the lack of comprehensive interoperable data
standards to allow for easy repurposing of clinical data to aid in
clinical decision making at the point of care. Further, the sometimes
excessive cost of updating or upgrading EHR products to meet
certification requirements is also at times burdensome.
Question. Have you had experiences where your ability (or
inability) to access health records has impacted the timeliness or
quality of the care you are able to provide your patients?
Answer. All physicians have experienced at least minor delays when
working with clinical patient data and lack of easy access to clinical
data remains at times problematic for care coordination efforts and
long-term tracking of patients' journeys. However, our fellows express
greater concern at the delays in care created by unnecessary prior
authorization requirements, which can consume immense amounts of time
and staff resources while adding no clinical benefit.
Question. Do existing Federal quality and payment incentive
programs under Medicare, like Promoting Interoperability under the
Merit-based Incentive Payment System, enable up-to-date, consolidated
longitudinal health records accessible without special effort?
Answer. Both the Medicare program and private health plans still
have a long way to go to achieve the full promise of EHRs and health
data. Having timely access to current and complete health data for the
patient in standardized data elements fit for use by multiple purposes
such as risk calculators, EHRs, registries, clinical decision tools,
health monitoring devices, and so forth would go a long way toward
improving care for patients.
Question. With over $40 billion spent and nearly 2 decades of
effort put into implementing electronic health information technology,
fax machines remain widely used for sharing health data in our health-
care system.
Why is this the case, and what challenges persist in accessing
patients' health information electronically?
Answer. At the time of the initial passage of the HITECH Act much
of the country's medical records were still solely in paper form. While
the Federal investments have gone a long way toward shifting the arena
of medicine into the digital age, progress has not been uniform, and
interoperability challenges still remain. Though the use of legacy
technologies is waning, they still do occur both provider-to-provider
and provider-to-insurer communications. ACS believes that much of the
problem is attributable to the early focus on the use of specific
technologies rather than on the standardization of data elements and
the use of the clinical data, which was the ultimate goal.
______
Prepared Statement of Hon. Ron Wyden,
a U.S. Senator From Oregon
This morning the Finance Committee gathers to discuss how to update
and strengthen Medicare's guarantee of high-quality health benefits for
the next generation of America's seniors.
Colleagues, I want to be clear from the outset: traditional
Medicare is falling behind when it comes to helping seniors manage
their health when they are living with multiple chronic conditions.
I know members of the committee are interested in reforms to the
way physicians and nonphysician practitioners are paid. In my view, any
update to the way physicians are paid by traditional Medicare must
provide a lifeline to the tens of millions of seniors who live with
chronic conditions and who are struggling to coordinate their health
care in a fragmented health system that's not putting their health
first. This hearing is going to jump-start that debate.
The Finance Committee delivered a wake-up call to America in 2018
when we passed our first round of reforms to care for chronic
conditions in Medicare, under the chairmanship of Orrin Hatch, who
graciously agreed to partner with me, along with Senators Warner and
Isakson. Together, we sounded the alarm that Medicare is no longer only
an acute care program. Medicare spending today is dominated by chronic
conditions. Often, chronic conditions cluster together in ways that
complicate health and require specific, ongoing management by a
physician.
Cardiovascular conditions like high blood pressure and high
cholesterol most often occur with diabetes, for example. If you add
conditions like cancer and COPD to the equation, seniors and their
doctors are left with a crazy quilt of appointments, prescriptions, and
care plans that lead to confusion and worse health care. When a
senior's health gets this complicated, care coordination is not
optional.
Recent events have underlined the growing cost of chronic disease
in America. Even before the COVID-19 pandemic, life expectancy began to
dip in the United States from a 2014 peak of 79 years old. The pandemic
led to a backlog of preventive care that may only accelerate chronic
illness in the U.S.
The way traditional Medicare pays physicians to manage and treat
these conditions has not kept up with the times. Democrats and
Republicans were right to tackle the problem in 2018, and it's now time
to act boldly again.
In contrast to traditional Medicare, in the past decade Medicare
Advantage plans have been given a host of tools to incorporate chronic
disease management into their plan choices. That's because MA was built
from the ground up to offer more flexible benefits to give seniors the
option to choose a Medicare plan that was tailored to their needs.
Plans are able to use rebates--growing from $12 billion in 2014 to $67
billion in 2024--to support these flexibilities and extra benefits.
Unfortunately, it's increasingly clear that insurance companies are
more interested in playing coding games with Medicare's payment rules
to maximize their bottom line. Medicare Advantage plans seem to be
using more and more of these excess dollars to juice their marketing
and enrollment. Experts told this committee that MA plans spend $6
billion per year on marketing middlemen who sell their plans to
seniors.
Just last week, the Centers for Medicare and Medicaid Services
announced it is cracking down on insurance middlemen selling seniors'
personal information over and over again, resulting in a blizzard of
phone calls and high-pressure marketing campaigns during enrollment
season.
This time around, I want to make sure that traditional Medicare is
keeping up with the needs of beneficiaries when it comes to care
coordination, nonmedical determinants of health, and the like. That
could include steps such as reducing or eliminating cost sharing for
care coordination services. Seniors shouldn't have to pick up the tab
when their primary care doctor works with their cardiologist or
physical therapist to coordinate a care plan for high blood pressure.
It also means empowering primary care. Physicians and other
providers who deliver primary care are on the front lines when it comes
to helping seniors manage their chronic illnesses. But as everybody in
this room knows, there is a persistent shortage of primary care
providers in many parts of the country. That's partially a result of
out-of-whack payment rules that make primary care a less appealing
specialty than other fields. Primary care providers need to be valued
and compensated more fully by Medicare--as they are put in the driver's
seat alongside seniors to help navigate their health needs.
In my view, the challenge before the Finance Committee is to
improve the way Medicare pays for services delivered in the doctor's
office, or at home, so there is a laser focus on managing those chronic
conditions that are dominating the health of seniors.
The Finance Committee has had a lot of success over the last decade
getting new policies in this area into black-letter law on a bipartisan
basis, but there's still more to be done. I'm looking forward to
hearing from our witnesses and getting to work on the next steps.
______
Communications
----------
Alliance for Home Dialysis
750 9th Street, NW, Suite 650
Washington, DC 20001
(202) 466-8700
The Alliance for Home Dialysis (the Alliance) appreciates the Senate
Finance Committee's focus on ensuring high-quality care for Medicare
beneficiaries with chronic conditions. Our organization focuses on the
chronic conditions of chronic kidney disease (CKD) and End Stage Kidney
Disease (ESKD) with a focus on dialysis treatment choice. We believe
that these conditions should be of particular interest to this
Committee not only because of the burden to patients, but also because
all ESKD patients, regardless of age, are eligible for Medicare.
As background, the Alliance is a coalition of kidney disease
stakeholders including patients, clinicians, dialysis facilities, other
providers, and industry who came together starting in 2012 to advocate
for policies that would increase access to and uptake of home dialysis
in the United States.
Improving the uptake of home dialysis matters for clinical and quality-
of-life reasons. Research shows that both home dialysis modalities
(peritoneal dialysis and home hemodialysis) offer quality-of-life and
clinical advantages--and patients deserve access to these benefits. For
example, home hemodialysis allows for tailoring the dialysis
prescription to allow for more frequent or longer-lasting sessions.
Such more frequent sessions can result in faster recovery and fewer
side effects,\1\ improved cardiac status,\2\ improved survival
rates,\3\ and increased rehabilitation opportunities.\4\ Peritoneal
dialysis patients also experience fewer side effects and have fewer
dietary restrictions that in-center dialysis patients.\5\ Both home
modalities also offer significant quality-of-life advantages like ease
of scheduling, ability to continue to work, ability to travel, and
reduced dependence on transportation to dialysis clinics.
---------------------------------------------------------------------------
\1\ Heidenheim AP, Muirhead N, Moist L et al. Patient Quality of
Life on Quotidian Hemodialysis. Am J Kidney Dis. 2003 Jul; 42(1
Suppl):36-41.
\2\ Culleton, B et al. Effect of Frequent NHD vs. CHD on Left
Ventricular Mass and Quality of Life. JAMA 2007;11
\3\ Foley, R.N., D.T. Gilbertson et al. Long interdialytic interval
and mortality among patients receiving hemodialysis. New England
Journal of Medicine. 2011 365, no.12:1099-1107.
\4\ Blagg, Christopher. ``It's Time to Look at Home Hemodialysis in
a New Light.'' Hemodialysis Horizons: Patient Safety & Approaches to
Reducing Errors. (2006): 22-28. Web. 12 Apr 2012. https://www.aami.org/
docs/defaultsource/uploadedfiles/filedownloads/horizons/home-blagg.pdf.
\5\ ``A Brief Overview of Peritoneal Dialysis.'' DaVita, Inc., Web.
16 Jul 2012. https://www.davita.com/treatment-services/
peritonealdialysis/living-well-on-pd.
While home dialysis has been growing in recent years, in large part due
to government and provider commitment to ensuring patients have access
to all modalities, it still only hovers at a little over 13% of
patients doing their treatments at home. This is striking given that
the Government Accountability Office (GAO) shared in 2015 that they
believe up to 25% of patients could be successful on home dialysis.\6\
Furthermore, a few years ago, HHS set a far loftier goal that 80% of
new ESKD patients should be receiving dialysis at home or be
transplanted by 2025. While we have seen increases in uptake of home
dialysis in recent years, additional policy changes, including through
legislation, are needed to ensure that patients can access these
important treatments and increase the overall number of patients on
home dialysis in the U.S.
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\6\ Government Accountability Office. (2015). End-Stage Renal
Disease: Medicare Payment Refinements Could Promote Increased Use of
Home Dialysis. (GAO Publication No. 16-125). Washington, D.C.: U.S.
Government Printing Office.
We appreciate all Congress has done thus far to increase access to home
dialysis. Congress has been particularly impactful with regard to
policy changes in telehealth; the Bipartisan Budget Act of 2018 \7\
included key elements of the Creating High-Quality Results and Outcomes
Necessary to Improve Chronic Care Act of 2017 (the CHRONIC Act),
including a provision that allowed home to be the originating site for
a telehealth visit. In practice, this means that patients can now see
their doctors for the monthly capitated payment visit from the comfort
of their homes, avoiding often lengthy travel to and from the dialysis
facility. Allowing this expanded access to telehealth makes home
dialysis more accessible for patients and has helped increase uptake to
these important therapies. Policy changes like this are key to ensuring
expansion of home dialysis.
---------------------------------------------------------------------------
\7\ Bipartisan Budget Act of 2018. Public Law 115-123. 2018.
https://www.congress.gov/115/plaws/publ123/PLAW-115publ123.pdf.
Congress has a key role in ensuring patients have choices when faced
with decisions about treating their ESKD through dialysis.
Specifically, Kidney Disease Education (KDE) is a policy area where the
Committee could advance policy changes to positively impact the lives
of patients and ensure that they have choices in their treatment. We
strongly believe this policy area merits the Committee's further
---------------------------------------------------------------------------
attention.
Medicare's current KDE benefit provides up to 6 sessions of educational
services for individuals with Stage 4 chronic kidney disease. KDE
covers a wide range of topics, including how to take care of your
kidneys, how to manage other chronic diseases that often come alongside
CKD, diet, medications, and treatment options for both dialysis and
transplant.
Unfortunately, KDE is extremely underutilized with only about 2% of
eligible patients taking advantage of the benefit. We believe, and the
Government Accountability Office (GAO) has stated as well, that the
expansion of KDE could lead to the expansion of home dialysis.\8\ The
Alliance urges the Senate Finance Committee to consider the following
legislative policy options for increasing access to KDE:
---------------------------------------------------------------------------
\8\ See citation 1.
1. Congress should permit reimbursement for stages 3b and 5 CKD
---------------------------------------------------------------------------
patients to receive the KDE benefit.
Currently, KDE is only permitted for patients with stage 4 CKD. The
Alliance believes that reimbursement for such services should be
allowed for patients with stage 3b and 5 CKD.
Stage 3b CKD means moderate to severe loss of kidney function, with
kidneys working somewhere between 30-44% of what the average healthy
kidneys do.\9\ In addition, health risks get higher at this stage of
CKD, including the risk of developing co-occurring heart disease or
high blood pressure and the stage of CKD progressing to stage 4. There
is also a higher risk of complications at this stage of CKD, like
anemia, bone disorders, and metabolic acidosis, which is a buildup of
certain acids in the blood. Patients with CKD stage 3 are likely to
need dialysis services at some point, though their disease may take
some time to develop. They deserve to be educated in the same manner as
patients with stage 4 CKD.
---------------------------------------------------------------------------
\9\ Stage 3b Chronic Kidney Disease. National Kidney Foundation.
https://www.kidney.org/atoz/content/stage-3b-chronic-kidney-disease-
ckd#about-stage-3b-ckd. Accessed 11 April 2024.
Stage 5 CKD actually refers to the first phase of ESKD, or kidney
failure; these patients have kidneys that are working less than 15% of
what the average healthy kidneys can do.\10\ Patients at stage 5 have
the highest risk for comorbidities like heart disease and the CKD
complications discussed above. They may also have symptoms of kidney
failure like urinating less or not at all, itchy skin, feeling tired,
trouble concentrating, numbness, achy muscles. Shortness of breath,
nausea, loss of appetite, trouble sleeping, and foul-smelling breath.
These patients require immediate dialysis or a transplant to survive;
they must be educated about their options, but they are currently not
allowed KDE.
---------------------------------------------------------------------------
\10\ Stage 5 Chronic Kidney Disease. National Kidney Foundation.
https://www.kidney.org/atoz/content/stage-5-chronic-kidney-disease-
ckd#::text=Stage%205%20CKD%20means%20you,or
%20they%20are%20on%20dialysis. Accessed 11 April 2024.
Based on these realities about stages 3b and 5, we strongly believe
that KDE should be allowed for both and ask the Committee to consider
---------------------------------------------------------------------------
this change.
2. Congress should expand the providers qualified to provide KDE
beyond doctors, physician assistants, nurse practitioners, and clinical
nurse specialists.
Under current law, only qualified persons can provide kidney disease
education services, which are defined as certain healthcare entities
for which payment can be made under the Physician Fee Schedule,
including physicians, physician assistants, nurse practitioners, and
clinical nurse specialists, or hospitals, Critical Access Hospitals,
skilled nursing facilities, home health agencies, or hospices in a
rural area. Notably, this excludes home dialysis nurses, who are
arguably some of the most knowledgeable professionals about kidney
disease. The Alliance urges the Committee to consider expanding who can
provide KDE to include home dialysis nurses.
In addition, current law does not allow dialysis facilities to provide
KDE. We believe that dialysis facilities are an appropriate place for
KDE services to occur and that they should be allowed to bill for KDE--
with appropriate guardrails. In our view, these guardrails should seek
to avoid so-called ``patient steering'' to one facility over another.
Specifically, we would urge Congress, alongside allowing facilities to
bill for KDE, to instruct CMS to enact requirements on what kind of
information can be provided to exclude any provider-specific or
advertising information. In addition, we recommend that CMS play a role
in approving educational materials before they are deployed to
patients.
Thank you for your work in ensuring that Americans with chronic
conditions have access to the treatments they need. We appreciate your
consideration of these requests related to Kidney Disease Education and
look forward to continuing to work with you to improve the lives of
Americans with CKD and ESKD.
______
Alliance for Women's Health and Prevention
607 14th Street, NW, Suite 675
Washington, DC 20005
https://womenshealthandprevention.org/
April 17, 2024
United States Senate
Committee on Finance
Dirksen Senate Office Bldg.
Washington, DC 20510
Dear Senator Wyden, Senator Crapo, and Members of the Senate Committee
on Finance,
The Alliance for Women's Health and Prevention (AWHP) respectfully
requests that you prioritize the impact of obesity on America's seniors
as you consider legislative proposals to update and strengthen Medicare
service payment and delivery, including providing coverage for anti-
obesity medications (AOMs). As an organization focused on women's
preventive health, AWHP recognizes that obesity is a chronic disease
with a significant impact on women, including those with coverage
through Medicare.
Obesity is a chronic, treatable disease that affects more than 3 in 10
women \1\ nationwide and has a disproportionate impact \2\ on women of
color. It is associated with over 200 other chronic conditions,
including many that specifically affect women throughout their lives,
such as breast and ovarian cancers as well as fertility issues. Women
with obesity are also more likely to face harmful social stigma and
discrimination. For instance, women with obesity are less likely \3\ to
be promoted at work, and as many as 69% of women \4\ with obesity face
weight bias in healthcare settings. Finally, obesity has a tremendous
economic burden, with economic costs (both direct and indirect)
totaling $1.72 trillion in 2018.\5\ Given obesity's extensive impact,
AWHP believes that insurance coverage for the full scope of obesity
care options is critical to improving women's health. Evidence-based
obesity care includes counseling or intensive behavioral therapy,
behavior modification, AOMs, weight loss surgeries, and nutrition
services.
---------------------------------------------------------------------------
\1\ https://www.kff.org/other/state-indicator/adult-obesity-bysex/
?currentTimeframe=0&sort
Model=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.
\2\ https://www.niddk.nih.gov/health-information/health-statistics/
overweight-obesity.
\3\ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6452122/.
\4\ https://www.obesityaction.org/wp-content/uploads/Weight-Bias-
in-Healthcare1.pdf.
\5\ https://milkeninstitute.org/content-hub/research-and-reports/
reports/modernizing-care-obesity-chronic-disease-how-guide-employers.
Unfortunately, even though obesity has serious consequences, especially
for women, it is often misunderstood, leading to health insurance
barriers that keep the full range of obesity care options out of reach
for many women--particularly AOMs. In fact, just half of U.S. employers
currently cover, or are considering covering, the latest generation of
AOMs. Only 16 state Medicaid programs \6\ cover AOMs. Notably, Medicare
does not cover \7\ AOMs.
---------------------------------------------------------------------------
\6\ https://files.kff.org/attachment/REPORT-50-State-Medicaid-
Budget-Survey-for%20State-Fiscal-Years-2023-and-2024.pdf.
\7\ https://www.cms.gov/medicare-coverage-database/view/
ncd.aspx?ncdid=38&ncdver=3&
chapter=all&sortBy=title&bc=18.
Medicare coverage for comprehensive obesity care is critical to ensure
that women over 65 living with obesity can access the care they need.
As such, AWHP strongly supports the passage of the Treat and Reduce
Obesity Act (TROA), bipartisan legislation that would ensure that
Medicare beneficiaries have access to the full scope of obesity care
options, including AOMs. Ensuring that Medicare beneficiaries and the
providers who care for them have access to all
evidence-based options for treating this disease is only fair. We
wouldn't place this type of restriction on care for other chronic
diseases like cancer or heart disease. As such, AWHP strongly
encourages the Senate Committee on Finance to prioritize this topic in
---------------------------------------------------------------------------
its future discussions on improvements to the Medicare program.
AWHP, along with leading stakeholders from across the healthcare
community, recently launched the EveryBODY Covered campaign, a first-
of-its-kind initiative aiming to activate women to advocate for
insurance coverage of comprehensive obesity care. We believe that
addressing obesity requires a comprehensive approach that includes
equitable access to all evidence-based treatments and interventions. We
encourage you to refer to the resources available on our website
(https://everybodycovered.org/) for more information about obesity's
particular impact on women, and we appreciate your attention to
addressing obesity and supporting women's health.
Respectfully,
Millicent Gorham, CEO
______
Alliance of Specialty Medicine
611 Pennsylvania Avenue, SE, #393
Washington, DC 20003
www.specialtydocs.org
The Alliance of Specialty Medicine (``Alliance''), a coalition of 16
medical specialty organizations representing more than 100,000
specialty physicians, is deeply committed to improving access to
specialty medical care through the advancement of sound health policy.
We thank the Committee for convening a hearing to examine how changes
to Medicare physician payment can bolster chronic care. Today, we
outline suggested actions that Congress should take to stabilize the
Medicare physician payment system while ensuring successful value-based
care incentives are available for specialty physicians. We continue to
have serious concerns about structural challenges and instability in
Medicare payments to physicians and request your assistance to begin
the process of stabilizing and improving Medicare physician
reimbursement and performance programs through legislative reforms.
Our statement addresses the major pain points our specialty
organizations and their members have been facing under the current
Medicare physician payment system and quality improvement programs. We
urge Congress to take the following actions to address many of the
challenges patients and doctors face:
Replace flat base payment updates and improve nominal base
payment updates (in CY 2026 and beyond) with annual payment updates to
the Medicare conversion factor that are based on an appropriate
inflationary index that reflects rising practice costs, such as the
Medicare Economic Index (MEI).
Exempt the following from budget-neutrality adjustments:
Newly-covered or expanded Medicare benefits,
items, and services, such as preventative services and new
technologies,
Items and services that are delivered in response
to a public health emergency (PHE), and,
Changes in relative values due to increased
practice costs (e.g., clinical labor, professional liability).
Authorize the Secretary of Health and Human Services the
flexibility to waive or modify budget neutrality requirements in other
circumstances, as appropriate.
Require ongoing and consistent updates of key data inputs used
to set Medicare payments to physicians (e.g., practice expense and
liability insurance) and hold physicians harmless from these updates,
which are outside their control,
Perform more granular and timely evaluations of the impact of
the Quality Payment Program (QPP) and Physician-Focused Payment Model
Technical Advisory Committee (PTAC) on health care quality and value,
as well as access to care-- particularly as it relates to specialty
care. While PTAC recently released an environmental scan of value-based
payment models,\1\ which includes a table listing the percentage of
physicians participating in Advanced alternative payment models (APMs)
by specialty, it is missing specialties and only reflects trends from
2017-2019. Such outdated information is of little value to our members.
Similarly, the QPP Experience Report data set, which provides aggregate
participation and performance information related to each year of the
Merit-based Incentive Payment System (MIPS), is also outdated. As of
April 2024, the most current data set available to the public relates
to the 2021 performance year. Given how frequently CMS changes MIPS
rules, performance thresholds, and measure sets, CMS' more than two-
year lag in reporting participation and performance trends makes it
nearly impossible for the public to meaningfully assess the impact of
the program and to comment on the feasibility of newly proposed
policies. Additionally, the QPP Experience Report data set, which is
slightly more current than the recently released PTAC data and includes
much more granular, individual clinician-level and specialty-specific
data, includes no information about APM participation through the QPP.
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\1\ https://aspe.hhs.gov/sites/default/files/documents/
6d9f300bb4b45d16485d2a2c013a4151/PTAC-Sep-18-Escan.pdf.
---------------------------------------------------------------------------
Make technical improvements to MACRA to strengthen the QPP,
including:
Providing CMS with the authority to truly
dismantle the silos that currently prevent more accurate and
efficient assessments of value. At the very least, Congress
should provide CMS with the authority to make MIPS more
streamlined and flexible, allowing physicians to earn credit
across the four performance categories of MIPS for certain
robust activities, such as reporting to and using data from a
clinical data registry to improve care.
Providing CMS with the authority to move away
from the current one-size-fits-all approach to measurement and
permit more flexibility in regard to measure adoption,
participation pathways, scoring, and performance thresholds to
better reflect the diversity of clinical practice in terms of
settings, specialties, and/or patient populations. This should
include:
t Providing CMS with the flexibility to adjust the
weights of the MIPS performance categories over time to
reflect the current state of the health care landscape,
shifting gaps in care, and the availability of relevant
measures.
t Allowing CMS to set the MIPS performance threshold
(i.e., the minimum points needed to avoid a penalty) at
an appropriate level each year based on performance
trends and stakeholder input, rather than setting it at
the mean or median score of all MIPS eligible
clinicians during a previous performance period, as
mandated by MACRA. Given the program's frequently
changing polices and unpredictable disruptions to our
healthcare system that impact participation and
performance scores, CMS should not be locked into using
historic averages as a barometer of success.
t Allowing CMS to set multiple performance thresholds,
such as a separate threshold for small and rural
practices.
t Providing CMS with the flexibility to provide MIPS
credit for more innovative and comprehensive
investments in quality and value, such as ongoing data
collection and performance feedback for purposes of
Board certification, performance measurement taking
place under other CMS programs, and quality and cost
analyses under APMs, so long as minimum standards of
reliability and validity are met.
Require CMS to better support and encourage the
use of specialty-focused Qualified Clinical Data Registries
(QCDRs), the development and use of
specialty-specific measures, and participation pathways that
are more meaningful to specialists.
Enforce MACRA's requirement that CMS provide
access to Medicare claims data to assist specialties and their
registries with better understanding existing gaps in care and
supporting the development of quality and cost measures.
Allow CMS to modify the MIPS Cost category by:
t Removing the primary care-based total per capita
costs measure mandate that continues to hold physician
practices--including specialties that are explicitly
excluded from the measure--responsible for costs
outside of their control.
t Removing the requirement that episode-based cost
measures account for at least \1/2\ of Part A and B
expenditures to ensure prioritization of episodes with
high variability and that specialists can directly
impact.
t Requiring that any evaluation of cost also
simultaneously account for any changes in quality among
the same patient population to ensure cost-containment
efforts do not result in poorer quality care or
negatively impact access to care.
Improve the APM pipeline to provide specialists
more opportunities to participate meaningfully in APMs and
qualify for the APM track of the QPP.
Restore and extend the full 5% APM incentive
payment, which expired following the 2022 performance year/2024
payment year, and maintain current QP thresholds to facilitate
specialty physician movement into APMs, including new and more
relevant models that have not yet materialized.
Require CMS to release more granular and timely data regarding
physician participation in MIPS, eligibility for the APM track of the
QPP, and participation in APMs in general, by specialty.
Reduce administrative burdens and ensure safe, timely, and
affordable access to care for patients by streamlining prior
authorization in the Medicare Advantage program.
Physician Payment Instability
Prior to the enactment of MACRA, the costs associated with running a
physician practice were on the rise, and the price of medical supplies,
equipment, and clinical and administrative labor remain substantial, as
demonstrated by the Consumer Price Index (CPI) and MEI (see American
Medical Association (AMA) Medicare Updates Compared to Inflation (2001-
2024) \2\). Unlike other Medicare providers that receive annual payment
updates based on an inflation proxy, such as the CPI, MACRA established
physician payments to include flat and nominal base updates in the
initial years, transitioning to a system that emphasizes performance-
based adjustments. Specifically, from 2016 to 2019, physicians were
slated to receive a 0.5% increase in their Medicare payments each year,
0% updates from 2020 to 2025, and based on their participation in the
QPP, an update of 0.25% or 0.75% in 2026 and beyond.
---------------------------------------------------------------------------
\2\ https://www.ama-assn.org/system/files/2024-medicare-updates-
inflation-chart.pdf.
Under MACRA, Congress aimed to create a period of stable, albeit not
inflation-
adjusted, payment levels, so physicians would have a predictable
revenue stream while transitioning to more value-based care models,
such as MIPS and APMs, which offer additional financial incentives
based on the quality and efficiency of care. The first problem was the
decision to undermine the onramp to value-based care by decreasing the
CY 2019 base update from 0.5% to 0.25.\3\ Then as the CMS
implementation of MACRA began to unfold (as the chart below shows), in
most years since MACRA's implementation, the ``budget neutral'' MIPS
payment incentive failed to close the gap between the change in the
Medicare conversion factor and practice costs. While some physicians
may have benefitted from additional incentives provided through an
``Exceptional Performance Bonus'' pool, these bonuses were short-term
and expired with the 2022 performance year.
---------------------------------------------------------------------------
\3\ Sec. 53106 of the Bipartisan Budget Act of 2018, Pub. L. 115-
123.
Change from
previous year in Actual Medicare
MIPS Payment Year Budget Neutral MIPS Medicare Economic Index Impact \7\
Adjustment \4\ Conversion Factor (MEI) \6\
\5\
2019 0.29 0.11 1.5 -1.10
\4\Represents the budget-
neutral MIPS adjustment for
those earning a MIPS final
score at the performance
threshold; excludes
additional payment bonuses
under the Exceptional
Performance Bonus.
2020 0.31 0.14 1.9 -1.45
\5\See the AMA History of
Medicare Conversion
Factors, https://www.ama-
assn.org/system/files/cf-
history.pdf.
2021 0.00 -3.3 1.4 -4.70
\6\See Actual Regulation
Market Basket Updates,
https://www.cms.gov/files/
zip/actual-regulation-
market-basket-updates.zip.
2022 0.01 -0.80 2.1 -2.89
\7\Difference in the payment
rate between a conversion
factor based on the budget-
neutral MIPS payment
adjustment and the payment
rate adjusted for increases
in practice costs as
measured by inflation
(e.g., MEI-adjusted
conversion factor).
2023 0.11 -.0 3.8 -5.69
2024 2.23 -2.00 \8\ 4.6 -4.37
\8\Estimated annualized
reduction in payments
relative to CY 2023
factoring in fact that
Congressional intervention
did not apply until claims
with dates of service on or
after March 9, 2024.
Beyond the challenges in physician payment created under MACRA, the
Medicare Physician Fee Schedule (MPFS) is plagued by other challenges,
including requirements to maintain budget neutrality, and slow,
irregular updates to practice expense data used to set payments. In
fact, physicians continue to ``pay down'' the significant budget
neutrality adjustment prompted by CMS' 2021 and 2023 implementation of
increased relative values for office and outpatient evaluation and
management (E/M) services and inpatient and other E/M services,
respectively, as well as absorb CMS' 2022 implementation of revised
clinical labor prices (an update that lagged 2 decades). For 2024, CMS
commenced paying for a new E/M add-on payment that Congress previously
prohibited CMS from implementing, prompting yet another substantial
budget neutrality adjustment and concomitant reduction to the PFS
conversion factor. We appreciate congressional efforts to temporarily
reduce conversion factor cuts, however, Congress has still allowed year
after year of cuts to the MPFS conversion factor, and this pattern is
unsustainable. In addition to
congressionally-mandated stabilization of the MPFS conversion factor,
it would be prudent to provide additional direction and authority to
the Secretary to address these issues; for example, requiring the
Agency to make consistent, ongoing updates to practice expense inputs
and authorizing the Secretary to, in certain circumstances, waive or
modify budget neutrality requirements.
As we have shared previously, the increasing downward financial
pressure on physicians is forcing many to sell or merge their practices
with hospitals, health systems, and private equity groups, which is
reflected in an April 2022 report \9\ prepared by Avalere. According to
the report, nearly 70% of all physicians are now employed--a figure
that spiked 19% in 2021 alone. This follows a 2020 AMA survey \10\
which found that less than half of physicians are working in physician-
owned practices. A consequence of increasing market consolidation is
rising health care costs for payers, patients, and the federal and
state governments. Indeed, as part of its March 2020 Report to the
Congress,\11\ MedPAC explained that:
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\9\ https://www.physiciansadvocacyinstitute.org/Portals/0/assets/
docs/PAI-Research/PAI%20
Avalere%20Physician%20Employment%20Trends%20Study%202019-
21%20Final.pdf?ver=ks
WkgjKXB_yZfImFdXlvGg%3d%3d.
\10\ https://www.ama-assn.org/press-center/press-releases/ama-
analysis-shows-most-physicians-work-outside-private-practice.
\11\ https://www.medpac.gov/wp-content/uploads/import_data/
scrape_files/docs/default-source/reports/mar20_medpac_ch15_sec.pdf.
[G]overnment policies have played a role in encouraging
hospital acquisition of physician practices. For example, when
hospitals acquire physician practices, Medicare payments
increase due to facility fees that Medicare pays for physician
services when they are integrated into a hospital's outpatient
department. The potential for facility fees from Medicare and
higher commercial prices encourages hospitals to acquire
physician practices and have physicians become hospital
---------------------------------------------------------------------------
employees. (p. 458)
Physician-hospital integration, specifically hospital
acquisition of physician practices, has caused an increase in
Medicare spending and beneficiary cost sharing due to the
introduction of hospital facility fees for physician office
services that are provided in hospital outpatient departments.
Taxpayer and beneficiary costs can double when certain services
are provided in a physician office that is deemed part of a
hospital outpatient department. (p. 460)
To what extent the MPFS contributes to rising health care costs because
it encourages consolidation is something that warrants thorough
examination and correction by Congress.
Ineffective Value Programs
Implementation of MACRA's two-track value-based payment system, the
QPP, has been ineffective and, arguably, detrimental to the delivery of
most specialty medical care. Many specialists perceive the QPP as an
enormous administrative hassle that simply diverts critical resources
away from more meaningful activities that could directly impact the
quality and value of specialty care. Under MIPS, in particular, many
specialty physicians often have no other choice but to report on
marginally relevant measures that result in data that is of little use
to physicians or their patients. Further, CMS has not produced any
evidence to suggest that quality, efficiency, and outcomes for
Medicare's seniors, the disabled, and underserved populations has
demonstrably improved as a result of the MACRA-established quality
programs.
As discussed below, most specialty physicians have also struggled to
meaningfully engage in the APM track of the QPP, as there are only a
few APMs that are applicable to specialty care. Through discussions
with Alliance member organizations and the physicians they represent,
we have found that Accountable Care Organizations (ACOs) are often the
only option for APM engagement, and usually the result of specialists'
hospital or health system employment, where any APM incentives are
directed. Specialists often have little control over their decision to
participate in these ACOs and the current set of metrics used to
measure quality of care provided under the ACO do not reflect the more
focused care provided by specialists.
Merit-based Incentive Payment System (MIPS)
In contrast to the promises of MACRA, MIPS has evolved into an overly
complex, disjointed, burdensome, and clinically irrelevant program for
many specialists. Even the U.S. Government Accountability Office
(GAO),\12\ in an October 2021 report, expressed concern that MIPS
performance feedback is neither timely nor meaningful, questioned
whether the program helps improve quality and patient outcomes, and
highlighted the program's low return on investment. In its March 2024,
environmental scan of value-based payment models,\13\ discussed
earlier, PTAC notes: ``Overall, there is little evidence that pay-for-
performance and public reporting of quality measures have improved
overall quality of care in the United States.'' The Alliance requests
that Congress consider the following fundamental flaws that continue to
plague MIPS:
---------------------------------------------------------------------------
\12\ https://www.gao.gov/assets/gao-22-104667.pdf.
\13\ https://aspe.hhs.gov/sites/default/files/documents/
dae3de25b874112a649445d6381f527e/PTAC-Mar-25-Escan.pdf.
Siloed Performance Categories. CMS has failed to produce a more
unified quality reporting structure, as promised under MACRA. MIPS
continues to rely on four separate performance categories that each
have distinct reporting requirements and scoring rules. Additionally,
for many specialties, what is being measured on the quality side rarely
aligns with what is being measured on the cost side, resulting in a
flawed value equation. The Alliance has repeatedly asked CMS to provide
cross-category credit for more robust value-based activities, such as
reporting to a clinical data registry, which would minimize duplicative
reporting and reward more innovative activities. However, CMS continues
to cite statutory constraints, including the mandate to measure
clinicians on each of the four MIPS performance categories as dictated
by MACRA. As a result, the program is not only challenging to navigate
and comply with, but for many specialties, it does not accurately
reflect the overall value of care.
Constantly Shifting Goalposts. Each year, CMS changes not only
the MIPS eligibility rules and reporting requirements, but also the
performance thresholds. As a result, it is challenging for physicians
to keep up with the program and to make year-to-year comparisons
regarding their performance. It is equally challenging for CMS to
accurately analyze the overall impact of the program over time.
Lack of Incentives for Specialty Measures. Many specialties have
also faced challenges developing more specialty-focused quality
measures and getting members to report on those measures as a result of
MIPS scoring policies and other challenging requirements associated
with maintaining a QCDR;
QCDRs were authorized by Congress to provide a
more flexible and rapid pathway for specialties to introduce
more innovative and clinically relevant measures under MIPS.
Instead, due to unnecessarily excessive and costly measure
testing and data validation requirements imposed by CMS, many
prominent specialty-sponsored registries have been given no
other choice but to leave the program. This is unfortunate
since clinician-led registries tend to collect more relevant
and meaningful clinical outcomes data, including
patient-reported outcomes data, that cannot be captured through
claims. They also provide more timely and actionable feedback
that is often more relevant to participating clinicians and
their patient populations than what is provided by CMS under
MIPS.
Flawed Cost Measures. Cost measures adopted for MIPS are also
extremely difficult to interpret and take meaningful action on. They
often reflect care decisions and costs that are outside of a
specialist's direct control and rarely align directly with quality
measures other than in title. For example, autoimmune diseases such as
rheumatoid arthritis and Crohn's disease are managed with highly
complex medications, including biologics and biosimilars. Depending on
the patient's unique biology, disease progression, and other clinical
factors, one therapy may be clinically-indicated, recommended and
prescribed over another. Regardless of the condition or disease,
measuring the cost of care in isolation is dangerous as it fails to
account for the impact that changes in spending have on care quality
and access to care.
Lack of Flexibility to Promote Interoperability. The MIPS
Promoting Interoperability category continues to take a one-size-fits-
all approach to care that fails to appreciate the diversity and
readiness of practices across the nation. The category also continues
to focus on very specific electronic health record (EHR)
functionalities rather than promote innovative use cases of health
information technology, such as clinical data registries, clinical
decision supports tools, and tracking data from wearables and other
digital devices that are more common among specialty patients.
Lack of Alignment Across CMS Programs. MIPS physician-level
reporting requirements and measures largely fail to align with other
CMS value-based incentive programs, including payment and delivery
models, that apply to other providers and settings of care. For
example, specialty practices submitting quality measure data for the
Bundled Payments for Care Initiative--Advanced (BPCI-A) cannot
simultaneously receive credit for the same measures under MIPS and must
submit data for the two programs separately. This results in
administrative redundancy, duplicative accountability, and conflicting
incentives-- particularly as it relates to team-based care
coordination. This misalignment is costly for taxpayers and continues
to make it challenging for Medicare to move the needle on the overall
value of care for its beneficiaries.
Failure to Provide a Glidepath to APM Participation. The intent
of MIPS, as envisioned by MACRA, was to prepare physicians to move into
APMs. However, the current program--even as recently revised through
the MIPS Value Pathways (MVP) Framework-- largely fails to align with
measures used under APMs and does little to ready specialists to move
into APMs. Further, there are ongoing barriers to APM participation
among specialists, as explained below.
Misguided Efforts to Improve MIPS. Although CMS' recently
introduced MVP framework was intended to address many of the problems
outlined above, it simply reshuffles the deck while doing very little
to address the program's foundational flaws, which increases
frustration and disillusionment among physicians at a time when worker
burnout is at an historical high.
Advanced Alternative Payment Models (Advanced APMs)
Unfortunately, the APM track of the QPP is no less challenging.
Alliance organizations continue to hear from their specialty physician
members that active engagement in APMs is near impossible. Specialty-
focused APMs exist, but they only consider a limited number of
conditions or procedures, leaving the vast majority of specialists
without a dedicated model. Others, such as the BPCI-A program, do not
align with other physician quality reporting requirements under MIPS
and fail to provide high performing practices with an incentive to stay
in the program since they are held to exceedingly high cost targets
that simply do not support high quality, appropriate care.
Additionally, as discussed earlier, specialists that are
``participants'' in ACOs are usually part of large hospitals or health
systems, but their role is passive; they do not meaningfully engage in
quality improvement or cost containment activities specific to the ACO,
as the accountability measures do not consider the conditions they
treat, nor services provide. Other specialists that attempt to join
ACOs are blocked from entry by the primary care physicians who lead
them.
These findings are not just speculative. As highlighted in MedPAC's
July 2022 Data Book,\14\ Health Care Spending and the Medicare Program,
---------------------------------------------------------------------------
\14\ https://www.medpac.gov/wp-content/uploads/2022/07/
July2022_MedPAC_DataBook_SEC
_v2.pdf.
Many specialties account for a larger share of clinicians in
larger ACOs. This finding may reflect smaller ACOs being more
often composed of independent physician practices with
relatively fewer specialists, while larger ACOs are often
affiliated with hospitals or health systems that have a broader
---------------------------------------------------------------------------
range of specialists. (p. 44)
MedPAC also explains that,
Specialists' participation in ACOs relative to their share of
all clinicians varies by specialty. For example, cardiologists
comprise about 2 percent of all clinicians participating in FFS
Medicare, but a larger share of clinicians participating in
ACOs. By contrast, specialties such as anesthesiology and
ophthalmology are underrepresented in ACOs relative to their
share of all FFS clinicians. (p. 44)
At the outset of the QPP, the Alliance and its member organizations--
independently and collectively--proactively connected with the ACO
member organization to discuss opportunities for improving specialists'
participation in ACOs. One approach discussed, which is contemplated in
a recent Health Affairs blog post by senior CMS Innovation Center
officials,\15\ was the development of ``shadow bundles.'' This concept
of nesting more specific episode-based or condition-specific models in
population-based total cost of care (PB-TCOC) models was also discussed
in PTAC's 2023 Request for Information (RFI) on Integrating Specialty
Care in Population-Based Models \16\ and its follow-up 2024 RFI on
Implementing Performance Measures for PB-TCOC.\17\ At the time, further
attempts to coalesce around this concept with the ACO community were
stalled. Ultimately, we were told that specialty medical care and
treatment was expensive and hurt ACOs financial performance, and--in
the case of primary care-led ACOs--there was no appetite for sharing
``savings'' with specialists.
---------------------------------------------------------------------------
\15\ https://www.healthaffairs.org/content/forefront/cms-
innovation-center-s-strategy-support-person-centered-value-based-
specialty-care.
\16\ https://aspe.hhs.gov/sites/default/files/documents/
2cd91b29eac2742fbc9babaf8f3b7962/PTAC-Specialty-Integration-RFI.pdf.
\17\ https://aspe.hhs.gov/sites/default/files/documents/
823f7133bbde9de118d693a4330d2645/PTAC-Perf-Meas-RFI.pdf.
The Alliance appreciates the CMS Innovation Center's recent recognition
that a comprehensive approach to accountable care must account for both
primary care and specialty care, and that it is exploring opportunities
to build on the shadow bundle concept. Some Alliance member
organizations have already invested in this type of work, yet they
continue to face challenges in terms of getting CMS to adopt these
models. The American Society of Cataract and Refractive Surgery
(ASCRS), for example, developed the Bundled Payment for Same-Day
Bilateral Cataract Surgery (BPBCS), which aims to promote same-day
bilateral cataract surgery to appropriate patients at a lower cost for
both patients and Medicare. Under this model, the Cataract Surgery Team
(the surgeon, facility, and anesthesiologist) would receive a single
bundled payment--rather than separate payments--for all services
associated with the surgery. Importantly, the patient would also have a
single cost-sharing amount for those services and there would be fewer
trips needed to the surgery center and to the physician for follow-up
visits, which would reduce out-of-pocket expenses for the patient and
family. This model supports a team-based approach to care that promotes
efficiencies that will result in the best outcomes at the lowest
possible cost. Despite multiple encouraging meetings where CMS
leadership expressed support for the model, the agency has yet to take
any action. As a result, ASCRS has begun to explore alternative
pathways, including working with Medicare Advantage plans to test the
model. The BPBCS is an example of a thoughtfully developed framework
that could work in tandem with CMS population-based, total-cost-of-care
models--such as ACOs--as a separate voluntary agreement with a cataract
surgery team, without requiring specialists to be part of an ACO. The
Alliance continues to urge CMS and the Innovation Center to work more
closely with the specialty community and to take advantage of
---------------------------------------------------------------------------
investments that have already been made in this space.
The specialty community has also faced challenges in terms of accessing
data that will help it to better understand specialty engagement in,
and barriers to, APM participation. Despite multiple requests, both CMS
and MedPAC have flat-out refused to provide data on the number and type
of specialists in APMs to help us better understand and overcome these
challenges. As noted earlier, just last month, PTAC finally released
some basic data on the participation rates of select specialties in
Advanced APMs; however, the data are over 5 years old and provide no
insight on more current trends.
Making matters worse is the fact that under MACRA, the 5% Medicare
incentive payment that has been offered since 2019 (based on 2017 APM
participation) to clinicians who are Qualifying Participants (QP) in an
Advanced APM was set to expire after the 2022 performance/2024 payment
year. Congress subsequently extended this incentive payment an
additional year, but at a reduced rate of 3.5%, and then again, for the
2024 performance/2026 payment year, but at a further reduced rate of
1.75%. Moving forward, as mandated under MACRA, physicians who qualify
as QPs will only receive a nominal base conversion factor update
starting in 2025 (0.75 percent vs. 0.25 percent for non-QPs, including
MIPS participants who are also eligible for upward performance-based
payment adjustments), limiting their incentives to join APMs going
forward.
MACRA also prescribes specific Medicare payment and patient thresholds
that clinicians must meet to become QPs. Beginning with the 2023
performance year, the Medicare QP Thresholds were supposed to increase
to 75% (from 50%) for the payment amount method and 50% (from 35%) for
the patient count method, making it more challenging for physicians to
meet the definition of a QP. While Congress froze these thresholds at
the lower levels for 2023 and 2024, they are scheduled to increase in
2025 without Congressional action.
While the Alliance appreciates the steps Congress has taken to date in
an attempt to continue to support movement of physicians into APMs, it
is still very concerned about the negative impact these shifting
policies will have on the already slow movement of specialists into
APMs. There have been very limited opportunities for specialists to
participate meaningfully in APMs and qualify as QPs to date. With the
expiring APM incentive payment, most specialists will never even have
had the opportunity to qualify for this critical source of funding,
which has been immensely helpful to physicians who must invest in
infrastructure and analytics to participate meaningfully in an APM.
Similarly, higher QP thresholds will result in even fewer specialists
qualifying for this track.
Finally, as mentioned earlier in the context of MIPS, CMS suffers from
internal disorganization in its administration of Medicare value-based
initiatives. Multiple offices within CMS are responsible for managing
similar, but separate, value-focused initiatives authorized by MACRA,
with little apparent coordination. For example, the staff responsible
for administering the QPP seem disconnected from the CMMI staff
administering APMs, despite the intrinsic link between the two, which
results in duplicative reporting and accountability for clinicians.
Additionally, to carry out these initiatives, CMS relies on numerous
contractors who are not aligned or coordinated with one another, which
leads to confusion, inefficiencies, and situations where individuals
with no institutional historical knowledge and very little
understanding of the clinical implications of their recommendations and
actions are making important decisions.
Recommendations to Improve MACRA
Congress sought to provide flexible options for clinicians to engage in
meaningful quality improvement and value-based care in the Medicare
program. However, the implementation of these statutory quality
programs has resulted in a rigid system that holds physicians
accountable for metrics and models that often do not apply to them. We
contend that MACRA must be overhauled and replaced with a payment
system that:
Ensures financial stability and predictability in the Medicare
Physician Fee Schedule;
Promotes and rewards value-based care innovation that
meaningfully improves patient care and outcomes, particularly within
specialty care; and
Safeguards timely access to high-quality care by advancing
health equity and reducing disparities.
This can be accomplished by acting on the aforementioned
recommendations. In addition, members of the Alliance participated in
efforts by the AMA to develop its ``Characteristics of a Rational
Medicare Payment System''\18\ and urge you to incorporate these
principles in any physician payment reform solution.
---------------------------------------------------------------------------
\18\ https://www.ama-assn.org/system/files/characteristics-
rational-medicare-payment-principles-signatories.pdf.
We look forward to working with the committee to ensure specialty
physician practice viability and success and will be happy to discuss
---------------------------------------------------------------------------
any other questions you may have going forward.
______
American Academy of Dermatology Association
1201 Pennsylvania Avenue, NW, Suite 540
Washington, DC 20004-2401
Main: (202) 842-3555
Fax: (202) 842-4355
https://www.aad.org/
Chairman Wyden and Ranking Member Crapo, on behalf of the more than
17,000 U.S. members of the American Academy of Dermatology Association
(AADA), we thank you for the opportunity to submit a statement for the
record regarding your hearing, ``Bolstering Chronic Care through
Medicare Physician Payment.''
As you explore ways to modernize and strengthen Medicare for seniors,
one critical aspect that needs immediate attention is the instability
of the Medicare physician payment system and the need for reform. The
AADA firmly believes that Congress must take action to advance Medicare
physician payment reform by:
Establishing a positive annual inflation adjustment.
Increasing the budget neutrality threshold, supporting a
lookback period to rectify errors associated with utilization
assumptions, and allowing specific services to be excluded from budget
neutrality requirements.
Reforming the Quality Payment Program (QPP) to increase
physician input and improve patient care without overly burdensome
documentation and compliance activity.
In addition to these reforms, it's important to emphasize that
Americans should have access to affordable, high-quality dermatologic
care with the freedom to choose their own physicians and health
insurance that best meets their needs. The Medicare program must ensure
beneficiaries have adequate access to networks of specialists and
subspecialists, including board-certified dermatologists. This goal can
only be possible when health care policy is driven by the welfare of
patients over short-sighted and siloed budgetary policies that increase
overall health care spending and further erode the stability and
predictability of the Medicare system.
Inflation and the Siloed Medicare Program Structure
The failure of the Medicare Physician Fee Schedule (MPFS) to keep up
with inflation is the greatest threat to maintaining seniors' timely
access to care in physician offices. Hospitals and other healthcare
facilities receive Medicare payment updates, but physicians receiving
payments under the MPFS are excluded from this type of adjustment. In
fact, CMS finalized a 3.4% cut in the Calendar Year (CY) 2024 MPFS
final rule. While the AADA appreciates the partial relief Congress
provided to the MPFS in the Consolidated Appropriations Act, 2024,
physician payments still ultimately received a cut from 2023.
Since 2001, the cost of operating a medical practice has increased 47%.
During this time, Medicare hospital and nursing facility updates
resulted in a roughly 70% increase in payments to these entities,
significantly outpacing physician reimbursement. Adjusted for inflation
in practice costs, Medicare physician reimbursement declined 30% from
2001 to 2024. This out-of-balance payment structure disproportionately
threatens the viability of medical practices, especially smaller,
independent, physician-owned practices, as well as those serving low-
income or historically marginalized patients. This issue is further
exacerbated by rising costs and inflation, leading to increased
consolidation and hospital ownership of physician practices, resulting
in higher expenses and reduced competition.
[GRAPHIC] [TIFF OMITTED] T1124.004
.epsCongress and CMS need to re-examine the siloed approach to
reimbursement tied to the Medicare program. According to the 2020 and
2021 Medicare Trustees' report, MPFS spending per enrollee was $2,107
in 2011 and $2,389 in 2021, growing at an average annual rate of 1.3%.
However, in contrast, Medicare spending per enrollee in Part A fee-for-
service (FFS) was $5,178 in 2011 and $5,576 in 2021--a 7.7% increase
and more than double the cost per patient treated under the MPFS.
In considering the failure of the MPFS to keep up with the rising costs
of delivering medical care, it is important to remember that physicians
rely on reimbursement to cover a multitude of practice expenses. These
expenses include staff salaries, benefits, federal and state regulatory
compliance costs, and expenses associated with insurance mandates, such
as step therapy and prior authorization. Moreover, technology
requirements associated with compliance of the QPP are costly and
contribute to the financial strain placed on physician offices.
Physician practices are often small businesses that contribute to the
economy of their communities. Other industries can adjust their
products' pricing to reflect rising costs and increased staff salaries.
However, physicians do not have the ability to do this. In fact, in the
face of crippling inflation the MPFS serves to destabilize practices
with year-after-year cuts. Such a structure is unsustainable, and we
must not expect physicians delivering essential medical care to
Medicare beneficiaries and their communities to endure it. Many
physicians have already had to close their doors, leave their
communities, retire early, or leave the practice of medicine. The below
chart demonstrates the staggering numbers of physicians leaving the
workforce, and this trend will continue as nearly 45% of physicians are
older than age 55. The loss of experienced physicians is detrimental to
patient outcomes and the young physicians who rely on them as a
learning resource.\1\
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\1\ https://www.definitivehc.com/sites/default/files/resources/
pdfs/Addressing-the-healthcare-staffing-shortage-2023.pdf.
[GRAPHIC] [TIFF OMITTED] T1124.005
.epsThe inability to provide inflationary pay raises to practice
employees is contributing to the current healthcare workforce crisis in
which we are seeing increasing burnout rates and a mass exodus of our
clinical, administrative, and clerical staff into other industries.
With reduced staff comes a diminished capacity to provide quality care
and maintain patient access. Reduced staffing leads to barriers in
communicating and coordinating care, such as scheduling appointments
and discussing lab reports, which can impact patient satisfaction and
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outcomes.
The threat of future additional cuts to Medicare physician
reimbursement jeopardizes physicians' ability to keep the doors open
and care for patients in our communities. Fewer physicians in our
communities means longer wait times for patients to receive care. When
those patients do receive care, their only option may be non-physician
providers of care with less training, or more expensive care in
suboptimal settings including emergency departments and hospital-based
practices. This is real, not theoretical, and is already occurring in
our communities. Medicare patients will suffer in the end with delayed
and second-rate care at a higher cost.
Physicians need positive, inflation-based reimbursement updates to
maintain financial stability and ensure patients have continued access
to care. Inflationary updates tied to the Medicare Economic Index (MEI)
need to be based on current data. In fact, the Medicare Payment
Advisory Commission (MedPAC) recommended that Congress tie physician
payment updates to the Medicare Economic Index (MEI) or practice cost
inflation rates for 2025.\2\ Specifically, MedPAC recommended that
Congress update the 2024 Medicare base payment rate for physician and
other health professional services by the amount specified in current
law plus 50% of the projected increase in the MEI. Based on CMS's MEI
projections at the time of the publication of the March 2024 MedPAC
Report to Congress, the recommended update for 2025 would be equivalent
to 1.3% above current law.
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\2\ https://www.medpac.gov/document/march-2024-report-to-the-
congress-medicare-payment-policy/.
The AADA appreciates MedPAC's acknowledgment that the current Medicare
physician payment system has not kept up with the cost of practicing
medicine. While we value this recognition, Congress should adopt a 2025
Medicare payment update that fully acknowledges the inflationary growth
of health care costs. This step is crucial for ensuring financial
stability in the Medicare physician payment system and maintaining
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continued access to high-quality patient care.
The AADA urges Congress to pass H.R. 2474, the Strengthening Medicare
for Patients and Providers Act, which would provide an inflationary
update to the conversion factor under the Medicare Physician Fee
Schedule based on the Medicare economic index.
Budget Neutrality
Downward pressure on Medicare reimbursement is due to budget neutrality
requirements. This has resulted in a decline of 26% since 2001. The
Medicare statute requires that changes made to fee schedule payments be
implemented in a budget-neutral manner.
Furthermore, by law, CMS must also create utilization assumptions for
newly introduced services. When an overestimation occurs, it remains
uncorrectable, leading to irreversible reductions in the funding
allocated to the Medicare physician payment pool. For example, in 2013,
transitional care management services were added to the MPFS. While CMS
estimated 5.6 million new claims, actual utilization was under 300,000
for the first year and less than a million claims after 3 years. This
overestimation led to a $5.2 billion reduction in Medicare physician
payments from 2013 to 2021. This example highlights the unintended
consequences of the current budget policies within the flawed system.
We firmly believe that CMS should have the authority to rectify
utilization assumption errors that impact budget neutrality.
In the absence of eliminating budget neutrality policy, we encourage
Congress to pass H.R. 6371, the Provider Reimbursement Stability Act,
to revise the budget neutrality policies to: (a) prevent erroneous
utilization estimates from leading to inappropriate cuts; (b) clarify
the types of services subject to budget neutrality adjustments; and (c)
update the projected expenditure threshold triggering the budget
neutrality adjustment, which has remained unchanged since 1992.
Reform Quality Payment Program
Value-Based Models
Current value-based programs are burdensome, have not demonstrated
improved care, and are not clinically relevant to the physician or the
patient, and we have serious concerns with the viability and
effectiveness of the Merit-based Incentive Payment System (MIPS)
program. Numerous studies have highlighted persistent challenges
associated with MIPS, including practices serving high-risk patients
and those that are small or in rural areas. A study titled ``Evaluation
of the Merit-Based Incentive Payment System and Surgeons Caring for
Patients at High Social Risk,'' examined whether MIPS
disproportionately penalized surgeons who care for patients at high
social risk. This study found a connection between caring for high
social risk patients, lower MIPS scores, and a higher likelihood of
facing negative payment adjustments.\3\
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\3\ Byrd JN, Chung KC. Evaluation of the Merit-Based Incentive
Payment System and Surgeons Caring for Patients at High Social Risk.
JAMA Surg. 2021;156(11):1018-1024. doi:10.1001/jamasurg.2021.3746.
Additionally, the Government Accountability Office (GAO) was tasked
with reviewing several aspects concerning small and rural practices in
relation to Medicare payment incentive programs, including MIPS. The
GAO's findings indicated that physician practices with 15 or fewer
providers, whether located in rural or non-rural areas, had a higher
likelihood of receiving negative payment adjustments in Medicare
incentive programs compared to larger practices.\4\
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\4\ Medicare Small and Rural Practices' Experiences in Previous
Programs and Expected Performance in the Merit-Based Incentive Payment
System. Report to Congressional Requesters. United States Government
Accountability Office. 2018. https://www.gao.gov/assets/gao-18-428.pdf.
These studies highlight flaws in traditional MIPS, particularly in
terms of potential disparities in care and the financial burdens placed
on physicians when caring for high-risk patient populations and
physicians in small practices. The AADA recommends that Congress
establish incentives, funding, and flexibility for physician offices
with targeting small and solo practices.
MIPS Value Pathways
Since the passage of the Medicare Access and CHIP Reauthorization Act
of 2015 (MACRA), CMS routinely introduces new changes to MIPS,
requiring physicians to adjust continuously. Physicians are
increasingly frustrated by the frequent modifications to the Quality
Payment Program (QPP), including the associated administrative burdens
of adhering to new program requirements and the lack of incentive
payments to adequately compensate for participation efforts. While the
AADA acknowledges CMS' attempt to address some of these concerns by
introducing MIPS Value Pathways (MVPs) aimed at creating more
meaningful groups of measures and activities to offer a more
comprehensive assessment of quality of care, this new reporting option
is falling short of achieving the Agency's goal.
The AADA has significant concerns with the Agency's approach to
constructing MVPs, as it is using excessively broad measure sets that
lack alignment and provide no added benefit in terms of enhancing
patient care or helping patients determine the value of the clinician
managing their care. CMS' approach fails to account for the realities
of clinical practice and adds yet another layer of complexity to an
already confusing program. Take for example, CMS' candidate MVP for
Dermatological Care. Despite nearly 2 years of discussions and meetings
between CMS and the AADA, CMS continues to express interest in the use
of a single MVP for dermatology. This decision ignores the critical
problem of a one-size-fits-all approach, as it cannot effectively
compare costs and quality of care. We have shared with CMS that each
subspecialty within dermatology provides unique services to distinct
patient populations with varying practice patterns. This diversity in
the practice of dermatology makes a one-size-fits-all model ineffective
for comparing the cost and quality of care. For instance,
dermatologists who treat psoriasis, which is currently considered in
the candidate MVP's quality measures may not treat melanoma, which is
currently the only measure related to cost available in the candidate
MVP. Regardless of how CMS ultimately scores MVP participants, if CMS
finalizes an MVP that includes a cost measure for a cancer-related
disease and quality measures for an inflammatory skin disease, patients
and clinicians will question its purpose and the extent to which it
fails to drive value-based care.
Due to these numerous concerns, the AADA calls on Congress to urge CMS
to pause on moving forward with the MVPs. The AADA welcomes the
opportunity to continue working with CMS and the Congress to identify
opportunities to improve quality, patient outcomes, and efficiencies.
Burden on Physician Practices
Furthermore, the QPP must keep a keen focus on preventing physician and
staff burnout based on the Department of Health and Human Services
(HHS) \5\ own priorities. This includes providing relief from systems-
level factors that contribute to healthcare worker burnout by
instituting measures that:
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\5\ https://www.hhs.gov/sites/default/files/health-worker-
wellbeing-advisory.pdf.
Implement systems changes that reduce administrative paperwork
overall.
Facilitate coordination at the systems level without adding
administrative burden to healthcare practices and healthcare workers.
Provide funds to purchase human-centered technology that
facilitates providing value-based care; and
Ensure engagement in value-based care does not lead to
additional workload, overhead, and work hours for specialists.
Conclusion
On behalf of the AADA and its member dermatologists, thank you for
holding this hearing, allowing the opportunity for stakeholders to
submit a statement for the record, and for your commitment to ensuring
physicians can continue to serve their Medicare patients. The AADA
looks forward to working with you and asks that you continue to
consider including physician stakeholders' opinions in your ongoing
hearings as you work to identify a permanent solution to stabilize the
Medicare physician payment program. Should you have any questions,
please contact Adam Harbison, Director of Congressional Affairs at
aharbison@aad.org.
______
American Academy of Home Care Medicine
6728 Old McLean Village Drive
McLean, VA 22101
Members of the United States Senate Committee on Finance, thank you for
holding this important hearing. We submit this statement for the record
on behalf of the American Academy of Home Care Medicine (www.aahcm.org)
to alert the committee about the status of the Independence at Home
(IAH) demonstration and to provide suggestions for extension and
revitalization of the model, especially to ensure access to home-based
primary care for those living with multiple complex chronic conditions.
History of Independence at Home and the Growing Need for Home-Based
Primary Care
For Medicare, home-based primary care brings multiple rewards--
enhancing quality of service and access to care for our nation's most
ill elders and their families while achieving the important side effect
of cost savings for Medicare. The Independence at Home (IAH)
demonstration under the Centers for Medicare and Medicaid Services
Innovation Center (CMMI) began in 2012 as first authorized by Section
3024 of the Affordable Care Act. Since its inception the demonstration
received strong bipartisan support and was extended three times by
Congress in the last decade, though never expanded to bring in
additional practices.
Under the demonstration, health care providers are rewarded for
providing high quality home-based primary care (HBPC) while reducing
costs. Focused on care for Medicare patients who have multiple chronic
conditions and disability, the IAH model uses mobile interdisciplinary
teams of medical and social service professionals to care for patients
in their homes, delivering high quality clinical care, excellent
patient experience, and significantly lower costs for the Medicare
program.
The demonstration was rooted in the reality that high-need Medicare
beneficiaries account for a disproportionate share of health care
spending. The IAH demonstration used simple criteria, apparent to a
clinician seeing a patient, yet also attributable through claims, to
identify this group:
Have two or more chronic conditions, expected to persist for
more than a year.
Have coverage from fee-for-serve Medicare A and B.
Needs personal assistance with 2 or more activities of daily
living such as bathing, dressing.
Had a non-elective hospital admission in the last 12 months.
Received Medicare Part A post-acute skilled services in the last
12 months.
At the start of the demonstration, such individuals represented 6% of
the Traditional Medicare population but accounted for 30% of
Traditional Medicare spending. Today, those qualified for IAH represent
nearly 11% of the Traditional Medicare population and account for 44%
of Traditional Medicare spending. The number of Traditional Medicare
beneficiaries who would qualify for Independence at Home has increased
by over 1.2 million since the start of the demonstration, but the
number receiving home based primary care has increased by less than
300,000. There are nearly 2 million more seniors who could be
benefitting from home-based primary care as delivered by the IAH model
but are not currently receiving these services. This number will only
grow as the population continues to age, with the first Baby Boomers
turning 80 in 2026.
The growing number of seniors in need of home-based primary care, the
insufficient supply of home-based primary care providers, particularly
in rural and underserved areas, and the increasing share of Medicare
costs associated with high need patients all require an effective
program that can meet the needs of such patients.
Independence at Home Model Works for Patients, Families, Communities,
and Providers
Patients, Families, and Communities
Many older adults living with severe chronic illnesses and disability
have trouble traveling to the doctor's office, forcing them to rely on
the emergency department or hospital due to cognitive, physical, or
social barriers. Homebound seniors are more likely to be socially and
economically disadvantaged, and are often socially isolated, with unmet
care needs. For seriously ill elders, providing 24/7 medical and social
services at home allows them to live a life with dignity and respect,
where they want to be . . . at home. It brings peace of mind to family
caregivers by coordinating all needed health services, prepares
patients and families for managing serious illness, and supports them
until the last day of life.
IAH practices can deliver many services available in an urgent care
center or hospital room--portable diagnostic, therapeutic, and
monitoring technologies that allow the patient to stay at home, rather
than come to the hospital. These services include urgent medical
visits, blood tests, X-rays, EKGs, IV medications, oxygen, social work,
and caregiver education. By providing such services, elders and
families gain access to skilled primary care, maximize their time at
home, call 911 less often, and are admitted less often to the hospital.
For providers and health systems, the practice of house calls is an old
idea, improved with modern technology. By visiting the home, providers
build close relationships and trust with patients and families, leading
to more accurate diagnosis and more effective treatment.
Through receipt of high-quality care at home, IAH patients experience
better quality outcomes. IAH providers are measured on six quality
metrics, including all-cause hospital readmissions, ambulatory
sensitive hospital admissions, and emergency department visits. In Year
8 of the demonstration, the median participant reduced readmissions by
23%, hospital admissions by 41%, and ED visits by 31%. These remarkable
reductions in healthcare utilization translate into what matters most
to patients: more time at home, less time cycling in and out of
healthcare facilities.
Providers
IAH was designed to bring home based primary care practices into value-
based care, with adequate resources to field the mobile teams these
patients require. IAH providers serve as the ``quarterback'' of a
mobile team, coordinating medical care and social services that are
often as important as medical treatment. These mobile teams of
Physicians, Nurse Practitioners or Physician Assistants, and Social
Workers address routine and urgent issues and manage nearly all needed
care in the home. IAH also encourages innovation in telehealth
services. For example, some IAH sites have implemented tele-video
after-hours or used specially trained paramedics to keep patients at
home and out of the hospital. Many of these services are not reimbursed
by traditional Medicare or are reimbursed at rates well below the cost
to provide them.
The IAH model allows health care providers to achieve the following
goals.
Spend more time with their patients.
Perform assessments in a patient's home environment.
Assume greater accountability for all aspects of a patient's
care.
Prevent chronic conditions from getting worse.
Avoid unnecessary emergency department visits and
hospitalizations.
Improve patient and caregiver satisfaction.
Lower overall costs to Medicare.
The field of home-based primary care overwhelmingly consists of small
practices: only 8% of practices have more than 750 patients. Of the
over 2,400 home-based primary care practices in 2021, 2,200 of them had
fewer than 500 patients. These practices are small businesses that
serve a critical role, providing high quality healthcare jobs in their
local communities. Delivering equivalent quality of care than larger
practices, small practices are also more likely (19% higher) to be in
underserved areas--the Area Deprivation Index, a composite metric of
how socially disadvantaged a geographic area is.
How the IAH Demonstration Functioned
According to CMS's independent model evaluation, over the 8 years for
which results are available, IAH practices have delivered care at $229
million less than expected, or an average of $3,100 per beneficiary per
year less than expected.\1\ These cost reductions have generated $148
million in net savings for CMS. Participants have generated savings in
every single year of the model. IAH practices have also reduced
hospitalizations 20% and increased the time that patients spend at home
by 13%. Patients of IAH practices have a 40% lower risk of entering a
nursing home long term.
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\1\ CMS uses a difference-in-difference methodology to calculate
savings generated by the model. Under this methodology, the total
savings over 8 years has been $117 million, or $201 per beneficiary per
month. However, this approach does not account for the lower costs that
IAH participants were already generating before they started the model.
Adjusting CMS's methodology to account for these lower costs pre-model
produces the $229 million savings estimate.
Participants also showed signs of improvement throughout the duration
of the model. In the first year, 12 of the 17 practices delivered care
at costs less than expected, while by Year 5 all practices were
delivering care at lower-than-expected costs. Practices that were not
initially delivering lower costs improved to a point where they were
saving $330 per beneficiary per month. Practices that were already
delivering low-cost care at the start of the model increased the
savings they delivered from $400 per beneficiary per month initially to
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over $700 per beneficiary per month in Year 8.
The IAH demonstration successfully enrolled high need patients, who
cost on average $40-$50,000 per year, throughout its 10 years of
operation. IAH was initially capped at only 10,000 beneficiaries and
never allowed new practices to join after the start of the model.
Despite these limitations, the demonstration retained over 80% of its
original participating practices through Year 5. Through Year 5, IAH
participants saved an average of $2,800 per beneficiary per year, for
an average savings rate of 6%.
After Year 5, some practices moved from IAH to other value-based models
that offered better cash flow to maintain operations. In the original
IAH design, practices would wait 18-24 months to receive any shared
savings. Despite newer CMMI models that could accommodate home-based
primary care practices, such as CPC+ and Primary Care First, nearly 60%
of the IAH practices remained in the demonstration through Year 7
because the primary care models didn't provide sufficient resources for
high need patient care. Over the last 2 years of the demonstration, the
remaining IAH practices have migrated to the High Needs Direct
Contracting/High Needs ACO REACH model, while still delivering high
value care. Unfortunately, the High Needs program excludes nearly a
quarter of IAH qualified beneficiaries, has a minimum size requirement
that excludes 96% of home-based primary care practices, and requires a
level of down-side risk that few primary care practices can accept.
High Needs ACO REACH is only an option for either the largest home-
based primary care practices or practices that are willing to use a
third-party aggregator, which typically takes a large portion of any
savings earned.
Apply Lessons Learned to Improve, Expand Independence at Home Model
IAH could benefit nearly two million more Medicare beneficiaries with
multiple chronic conditions and disability, the fastest growing and
most costly segment of the Medicare population. IAH pays for itself
from savings to the Medicare program through a smarter use of
resources, providing monitoring and maintenance therapy and using
technologically enhanced urgent care services in the home. IAH also
eases the overwhelming demand from those living with severe chronic
illness and disability, who wish to avoid institutionalization.
The Independence at Home model has benefited from over a decade of
experience, including lessons learned from other value-based systems.
See Exhibit 1 at end summarizing the many studies and analyses of the
Independence at Home model.
With a revitalization of the model, IAH could address the significant
disparities in who has access to home-based primary care in their
community today. The current supply of home-based primary care is
concentrated in urban metropolitan areas. According to one study, rural
residents were 78% less likely to receive home-based care than
residents of the largest metropolitan county.\2\
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\2\ Yao N, Richie C, Cornwall T and Leff B. Use of Home-Based
Medical Care and Disparities. Journal of the American Geriatrics
Society. 07 August 2018.
We humbly ask the committee to not waste the precious resources devoted
to this program over the last decade and to capitalize on the promise
for IAH's future, especially given the growing need for home-based
primary care in the aging Medicare population. We ask that you work
with us to extend and revitalize the model in a few modest ways to
ensure that it can continue to serve our nation's elderly.
Modifications include better targeting beneficiaries in need, providing
appropriate financial incentives and supports, bolstering practices
with additional care management tools, and incorporating a broader set
of services.
Provide Caregiver Assessment and Support
Expand the HBPC model to a new cohort of practices without a
beneficiary cap.
Include voluntary and claims-based alignment.
Align all beneficiaries who receive a plurality of primary care
from the participating practice; at least 30% of a practice's patients
must meet High Needs criteria to be eligible for the model.
Provide Appropriate Financial Incentives and Supports
Introduce monthly enhanced primary care and health equity
payments to support care investments.
Reduce Medicare's guaranteed discount to ACO REACH levels.
Use a concurrent risk adjustment methodology.
Bolster Practices with Additional Care Management Tools
Provide monthly performance data in a user-friendly format.
Allow benefit enhancements such as the cost sharing waiver, SNF
3-day waiver, and nurse practitioner provision of service waivers.
Incorporate a Broader Set of Services
Unpaid caregiver support.
Coordination and management of home- and community-based
services.
Thank you for your committee's focus on home care for our nation's
seniors. Providers and allies of the American Academy of Home Care
stand with you and commit to assisting you in the laudable goal of best
serving our nation's seniors.
For further information, contact Peggy Tighe at
Peggy.Tighe@PowersLaw.com or Emily Johnson at
ejohnson@bloomhealthcare.com.
Exhibit 1: The Independence at Home Demonstration, PA Table Review of
the Literature
------------------------------------------------------------------------
Title Authors Publication/Link Year
------------------------------------------------------------------------
Laying the Groundwork for Independence at Home
------------------------------------------------------------------------
Effects of Home-Based Eric De Jonge et 62 J. Am. Geriatrics 2014
Primary Care on al. Soc'y \1\
Medicare Costs in High-
Risk Elders
------------------------------------------------------------------------
Better Access, Quality, Thomas Edes et 62 J. Am. Geriatrics 2014
and Cost for al. Soc'y \2\
Clinically Complex
Veterans with Home-
Based Primary Care
------------------------------------------------------------------------
Geriatric Care Steven R. 298 JAMA \3\ 2007
Management for Low- Counsell,
PIncome Seniors: A Christopher M.
Randomized Controlled Callahan, Daniel
Trial O. Clark et al.
------------------------------------------------------------------------
Analysis of Independence at Home Results
------------------------------------------------------------------------
Independence at Home: Konstantinos E. 71 J. Am. Geriatrics 2023
After 10 Years of Deligiannidis, Soc'y \4\
Evidence, It's Time Peter Boling,
for a Permanent George Taler,
Medicare Program Bruce Leff, &
Bruce Kinosian
------------------------------------------------------------------------
Evaluation of the Laura Kimmey, Mathematica \5\ 2023
Independence at Home Jason Rotter,
Demonstration: An Joseph Lovins, &
Examination of Year 7, Rachel Kogan
the First Year of the
COVID-19 Pandemic
------------------------------------------------------------------------
Letter to the Editor: Laura Kimmey & 72 J. Am. Geriatrics 2023
Independence at Home Jason Rotter Soc'y \6\
Evaluation Findings Do
Not Support Creating a
Permanent Medicare
Program
------------------------------------------------------------------------
Reply to: Independence Konstantinos E. 72 J. Am. Geriatrics 2023
at Home Evaluation Deligiannidis et Soc'y \7\
Findings Do Not al.
Support Creating a
Permanent Medicare
Program--It Does
------------------------------------------------------------------------
The Underappreciated Katherine 69 J. Am. Geriatrics 2021
Success of Home-Based Ornstein, David Soc'y \8\
Primary Care: Next M. Levine, &
Steps for CMS' Bruce Leff
Independence at Home
------------------------------------------------------------------------
Comment on: The Laura Kimmey & 70 J. Am. Geriatrics 2022
Underappreciated Valerie Cheh Soc'y \9\
Success of Home-Based
Primary Care: Next
Steps for CMS'
Independence at Home
------------------------------------------------------------------------
Reply to: Comment on: Katherine 70 J. Am. Geriatrics 2022
The Underappreciated Ornstein, David Soc'y \10\
Success of Home-Based M. Levine, &
Primary Care: Next Bruce Leff
Steps for CMS'
Independence at Home
------------------------------------------------------------------------
Integrated Home- and Girish Valluru et 67 J. Am. Geriatrics 2019
Community-Based al. Soc'y \11\
Services Improve
Community Survival
Among Independence at
Home Medicare
Beneficiaries Without
Increasing Medicaid
Costs
------------------------------------------------------------------------
Randomized Controlled Trials
------------------------------------------------------------------------
Outcomes of Home-Based Alex D. Federman 71 J. Am. Geriatrics 2022
Primary Care for et al. Soc'y \12\
Homebound Older
Adults: A Randomized
Clinical Trial
------------------------------------------------------------------------
Editorial: The Peter A. Boling & 71 J. Am. Geriatrics 2022
Challenge of Proving Bruce Kinosian Soc'y \13\
the Value of Medical
Care in the Home
------------------------------------------------------------------------
Expanding Independence at Home: Model Projection Papers
------------------------------------------------------------------------
Home-Based Primary James Rotenberg 66 J. Am. Geriatrics 2018
Care: Beyond Extension et al. Soc'y \14\
of the Independence at
Home Demonstration
------------------------------------------------------------------------
Projected Savings and Bruce Kinosian, 64 J. Am. Geriatrics 2016
Workforce George Taler, & Soc'y \15\
Transformation from Peter Boling
Converting
Independence at Home
to a Medicare Benefit
------------------------------------------------------------------------
Targeting Frail High T.E. Edes et al. 1 Innovation in Aging 2017
Cost Veterans Improves \16\
Impact and Efficiency
of Home Based Primary
Care (HBPC)
------------------------------------------------------------------------
To Strengthen the Bruce Leff, Peter Health Affairs Blog 2020
Primary Care First Boling, George \17\
Model for the Most Taler, & Bruce
Frail, Look to the Kinosian
Independence at Home
Demonstration
------------------------------------------------------------------------
Home-Based Care Systematic Reviews of Outcomes
------------------------------------------------------------------------
Systematic Review of Nathan Stall, 62 J. Am. Geriatrics 2014
Outcomes from Home- Mark Soc'y \18\
Based Primary Care Nowaczynski, &
Programs for Homebound Samir K. Sinha
Older Adults
------------------------------------------------------------------------
Comparative Agency for AHRQ \19\ 2016
Effectiveness Review Healthcare Rsch.
No. 164: Home Based and Quality,
Primary Care U.S. Dep't of
Interventions HHS.
------------------------------------------------------------------------
Home-Based Primary Robert M. 69 J. Am. Geriatrics 2021
Care: A Systematic Zimbroff, Soc'y \20\
Review of the Katherine A.
Literature, 2010-2020 Ornstein, & Orla
C. Sheehan
------------------------------------------------------------------------
Continuing Need for and Disparities in Access to Home-Based Care
------------------------------------------------------------------------
Primary Care in the George Taler, Primary Care for 2018
Home: The Independence Peter Boling, & Older Adults \21\
at Home Demonstration Bruce Kinosian
in Primary Care for
Older Adults
------------------------------------------------------------------------
Use of Home-Based Jennifer M. 24 J. Am. Medical 2023
Clinical Care and Long- Reckrey et al. Directors
Term Services and Association \22\
Supports Among
Homebound Older Adults
------------------------------------------------------------------------
Geographic Nengliang Yao et 35 Health Affairs 2016
Concentration of Home- al. \23\
Based Medical Care
Providers
------------------------------------------------------------------------
Home-Based Medical Care Jeffrey Marr et 42 Health Affairs 2023
Use in Medicare al. \24\
Advantage and
Traditional Medicare
in 2018
------------------------------------------------------------------------
County-Level Social Harriet Mather, JAMA Open Network 2023
Vulnerability, Katherine A. \25\
Metropolitan Status, Ornstein, &
and Availability of Catherine
Home Health Services McDonough
------------------------------------------------------------------------
The Dynamics of Being Claire K. Ankuda 69 J. Am. Geriatrics 2021
Homebound Over Time: A et al. Soc'y \26\
Prospective Study of
Medicare Beneficiaries
------------------------------------------------------------------------
\1\ https://agsjournals.onlinelibrary.wiley.com/doi/pdf/10.1111/
jgs.12974.
\2\ https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.13030.
\3\ https://jamanetwork.com/journals/jama/fullarticle/209717.
\4\ https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.18386.
\5\ https://www.mathematica.org/publications/evaluation-of-the-
independence-at-home-demonstration-an-examination-of-year-7-the-first-
year.
\6\ https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.18656.
\7\ https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.18659.
\8\ https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.17426.
\9\ https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.17640.
\10\ https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.17641.
\11\ https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.15968.
\12\ https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.17999.
\13\ https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.18153.
\14\ https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.15314.
\15\ https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.14176.
\16\ https://academic.oup.com/innovateage/article/1/suppl_1/1328/
3902111?login=false.
\17\ https://www.healthaffairs.org/content/forefront/strengthen-primary-
care-first-model-most-frail-look-independence-home-demonstration.
\18\ https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.13088.
\19\ https://effectivehealthcare.ahrq.gov/sites/default/files/pdf/home-
based-care_research.pdf.
\20\ https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.17365.
\21\ https://link.springer.com/chapter/10.1007/978-3-319-61329-1_11.
\22\ https://pubmed.ncbi.nlm.nih.gov/37084771/.
\23\ https://www.healthaffairs.org/doi/10.1377/
hlthaff.2015.1437?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.
org&rfr_dat=cr_pub%20%200pubmed.
\24\ https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2023.00376.
\25\ https://jamanetwork.com/journals/jamanetworkopen/fullarticle/
2810650.
\26\ https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.17086.
______
American Academy of Ophthalmology
20 F Street, NW, Suite 400
Washington, DC 20001-6701
T: +1 202-737-6662
https://www.aao.org/
Dear Chairman Wyden and Ranking Member Crapo:
The American Academy of Ophthalmology appreciates the opportunity to
share our perspectives on bolstering chronic care through Medicare
physician payment. Ophthalmologists regularly treat numerous chronic
and potentially blinding eye conditions such as age-related macular
degeneration, diabetic retinopathy, and glaucoma, among others.
Ophthalmology practices also treat large numbers of Medicare patients
and are significantly impacted by Medicare physician payment policies.
We commend you for holding this timely hearing as the current Medicare
physician payment system is on an unsustainable path at a time when
physicians are providing more care with fewer resources to maintain
their practices as they manage patients in an increasingly complex
health care environment. Without Congressional action, physicians will
again be facing Medicare payment cuts in 2025, which could negatively
impact Medicare beneficiaries' timely access to the health care they
need.
The Academy is the largest association of eye physicians and surgeons
in the United States. A nationwide community of nearly 22,000 medical
doctors, we protect sight and empower lives by setting the standard for
ophthalmic education and advocating for our patients and the public. We
innovate to advance our profession and to ensure the delivery of the
highest-quality eye care. As such, we stand ready to work with the
Committee and Congress to develop long-term solutions to the systemic
problems within the Medicare physician payment system and preserve
patient access to the highest-quality eye care.
Our recommendations for long-term reform are listed below. We look
forward to working with you on the implementation of these needed
changes.
Annual Inflation-Based Payment Update:
When looking at the data, physician payments have fallen far behind
inflation and increasing practice costs. In the past 22 years, Medicare
physician payments have only seen a modest increase of 9 percent,
averaging just 0.4 percent per year. Meanwhile, the expenses associated
with running a medical practice have surged by 47 percent from 2001 to
2023. Adjusted for inflation's impact on practice costs, Medicare
physician pay has declined 26 percent during the same period (2001 to
2023). This impact is unique to physician payments as nearly all other
Medicare providers and suppliers receive an annual inflationary payment
update. With this significant decline in real value of allowed charges,
financial challenges have disproportionately impacted small,
independent, and rural physicians, which incentivizes market
consolidation and practice closures.\1\
---------------------------------------------------------------------------
\1\ Kaiser Family Foundation. What We Know About Provider
Consolidation. September 2, 2020. https://www.kff.org/health-costs/
issue-brief/what-we-know-about-provider-consolidation/. Accessed June
15, 2023.
As the Senate Committee on Finance continues work to address the broken
Medicare physician payment system, we urge the Committee to support
legislation which would provide an annual inflation-based payment
update based on the full Medicare Economic Index (MEI). A full
inflation-based update would be a critical step towards resolving the
problems created by ongoing yearly payment cuts that are plaguing our
healthcare system and would help provide long fiscal stability for
physicians.
Budget Neutrality:
Another key factor to consider addressing is the mandated budget
neutrality requirement in the Medicare Physician Fee Schedule. By law,
Medicare is a budget neutral financing system for physician
reimbursements. Any positive payment adjustments for those who exceed
the performance threshold are paid for by those receiving penalties. In
the early years of the program, it was possible to avoid a penalty
because the performance threshold was understandably set low as
eligible providers grew familiar with the new program. As expected, the
positive payment adjustments were small because most participants were
not getting a penalty. Fortunately, during these early years Congress
set aside a pool of money to be split among the exceptional performers
who exceeded the performance threshold. This provided at least a small
incentive to adopt meaningful changes to support high-quality care.
Though the performance threshold has been raised year over year, the
budget-
neutral nature of the bonus payment adjustments continues to suppress
the Congressionally intended meaningful positive payment incentives
that can be realized. An article in Ophthalmology \2\ reviewed the
national allowable payments for 13 of the 15 commonly performed
ophthalmology procedures from 2011 to 2020, documenting a significant
6.2% decline in reimbursement. The decline is a 17.7% cut when adjusted
for inflation. While some reductions were due to revaluing misvalued
codes, this study shows that the statutorily mandated budget neutrality
requirement is forcing CMS to undervalue ophthalmology and other
surgical services in the absence of legislation to enlarge the
physician payment pool. As such, we urge the Committee to address the
budget neutrality requirement. Therefore, the Academy strongly
recommends that Congress enact reforms to the budget-
neutrality policies of the Medicare Physician Fee Schedule to reduce
inappropriate payment cuts and provide stability for Medicare physician
payments.
---------------------------------------------------------------------------
\2\ Patel S, Glasser D, Repka M, Berkowitz S, Sternberg P. Changes
in Medicare Reimbursement for Commonly Performed Ophthalmic Procedures.
Ophthalmology 2021. doi:10.1016/j.ophtha.2021.02.026. https://
www.aaojournal.org/article/S0161-6420(21)00194-9/fulltext.
---------------------------------------------------------------------------
Global Surgical Code Payments:
Medicare currently pays surgeons and other specialists a single fee
(global payment) when they perform major or minor surgery such as brain
tumor removal, joint replacement, heart surgery, or cataract surgery.
CMS established these global payments to cover the costs of a
procedure, plus the typical pre-operative and follow-up care needed
within a 10- or 90-day post-operative timeframe. Postop visits require
the same physician work, medical decision making, and practice expenses
as office E/M visits. Patient complexity does not disappear during the
post-operative global period. In contrast, it is not unusual for
surgery to destabilize comorbid conditions for patients with systemic
conditions such as diabetes, hypertension, or glaucoma, that were
stable prior to surgery. Surgeons, therefore, must also consider the
complexity of problems and complications and/or morbidity or mortality
of patient management just as they would do for a standalone E/M visit.
In 2021, CMS increased payment for E/M services. However, the agency
did not apply these increases to post-operative visits included in
global surgical codes. The expense and complexity of these visits has
increased just as those visits outside of the surgical global period.
Despite engagement efforts by the Academy, the American Medical
Association, the American College of Surgeons and others, CMS again
declined to apply the increased E/M values to post-operative visits in
both the 2023 and 2024 Medicare Physician Fee Schedules.
Arbitrarily adjusting certain E/M codes in the Fee Schedule conflicts
with the Omnibus Budget Reconciliation Act (OBRA) of 1989 (Public Law
101-239), which prohibits Medicare from paying physicians differently
for the same work. Failing to adjust payment for E/M visits included in
global codes results in paying surgeons less than other physicians, in
violation of the law. Every time CMS has increased payment for office
visits in the past, the agency also adjusted global surgery bundled
payments to account for the E/M portion of these codes.
Ophthalmology services, such as the recently revalued retinal
detachment surgery, demonstrate why the current policy creates
inequity. Surgeons now receive LESS pay for the work of a retinal
detachment procedure AND the two post-operative visits, than if the
surgeon did the procedure for free, and only billed for the two post-
operative visits at the current rate for E/M office visits. This is
illogical and emphasizes why CMS' policy must change.
One reason CMS uses to justify undervaluing surgical E/M visits, is
that the agency is not convinced surgeons provide all the post-
operative visits included in global surgical codes. However, a process
already exists through the American Medical Association's Relative
Value Scale Update Committee (RUC) to evaluate any global codes
believed to be ``misvalued'' including the number of postoperative
visits. The adjustment of cataract surgery fees show how the process
ensures codes are appropriately valued.
CMS revalued cataract surgery payment through this medicine-supported
process in 2019. Since CMS accepted the RUC's recommended revaluation,
including that ophthalmologists provide three post-operative visits in
the procedure's 90-day global period, these doctors should be paid
equally to other physicians for providing the same level of service per
patient. The Academy continues working with other surgical
organizations to have CMS revisit its decision and apply the increased
values to the E/M portion of the global codes. The Academy urges the
Committee to put additional pressure on the agency to provide proper
equitable payment for postoperative E/M visits included in global
surgical packages.
Payment Challenges and Healthcare Consolidation:
Historically, ophthalmology practices have been small businesses with
more than 90% of our members in small practices, defined by Medicare as
having 15 or fewer physicians. However, medical practice consolidation
including ophthalmology has increased significantly in recent years.\3\
While ophthalmology had largely escaped hospital and health system
practice acquisitions in the past, the specialty is now experiencing a
trend in private equity consolidation.
---------------------------------------------------------------------------
\3\ Chen E, Cox J, Begaj T, Armstrong G, Khurana R, Parikh R.
Private Equity in Ophthalmology and Optometry. Ophthalmology.
2020;127(4):445-455. doi:10.1016/j.ophtha.2020.01.007. https://
www.aaojournal.org/article/S0161-6420(20)30012-9/fulltext. Published
2020.
Looking at consolidation more broadly across medicine, an AMA report
stated that 2020 was the first year when less than half (49.1%) of
patient care physicians worked in a private practice. The report also
noted that the decrease in private practice physicians appears to have
accelerated in recent years.\4\
---------------------------------------------------------------------------
\4\ Kane C. Policy Research Perspectives: Recent Changes in
Physician Practice Arrangements: Private Practice Dropped to Less Than
50 Percent of Physicians in 2020. Ama-assn.org. https://www.ama-
assn.org/system/files/2021-05/2020-prp-physician-practice-
arrangements.pdf. Published 2021.
The Academy is concerned about what greater consolidation within
medicine could mean for patient care. While private equity has a
diversity of forms, some of our members are troubled that private
equity consolidation is prioritizing profit over patient care through
understaffing and incentivizing unnecessary procedures. Consistent with
these concerns, the Medicare Payment Advisory Commission's (MedPAC)
March 2021 report stated that hospitals and physician groups were
driving up prices as they consolidated.\5\
---------------------------------------------------------------------------
\5\ Medicare Payment Advisory Commission. Report to the Congress:
Medicare Payment Policy. 2021:xiv. http://www.medpac.gov/docs/default-
source/reports/mar21_medpac_report_to_the_
congress_sec.pdf?sfvrsn=0.
As one of the primary physician specialties caring for Medicare
beneficiaries, we support the oversight of Medicare spending. The
Academy strongly believes the lack of fair updates to the Medicare
Physician Fee Schedule is a major contributing factor to the
consolidation trend. We believe Congress should review the current
incentives to consolidate to ensure that Medicare policies are not
inadvertently contributing to the drive towards greater consolidation
of medical practices.
Administrative Burdens on Physician Practices:
Another aspect impacting the delivery of care is administrative and
financial burdens dealing with prior authorization, which impose a
significant strain on physicians and the patients they treat. Obtaining
pre-approval for medical treatments or tests before administering care
to their patients is a time-consuming and costly procedure that often
forces physicians and their staff to spend a significant portion of
their week engaging in negotiations with insurance companies. In most
cases the care is ultimately approved. This time would be better
utilized in caring for patients.
The practice of prior authorization is rampant, and in 2018, the Office
of the Inspector General (OIG) conducted a study that revealed an
alarming trend in Medicare Advantage (MA) plans. It was found that MA
plans overturned 75% of their own denials, strongly suggesting that the
prior authorization process significantly delays medically necessary
care. Furthermore, a more recent analysis conducted by the OIG
demonstrated that the use of prior authorization by MA plans has led to
the denial of medically necessary care that would have been covered
under Medicare Fee-For-Service (FFS) for beneficiaries.
The Academy has heard from many ophthalmologists, especially retina
specialists, that some MA plans are requiring prior authorization for
each visit and each intravitreal injection used to treat age-related
macular degeneration (AMD), a chronic condition that requires monthly
treatment in many patients. When asked, these retina specialists report
that MA plans are approving essentially 100% of their prior
authorization requests for this service. This continued prior
authorization requirements are daily care and add additional cost.
The Academy urges the Committee to support legislation that establishes
an electronic prior authorization (e-PA) program within Medicare
Advantage (MA), and also require MA plans to provide real-time decision
making when responding to requests for items and services. By
implementing an e-PA program and ensuring timely decisions, Congress
can help streamline the prior authorization process, reduce
administrative burdens, decrease pressure for consolidation, and
improve access to necessary care and services for patients.
Conclusion:
The Academy applauds the Committee for conducting this hearing in order
to develop policies that will improve physician payment and increase
access to care for patients across the United States. We stand ready to
work with the Committee and provide feedback as you pursue future
policy changes.
______
American Academy of Orthopaedic Surgeons and
American Association of Orthopaedic Surgeons
317 Massachusetts Avenue, NE, Suite 100
Washington, DC 20002-5701
Phone 202-546-4430
https://www.aaos.org/advocacy/
AAOS Recommendations: A Specialty Care Reimbursement Model to
Operationalize Value-based Care for Musculoskeletal Conditions
Prepared and Reviewed by AAOS Healthcare Systems Committee
Karl M. Koenig, Chair
A. Executive Summary
In response to the Center for Medicare and Medicaid Innovation (CMMI)
initiatives in the space of value-based payment reform, the American
Academy of Orthopaedic Surgeons (AAOS) and physician leaders have
worked closely to develop recommendations toward advancing high value
orthopaedic payment and practice models. With the end goal of moving
away from dominant traditional fee-for-service models, the most
prolific step to date is the sharing of risk on the total cost of care
with health systems through accountable care organizations (ACOs).
Building on this foundation, the challenge then remains to develop a
structure by which ACOs and primary care providers can interact with
musculoskeletal specialists and teams in a meaningful way. This can be
achieved by creating opportunities to reward the practice of evidence-
based, high value, cost-efficient care for patients.
ACOs have matured at the primary care level, and many are on the road
to improving quality of care for their populations through enhanced
coordination and comprehensive chronic and complex disease management
while sharing savings and lowering costs. However, ACOs still face
challenges when it comes to organizational transformation around
specialty care. At the specialty level, procedure-based bundled episode
payment models, such as those involving total joint replacement surgery
for osteoarthritis (OA) of the hip or knee, have been met with limited
success. Cost reductions have been achieved through reductions in
utilization (e.g., post-acute care), while maintaining but not
substantially improving, clinical outcomes. Ultimately such models were
never directly configured to address procedural appropriateness, or the
provision of timely, equitable, and comprehensive specialized care, nor
tailored to meet the holistic needs of diverse populations with a view
to improving their health outcomes more broadly. In essence, the goal
of true value for patients with specialized conditions has yet to be
realized.
Momentum is building among stakeholders in health care to shift the
status quo toward a whole person approach that considers the patient's
condition alongside their preferences, values, and needs (characterized
as ``Comprehensive Condition-Based Care''). This shift promises to
support and incentivize the reorganization of musculoskeletal care into
multidisciplinary teams that aim to deliver more coordinated and
efficient management of conditions across the full cycle of care. Most
health systems currently perform ``non-operative care'' on the backdrop
of primary care providers with insufficient support systems and/or
training in managing musculoskeletal conditions. This often leads to a
myriad of unnecessary imaging studies, non-value-added interventions,
and delays to patient care. Once the PCP has exhausted their
capabilities in caring for a particular condition, they are expected to
navigate a broad portfolio of specialists and subspecialists who are
all working under different sets of incentives and payment
infrastructures. One logical approach to solving this issue is to
incentivize care through condition-based payments with the aim of
driving reorganization and model redesign on the specialty front. The
end goal for ACOs would be early referral of these patients into the
sphere of efficient, high quality specialty care teams without a
concern that such patients will immediately become ``high cost,'' but
instead confidence that they will receive high value care.
In a comprehensive condition-based payment, a team of providers is paid
a contracted rate to provide all care for a specified medical condition
(or set of conditions) while holding themselves accountable to outcome
measures relevant to that condition. The team is therefore incentivized
to deliver high-value care throughout the entire cycle of the
condition, including appropriate decision-making around when to proceed
with surgical or non-surgical interventions. Such a system offers
multiple positive effects on the delivery of care for musculoskeletal
conditions. During our time conceptualizing value-based payment reform
initiatives, as ``The Consortium for the Next Generation of Alternative
Payment Models,'' we have identified a comprehensive set of
considerations for condition-based care that should be addressed by
stakeholders attempting to collaboratively build such models. These
considerations have been framed as a design process of discovering the
nature, scale, and opportunity; defining an analytical approach;
developing model specifications fit for practice; and delivering the
transformation.
B. Discovery: Discovering the Nature, Scale, and Opportunity
Stakeholders should get a sense of the nature, scale, and opportunity
(clinical, financial, and experiential) of a new business model
centered on a high value condition-based payment program. A first step
is to define who is going to participate in building the most effective
program before understanding how a new program fits among competing
priorities within the organization and appreciating the potential
challenges faced in specifying and building the requirements for such a
program.
Who is Going to Participate and How?
Multiple stakeholders--whether payer, provider, or vendor--can spark
the transformation toward high value musculoskeletal care and should
remain steadfast in motivating others to join forces. Orthopaedic
surgeons must be at the forefront of this change and either lead or be
heavily involved with these teams because we have the highest level of
training and often provide the full breadth of evidence-based treatment
options for a given musculoskeletal condition. Expertise in the full
spectrum of treatments allows the team to reduce unnecessary diagnostic
testing that does not change treatment, reduces non-value-added
interventions for patients, and provides timely evaluation and
intervention when surgical treatment is the best answer. Having the
full suite of evidence-based options catalyzes efficiency across the
system and maximizes value from the patient perspective (which is our
primary goal).
A team delivering condition-based care must have ``all the tools in
their toolbox'' to avoid unnecessary delays in access and treatment.
Depending on the condition, the clinical team structure may vary and
includes a multitude of musculoskeletal providers such as Orthopaedic
surgeons, rheumatologists, primary care sports medicine specialists,
physical therapists, physiatrists, associate providers, podiatrists,
chiropractors, prosthetist/orthotists, dieticians and mental health
providers.
Should our team participate? Gaining a broader understanding of
participating entities across the stakeholder groups and the base
configuration of the contracting arrangement will enable the design of
a program that is fit for purpose. Are we confident we will
collectively have the people, resources, creativity, and capabilities
to successfully implement condition-based care and most importantly the
belief that this is ultimately better care? If not, then working with
another entity to convene and manage comprehensive, condition-based
payments on a larger scale may be the best entry point.
Scoping Exercise
We recommend an initial scoping exercise to concretely identify the
affected patient population, geographical distribution, key
stakeholders/service providers, affected membership count (including
identified payer segments), and estimate of medical expenses for
affected members. The most obvious candidates for a Medicare population
would be ``Knee Pain/Knee Osteoarthritis'' or ``Low Back Pain/
Degeneration.'' Given the previous experience with procedure bundles in
these conditions, prior experience can facilitate the genesis of a
pilot program.
Clear gaps and opportunities for improvement should be articulated,
such as suboptimal utilization, deficiencies in existing care pathways,
outcomes assessed, issues of access and health equity, and
affordability of care.
C. Definition: Defining an Analytical Approach and Assumptions
It is important to define an analytical approach and set expectations
on analytical outputs early as part of the cycle of evidence generation
that will fuel program configuration, implementation, and scaling. From
this point onward, we illustrate recommendations and a framework with
the management of knee pain/knee osteoarthritis in general (secondary
to degenerative joint disease). Ideally, this phase should also
accompany an actuarial model of the targeted population to identify
reasonable financial constructs and targets.
_______________________________________________________________________
1. Condition Scope
------------------------------------------------------------------------
Knee pain, degeneration, and derangement
- Osteoarthritis
- Meniscal tear
------------------------------------------------------------------------
2. Condition Scope--Exclusions
------------------------------------------------------------------------
Exclude
- Malignancy (primary or metastatic)
- Post-traumatic Arthritis (Motor vehicle accidents, trauma, intra-
articular fracture)
- Autoimmune arthrosis (e.g., Rheumatoid arthritis, lupus) or other
inflammation
------------------------------------------------------------------------
3. Diagnostic Coding
------------------------------------------------------------------------
Global MSK codes (ICD-10)--the partnership intent is to effectively
capture all relevant MSK diagnoses together (e.g., Knee Osteoarthritis
(side specific), Mensical Tear, Sprain/Strain, etc). (See Appendix)
A separate consideration is to include pain diagnoses that are later
confirmed with an Eligible MSK Diagnosis. (e.g., member diagnosed with
knee OA, but presented with knee pain 2 months prior--therefore,
include all related Knee Pain services during that 2-month interim
period). Such relevant services for pain episodes that lead to a
diagnosed clinical condition (e.g., E&M, imaging, rehabilitation) could
reasonably be included for maintaining accountability.
------------------------------------------------------------------------
4. Service Scope
------------------------------------------------------------------------
Type of service (some or all)
1. All related E&M codes for musculoskeletal providers
2. Specific CPT codes (e.g., surgery, physical therapy, anesthesia)
3. Capture but "bucket" lower value interventions (e.g., MRI,
hyaluronic acid, arthroscopy)
Geographic
1. ZIP code/county level
2. State level
3. MSA level
4. Other strategic level
Place of service (some or all)
1. Inpatient
2. Outpatient
3. Office
4. Ambulatory Surgical Center (ASC)
5. ED
Illustration
Include all CPT codes that evidence an eligible diagnosis (defined
earlier by Scope considerations) within a prespecified claim level
(e.g., first four positions), at any Place of Service, in as wide a
geography as feasible. More is better to create critical mass for
clinicians, patients, and finances (practice revenue potential, medical
expense savings potential; spread out fixed costs for everyone for this
transformation). (See Appendix H).
------------------------------------------------------------------------
5. Performance Evaluation
------------------------------------------------------------------------
Performance Start-Stop
1. Performance Year--predefined 12-month period wherein APM
eligibility, attribution, and accountability are adjudicated. Most
obvious is calendar year (January 1-December 31).
2. Episode basis--member-specific starting date when initial
eligible diagnosis/Trigger starts. Unique for each member (e.g.,
one member on March 13th, another on April 3rd, etc)
Duration of Performance
1. 90 days
2. 6 months
3. 12 months
Illustration
12-month performance year on a calendar year basis with 90 day and 6-
month evaluations
Outcomes Reporting:
1. Patient-reported Pain/Function: participation requires the
incorporation of knee specific PRO scores and aggregate reporting
at 6 months and 12 months (for accountability rather than
comparison across participants). KOOS JR is currently used most
broadly.
2. Clinical: Utilize current clinical outcome metrics reporting for
surgical patients (readmissions, reoperations)
------------------------------------------------------------------------
Define and Communicate Savings Assumptions
Based upon the analytical approach and analytical outputs, the
participating service provider(s) should be able to use the data to
specify a) where they identify the opportunity, b) how they approach
that identified opportunity in their service delivery configuration,
and c) the projected magnitude of impact on outcomes related to
quality, finances, and/or experience.
For example, illustrative opportunities in musculoskeletal care are
shown in the table below where impact can be generated around
utilization (increase high value and decrease low value strategies),
intensity (reduce the intensity of utilization of specific strategies),
locus of services (shift the location of services to enable more
convenience, quality, experience while reducing cost).
------------------------------------------------------------------------
Projected area/
Opportunity Area Approach magnitude of Impact
------------------------------------------------------------------------
Injections Reduce utilization Financial
(e.g., hyaluronic
acid) and reduce
intensity (e.g.,
steroid)
------------------------------------------------------------------------
Advanced Imaging Reduce utilization Financial
(e.g., MRI) and reduce
intensity (e.g.,
Frequency of x-rays)
------------------------------------------------------------------------
Rehabilitation Shift locus of services Financial/Quality/
to self-management at Experience
home; Reduce
utilization of post-
acute care; Increase
utilization of
exercise therapy,
education, and self-
management
------------------------------------------------------------------------
Pain education and Increase assessments of Financial/Quality/
behavioral health mental/behavioral Experience
management health, train in
coping strategies,
health coaching,
psychological
interventions
------------------------------------------------------------------------
Overall visits Reduce number of Financial/Experience
outpatient visits
------------------------------------------------------------------------
Surgery Reduce inappropriate Financial/Quality/
surgical utilization Experience
and increase
appropriate surgical
selection through
shared decision-
Pmaking
------------------------------------------------------------------------
Broad statements of savings assumptions e.g., ``15% savings on
musculoskeletal-
related costs'' should be validated and articulated lever-by-lever by
both payer and provider, including actuarial associates from each.
These assumptions should be founded upon the payer's actual membership
population and the provider's current or desired-future membership
reach, as well as incorporate program engagement assumptions, e.g., 15%
savings on 10% engaged members in a given year over 100,000 lives by
specific geographies.
C. Develop
_______________________________________________________________________
Program Pricing
------------------------------------------------------------------------
Key Q. What should the episode price be inclusive of and what are
withholding criteria?
Key Points. The price is inclusive of:
- Historical per-patient annual spend on relevant services
(according to the program specifications regarding included ICD-
10s, CPTs, sites, types, provider, geographies, lines of business,
etc.)
------------------------------------------------------------------------
MSK Illustration
Include surgical professional fee distributed across all patients as
fraction of utilization rate (e.g., $1,000 fee, 15% utilization rate =
$150 added to each per-member per-period payment)
- For the related-but-separate surgical bundle, there will exist a
separate target price (less the surgical professional fee)
Apply withholds for 1) episode completion/attribution and 2) quality
measurement
Balance provider-specific and multi-provider/regional utilization
history
Also need to include correction for under-utilization of relevant
services (e.g., nutrition, mental health)
------------------------------------------------------------------------
Type and Level of Risk
------------------------------------------------------------------------
Key Q. What are the key considerations around type and level of risk?
Key Points. Likely begin with initial upside for 1-2 years, introduce
downside years 2-3 and beyond, moving eventually toward risk-adjusted
capitated payment. Scope of risk to be defined by Program Parameters
(diagnosis, service, site, type, provider, geography, etc.,).
------------------------------------------------------------------------
D. Delivery: Delivering the Transformation
With the incentive of appropriate condition-based payments as an
organizing principle, a variety of different structures will be viable.
Time and experience will yield the most efficient structures and the
system will adjust appropriately.
Multidisciplinary MSK Practices: Many such practices currently exist
who could take on a condition-based payment structure with minimal
investment and adjustment. Often created by the expansion of
Orthopaedic surgery groups, there are many examples of teams that
already include Rheumatology, PMNR, Primary Care Sports, Physical
Therapy, Podiatry, and Prosthetists/Orthotists. Such groups will be
poised to take on pilot programs and prove the concept in conjunction
with CMS. Internal reorganization will be required for many, but new
capital investment and hiring could be minimized.
Fully integrated health systems: Broad Solutions engage with both
providers and members to improve care delivery and assume deep global/
total accountability for cost and quality. For members they may offer
care management, navigation, education, and other virtual or in-person
services. For providers they may offer service line management, care
pathways, incentive structures, ancillary services.
Role of Market-based and digital health solutions:
Utilization management solutions can be denial or education-based to
enable provider (and member) adherence to clinical practice guidelines.
These entities can provide immediate value but may also trigger some
friction with the provider community. Such solutions could be used to
stimulate accountable entities to perform and/or accept substantial
risk to dial down the utilization management, or even turn it off.
Point Solutions have rapidly expanded with a laser-focus on member
experience and the delivery of coordinated, continuous, and convenient
care for patients both in-person and through virtual care. Such
solutions can provide relatively immediate value for health plans and
accountable entities, with return on investment (ROI) guarantees.
However, point solution coordination and integration with traditional
provider networks is generally lacking at this time. In order to
provide the full spectrum of care and take on a condition-based
payment, these entities will need to partner with existing providers.
This is another method of organization that will ``naturally'' create
new entities and enable participation by smaller independent providers
and practice groups.
Appendix: Included ICD-10 Codes for ``Knee Pain/Knee Osteoarthritis''
for Medicare Patients
_______________________________________________________________________
M13861 Lower Extremity Other specified arthritis, right
knee
------------------------------------------------------------------------
M13862 Lower Extremity Other specified arthritis, left
knee
------------------------------------------------------------------------
M170 Lower Extremity Bilateral primary osteoarthritis
of knee
------------------------------------------------------------------------
M1711 Lower Extremity Unilateral primary
osteoarthritis, right knee
------------------------------------------------------------------------
M1712 Lower Extremity Unilateral primary
osteoarthritis, left knee
------------------------------------------------------------------------
M1712 Lower Extremity Unilateral primary
osteoarthritis, left knee
------------------------------------------------------------------------
M1712 Lower Extremity Unilateral primary
osteoarthritis, left knee
------------------------------------------------------------------------
M174 Lower Extremity Other bilateral secondary
osteoarthritis of knee
------------------------------------------------------------------------
M222X1 Lower Extremity Patellofemoral disorders, right
knee
------------------------------------------------------------------------
M2241 Lower Extremity Chondromalacia patellae, right
knee
------------------------------------------------------------------------
M23051 Lower Extremity Cystic meniscus, posterior horn
of lat mensc, right knee
------------------------------------------------------------------------
M2341 Lower Extremity Loose body in knee, right knee
------------------------------------------------------------------------
M2341 Lower Extremity Loose body in knee, right knee
------------------------------------------------------------------------
M2341 Lower Extremity Loose body in knee, right knee
------------------------------------------------------------------------
M238X9 Lower Extremity Other internal derangements of
unspecified knee
------------------------------------------------------------------------
M2392 Lower Extremity Unspecified internal derangement
of left knee
------------------------------------------------------------------------
M24661 Lower Extremity Ankylosis, right knee
------------------------------------------------------------------------
M25462 Lower Extremity Effusion, left knee
------------------------------------------------------------------------
M25561 Lower Extremity Pain in right knee
------------------------------------------------------------------------
M25562 Lower Extremity Pain in left knee
------------------------------------------------------------------------
M67461 Lower Extremity Ganglion, right knee
------------------------------------------------------------------------
M7041 Lower Extremity Prepatellar bursitis, right knee
------------------------------------------------------------------------
M7121 Lower Extremity Synovial cyst of popliteal space
[Baker], right knee
------------------------------------------------------------------------
M7122 Lower Extremity Synovial cyst of popliteal space
[Baker], left knee
------------------------------------------------------------------------
M7122 Lower Extremity Synovial cyst of popliteal space
[Baker], left knee
------------------------------------------------------------------------
M7651 Lower Extremity Patellar tendinitis, right knee
------------------------------------------------------------------------
M93261 Lower Extremity Osteochondritis dissecans, right
knee
------------------------------------------------------------------------
M9689 Lower Extremity Oth intraop and postproc comp
and disorders of the ms sys
------------------------------------------------------------------------
Q686 Lower Extremity Discoid meniscus
------------------------------------------------------------------------
S8001XD Lower Extremity Contusion of right knee,
subsequent encounter
------------------------------------------------------------------------
S83004A Lower Extremity Unspecified dislocation of right
patella, initial encounter
------------------------------------------------------------------------
S83004D Lower Extremity Unspecified dislocation of right
patella, subs encntr
------------------------------------------------------------------------
S83200D Lower Extremity Bucket-hndl tear of unsp mensc,
current injury, r knee, subs
------------------------------------------------------------------------
S83206A Lower Extremity Unsp tear of unsp meniscus,
current injury, right knee,
init
------------------------------------------------------------------------
S83206D Lower Extremity Unsp tear of unsp meniscus,
current injury, right knee,
subs
------------------------------------------------------------------------
S83207A Lower Extremity Unsp tear of unsp meniscus,
current injury, left knee, init
------------------------------------------------------------------------
S83207D Lower Extremity Unsp tear of unsp meniscus,
current injury, left knee, subs
------------------------------------------------------------------------
S83207S Lower Extremity Unsp tear of unsp meniscus,
current injury, l knee, sequela
------------------------------------------------------------------------
S83209A Lower Extremity Unsp tear of unsp meniscus,
current injury, unsp knee, init
------------------------------------------------------------------------
S83209D Lower Extremity Unsp tear of unsp meniscus,
current injury, unsp knee, subs
------------------------------------------------------------------------
S83221D Lower Extremity Prph tear of medial meniscus,
current injury, r knee, subs
------------------------------------------------------------------------
S83222D Lower Extremity Prph tear of medial meniscus,
current injury, l knee, subs
------------------------------------------------------------------------
S83231A Lower Extremity Complex tear of medial mensc,
current injury, r knee, init
------------------------------------------------------------------------
S83231D Lower Extremity Complex tear of medial mensc,
current injury, r knee, subs
------------------------------------------------------------------------
S83232D Lower Extremity Complex tear of medial mensc,
current injury, l knee, subs
------------------------------------------------------------------------
S83241D Lower Extremity Oth tear of medial meniscus,
current injury, r knee, subs
------------------------------------------------------------------------
S83242D Lower Extremity Oth tear of medial meniscus,
current injury, left knee, subs
------------------------------------------------------------------------
S83251A Lower Extremity Bucket-hndl tear of lat mensc,
current injury, r knee, init
------------------------------------------------------------------------
S83251D Lower Extremity Bucket-hndl tear of lat mensc,
current injury, r knee, subs
------------------------------------------------------------------------
S83261A Lower Extremity Prph tear of lat mensc, current
injury, right knee, init
------------------------------------------------------------------------
S83261D Lower Extremity Prph tear of lat mensc, current
injury, right knee, subs
------------------------------------------------------------------------
S83271A Lower Extremity Complex tear of lat mensc,
current injury, right knee,
init
------------------------------------------------------------------------
S83281D Lower Extremity Oth tear of lat mensc, current
injury, right knee, subs
------------------------------------------------------------------------
S83411A Lower Extremity Sprain of medial collateral
ligament of right knee, init
------------------------------------------------------------------------
S83412A Lower Extremity Sprain of medial collateral
ligament of left knee, init
------------------------------------------------------------------------
S83422A Lower Extremity Sprain of lateral collateral
ligament of left knee, init
------------------------------------------------------------------------
S83521A Lower Extremity Sprain of posterior cruciate
ligament of right knee, init
------------------------------------------------------------------------
S838X2A Lower Extremity Sprain of other specified parts
of left knee, init encntr
------------------------------------------------------------------------
S8391XA Lower Extremity Sprain of unspecified site of
right knee, initial encounter
------------------------------------------------------------------------
S8392XA Lower Extremity Sprain of unspecified site of
left knee, initial encounter
------------------------------------------------------------------------
Z96651 Lower Extremity Presence of right artificial
knee joint
------------------------------------------------------------------------
Z96652 Lower Extremity Presence of left artificial knee
joint
------------------------------------------------------------------------
Z96653 Lower Extremity Presence of artificial knee
joint, bilateral
------------------------------------------------------------------------
Z96659 Lower Extremity Presence of unspecified
artificial knee joint
------------------------------------------------------------------------
M1710 Lower Extremity Unilateral primary
osteoarthritis, unspecified
knee
------------------------------------------------------------------------
M175 Lower Extremity Other unilateral secondary
osteoarthritis of knee
------------------------------------------------------------------------
M179 Lower Extremity Osteoarthritis of knee,
unspecified
------------------------------------------------------------------------
M179 Lower Extremity Osteoarthritis of knee,
unspecified
------------------------------------------------------------------------
M179 Lower Extremity Osteoarthritis of knee,
unspecified
------------------------------------------------------------------------
M25569 Lower Extremity Pain in unspecified knee
------------------------------------------------------------------------
M25569 Lower Extremity Pain in unspecified knee
------------------------------------------------------------------------
M11269 Lower Extremity Other chondrocalcinosis,
unspecified knee
------------------------------------------------------------------------
M13169 Lower Extremity Monoarthritis, not elsewhere
classified, unspecified knee
------------------------------------------------------------------------
M25469 Lower Extremity Effusion, unspecified knee
------------------------------------------------------------------------
M25669 Lower Extremity Stiffness of unspecified knee,
not elsewhere classified
------------------------------------------------------------------------
M67469 Lower Extremity Ganglion, unspecified knee
------------------------------------------------------------------------
M2212 Lower Extremity Recurrent subluxation of
patella, left knee
------------------------------------------------------------------------
M222X2 Lower Extremity Patellofemoral disorders, left
knee
------------------------------------------------------------------------
M222X9 Lower Extremity Patellofemoral disorders,
unspecified knee
------------------------------------------------------------------------
M2240 Lower Extremity Chondromalacia patellae,
unspecified knee
------------------------------------------------------------------------
M2242 Lower Extremity Chondromalacia patellae, left
knee
------------------------------------------------------------------------
M23222 Lower Extremity Derang of post horn of medial
mensc d/t old tear/inj, l knee
------------------------------------------------------------------------
M23322 Lower Extremity Oth meniscus derang, post horn
of medial meniscus, l knee
------------------------------------------------------------------------
M2342 Lower Extremity Loose body in knee, left knee
------------------------------------------------------------------------
M2351 Lower Extremity Chronic instability of knee,
right knee
------------------------------------------------------------------------
M23612 Lower Extremity Oth spon disrupt of anterior
cruciate ligament of left knee
------------------------------------------------------------------------
M25369 Lower Extremity Other instability, unspecified
knee
------------------------------------------------------------------------
M6751 Lower Extremity Plica syndrome, right knee
------------------------------------------------------------------------
M6752 Lower Extremity Plica syndrome, left knee
------------------------------------------------------------------------
M71569 Lower Extremity Other bursitis, not elsewhere
classified, unspecified knee
------------------------------------------------------------------------
S76111A Lower Extremity Strain of right quadriceps
muscle, fascia and tendon, init
------------------------------------------------------------------------
S83005A Lower Extremity Unspecified dislocation of left
patella, initial encounter
------------------------------------------------------------------------
S83005S Lower Extremity Unspecified dislocation of left
patella, sequela
------------------------------------------------------------------------
S83015D Lower Extremity Lateral dislocation of left
patella, subsequent encounter
------------------------------------------------------------------------
S83203D Lower Extremity Oth tear of unsp meniscus,
current injury, right knee,
subs
------------------------------------------------------------------------
S83204D Lower Extremity Oth tear of unsp meniscus,
current injury, left knee, subs
------------------------------------------------------------------------
S83221A Lower Extremity Prph tear of medial meniscus,
current injury, r knee, init
------------------------------------------------------------------------
S83222A Lower Extremity Prph tear of medial meniscus,
current injury, l knee, init
------------------------------------------------------------------------
S83222S Lower Extremity Prph tear of medial mensc,
current injury, l knee, sequela
------------------------------------------------------------------------
S83241A Lower Extremity Oth tear of medial meniscus,
current injury, r knee, init
------------------------------------------------------------------------
S83242A Lower Extremity Oth tear of medial meniscus,
current injury, left knee, init
------------------------------------------------------------------------
S83262D Lower Extremity Prph tear of lat mensc, current
injury, left knee, subs
------------------------------------------------------------------------
S83281A Lower Extremity Oth tear of lat mensc, current
injury, right knee, init
------------------------------------------------------------------------
S83412D Lower Extremity Sprain of medial collateral
ligament of left knee, subs
------------------------------------------------------------------------
S83412S Lower Extremity Sprain of medial collateral
ligament of left knee, sequela
------------------------------------------------------------------------
S83511A Lower Extremity Sprain of anterior cruciate
ligament of right knee, init
------------------------------------------------------------------------
S83511D Lower Extremity Sprain of anterior cruciate
ligament of right knee, subs
------------------------------------------------------------------------
S83511S Lower Extremity Sprain of anterior cruciate
ligament of right knee, sequela
------------------------------------------------------------------------
S83512A Lower Extremity Sprain of anterior cruciate
ligament of left knee, init
------------------------------------------------------------------------
S83512D Lower Extremity Sprain of anterior cruciate
ligament of left knee, subs
------------------------------------------------------------------------
S83521D Lower Extremity Sprain of posterior cruciate
ligament of right knee, subs
------------------------------------------------------------------------
Appendix: Included E&M, CPT, and Services
_______________________________________________________________________
20610 Arthrocentesis, Aspiration and/or Injection; Major
Joint or Bursa (e.g., Shoulder, Hip, Knee Joint,
Subacromial Bursa);
------------------------------------------------------------------------
20611 Arthrocentesis, Aspiration and/or Injection, Major
Joint Or Bursa (e.g., Shoulder, Hip, Knee,
Subacromial Bursa); With Ultrasound Guidance, With
Permanent Recording and Reporting
------------------------------------------------------------------------
20680 Removal of Implant; Deep (e.g., Buried Wire, Pin,
Screw, Metal Band, Nail, Rod or Plate)
------------------------------------------------------------------------
27327 Excision, Tumor, Soft Tissue of Thigh or Knee Area,
Subcutaneous; Less Than 3 Cm
------------------------------------------------------------------------
27347 Excision of Lesion of Meniscus or Capsule (e.g., Cyst,
Ganglion), Knee
------------------------------------------------------------------------
27438 Arthroplasty, patella; with prosthesis
------------------------------------------------------------------------
27446 Arthroplasty, knee, condyle and plateau; medial OR
lateral compartment
------------------------------------------------------------------------
27447 Arthroplasty, Knee, Condyle And Plateau; Medial and
Lateral Compartments With or Without Patella
Resurfacing (Total Knee Arthroplasty)
------------------------------------------------------------------------
29505 Application Of Long Leg Splint (Thigh To Ankle Or
Toes)
------------------------------------------------------------------------
29874 Arthroscopy, Knee, Surgical; For Removal Of Loose Body
Or Foreign Body (e.g., Osteochondritis Dissecans
Fragmentation, Chondral Fragmentation)
------------------------------------------------------------------------
29875 Arthroscopy, Knee, Surgical; Synovectomy, Limited
(e.g., Plica Or Shelf Resection) (Separate Procedure)
------------------------------------------------------------------------
29876 Arthroscopy, Knee, Surgical; Synovectomy, Major, 2 Or
More Compartments (e.g., Medial Or Lateral)
------------------------------------------------------------------------
29877 Arthroscopy, Knee, Surgical; Debridement/Shaving of
Articular Cartilage (Chondroplasty)
------------------------------------------------------------------------
29879 Arthroscopy, Knee, Surgical; Abrasion Arthroplasty
(Includes Chondroplasty Where Necessary) Or Multiple
Drilling Or Microfracture
------------------------------------------------------------------------
29880 Arthroscopy, Knee, Surgical; With Meniscectomy (Medial
And Lateral, Including Any Meniscal Shaving)
Including Debridement/Shaving of Articular Cartilage
(Chondroplasty), Same or Separate Compartment(S),
When Performed
------------------------------------------------------------------------
29881 Arthroscopy, Knee, Surgical; With Meniscectomy (Medial
or Lateral, Including Any Meniscal Shaving) Including
Debridement/Shaving of Articular Cartilage
(Chondroplasty), Same or Separate Compartment(s),
When Performed
------------------------------------------------------------------------
73552 Radiologic Examination, Femur; Minimum 2 Views
------------------------------------------------------------------------
73560,TC Radiologic Examination, Knee; 1 or 2 Views
------------------------------------------------------------------------
73560 Radiologic Examination, Knee; 1 or 2 Views
------------------------------------------------------------------------
73562,TC Radiologic Examination, Knee; 3 Views
------------------------------------------------------------------------
73562 Radiologic Examination, Knee; 3 Views
------------------------------------------------------------------------
73564 Radiologic Examination, Knee; Complete, 4 Or More
Views
------------------------------------------------------------------------
73565,TC Radiologic Examination, Knee; Both Knees, Standing,
Anteroposterior
------------------------------------------------------------------------
73565 Radiologic Examination, Knee; Both Knees, Standing,
Anteroposterior
------------------------------------------------------------------------
73590 Radiologic Examination; Tibia And Fibula, 2 Views
------------------------------------------------------------------------
73721 MRI Knee Lt or Rt W/O Contrast
------------------------------------------------------------------------
73718 MRI Lower Leg Lt or Rt W/O Contrast
------------------------------------------------------------------------
73720 MRI Lower Leg Lt or Rt W/O & W/Contrast
------------------------------------------------------------------------
73723 MRI Knee Lt or Rt W/O & W/Contrast
------------------------------------------------------------------------
73700 CT Knee w/o IV contrast
------------------------------------------------------------------------
73701 CT knee w/ IV contrast
------------------------------------------------------------------------
73702 CT knee w/ and w/o IV contrast
------------------------------------------------------------------------
76377 CT knee 3D postprocessing
------------------------------------------------------------------------
76000,TC Fluoroscopy (Separate Procedure), up to 1 Hour
Physician or Other Qualified Health Care Professional
Time, Other Than 71023 or 71034 (e.g., Cardiac
Fluoroscopy)
------------------------------------------------------------------------
76000 Fluoroscopy (Separate Procedure), up to 1 Hour
Physician or Other Qualified Health Care Professional
Time, Other Than 71023 or 71034 (e.g., Cardiac
Fluoroscopy)
------------------------------------------------------------------------
76882 Ultrasound, Extremity, Nonvascular, Real-Time With
Image Documentation; Limited, Anatomic Specific
------------------------------------------------------------------------
90832 Psychotherapy, 30 Minutes With Patient and/or Family
Member
------------------------------------------------------------------------
90834 Psychotherapy, 45 Minutes With Patient and/or Family
Member
------------------------------------------------------------------------
90837 Psychotherapy, 60 Minutes With Patient and/or Family
Member
------------------------------------------------------------------------
93971 Duplex Scan of Extremity Veins Including Responses to
Compression and Other Maneuvers; Unilateral Or
Limited Study
------------------------------------------------------------------------
97110 Therapeutic Procedure, 1 or More Areas, Each 15
Minutes; Therapeutic Exercises to Develop Strength
and Endurance, Range of Motion and Flexibility
------------------------------------------------------------------------
97140 Manual Therapy Techniques (e.g., Mobilization/
Manipulation, Manual Lymphatic Drainage, Manual
Traction), 1 or More Regions, Each 15 Minutes
------------------------------------------------------------------------
97161 Physical Therapy Eval Low Complex 20 Min
------------------------------------------------------------------------
97162 Physical Therapy Eval Mod Complex 30 Min
------------------------------------------------------------------------
99024 Postoperative Follow-Up Visit, Normally Included in
the Surgical Package, to Indicate That an Evaluation
and Management Service was Performed During a
Postoperative Period for a Reason(s) Related To the
Original Procedure
------------------------------------------------------------------------
99201 Office or Other Outpatient Visit for the Evaluation
and Management of a New Patient; Low Severity. Level
1
------------------------------------------------------------------------
99202 Office Or Other Outpatient Visit for the Evaluation
and Management of a New Patient; Low to Moderate
Severity. Level 2
------------------------------------------------------------------------
99203 Office or Other Outpatient Visit for the Evaluation
and Management of a New Patient; Moderate Severity.
Level 3
------------------------------------------------------------------------
99204 Office or Other Outpatient Visit for the Evaluation
and Management of a New Patient, Moderate to High
Severity. Level 4
------------------------------------------------------------------------
99205 Office or Other Outpatient Visit for the Evaluation
and Management of a New Patient; Moderate to High
Severity. Level 5
------------------------------------------------------------------------
99211 Office Or Other Outpatient Visit for the Evaluation
and Management of an Established Patient; Low
Severity. Level 1
------------------------------------------------------------------------
99212 Office or Other Outpatient Visit for the Evaluation
and Management of an Established Patient; Low to
Moderate Severity. Level 2
------------------------------------------------------------------------
99213 Office or Other Outpatient Visit for the Evaluation
and Management of an Established Patient; Low to
Moderate Severity. Level 3
------------------------------------------------------------------------
99214 Office or Other Outpatient Visit for the Evaluation
and Management of an Established Patient; Moderate to
High Severity. Level 4
------------------------------------------------------------------------
99215 Office or Other Outpatient Visit for the Evaluation
and Management of an Established Patient; Moderate to
High Severity. Level 5
------------------------------------------------------------------------
99492 First 70 Minutes in the First Calendar Month for
Behavioral Health Care Manager Activities, in
Consultation With a Psychiatric Consultation and
Directed by the Treating Provider
------------------------------------------------------------------------
99493 First 60 Minutes in a Subsequent Month for Behavioral
Health Care Manager Activities
------------------------------------------------------------------------
99494 Each Additional 30 Minutes in a Calendar Month of
Behavioral Health Care Manager Activities
------------------------------------------------------------------------
J3301 Injection, Triamcinolone Acetonide, Not Otherwise
Specified, 10 mg
------------------------------------------------------------------------
L1810 Knee Orthosis, Elastic With Joints, Prefabricated Item
That Has Been Trimmed, Bent, Molded, Assembled, or
Otherwise Customized to fit a Specific Patient by an
Individual With Expertise
------------------------------------------------------------------------
L1812 Knee Orthosis, Elastic With Joints, Prefabricated, Off-
The-Shelf
------------------------------------------------------------------------
L1820 Knee Orthosis, Elastic With Condylar Pads and Joints,
With or Without Patellar Control, Prefabricated,
Includes Fitting and Adjustment
------------------------------------------------------------------------
L1845 Knee Orthosis, Double Upright, Thigh and Calf, With
Adjustable Flexion and Extension Trimmed, Bent,
Molded, Assembled
------------------------------------------------------------------------
MISCLMSW30 Lmsw Visit 30 min.
------------------------------------------------------------------------
MISCLMSW45 Lmsw Visit 45 min.
------------------------------------------------------------------------
MISCLMSW60 Lmsw Visit 60 min.
------------------------------------------------------------------------
MISCMG30 Social Worker Meet And Greet/Cp Visit 30 min.
------------------------------------------------------------------------
MISCMG45 Social Worker Meet And Greet/Cp Visit 45 min.
------------------------------------------------------------------------
MISCMG60 Social Worker Meet And Greet/Cp Visit 60 min.
------------------------------------------------------------------------
MISCRD30 Registered Dietitian Visit 30 min.
------------------------------------------------------------------------
MISCRD45 Registered Dietitian Visit 45 min.
------------------------------------------------------------------------
MISCRD60 Registered Dietitian Visit 60 min.
------------------------------------------------------------------------
MISCSW Collab Care Social Worker Non-Billable Visit
------------------------------------------------------------------------
80053 Pathology & Labs
------------------------------------------------------------------------
85027 Pathology & Labs
------------------------------------------------------------------------
85652 Pathology & Labs
------------------------------------------------------------------------
86140 Pathology & Labs
------------------------------------------------------------------------
87641 Pathology & Labs
------------------------------------------------------------------------
97163 Physical Therapy
------------------------------------------------------------------------
G0502 Risk Modification
------------------------------------------------------------------------
G0503 Risk Modification
------------------------------------------------------------------------
20610 Arthrocentesis, Aspiration and/or Injection; Major
Joint or Bursa
------------------------------------------------------------------------
20611 Arthrocentesis, Aspiration and/or Injection, Major
Joint or Bursa (e.g., Shoulder, Hip, Knee,
Subacromial Bursa); With Ultrasound Guidance, With
Permanent Recording and Reporting
------------------------------------------------------------------------
20680 Removal of Implant; Deep (e.g., Buried Wire, Pin,
Screw, Metal Band, Nail, Rod or Plate)
------------------------------------------------------------------------
27327 Excision, Tumor, Soft Tissue of Thigh or Knee Area,
Subcutaneous; Less Than 3 cm
------------------------------------------------------------------------
27347 Excision of Lesion of Meniscus or Capsule (e.g., Cyst,
Ganglion), Knee
------------------------------------------------------------------------
27438 Arthroplasty, patella; with prosthesis
------------------------------------------------------------------------
27446 Arthroplasty, knee, condyle and plateau; medial OR
lateral compartment
------------------------------------------------------------------------
27447 Arthroplasty, Knee, Condyle and Plateau; Medial and
Lateral Compartments With or Without Patella
Resurfacing (Total Knee Arthroplasty)
------------------------------------------------------------------------
29505 Application of Long Leg Splint (Thigh to Ankle or
Toes)
------------------------------------------------------------------------
29874 Arthroscopy, Knee, Surgical; for Removal of Loose Body
or Foreign Body (e.g., Osteochondritis Dissecans
Fragmentation, Chondral Fragmentation)
------------------------------------------------------------------------
29875 Arthroscopy, Knee, Surgical; Synovectomy, Limited
(e.g., Plica Or Shelf Resection) (Separate Procedure)
------------------------------------------------------------------------
29876 Arthroscopy, Knee, Surgical; Synovectomy, Major, 2 or
More Compartments (e.g., Medial or Lateral)
------------------------------------------------------------------------
29877 Arthroscopy, Knee, Surgical; Debridement/Shaving Of
Articular Cartilage (Chondroplasty)
------------------------------------------------------------------------
29879 Arthroscopy, Knee, Surgical; Abrasion Arthroplasty
(Includes Chondroplasty Where Necessary) or Multiple
Drilling or Microfracture
------------------------------------------------------------------------
29880 Arthroscopy, Knee, Surgical; With Meniscectomy (Medial
And Lateral, Including Any Meniscal Shaving)
Including Debridement/Shaving Of Articular Cartilage
(Chondroplasty), Same Or Separate Compartment(S),
When Performed
------------------------------------------------------------------------
29881 Arthroscopy, Knee, Surgical; With Meniscectomy (Medial
or Lateral, Including Any Meniscal Shaving) Including
Debridement/Shaving of Articular Cartilage
(Chondroplasty), Same Or Separate Compartment(S),
When Performed
------------------------------------------------------------------------
73552 Radiologic Examination, Femur; Minimum 2 Views
------------------------------------------------------------------------
73560, TC Radiologic Examination, Knee; 1 or 2 Views
------------------------------------------------------------------------
73560 Radiologic Examination, Knee; 1 or 2 Views
------------------------------------------------------------------------
73562, TC Radiologic Examination, Knee; 3 Views
------------------------------------------------------------------------
73562 Radiologic Examination, Knee; 3 Views
------------------------------------------------------------------------
73564 Radiologic Examination, Knee; Complete, 4 or More
Views
------------------------------------------------------------------------
73565, TC Radiologic Examination, Knee; Both Knees, Standing,
Anteroposterior
------------------------------------------------------------------------
73565 Radiologic Examination, Knee; Both Knees, Standing,
Anteroposterior
------------------------------------------------------------------------
73590 Radiologic Examination; Tibia And Fibula, 2 Views
------------------------------------------------------------------------
73721 MRI Knee Lt or Rt W/O Contrast
------------------------------------------------------------------------
73718 MRI Lower Leg Lt or Rt W/O Contrast
------------------------------------------------------------------------
73720 MRI Lower Leg Lt or Rt W/O & W/Contrast
------------------------------------------------------------------------
73723 MRI Knee Lt or Rt W/O & W/Contrast
------------------------------------------------------------------------
73700 CT Knee w/o IV contrast
------------------------------------------------------------------------
73701 CT knee w/ IV contrast
------------------------------------------------------------------------
73702 CT knee w/ and w/o IV contrast
------------------------------------------------------------------------
76377 CT knee 3D postprocessing
------------------------------------------------------------------------
76000,TC Fluoroscopy (Separate Procedure), up to 1 Hour
Physician or Other Qualified Health Care Professional
Time, Other Than 71023 or 71034 (e.g., Cardiac
Fluoroscopy)
------------------------------------------------------------------------
76000 Fluoroscopy (Separate Procedure), up to 1 Hour
Physician or Other Qualified Health Care Professional
Time, Other Than 71023 or 71034 (e.g., Cardiac
Fluoroscopy)
------------------------------------------------------------------------
76882 Ultrasound, Extremity, Nonvascular, Real-Time With
Image Documentation; Limited, Anatomic Specific
------------------------------------------------------------------------
90832 Psychotherapy, 30 Minutes With Patient and/or Family
Member
------------------------------------------------------------------------
90834 Psychotherapy, 45 Minutes With Patient and/or Family
Member
------------------------------------------------------------------------
90837 Psychotherapy, 60 Minutes With Patient and/or Family
Member
------------------------------------------------------------------------
93971 Duplex Scan of Extremity Veins Including Responses to
Compression and Other Maneuvers; Unilateral or
Limited Study
------------------------------------------------------------------------
97110 Therapeutic Procedure, 1 or More Areas, Each 15
Minutes; Therapeutic Exercises to Develop Strength
and Endurance, Range of Motion and Flexibility
------------------------------------------------------------------------
97140 Manual Therapy Techniques (e.g., Mobilization/
Manipulation, Manual Lymphatic Drainage, Manual
Traction), 1 Or More Regions, Each 15 Minutes
------------------------------------------------------------------------
97161 Physical Therapy Eval Low Complex 20 Min.
------------------------------------------------------------------------
97162 Physical Therapy Eval Mod Complex 30 Min.
------------------------------------------------------------------------
99024 Postoperative Follow-Up Visit, Normally Included in
the Surgical Package, to Indicate That an Evaluation
and Management Service was Performed During a
Postoperative Period for a Reason(s) Related to the
Original Procedure
------------------------------------------------------------------------
99201 Office or Other Outpatient Visit for the Evaluation
and Management of a New Patient; Low Severity. Level
1
------------------------------------------------------------------------
99202 Office or Other Outpatient Visit for the Evaluation
and Management of a New Patient; Low to Moderate
Severity. Level 2
------------------------------------------------------------------------
99203 Office or Other Outpatient Visit for the Evaluation
and Management of a New Patient; Moderate Severity.
Level 3
------------------------------------------------------------------------
99204 Office or Other Outpatient Visit for the Evaluation
and Management of a New Patient, Moderate to High
Severity. Level 4
------------------------------------------------------------------------
99205 Office or Other Outpatient Visit for the Evaluation
and Management of a New Patient; Moderate to High
Severity. Level 5
------------------------------------------------------------------------
99211 Office or Other Outpatient Visit for the Evaluation
and Management of an Established Patient; Low
Severity. Level 1
------------------------------------------------------------------------
99212 Office or Other Outpatient Visit for the Evaluation
and Management of an Established Patient; Low to
Moderate Severity. Level 2
------------------------------------------------------------------------
99213 Office or Other Outpatient Visit for the Evaluation
and Management of an Established Patient; Low to
Moderate Severity. Level 3
------------------------------------------------------------------------
99214 Office or Other Outpatient Visit for the Evaluation
and Management of an Established Patient; Moderate to
High Severity. Level 4
------------------------------------------------------------------------
99215 Office or Other Outpatient Visit for the Evaluation
and Management of an Established Patient; Moderate To
High Severity. Level 5
------------------------------------------------------------------------
99492 First 70 Minutes in the First Calendar Month for
Behavioral Health Care Manager Activities, in
Consultation With a Psychiatric Consultation and
Directed by the Treating Provider
------------------------------------------------------------------------
99493 First 60 Minutes in a Subsequent Month for Behavioral
Health Care Manager Activities
------------------------------------------------------------------------
99494 Each Additional 30 Minutes in a Calendar Month of
Behavioral Health Care Manager Activities
------------------------------------------------------------------------
J3301 Injection, Triamcinolone Acetonide, Not Otherwise
Specified, 10 mg
------------------------------------------------------------------------
L1810 Knee Orthosis, Elastic With Joints, Prefabricated Item
That Has Been Trimmed, Bent, Molded, Assembled, or
Otherwise Customized to fit a Specific Patient by an
Individual With Expertise
------------------------------------------------------------------------
L1812 Knee Orthosis, Elastic With Joints, Prefabricated, Off-
the-Shelf
------------------------------------------------------------------------
L1820 Knee Orthosis, Elastic With Condylar Pads and Joints,
With or Without Patellar Control, Prefabricated,
Includes Fitting and Adjustment
------------------------------------------------------------------------
L1845 Knee Orthosis, Double Upright, Thigh and Calf, With
Adjustable Flexion And Extension Trimmed, Bent,
Molded, Assembled
------------------------------------------------------------------------
MISCLMSW30 Lmsw Visit 30 Min.
------------------------------------------------------------------------
MISCLMSW45 Lmsw Visit 45 Min.
------------------------------------------------------------------------
MISCLMSW60 Lmsw Visit 60 Min.
------------------------------------------------------------------------
MISCMG30 Social Worker Meet and Greet/Cp Visit 30 Min.
------------------------------------------------------------------------
MISCMG45 Social Worker Meet and Greet/Cp Visit 45 Min.
------------------------------------------------------------------------
MISCMG60 Social Worker Meet And Greet/Cp Visit 60 Min.
------------------------------------------------------------------------
MISCRD30 Registered Dietitian Visit 30 Min.
------------------------------------------------------------------------
MISCRD45 Registered Dietitian Visit 45 Min.
------------------------------------------------------------------------
MISCRD60 Registered Dietitian Visit 60 Min.
------------------------------------------------------------------------
MISCSW Collab Care Social Worker Non-Billable Visit
------------------------------------------------------------------------
80053 Pathology & Labs
------------------------------------------------------------------------
85027 Pathology & Labs
------------------------------------------------------------------------
85652 Pathology & Labs
------------------------------------------------------------------------
86140 Pathology & Labs
------------------------------------------------------------------------
87641 Pathology & Labs
------------------------------------------------------------------------
97163 Physical Therapy
------------------------------------------------------------------------
G0502 Risk Modification
------------------------------------------------------------------------
G0503 Risk Modification
------------------------------------------------------------------------
______
American Academy of Otolaryngology--Head and Neck Surgery
1650 Diagonal Road
Alexandria, VA 22314
T: 1-703-836-4444
F: 1-703-683-5100
W: https://www.entnet.org/
On behalf of the American Academy of Otolaryngology--Head and Neck
Surgery (AAO--HNS), I am pleased to submit the following comments in
response to the Senate Finance Committee's hearing to examine how
changes to Medicare physician payment can bolster chronic care.
The AAO--HNS is the national medical association of physicians
dedicated to the care of patients with disorders of the ears, nose, and
throat, as well as related structures of the head and neck. The Academy
has approximately 13,000 members who provide clinical, surgical, and
hospital care in rural, urban, and suburban communities. Our membership
spans academic, private independent practices, and employed physicians
across all practice sizes from solo to large single-specialty and
multi-specialty groups, reaching into the hundreds.
Otolaryngologist--head and neck surgeons--diagnose and treat patients
from conception to end of life, providing complete diagnostic, medical
and surgical treatment for a wide range of medical conditions,
including allergic and sinus disease, hearing and balance disorders,
head and neck cancer, sleep disorders, speech and swallowing problems,
cosmetic reconstructive surgery of the face and neck, acute trauma to
the head and neck, and pediatric and geriatric care.
Reforming our nation's healthcare system is a complex endeavor, and
there is no one-size-fits-all solution. The AAO--HNS shares the
Committee's desire to work toward a more affordable, sustainable, and
patient-centered healthcare system--particularly on ways to reduce the
burden of chronic disease management in the Medicare program.
Our statement addresses the major issues affecting our members under
the current Medicare physician payment system and quality improvement
program. We urge the Committee to consider our recommendations (in
bold), and we look forward to working together to advance policies that
ensure access to comprehensive care for our patients and provide much-
needed stability for physicians.
Reforming the Medicare Physician Fee Schedule
The AAO--HNS continues to be deeply alarmed about the growing financial
instability of the Medicare physician payment system due to a
confluence of fiscal uncertainties. For the past 4 years, physicians
participating in Medicare have faced annual statutory payment cuts
which come in the absence of inflationary updates. The payment system
remains on an unsustainable path threatening beneficiaries' access to
physicians. When adjusted for inflation, Medicare physician payment has
effectively declined 29% from 2001 to 2024 (see chart below).
[GRAPHIC] [TIFF OMITTED] T1124.006
.epsThe Medicare physician payment system lacks an adequate annual
physician payment update, unlike those that apply to other Medicare
provider payments. A continuing statutory freeze in annual Medicare
physician payments is scheduled to last until 2026, when updates resume
at a rate of 0.25% per year indefinitely, well below current rates of
inflation.
Physician practices cannot continue to absorb increasing costs while
their payment rates dwindle. Several Medicare Trustees reports \1\ have
underscored that they ``expect access to Medicare participating
physicians to become a significant issue in the long term'' unless
Congress takes steps to bolster the system. The current Medicare
physician payment system--with its lack of an inflationary update--is
particularly destabilizing. We therefore urge the passage of the
Strengthening Medicare for Patients and Providers Act (H.R. 2474),\2\
which provides a permanent annual update equal to the increase in the
Medical Economic Index. Such an update would provide much needed
financial stability for physicians and strengthen Medicare patients'
access to care.
---------------------------------------------------------------------------
\1\ https://home.treasury.gov/news/press-releases/jy1381.
\2\ https://www.congress.gov/bill/118th-congress/house-bill/2474/
text?s=1&r=1&q=%7B%22
search%22%3A%22hr+2474%22%7D.
Physician payments are further eroded by the budget neutrality
requirement within the Medicare Physician Fee Schedule. Budget
neutrality requires spending on Medicare to have no budgetary impact--
which means increases in payment for a subset of physician services in
a given year require across-the-board decreases in payment for all
physicians. This does not take into consideration the varying costs
associated with performing these services. CMS actuaries have on
occasion overestimated the impact of Relative Value Units (RVUs)
changes in the fee schedule. When these misestimates are not adjusted
in a timely way, it results in permanent removal of billions of dollars
from the payment pool. Increasing the budget neutrality threshold and
allowing for corrections is one critically necessary step towards
getting physicians out of the cycle of annual pay cuts. As such, the
AAO--HNS supports the Provider Reimbursement Stability Act (H.R.
6371),\3\ which would increase the budget neutrality threshold, allow
for corrections of overestimates and underestimates of budget
neutrality adjustments, and require timely updates to practice expense
RVUs.
---------------------------------------------------------------------------
\3\ https://www.congress.gov/bill/118th-congress/house-bill/6371/
text?s=2&r=1&q=%7B%22
search%22%3A%22hr+6371%22%7D.
In summary, we urge action to improve the physician payment system by
providing an inflationary payment update and revisiting budget-
neutrality requirements.
Improving Alternative Payment Models (APMs) and Merit-based Incentive
Payment System (MIPS)
Our specialty is actively involved in the transition of care, when safe
and effective, from the inpatient setting to the hospital outpatient
and Ambulatory Surgery Centers (ASC) settings and ultimately, the
office setting, to increase flexibility and access to care while saving
the overall healthcare system significant expense. Our specialty is
engaged in defining quality for diagnosis and treatment of
otolaryngologic disease using Clinical Practice Guidelines \4\ and a
Clinical Data Registry \5\ that also works to improve outcomes,
eliminate unnecessary care, and decrease costs.
---------------------------------------------------------------------------
\4\ https://www.entnet.org/quality-practice/quality-products/
clinical-practice-guidelines/.
\5\ https://www.entnet.org/quality-practice/reg-ent-clinical-data-
registry/.
Otolaryngologist--head and neck surgeons around the country are
participating in various types of value-based care networks, including
specialty-run clinically integrated networks and other shared savings
---------------------------------------------------------------------------
models.
MACRA's Merit-based Incentive Payment System (MIPS) program was felt to
have great promise when introduced, but the program has failed in most
ways to deliver either savings or improved care. The majority of
quality measures used in MIPS do not follow standard practice patterns
of specialist physicians and have not shown any tracking toward
improved patient outcomes, the final measuring stick. The only
consistent quality of the MIPS program is that it gets more difficult
and expensive by the year for physicians, especially those in
independent practice, to comply with the cadre of rules promulgated
annually.
The AAO--HNS recognizes that alternative payment models (APMs) may
provide value-based care by providing incentive payments to deliver
high-quality and cost-efficient care for a clinical condition, a care
episode or a patient population. However, due to a lack of approved
APMs that apply to specialty physicians, high initial costs of
transitioning to an APM, and the looming end of the incentive payment,
far fewer physicians participate in APMs than had been forecast. Given
the program's current shortcomings, the AAO--HNS supports the
continuation of an extension of the 5% APM bonus payment to help
physicians make the transition towards these evolving payment models.
We offer the following recommendations for the Committee's
consideration:
A true value-based, quality program under Medicare should relate
to the day-to-day practice of medicine and measure outcomes that are
important to both physicians and their patients by measuring outcomes
they are trying to achieve, not administrative markers. To increase
participation in MACRA or a successor program, one must also consider
economic principles. Physicians must be compensated appropriately, and
the administrative costs and complexity must not dissuade
participation. In terms of appropriate compensation, physicians must be
treated equally to other Medicare providers and, at a minimum, receive
annual payment updates based on an inflation proxy such as the Consumer
Price Index (CPI).
In developing new measures of value-based care, CMS should work
with each medical specialty society to develop best-care paradigms for
the most common diseases/problems seen by each specialty. These
paradigms will serve as the underlying foundation for value-based care
and allow for well-defined cost and quality alignment modeling.
Performance feedback based on these best care paradigms will enable
physicians to compare themselves to their peer group and help
facilitate care improvement solutions. In addition, value-based care
measures should not be limited to claims data but should incorporate
patient-reported outcomes. The data is there, and it should be
incorporated.
It is important to maintain Qualified Clinical Data Registries
(QCDRs) as an anchor to the current MIPS and any forthcoming Medicare
quality improvement program. These registries, such as the AAO--HNS'
Reg-ent registry,\6\ can adequately recognize and incentivize high-
quality care as well as identify areas for clinical improvement and
cost savings.
---------------------------------------------------------------------------
\6\ https://www.entnet.org/quality-practice/reg-ent-clinical-data-
registry/.
When having discussions around more equitable, value-based
systems, it is essential to allow flexibility through pilot studies to
gather data on the value of each of these pilots before committing to
one particular solution. As we have learned through MACRA, there may
---------------------------------------------------------------------------
not be one system that equitably fits all.
A reliable cost-reduction strategy available to CMS is to
transition care from high to low-cost facilities when clinically
appropriate. As mentioned, our specialty can shift specific care away
from hospital outpatient departments and into lower-cost Ambulatory
Surgical Centers (or other non-facility settings). To enable care in
lower-cost facilities, Congress can urge CMS to provide appropriate
reimbursement on both the physician work and practice expense portion
for these services. While this initially increases rates to the
provider, it creates much greater savings to Medicare by avoiding the
higher hospital outpatient fees. Accomplishing this will require
Medicare Part B to have a similar funding mechanism as Medicare Part A
that allows CMS flexibility to move away from the budget-neutral
requirement that has created the current situation.
Supporting the healthcare team to transform chronic disease care
Physicians, including otolaryngologist--head and neck surgeons, and
health systems across the country continue to face the growing
challenge of preventing and managing chronic diseases. The Centers for
Disease Control and Prevention estimates that 90% of all healthcare
costs in the U.S. go toward treating chronic disease and mental
health--about $3.7 trillion a year. This highlights the need to support
and create innovative approaches, such as team-base care, to ensure
patients with chronic disease have access to both medical and surgical
care--particularly in rural and underserved areas.
As the Committee considers changes to the current Medicare payment
system, flexibility in supporting the comprehensive physician-led
healthcare team is essential to effectively managing the growing burden
of chronic disease on the overall health system.
Accounting for economic benefits of healthcare legislation
Allowing Congress the ability to look at the financial impact of
preventive health legislation beyond the 10-year Congressional Budget
Office (CBO) scoring window is another important tool that is critical
for addressing chronic conditions. That is why the AAO-HNS has endorsed
the Dr. Michael C. Burgess Preventive Health Savings Act (H.R. 766/S.
114), which would allow Congress to consider the long-term economic
benefits of legislation that promotes wellness and reduces the
incidence of chronic conditions. It is widely recognized that
preventing a chronic condition will improve health outcomes, reduce
costs to our healthcare system, and provide patients with a better
quality of life. It is time for the CBO to have an updated scoring
methodology that accounts for these long-term economic benefits, and
therefore, we urge Congress to pass the Dr. Michael C. Burgess
Preventive Health Savings Act.
Again, we thank the Senate Finance Committee for furthering the
discussion to improve Medicare physician payment and increase patient
access. The AAO--HNS stands ready to offer ourselves as a resource for
further discussions. If you have any questions or require further
information, please contact govtaffairs@entnet.org.
Sincerely,
James C. Denneny III, M.D.
Executive Vice President and CEO
______
American Association of Clinical Urologists
1061 East Main Street, Suite 300
East Dundee, Illinois 60118
(847) 752-5355
email: info@aacuweb.org
website: https://aacuweb.org/
U.S. Senate
Committee on Finance
219 Dirksen Senate Office Building
Washington, DC 20510-6200
April 11, 2024
Dear Chairman Wyden, Ranking Member Crapo and Members of the Committee,
On behalf of the American Association of Clinical Urologists (AACU) we
wanted to send in our comments on the April 11, 2024 hearing titled
``Bolstering Chronic Care through Medicare Physician Payment.''
Founded in 1968 by urologists concerned by the government's increasing
role in the practice of medicine, the AACU is a professional
organization representing the interests of more than 3,700+ member
urologists, and urologic societies engaged as advocacy affiliates
across the United States. We are dedicated to developing and advancing
health policy education as it affects urologic practice in order to
preserve and promote the professional autonomy of our members and
support the highest quality of care for Patients.
On behalf of our urology members, we remain cautiously optimistic that
Congress will finally come to the correct policy decision in order to
protect physicians by awarding an adequate and sustainable
reimbursement metric for our members. This is especially true for
urologists whose patients are dealing with chronic conditions. If these
conditions aren't managed appropriately, these conditions will
undoubtedly be another cause of significantly contributing to the
alarmingly increasing higher drug spend in our country.
Urologists care deeply about patient access and adherence and improved
outcomes but have found the last several years difficult to achieve
this due to Medicare's constantly shrinking reimbursement metrics.
Physicians have been pleading for Congress to solve this issue for
years since this problem is now being compounded with others that
threaten our healthcare system. From physician shortages due to
retirements and low reimbursements, to increased wages and operational
expenses as a direct result of the physician shortages, our industry is
in trouble. All the while we are expected to continue business and
usual when our patients need us the most. Something has to give.
Notwithstanding, we have been grateful for Congress' effort to pass a
skinny package of health extenders for fiscal 2024 in early March that
included a 1.68% partial fix for the 3.37% cut to Medicare physician
payments. We are also hopeful that conversations between the Medicare
payment reform working group, MedPAC and this Committee will hear our
concerns and put a permanent solution in place such as directing the
Centers for Medicare and Medicaid Services (CMS) to include an
inflationary index to the conversion factor so that the income of
providers is not eroded over time due to the effects of inflation.
We look forward to serving as a resource to you and this Committee.
Please reach out to Ron Lanton, AACU Director of Government Affairs at
rlanton@aacuweb.org with any questions or concerns.
Sincerely,
Harbhajan S. Ajrawat, M.D., FACS Ian M Thompson III, M.D.
President Health Policy Chair
______
American Association of Hip and Knee Surgeons
9400 W Higgins Road, Suite 230
Rosemont, IL 60018-4976
OFFICE: 847-698-1200
FAX: 847-698-0704
https://www.aahks.org/
Chairman Wyden and Ranking Member Crapo, thank you for holding this
hearing on critical patient care improvements and Medicare Physician
Fee Schedule (``MPFS'') reforms that are necessary to provide stability
and appropriate levels of support for the care that hip and knee
surgeons provide to beneficiaries across the country.
AAHKS is the foremost national specialty organization of more than
4,900 physicians with expertise in total joint arthroplasty (``TJA'')
procedures. Many of our Members conduct research in this area and are
experts on the evidence-based medicine issues associated with the risks
and benefits of treatments for patients suffering from lower extremity
joint conditions. AAHKS is guided by four principles:
Patient access, especially for high-risk patients, and physician
incentives must remain a focus;
Reductions in physician reimbursement by public and private
payers drives provider consolidation;
Payment reform is most effective when physician-led; and
The burden of excessive physician reporting on metrics detracts
from care.
Continued Medicare cuts to physician reimbursement for total hip and
knee arthroplasty, which have drastically outpaced overall cuts to the
Physician Fee Schedule over the past 30 years, is one of the primary
factors driving health care consolidation and the growing inability of
physicians to maintain an independent practice. AAHKS appreciates the
hearing statements from Committee Members and witnesses regarding the
unsustainable MPFS annual updates, and the harm that the MPFS budget
neutrality function inflicts when reimbursement for some services are
increased causing completely unrelated services to be cut.
[GRAPHIC] [TIFF OMITTED] T1124.007
.eps The cuts to total hip and knee arthroplasty are not grounded
in the value to our patients, advancements in patient care, or the
effort that our members invest in improving outcomes and reducing
overall spend for the procedure. The cuts have also come from multiple
aspects of the Medicare program, each of which has major policy
implications for this Committee's priorities for the Medicare program.
We urge the Committee to consider the cumulative impact of the
following cuts on our Members and the Medicare beneficiaries they
serve: Devaluing total hip and knee arthroplasty's primary surgical
code (i.e., unjustified reduction in relative value units (RVUs) as
advocated by a private insurer).
Not recognizing surgeons' increasing role in value-based driven
work managing patient health through primary care-like pre-surgical
optimization and coordination services.
Unilaterally regrouping the procedures used to value different
TJA procedures (i.e., shifting Ambulatory Payment Classification
(``APC'') code groupings without public notice or the opportunity to
comment or any input from physicians on clinical matters).
Reductions in the Alternative Payment Model (``APM'')
participation payment.
Cuts caused by unrelated MPFS services being increased (budget
neutrality function of MPFS).
The lack of an inflationary update to the MPFS despite
escalating costs.
All of these cuts are exacerbated by the growth and capriciousness of
prior authorization programs that ignore patient clinical needs, and
rising complexity and administrative burdens from all payers.
There is no doubt that TJA reimbursement has been a disproportionate
target of physician cuts because it is Medicare's largest procedural
code. Americans are living longer, as your Committee well knows, are
increasingly burdened with comorbidities that accelerate the end-stage
osteoarthritis and necessitates a total hip and knee replacements. As
such, there is urgent demand for our Members' surgical interventions
but cuts to TJA physician reimbursement undermine the goal of improving
care and reducing costs. Advancements in patient care, pioneered by
many of our Members, have drastically reduced hospital patient days,
improved recovery times, reduced use of opioids and saved the Medicare
program billions. We urge the Committee support our physicians in their
continued efforts to bring value to the Medicare beneficiary and the
Medicare Trust Funds.
Beyond undermining physician work that benefits Medicare beneficiaries
and reduces total Medicare expenditures, there is a basic math problem
in the strategy of cutting surgeon reimbursement year-over-year to
achieve savings: Surgeons represent less than 6% of the overall cost of
hip and knee replacement, but their services are essential to
controlling costs in the other 94%.
[GRAPHIC] [TIFF OMITTED] T1124.008
.epsThere are deeply concerning policy implications for patient care
associated with chronic reductions in physician reimbursement in
response to growing demand, improved outcomes, increased physician
labor, rising practice costs and complex administrative burdens. If the
goal is purely savings, it's not in the best interest of the program or
Medicare beneficiaries to undermine the lowest-cost/highest-value
clinical partner the Centers for Medicare and Medicaid Services (CMS)
has to improve care and control costs.
HIP & KNEE SURGEONS HAVE THE HIGHEST
LEVEL OF PARTICIPATION IN APMS
Hip and knee surgeons have been at the forefront of the transition to
value-based models of care. Our members have worked with CMS to develop
existing alternative payment models (``APMs''), improve risk-adjustment
models to ensure all patients have equitable access to care, and
develop new global payment models for osteoarthritis which will result
in even more hip and knee surgeons joining innovative models of care.
They were early voluntary adopters of the Bundled Payments for Care
Improvement (BPCI) model, where physician-led bundles have improved
care and reduced costs. Their procedures were also the first to be
subjected to a mandatory Centers for Medicare and Medicaid Innovation
(CMMI) APM: the Comprehensive Care for Joint Replacement Model (CJR).
There is no other subspecialty with a greater level of participation in
APMs, as our members approach 50% participation.
Members of AAHKS have worked for several years on developing a
longitudinal osteoarthritis disease state model that leverages our
surgeons' unrecognized work as the primary care provider for Medicare
beneficiaries with osteoarthritis. This model represents a paradigm
shift that aligns risk-sharing with effective management of the
underlying condition that can lead to TJA and removing barriers to care
when TJA is necessary; improving patient outcomes, safeguarding the
Medicare trust fund, and reducing administrative burdens.
AAHKS agrees with the comments by hearing witnesses regarding the need
for enhanced clinical stakeholder input in APM development. While AAHKS
has been grateful for some of the changes that the CMMI has made as a
result of AAHKS engagement, improving clinical stakeholders' ability to
effectively improve APM design is critical for their success. We share
witness concerns that the Physician-
Focused Payment Model Technical Advisory Committee (PTAC) has
recommended 14 models for implementation, and none of them has been
implemented; including the longitudinal osteoarthritis model AAHKS
members have proposed.
APM PATIENT CARE IMPROVEMENTS & SAVINGS HAVE
BEEN USED TO JUSTIFY ADDITIONAL PHYSICIAN CUTS
While our surgeons are proud to be APM pioneers, they have also been
the first to hit the policy speed-bumps on the onramp to value-based
care. One of the most problematic cuts to TJA reimbursement stemmed
directly from AAHKS-members success in APMs. This was the result of the
disconnect between fee-for-service Medicare rate-setting policies and
the work our physicians do in APMs.
One of the main drivers of savings for TJA within the CJR and BPCI has
been our surgeon's work with patients to optimize their health prior to
surgery. Similar to primary care and care-coordination services, this
``pre-surgical optimization'' requires our surgeons to work with
patients in the weeks and months prior to surgery to address health
conditions that could complicate their surgical outcomes (e.g., reduce
their body mass index (BMI), treat hypertension, manage diabetes
management, etc). The results of this work are that patients are
healthier, have better surgical outcomes, and shorter recovery times.
This not only lays the groundwork for improved patient experience, but
results in significant Medicare savings by reducing hospital stays.
This is an example of the <6% of overall TJA reimbursement to surgeons
being leveraged to reduce costs for the other 94% of the total
procedure reimbursement. This is only possible through the tremendous
amount of work our surgeons do outside of the operating room. However,
in 2018 an American Medical Association (AMA) RVS Update Committee
(RUC) review of THA and TKA was initiated anonymously by a national
for-profit insurance company \1\ used the physician reimbursement
review process to allege that Medicare THA/TKA reimbursement, along
with many other procedures are overvalued. For hip and knee
replacement, the insurance company based this allegation mainly on one
study of only two facilities.
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\1\ Private insurance companies stand to gain from a proposed
reduction by the AMA RUC by reducing their own payments to surgeons
under commercial insurance arrangements that are pegged to a percentage
of the national Medicare rate.
Due to the limitations of the current RUC process, only work done 24
hours prior to a surgical procedure and 90 days afterwards was
considered. Subsequently, it did not recognize all the pre-service work
incentivized over the weeks/months in APMs, but did recognize the
resulting shorter hospitalizations and fewer post-operative doctor
visits. This was despite being presented with a study that accounted
for the time commitment needed for delivery of value-based patient care
and an independent national survey of AAHKS members, it was found that
more than 98% of respondents are providing preoptimization services.
The RUC ultimately recommended a cut in TKA and THA reimbursement,
despite acknowledging that the pre-optimization work was occurring. CMS
---------------------------------------------------------------------------
finalized the recommended cut in 2021.
These cuts fundamentally undermine the investments AAHKS members have
made to improve patient care and take on substantial risk in APMs to
reduce overall Medicare spending. The real work that thousands of our
surgeons do, backed up by studies and a national survey, was discounted
by an anonymously submitted two-site survey that was never intended to
capture the value of the services our surgeons provide to their
patients and the Medicare program. It sends a chilling message to all
physicians that high levels of participation and success in APMs will
result in punitive compensation cuts for their services.
AAHKS was encouraged to hear Committee Members support for coordinated
care. During the hearing, a Member of the Committee asked the panel how
to create payments to incentivize physicians to provide the ``right
care''. We strongly urge the Committee to address the disconnect
between fee-for-service rate-setting process and the valuable work that
occurs within APMs and reverse the cuts that hip and knee surgeons
received for providing the right care.
EXTENSION OF APM PARTICIPATION PAYMENT
AAHKS strongly supports the extension of the full 5% APM participation
payment. We appreciate that Congress extended the participation at
1.88% on March 8th, and that the payment could have lapsed entirely
without allocating limited federal funds to this priority. However,
AAHKS is concerned that the reduced reauthorized payment is not
sufficient to speed physician adoption of value-based care and support
continued participation in APMs.
AAHKS supports the Committee Member and witness statements highlighting
the importance of the payment for APM uptake, and we urge the Committee
to consider the importance of ongoing support while CMS is still
developing, testing and changing APMs. While many of our members
already participate in APMs, they are frequently updated with new
target benchmarks, risk adjustment methodology and other program
elements. Supporting current APM participants through these changes is
also an important function of the participation payment. AAHKS is
concerned by some policy proposals that have introduced the concept of
phasing-out of the APM participation fee based on how long a
participant has been in an APM. We urge the Committee to recognize the
changing nature of CMMI APMs and reject phase-out proposals, especially
amid increasing practice expenses and reimbursement pressures outlined
in this statement.
PRIOR AUTHORIZATION: A BARRIER FOR PATIENT CARE,
A BURDEN FOR PHYSICIANS
AAHKS appreciates the Committee's attention to prior authorization
reform, and the hearing comments of Members and witnesses regarding
ongoing challenges to patient access to care and physician
administrative burdens.
Delays for our patients translate into more days wrestling with the
pain of osteoarthritis; more days away from their jobs and basic
activities they enjoy. Our surgeons have dedicated their careers to
restoring our patients to a pain free, productive and mobile life. It
is a daily occurrence to have their medically necessary care delayed by
prior authorization decisions made by reviewers without expertise in
TJA that deeply conflict with the health care needs of the Medicare
beneficiary.
Within a declining reimbursement environment, hip and knee surgeons
have been diverting more time and resources ensuring their patients are
covered for their medically necessary TJA. It is commonplace, even in
small independent practices, to have full-time staff handling prior
authorization documentation. There is no separate revenue stream to
support those staff; it all comes out of the dwindling 6% of
reimbursement surgeons receive for the total TJA episode of care.
We support the finalized regulations that modernize prior authorization
programs within Medicare Advantage.\2\ We look forward to sharing with
the Committee additional suggested reforms to ensure that patient
access to care is not delayed.
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\2\ 89 FR 8758.
AAHKS is interested in providing stakeholder feedback on the draft
``prior authorization for prior authorization'' legislation mentioned
during the hearing. We support the need for stricter parameters, and
strong justification for the implementation of any prior authorization
program or new requirements within existing prior authorization
programs.
APPROPRIATE SETTING FOR APPROPRIATE CARE
It is essential that the most appropriate setting of care for a major
surgery is a decision made by the physician and their informed patient.
Prior authorization programs can interfere with when a patient can
receive care, but other recent Medicare policy changes have made
substantial changes to where a patient can receive TJA.
Until 2018, all lower-joint TJAs were performed in the inpatient
setting, and CMS maintained the procedures on the ``inpatient-only
list'' (``IPO''). CMS began removing the procedures from the IPO list
in 2018, when they made total knee replacement surgery available in the
outpatient setting for the first time. In 2019 they allowed for the
procedure in Ambulatory Surgery Centers (``ASCs'') in 2019, and total
hip replacement surgery followed in 2020.
AAHKS supports the ability for the physician to choose the most
clinically appropriate setting for their patients' treatment. However,
procedures coming off the Medicare inpatient-only list do not have
established clinical criteria within Medicare's ``Two-Midnight Rule''
to ensure the availability of inpatient care for medically complex
patients. That creates ambiguity unique to procedures coming off the
IPO list that has caused many hospitals to push patients into the
outpatient setting, regardless of clinical considerations, for fear of
audits and penalties.
AAHKS recommends that any legislative action on the Medicare IPO list
include a requirement for clear Two-Midnight Rule guidance for
procedures coming off the IPO list to ensure that patients are treated
in the most clinically appropriate setting of care.
CHOICE IS THE KEY TO ADDRESSING CONSOLIDATION
Continued cuts to Medicare reimbursement makes it more difficult for
surgeons to sustain independent practices or have a realistic range of
options for practice models. This leads to mergers and consolidation.
Consolidation leads to fewer choices for consumers across the care
continuum, higher prices, and decreased access to care--particularly in
rural and underserved areas. Reduced reimbursement for Total Hip
Arthroplasty (THA)/Total Knee Arthroplasty (TKA) can also lead to
surgeons shifting their focus to other procedures and conditions for
which they have trained, despite the accelerating need for joint
replacement in the Medicare age eligible population.
AAHKS supports surgeons that work across all employment arrangements,
from small independent practices to academic medical centers.
Physicians should have a choice of the setting in which they work;
however, their ability to choose is diminishing as a result of the
dwindling 6% of the total reimbursement for TJA they receive to keep
their practices afloat. The financial strain imposed on small practices
drives consolidation and, in turn, increases the cost of care for the
Medicare program and beyond.
In light of President Biden's Executive Order on Promoting Competition
in the American Economy, CMS should evaluate whether its proposed
reductions in Medicare physician rates promote competition in health
care or facilitate consolidation. AAHKS is optimistic for the future
passage of H.R. 3284, the Providers and Payers COMPETE Act of 2023,
which recently was reported out of the House Committee on Energy and
Commerce by a vote of 49-0. HR 3284 would require the Secretary of the
Department of Health and Human Services (HHS) to assess and report to
Congress on the impact of any Medicare reimbursement or regulatory
changes on consolidation of healthcare providers and payers. Such
reporting is an important step to better inform Congress and CMS on how
not to exacerbate health industry consolidation through Medicare
payment rates reductions.
Conclusion
AAHKS appreciates the Committee's attention to the urgent need to
address beneficiaries' chronic care needs through Medicare physician
payment reform and looks forward to partnering with the Committee in
its work. As Americans live longer and increasingly struggle with
comorbidities that can exacerbate osteoarthritis, our surgeons provide
a lifeline to return them to a pain-free, productive, and healthier
life. With the right supports, our Members are ready and able to meet
the growing demand for TJA to continue bringing value to beneficiaries
and their families.
AAHKS appreciates the Committees consideration of the perspectives
shared in this Statement for the Record. If you have any questions, you
can reach Mike Zarski at mzarski@aahks.org or Joshua Kerr at
jkerr@aahks.org.
______
American Association of Nurse Practitioners
1400 Crystal Drive, Suite 540
Arlington, VA 22202
Website: https://www.aanp.org/
The American Association of Nurse Practitioners (AANP), representing
the 385,000 Nurse Practitioners (NPs) in the United States, appreciates
the opportunity to provide a statement for the record for the Senate
Committee on Finance hearing entitled ``Bolstering Chronic Care through
Medicare Physician Payment.'' AANP is committed to empowering all NPs
to advance high-quality, equitable care, while addressing health care
disparities through practice, education, advocacy, research, and
leadership (PEARL).\1\ We appreciate the Committee's attention to
Medicare reimbursement policies and their impact on patient access to
care. We thank Chairman Wyden and Ranking Member Crapo for holding this
hearing. Members and expert witnesses identified the need to address
the structural inequities within the Medicare reimbursement model which
inhibit beneficiary access to coordinated, whole-person, patient-
centered care. We look forward to working with the Committee on a
Medicare reimbursement model which equitably reimburses NPs for the
care they provide to patients.
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\1\ https://www.aanp.org/advocacy/advocacy-resource/position-
statements/commitment-to-addressing-health-care-disparities-during-
covid-19, https://www.aanp.org/about/about-the-american-association-of-
nurse-practitioners-aanp/strategic-focus.
This issue is of particular importance to our members, as NPs provide a
substantial portion of the high-quality,\2\ cost-effective \3\ care
that our communities require. As of 2021, there were over 193,000 NPs
billing for Medicare services, making NPs the largest and fastest
growing Medicare designated provider specialty.\4\ Approximately 42% of
Medicare patients receive billable services from a nurse
practitioner,\5\ and approximately 80% of NPs are seeing Medicare and
Medicaid patients.\6\
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\2\ https://www.aanp.org/images/documents/publications/
qualityofpractice.pdf.
\3\ https://www.aanp.org/images/documents/publications/
costeffectiveness.pdf.
\4\ https://data.cms.gov/ MDCR Providers 6 Calendar Years 2017-
2021.
\5\ Ibid.
\6\ NP Fact Sheet (aanp.org).
NPs also provide a significant portion of health care in rural areas
and areas of lower socioeconomic and health status. As such, they
understand the barriers to care that face vulnerable populations on a
daily basis.\7\, \8\, \9\ They are also
``significantly more likely than primary care physicians to care for
vulnerable populations. Nonwhites, women, American Indians, the poor
and uninsured, people on Medicaid, those living in rural areas,
Americans who qualify for Medicare because of a disability, and dual-
eligibles are all more likely to receive primary care from NPs than
from physicians.''\10\
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\7\ Davis, M. A., Anthopolos, R., Tootoo, J., Titler, M., Bynum, J.
P. W., & Shipman, S. A. (2018). Supply of Healthcare Providers in
Relation to County Socioeconomic and Health Status. Journal of General
Internal Medicine, 4-6. https://doi.org/10.1007/s11606-017-4287-4.
\8\ Xue, Y., Smith, J. A., & Spetz, J. (2019). Primary Care Nurse
Practitioners and Physicians in Low-Income and Rural Areas, 2010-2016.
Journal of the American Medical Association, 321(1), 102-105.
\9\ Andrilla, C. H. A., Patterson, D. G., Moore, T. E., Coulthard,
C., & Larson, E. H. (2018). Projected Contributions of Nurse
Practitioners and Physicians Assistants to Buprenorphine Treatment
Services for Opioid Use Disorder in Rural Areas. Medical Care Research
and Review, Epub ahead. https://doi.org/10.1177/1077558718793070.
\10\ https://www.aei.org/research-products/report/nurse-
practitioners-a-solution-to-americas-primary-care-crisis/.
As has been highlighted by MedPAC and data from the Centers for
Medicare and Medicaid Services, NPs provide a growing amount of care to
Medicare beneficiaries. As noted above, in the June 2022 report to the
Congress, the Medicare Provider Advisory Commission (MedPAC) found that
NPs and PAs comprise approximately one-third of the primary care
workforce, and up to half in rural areas.\11\ Along with primary care,
MedPAC has also published data on the importance of NPs providing
mental and behavioral health care.\12\ NPs are also the second largest
provider group in the National Health Services Corps \13\ and the
number of NPs practicing in community health centers has grown
significantly over the past decade.\14\
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\11\ https://www.medpac.gov/wp-content/uploads/2022/06/
Jun22_MedPAC_Report_to_
Congress_SEC.pdf (see Chapter 2).
\12\ https://www.medpac.gov/wp-content/uploads/2023/06/
Jun23_MedPAC_Report_To_
Congress_SEC.pdf.
\13\ https://www.hrsa.gov/sites/default/files/hrsa/about/budget/
budget-justification-fy2024.pdf.
\14\ https://www.nachc.org/wp-content/uploads/2023/07/Community-
Health-Center-Chartbook-2023-2021UDS.pdf.
We strongly support the opening statement by Chairman Wyden which notes
the importance of empowering health care providers who are managing and
coordinating patient care. We further agree that Medicare's ``out-of-
whack payment rules''\15\ do not reflect the modern delivery of health
care, and that all providers ``need to be valued and compensated more
fully by Medicare.''\16\ As Ranking Member Crapo stated in his
testimony, ``Medicare's coverage and payment policies play a dominant
role in setting benchmarks and baseline rules of the road not just for
the program itself, but also for countless other payers''\17\ which
impacts patients across the spectrum of care. Therefore, we concur that
``structural fee schedule reforms should shift away from the status
quo, which forces clinicians to vie for ever-
dwindling resources and move toward models that promote and reward
team-based, patient-centered approaches.''\18\
---------------------------------------------------------------------------
\15\ https://www.finance.senate.gov/imo/media/doc/
0411_wyden_statement.pdf (senate.gov).
\16\ Ibid.
\17\ https://www.finance.senate.gov/imo/media/doc/
0411_crapo_statement.pdf (senate.gov).
\18\ Ibid.
It is critical that Medicare's payment policies are updated to reflect
the modern delivery of health care. When the Medicare fee schedule was
initially introduced, nurse practitioners were authorized to bill
Medicare on a limited basis. However, there has been a significant
evolution in providers who bill the Medicare program, and the fee
schedule is no longer limited to physicians. It sets the rates and
policies for a broad spectrum of providers who bill Medicare, including
NPs. As Congress has taken action to expand which clinicians are
authorized to bill the Medicare program, many Medicare statutes and
---------------------------------------------------------------------------
payment policies do not reflect these changes.
Included below are our suggested proactive policy solutions which would
work towards the important goals identified by the Committee members,
including increasing access to care, and equitably reimbursing
providers. These policies include addressing the 15 percent payment
reduction NPs receive in the Medicare program, including NPs within the
Health Professional Shortage Area (HPSA) Medicare bonus, including NPs
within the Medicare fee schedule valuation process, and removing
longstanding barriers within the Medicare program. We greatly
appreciate your consideration of this statement and look forward to
working with the Committee on these issues.
Equitable Reimbursement for Nurse Practitioners
As NPs continue to provide increasing amounts of care for Medicare
patients, it is important to understand the significant evolution of
the role of NPs in Medicare. In 1977, Congress first formally
recognized care delivered by nurse practitioners in the Medicare
program in rural health clinics.\19\ In 1989, Congress authorized
direct reimbursement under the Medicare program for services rendered
by nurse practitioners in rural areas, and indirect reimbursement for
NPs rendering services in skilled nursing facilities.\20\ Since 1997,
Congress has authorized reimbursement under the Medicare program to NPs
regardless of setting or geographic area, for any services that would
be covered when provided by a physician, in accordance with State law,
at 85% of the fee schedule rates.\21\
---------------------------------------------------------------------------
\19\ https://www.govinfo.gov/content/pkg/STATUTE-91/pdf/STATUTE-91-
Pg1485.pdf (govinfo.gov).
\20\ https://www.govinfo.gov/app/details/STATUTE-103/STATUTE-103-
Pg2106 (govinfo.gov).
\21\ 63 FR 30862, https://www.govinfo.gov/content/pkg/FR-1998-06-
05/pdf/98-14650.pdf.
Since this policy was implemented in 1997, despite the increasing
importance of NPs in Medicare, the reimbursement structure has not
changed in over 26 years. NPs are still reimbursed at 85% of the fee
schedule for the services they provide. This means that if an NP
provides a patient with the exact same service, with the exact same
components and time requirements as their physician colleagues, they
are paid 15% less. This 15% differential is significant and is in
addition to other factors which impact reimbursement rates, including
statutory reductions and corresponding adjustments to the conversion
factor.\22\ It is important to note that inflation and other financial
pressures identified by the Committee members are exacerbated for NPs
due to this decreased reimbursement rate. This inequitable
reimbursement structure is an anachronism and does not reflect the
modern health care system.
---------------------------------------------------------------------------
\22\ CY 2024 Medicare Physician Fee Schedule Final Rule, https://
www.cms.gov/newsroom/press-releases/cms-finalizes-physician-payment-
rule-advances-health-equity.
Therefore, we respectfully request that the Committee address the
inequitable reimbursement structure for NPs within the Medicare
program, and ensure any legislation includes equitable reimbursement
for nurse practitioners. This is directly aligned with NAM Future of
Nursing report which stated, ``Payment reform can help improve
population health, address social needs and [social determinants of
health], reduce health disparities, supporting the provision of
effective, efficient, equitable, and accessible care for all across the
care continuum instead of incentivizing the volume of care or low value
procedures and practices.''\23\
---------------------------------------------------------------------------
\23\ The Future of Nursing 2020-2030--National Academy of
Medicine, https://nam.edu/publications/the-future-of-nursing-2020-2030/
(nam.edu).
---------------------------------------------------------------------------
Medicare Payment in Rural and Underserved Communities
Nurse practitioners are a critical, and growing, part of the health
care workforce. While reimbursement equity is an important principal
regardless of geographic location, we recognize the unique challenge of
rural and underserved communities in addressing clinician shortages. As
noted above, in the June 2022 report to the Congress, MedPAC found that
NPs and PAs comprise approximately one-third of the primary care
workforce, and up to half in rural areas.\24\ When rural communities
experience hospital closures, it is often NPs who are filling the gaps
and providing critical care to these communities. According to the
Government Accountability Office (GAO), an exception to the pattern of
clinicians leaving rural areas after rural hospital closures were
APRNs, finding that ``[c]ounties with rural hospital closures
experienced a greater increase in the availability of advanced practice
registered nurses (61.3 percent), compared to counties without closures
(56.3 percent).''\25\
---------------------------------------------------------------------------
\24\ https://www.medpac.gov/wp-content/uploads/2022/06/
Jun22_MedPAC_Report_to_
Congress_SEC.pdf (see Chapter 2).
\25\ https://www.gao.gov/assets/gao-21-93.pdf.
However, despite the importance of NPs to the health care workforce in
rural and underserved communities, NPs are not eligible for the 10%
Medicare bonus available to their physician colleagues in health
professional shortage areas (HPSAs).\26\ For NPs in HPSAs, this means
there can be up to a 25% difference in reimbursement rates between NPs
and their physician colleagues.\27\ This differential is substantial,
and impacts both primary care and mental health HPSAs. According to the
Health Resources and Services Administration (HRSA), there are
currently 101 million patients living in 8,504 Primary Care HPSAs which
require 17,463 practitioners. There are 166 million patients living in
6,767 Behavioral Health HPSAs which require 8,358 practitioners.\28\
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\26\ Physician Bonuses, CMS, https://www.cms.gov/medicare/payment/
fee-for-service-providers/physician-bonuses-health-professional-
shortage-areas-hpsas.
\27\ Health Professional Shortage Area Physician Bonus Program,
https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-
documents/HPSAfctshtTextOnly.pdf (hhs.gov).
\28\ Shortage Areas, https://data.hrsa.gov/topics/health-workforce/
shortage-areas (hrsa.gov).
As the Committee considers policy options to better support rural and
underserved providers, ensuring NPs practicing in rural and underserved
communities have equitable access to the HPSA Medicare Bonus Program is
critical. Therefore, we respectfully request the Committee update the
Medicare HPSA incentive bonus program to include NPs. This is aligned
with the FY 2025 Department of Health and Human Services (HHS) Budget
in Brief \29\ which included a legislative proposal to broaden the HPSA
incentive program to include NPs. In the request, HHS notes that ``This
proposal responds to the evolving delivery of healthcare in the United
States. Academic research found that the share of medical visits
delivered by nurse practitioners or physician assistants increased from
14 percent to 26 percent among Medicare beneficiaries between 2013 and
2019. Research also found that nurse practitioners make up a larger
share of the primary care workforce in lower income and rural areas.''
---------------------------------------------------------------------------
\29\ Ibid.
The confluence of the COVID-19 PHE, opioid epidemic and behavioral
health workforce shortages have led to an ongoing behavioral health
crisis in the United States. According to HRSA, more than one-third of
Americans live within mental health professional shortage areas.\30\
Data demonstrates that nurse practitioners have been critical in
filling access gaps and providing mental and behavioral health care to
Medicare beneficiaries. A recent study published in Health Affairs
found that from 2011-2019 the number of psychiatric-mental health NPs
(PMHNPs) treating Medicare beneficiaries grew by 162%, compared to a 6%
drop in psychiatrists during that same period.\31\ The study also found
that the proportion of all mental health prescriber visits provided by
PMHNPs to Medicare beneficiaries increased from 12.5% to 29.8% during
that same period, exceeding 50% in rural, full practice authority
regions.\32\
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\30\ 88 FR 52366.
\31\ Trends in Mental Health Care Delivery By Psychiatrists and
Nurse Practitioners in Medicare, 2011-19, Health Affairs, https://
www.healthaffairs.org/doi/full/10.1377/hlthaff.2022.00
289?journalCode=hlthaff.
\32\ Ibid.
In addition, MedPAC found ``large shifts in the behavioral health
workforce over time: Between 2016 and 2021, substantial growth in
behavioral health services provided by nurse practitioners occurred,
while volume by psychiatrists declined.''\33\ The report also states
that ``we found shifts over time in the specialty of the clinicians who
provide Part B behavioral health services. Most notably, between 2016
and 2021, the volume of these services provided by psychiatrists
declined (5 percent average annual decrease) and rose for nurse
practitioners (12 percent average annual increase).''\34\ Accordingly,
we also support section 101 of the Better Mental Health Care, Lower-
Cost Drugs, and Extenders Act which would expand the HPSA bonuses to
15% for mental health and substance use disorder services provided in
mental health HPSAs by a broader group of clinicians, including NPs.
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\33\ https://www.medpac.gov/wp-content/uploads/2023/06/
Jun23_MedPAC_Report_To_
Congress_SEC.pdf.
\34\ Ibid.
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Increase Access by Removing Federal Medicare Barriers
In the hearing, Senator Grassley highlighted the need to remove federal
barriers that prevent clinicians from practicing to the full extent of
their state scope of practice, to strengthen access to care and improve
outcomes. We strongly agree with updating outdated federal statutes
which do not reflect the modern provision of health care and prevent
NPs from fully meeting the health care needs of their communities.
Reports issued by the National Academies of Medicine,\35\ American
Enterprise Institute,\36\ the Brookings Institution,\37\ the Federal
Trade Commission,\38\ the Bipartisan Policy Center \39\ and the U.S.
Department of Health and Human Services under multiple administrations
\40\, \41\, \42\ have all highlighted the
positive impact of removing barriers confronted by NPs and their
patients. The World Health Organization's State of the World's Nursing
2020 report also recommends modernizing regulations to authorize APRNs
to practice to the full extent of their education and clinical
training, and noted the positive impact this would have on addressing
health care disparities and improving health care access within
vulnerable communities.\43\ As noted by MedPAC data, the number of
encounters per FFS beneficiary with APRNs and PAs increased by 10.4
percent from 2021-2022.\44\ This increase underscores the urgent need
for Congressional action to remove these barriers to care.
---------------------------------------------------------------------------
\35\ The Future of Nursing 2020-2030--National Academy of Medicine,
https://nam.edu/publications/the-future-of-nursing-2020-2030/
(nam.edu).
\36\ https://www.aei.org/wp-content/uploads/2018/09/Nurse-
practitioners.pdf.
\37\ https://www.brookings.edu/wp-content/uploads/2018/06/
AM_Web_20190122.pdf.
\38\ https://www.aanp.org/advocacy/advocacy-resource/ftc-advocacy.
\39\ Strengthening the Health Professional Workforce, Bipartisan
Policy Center, https://bipartisanpolicy.org/blog/strengthening-health-
professional-workforce/.
\40\ https://www.hhs.gov/sites/default/files/Reforming-Americas-
Healthcare-System-Through-Choice-and-Competition.pdf.
\41\ https://aspe.hhs.gov/pdf-report/impact-state-scope-practice-
laws-and-other-factors-practice-and-supply-primary-care-nurse-
practitioners.
\42\ https://www.cms.gov/About-CMS/Agency-Information/OMH/
Downloads/Rural-Strategy-2018.pdf.
\43\ https://apps.who.int/iris/bitstream/handle/10665/331673/
9789240003293-eng.pdf.
\44\ medpac.gov/wp-content/uploads/2024/03/
Mar24_MedPAC_Report_To_Congress_SEC.pdf.
As the Committee works on legislation to enhance access to care, we
strongly encourage inclusion of the following bipartisan legislation;
the Promoting Access to Diabetic Shoes Act (S. 260), the Improving Care
and Access to Nurses Act (S. 2418), and the Increasing Access to
Quality Cardiac Rehabilitation Care Act of 2023 (S. 3481). These
bipartisan bills will reduce the administrative burden for NPs and
increase needed access to care for patients. This is especially true in
rural and underserved communities, where requiring unnecessary visits,
referrals or certifications presents immense challenges for patients.
Promoting Access to Diabetic Shoes Act (S. 260)
S. 260 would authorize NPs to satisfy the documentation requirement for
coverage of therapeutic shoes for individuals with diabetes. NPs
provide the full range of care to patients with diabetes, but federal
law requires that an NP must send a patient who needs therapeutic shoes
to a physician to certify that need. Additionally, according to current
statute, the certifying physician must take over the treatment of the
patient's diabetic condition going forward. These barriers often lead
to delays in accessing needed items and undermine care continuity. The
estimated total annual cost of an individual patient with diabetes is
$17,000.\45\ However, if left untreated, patients with diabetes may
face serious complications including foot ulcers or amputations,
driving up the estimated annual individual costs to $52,000.\46\ By
removing this outdated and unnecessary barrier, NPs would be authorized
to certify the need for therapeutic shoes for patients with diabetes,
and ensure they get the care they need in a timely fashion.
---------------------------------------------------------------------------
\45\ American Diabetes Association. (2018). Economic Costs of
Diabetes in the U.S. in 2017. Diabetes Care, 41, 917-928. http://
care.diabetesjournals.org/content/diacare/early/2018/03/20/dci18-
0007.full.pdf.
\46\ Agency for Healthcare Research and Quality (2011). Data points
#3: Economic burden of diabetic foot ulcers and amputations. https://
effectivehealthcare.ahrq.gov/topics/diabetes-foot-ulcer-amputation-
economics/research.
Passage of this legislation will also reduce Medicare spending by
eliminating duplicative services. Removing the unnecessary additional
certifying visit requirements could save the Medicare program $12.1
million annually.\47\ Data also demonstrates that NPs manage the care
for patients with diabetes in a cost-effective manner that results in
health care savings. A recent study utilizing Veterans Affairs (VA)
data from FY 2013 found significant savings, 6-7% lower costs, for
highly complex diabetic patients who had an NP as their primary
provider compared to those with a physician.\48\ Other researchers
found even greater savings, 12-13% lower costs when examining patients
with diabetes with varying degrees of complexity served by the VA. For
a single VA medical center, this equated to an annual savings of just
over $14 million, exemplifying the efficiency and effectiveness of NP
delivered care in the VA.\49\ Patients who choose nurse practitioners
as their health care providers deserve equitable access to care from
their chosen health care provider.
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\47\ Analysis based on author calculations. Approximately 134,000
Medicare patient visits billed using an established patient level 3 E/M
code (CPT 99213).
\48\ Morgan, et al. (2019). Impact of Physicians, Nurse
Practitioners, and Physician Assistants on Utilization and Costs for
Complex Patients. Health Affairs, 38(6), 1028-1036. https://
www.healthaffairs.org/doi/10.1377/hlthaff.2019.00014.
\49\ Rajan, et. al (2021) ``Health care costs associated with
primary care physicians versus nurse practitioners and physician
assistants.'' https://pubmed.ncbi.nlm.nih.gov/34074952/.
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Improving Care and Access to Nurses (ICAN) Act (S. 2418)
S. 2418 would update the Medicare and Medicaid programs to ensure that
NPs and other APRNs are authorized to provide care as effectively and
efficiently as possible, consistent with state law. This includes
updating Medicare and Medicaid to remove barriers to evidence-based
preventive services such as authorizing NPs to order cardiac and
pulmonary rehabilitation, refer patients for medical nutrition therapy,
certify patients' needs for diabetic shoes, establish home infusion
plans of care, and perform mandatory visits in skilled nursing
facilities. This bill does not supersede any state laws, it simply
modernizes these provisions within Medicare and Medicaid to make them
consistent with state law to ensure that beneficiaries have access to
these health care services, from their provider of choice, without
undue burden. This legislation is supported by over 235 national,
state, and local organizations \50\ including the National Rural Health
Association, National Association of Rural Health Clinics, American
Health Care Association, LeadingAge, Americans for Prosperity, and
AARP.\51\ Patients who choose NPs as their health care providers should
not face increased burdens and decreased access to medically necessary
treatment that are covered by Medicare and Medicaid.
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\50\ https://www.aanp.org/news-feed/more-than-235-organizations-
show-their-support-for-the-ican-act.
\51\ https://www.aana.com/comment-letter/aarp-endorsement-of-i-can-
act-hr-2713.
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Increasing Access to Quality Cardiac Rehabilitation Care
Act (S. 3481)
S. 3481 would authorize NPs to order cardiac and pulmonary
rehabilitation for Medicare patients. In 2018, Congress passed
legislation which authorized NPs, clinical nurse specialists (CNSs) and
physician assistants (PAs) to supervise cardiac and pulmonary
rehabilitation starting in 2024. However, these clinicians are still
not authorized to order cardiac and pulmonary rehabilitation for
Medicare patients.
Cardiac rehabilitation and pulmonary rehabilitation are programs
designed to improve a patient's physical, psychological, and social
functioning after a qualifying diagnosis or procedure, such as a heart
attack or coronary artery bypass surgery or after a diagnosis of
chronic obstructive pulmonary disease (COPD). Heart disease remains the
leading cause of death in the United States with nearly 700,000 deaths
per year.\52\ Not only does heart disease have a tremendous impact on
the lives of patients and their families, but managing and treating
heart disease and related risk factors is estimated to cost the United
States over $320 billion annually.\53\ Chronic obstructive pulmonary
disease (COPD) is the sixth leading cause of death in the United
States, with nearly 150,000 deaths per year.\54\ COPD is estimated to
cost the United States nearly $50 billion annually in related health
care expenditures and indirect mortality and morbidity costs.\55\
---------------------------------------------------------------------------
\52\ https://www.cdc.gov/heartdisease/about.htm.
\53\ Birger M, Kaldjian AS, Roth GA, Moran AE, Dieleman JL, Bellows
BK. Spending on Cardiovascular Disease and Cardiovascular Risk Factors
in the United States: 1996 to 2016. Circulation. 2021 Jul
27;144(4):271-282. doi: 10.1161/CIRCULATIONAHA.120.053216. Epub 2021
Apr 30. PMID: 33926203; PMCID: PMC8316421.
\54\ https://www.lung.org/research/trends-in-lung-disease/copd-
trends-brief/copd-mortality.
\55\ https://www.lung.org/research/trends-in-lung-disease/copd-
trends-brief/copd-burden.
Yet, while studies show that these programs can reduce
hospitalizations, decrease heart attack recurrence, increase adherence
to preventive medication, improve overall health and reduce the need
for costly care, less than 25 percent of qualifying patients receive
cardiac rehabilitation and only three percent of Medicare patients with
COPD receive pulmonary rehabilitation.\56\, \57\,
\58\ Participation rates are even lower for female and minority
patients and those who live outside metropolitan areas or in lower
income urban areas.\59\, \60\ Research also indicates that
cardiac rehabilitation is associated with lower all-cause mortality
rates in patients with diabetes, however patients with diabetes have
lower participation rates than the non-
diabetes population.\61\ For these reasons, it is essential that
Congress increase access to these vital services.
---------------------------------------------------------------------------
\56\ https://millionhearts.hhs.gov/data-reports/factsheets/
cardiac.html.
\57\ https://www.ahajournals.org/doi/10.1161/
CIRCOUTCOMES.119.005902
\58\ https://www.atsjournals.org/doi/10.1513/AnnalsATS.201805-
332OC.
\59\ Li S, Fonarow GC, Mukamal K, Xu H, Matsouaka RA, Devore AD,
Bhatt DL. Sex and Racial Disparities in Cardiac Rehabilitation Referral
at Hospital Discharge and Gaps in Long-Term Mortality. J Am Heart
Assoc. 2018 Apr 6;7(8):e008088. doi: 10.1161/JAHA.117.008088. PMID:
29626153; PMCID: PMC6015394.
\60\ Castellanos LR, Viramontes O, Bains NK, Zepeda IA. Disparities
in Cardiac Rehabilitation Among Individuals from Racial and Ethnic
Groups and Rural Communities--A Systematic Review. J Racial Ethn Health
Disparities. 2019 Feb;6(1):1-11. doi: 10.1007/s40615-018-0478-x. Epub
2018 Mar 13. PMID: 29536369.
\61\ https://www.ahajournals.org/doi/10.1161/JAHA.117.006404.
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Improving Accountable Care Organizations
The Medicare Shared Savings Program (MSSP) is an important component of
Medicare, which saved more than 1.8 billion dollars in 2022.\62\ Over
140,000 NPs are participating in MSSP ACOs, providing critical services
to millions of Medicare beneficiaries within the program.\63\ However,
statutory requirements \64\ still exist which require a beneficiary to
receive a primary care service from a physician as a pre-step before
they can be assigned to a MSSP accountable care organization (ACO).
This requirement inhibits the ability of Medicare to equitably provide
accountable care, and limits the participation of patients who see NPs
as their primary care providers. Therefore, we strongly support the
passage of the ACO Assignment Improvement Act of 2024 (S. 3939) which
would address this barrier and fully include NPs and their patients in
the MSSP.
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\62\ Medicare Shared Savings Program Saves Medicare More Than $1.8
Billion in 2022 and Continues to Deliver High-quality Care. CMS.
https://www.cms.gov/newsroom/press-releases/medicare-shared-savings-
program-saves-medicare-more-18-billion-2022-and-continues-deliver-high.
\63\ https://data.cms.gov/medicare-shared-savings-program/
performance-year-financial-and-quality-results/data. (January 2022
Performance Year Financial and Quality Results).
\64\ Social Security Act Section 1899(c)(1).
We appreciate that in the 2024 Medicare Physician Fee Schedule final
rule, CMS updated the MSSP to better include patients seen by NPs, and
better align beneficiaries with the clinician who is providing their
care.\65\ The CMS analysis of this expansion of the assignment
methodology to better account for NPs' patients notes that the changes
would add a population of patients who have been historically
underrepresented in the MSSP.\66\ This includes those with a disabled
Medicare enrollment type, those residing in areas with a slightly
higher average ADI national percentile rank, and a larger share of
Medicare Part D LIS enrollment. This is consistent with the June 2022
MedPAC report which found that, among all clinician types, NPs on
average had the highest share of allowed charges associated with low-
income subsidy (LIS) beneficiaries. ``In 2019, 41 percent of the
allowed charges billed by NPs who practiced in primary care were for
LIS beneficiaries, as were 36 percent for NPs who practiced in
specialty care compared with 28 percent for primary care physicians and
PAs and 25 percent for specialty care physicians and PAs.''\67\
---------------------------------------------------------------------------
\65\ P. 961 2024 PFS Final Rule. https://public-
inspection.federalregister.gov/2023-24184.pdf.
\66\ 88 FR 52440. https://www.federalregister.gov/documents/2023/
08/07/2023-14624/medicare-and-medicaid-programs-cy-2024-payment-
policies-under-the-physician-fee-schedule-and-other.
\67\ medpac.gov/wp-content/uploads/2023/03/
Mar23_MedPAC_Report_To_Congress_SEC.pdf (Page 135).
In its FY 2021 Budget in Brief, HHS stated that basing ACO-assignment
on a broader set of primary care providers, including NPs, better
reflects our current primary care workforce and would lead to $80
million in savings for the Medicare program over 10 years.\68\ However,
statutory barriers still need to be fixed in order to fully include NPs
and their patients in the program. Therefore, we respectfully request
the Committee include S. 3939 in any legislative efforts pursuant to
this hearing in order to fully include NPs and their patients in the
MSSP.
---------------------------------------------------------------------------
\68\ HHS. https://www.hhs.gov/sites/default/files/fy-2021-budget-
in-brief.pdf (hhs.gov) (page 84).
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Creation of a Medicare Payment Technical Advisory Committee
During the hearing, Senator Whitehouse and witness Dr. Amol Navathe
discussed the importance of establishing a technical advisory committee
to help CMS more accurately determine fee schedule rates. We appreciate
the Committee's attention to this matter, and firmly believe that
reform is needed for the current valuation process. The historic issues
with undervaluation of primary care services are directly aligned with
the issues within the overall valuation process. Therefore, the process
must be reformed to improve accuracy and ensure the updates are regular
and comprehensive. These reforms must include a CMS technical advisory
committee which is inclusive of all health care providers billing the
Medicare program.
Multiple official reports from government agencies and MedPAC have
identified serious flaws with the current process, and CMS' valuation
of services. In May 2015, the United States Government Accountability
Office (GAO) issued a report to Congressional Committees on Medicare
Physician Payment: Better Data and Greater Transparency Could Improve
Accuracy.\69\ In this report, GAO states that ``CMS's process for
establishing relative values embodies several elements that cast doubt
on whether it can ensure accurate Medicare payment rates and a
transparent process.''\70\ The report identifies numerous flaws within
the process and concludes that ``CMS's process for establishing
relative values embodies several elements that cast doubt on whether it
can ensure accurate Medicare payment rates and a transparent
process.''\71\ GAO also noted that ``in the majority of cases, CMS
accepts the RUC's recommendations and participation by other
stakeholders is limited''\72\ and that ``Given the process and data
related weaknesses associated with the RUC's recommendations, such
heavy reliance on the RUC could result in inaccurate Medicare payment
rates.''\73\ As noted in the GAO report, ``the reliability of work
relative value recommendations may be undermined by survey respondents'
potential conflicts of interest.''\74\
---------------------------------------------------------------------------
\69\ GAO-15-434, Medicare Physician Payment Rates: Better Data and
Greater Transparency Could Improve Accuracy. https://www.gao.gov/
assets/gao-15-434.pdf.
\70\ Ibid.
\71\ Ibid.
\72\ Ibid.
\73\ Ibid.
\74\ Ibid.
These inherent conflicts in the valuation process led to a historic
undervaluation of E&M services, which are a foundational aspect of the
primary care system. The resulting negative impact on Medicare
beneficiaries was identified in MedPAC's 2018 Report to the Congress
Medicare and the Health Care Delivery System. Chapter 3 of this report,
stated that ``this mispricing may lead to problems with beneficiary
access to these services'' which are ``essential for a high-quality,
coordinated health care delivery system.''\75\ The report states that
``to estimate clinician work time for specific services, CMS relies on
data from surveys conducted by specialty societies that are reviewed by
the RUC. We have concerns about these data; for example, the surveys
have low response rates and low total number of responses, which raises
questions about the representativeness of the results.''\76\ The
Commission stated that the systemic undervaluation of E&M services was
partially ``because the fee schedule is budget neutral, ambulatory E&M
services become underpriced through a process of passive
devaluation.''\77\
---------------------------------------------------------------------------
\75\ jun18_medpacreporttocongress_rev_nov2019_note_sec.pdf.
\76\ Ibid.
\77\ jun18_ch3_medpacreport_sec.pdf.
From 2011 to 2015, CMS agreed 69% of the time with the valuations set
by the RUC.\78\ GAO highlighted the inherent conflict in their report,
noting that ``stakeholder participation in CMS's process is limited
because of incomplete information regarding which services are
undergoing RUC--and eventually CMS--review.''\79\ In its 2015 report,
GAO recommended ``to help improve CMS's process for establishing
relative values for Medicare physicians' services, the Administrator of
CMS should incorporate data and expertise from physicians and other
relevant stakeholders into the process as well as develop a timeline
and plan for using the funds appropriated by the Protecting Access to
Medicare Act of 2014.''\80\
---------------------------------------------------------------------------
\78\ GAO-15-434, Medicare Physician Payment Rates: Better Data and
Greater Transparency Could Improve Accuracy. https://www.gao.gov/
assets/gao-15-434.pdf.
\79\ Ibid.
\80\ Medicare Physician Payment Rates: Better Data and Greater
Transparency Could Improve Accuracy, U.S. GAO. https://www.gao.gov/
products/gao-15-434.
In a 2022 update, GAO noted that ``to close this recommendation, we
need documentation that CMS has started to incorporate data more
broadly into its process for establishing relative values and that it
has a documented timeline and plan for how it will use the funds
appropriated by the Protecting Access to Medicare Act of 2014. As of
December 2022, we had not received this documentation.''\81\ Therefore,
as the Committee considers action on reimbursement, we support the
establishment of a technical advisory panel, which is aligned with the
recommendation from GAO.
---------------------------------------------------------------------------
\81\ Ibid.
---------------------------------------------------------------------------
Conclusion
We appreciate the Committee's recognition of the need to address the
structural inequities within the Medicare program which inhibit
beneficiary access to coordinated, whole-person, patient-centered care.
NPs are inequitably reimbursed for the care they provide to Medicare
patients and still face barriers to participation in the program,
despite the essential value that they provide in maintaining access to
high-quality care for Medicare beneficiaries. We look forward to
working with the Committee on improving and modernizing the Medicare
program to reflect the current health care workforce and to meet the
needs of Medicare beneficiaries.
______
American Association of Orthopaedic Surgeons
317 Massachusetts Avenue, NE, Suite 100
Washington, DC 20002-5701
Phone 202-546-4430
https://www.aaos.org/advocacy/
On behalf of its 39,000 orthopaedic surgeon members, the American
Association of Orthopaedic Surgeons (AAOS) is pleased to submit this
statement for the record of the April 11, 2024 hearing, ``Bolstering
Chronic Care through Medicare Physician Payment,'' before U.S. Senate
Committee on Finance. We share the committee's goal of preserving
patient access to care by reimbursing physicians appropriately under
Medicare. Given ongoing concerns about increased consolidation and
vertical integration in healthcare that the committee highlighted in a
separate hearing last summer, it is critical that Congress take this
opportunity to get Medicare payment reform right.
Consolidation Trends in the U.S. Health Care System
Consolidation is inextricably linked to Medicare payment policy, as
declining physician reimbursements often fail to cover the skyrocketing
cost of practicing medicine. As a result, small independent physician
practices are being pushed to their financial brink and forced to merge
with massive healthcare conglomerates and larger hospital systems.
Ultimately, it is our patients who are most negatively impacted by this
trend, as it has been well established that consolidation has not led
to improved health of patients and often leads to higher costs and
decreased patient choice.\1\ The stress of running a medical practice,
including amplified financial pressures and administrative burdens, is
causing one in five physicians to consider leaving private practice
within 2 years.\2\ Unfortunately, the negative impact of the rising
costs of running a medical practice disproportionately impacts small,
independent practices, rural physicians, and those serving low-income
and marginalized communities increasing the risk of access to care
issues for some of our country's most vulnerable patients who are most
in need of chronic care.
---------------------------------------------------------------------------
\1\ https://www.kff.org/health-costs/issue-brief/what-we-know-
about-provider-consolidation/.
\2\ https://www.mcpiqojournal.org/article/S2542-4548(21)00126-0/
fulltext.
Despite promises of increased productivity and reducing redundancies,
consolidation has not resulted in the lower costs and better care
promised by the massive U.S. health care systems. Rather, research
shows that increased consolidation has led to higher health care prices
across the board. The consolidation of practices and integration with
hospital systems can lead to increased prices for common orthopaedic
procedures and decrease competition and opportunities among independent
practices in the same market. For example, the cost for knee
replacement and lumbar spine fusion were approximately 30 percent
higher in concentrated markets versus competitive markets.\3\ This data
amplifies the concerning trend that consolidation has consistently led
to higher costs for patients and payers, undermining affordability and
access to care.
---------------------------------------------------------------------------
\3\ JC Robinson. Hospital Market Concentration, Pricing, and
Profitability in Orthopedic Surgery and Interventional Cardiology. Am J
Managed Care 2011; 17(6):e241-e248.
---------------------------------------------------------------------------
Stabilizing Medicare Reimbursement for Physicians
Our nation's physicians are currently grappling with yet another cut to
the Medicare Physician Fee Schedule (MPFS). Coupled with medical
practice costs which are projected to increase by 4.6% this year, even
the reduced cut of 1.69% that Congress implemented in its recent
appropriations package is financially straining physician practices
past their breaking point.
While the gap between rising physician costs and stagnant or declining
reimbursement has grown more volatile in recent years, the economic
uncertainty it creates for physicians has been slowly building for
decades. The projected 4.6% increase clinicians' input costs for CY
2024--as measured by the Medicare Economic Index (MEI)--is the highest
it's been this century, beating last year's record of 3.8%. In fact,
since 2001, the cost of running a medical practice has increased 39%,
but the Centers for Medicare & Medicaid Services (CMS) has only
increased reimbursement for physicians by 11%.\4\ Unlike hospitals and
nursing homes--physicians and other health care professionals do not
receive an automatic increase to help keep up with the rate of
inflation. As a result, when adjusting for inflation in practice cost,
Medicare physician pay dropped by 20% over the past 2 decades.\5\
---------------------------------------------------------------------------
\4\ https://www.ama-assn.org/system/files/medicare-pay-chart-
2021.pdf.
\5\ https://www.ama-assn.org/sites/ama-assn.org/files/2022-09/
medicare-updates-inflation-chart.jpg.
Given this economic climate, it should come as no surprise that many
practices are forced to choose between closing their doors or
consolidating with larger healthcare institutions that can provide the
kind of economic stability needed to continue treating patients.
Increasing physician reimbursement to keep pace with hospital
reimbursement is one very tangible way that Congress can alleviate the
economic conditions that lead to consolidation and ultimately higher
costs for health care. Providing physicians with a full inflationary
update tied to MEI is a necessary first step to further stabilize the
MPFS. For this reason, we urge Congress to pass H.R. 2474, the
Strengthening Medicare for Patients and Providers Act, which would
accomplish this goal.
Budget Neutrality
Physicians are not only struggling to keep up with inflation, but they
also face Medicare reimbursement cuts year-after-year due to budget
neutrality constraints. The Omnibus Budget Reconciliation Act of 1989
contained a provision which mandated that any upward payment
adjustments or the addition of new procedures that will increase
spending by $20 million or more must be offset by cuts elsewhere in the
MPFS. As a result, the various medical specialties are pitted against
each other in competition over the size of their respective pieces of
the MPFS pie, creating even more uncertainty for physicians. It is not
uncommon for a physician in one specialty to see their payments reduced
because of policy decisions aimed at a completely different specialty
that have little to do with their day-to-day practice of medicine. In
fact, roughly 60% of the original 3.37% cut that CMS proposed in this
year's MPFS can be attributed to one such policy decision--the
implementation of the G2211 add on code that is primarily directed
towards primary care and other office/outpatient evaluation and
management (E/M) intensive specialties.
The idea that physicians must compete against each other for fewer and
fewer resources is completely antithetical to the team-based, patient
centered approach that is so vital to chronic care. Rather than
promoting the kind of collaborative, cooperative environment necessary
to coordinate care for patients with chronic conditions across multiple
specialties, the current payment reimbursement reinforces a zero-sum
view of delivering healthcare, where one specialty's reimbursement bump
is another specialty's loss. A good first step would be to raise the
MPFS budget neutrality threshold and index it to inflation going
forward, as well as providing statutory guard rails to limit the year-
over-year changes to the conversion factor (CF).
Unless we make long-term, structural changes to how Medicare--and by
extension, how the rest of the private market, which often adjusts its
rates based on changes to Medicare--values the services physicians
provide, the idea of the independent, private practice physician will
continue to fade from our health care system. For that model of health
care delivery to be a financially viable option for physicians, they
must have some sense of long-term financial security that the current
patchwork of yearly payment fixes fails to provide to those who aren't
salaried employees of a larger institution. While we appreciate
Congress' efforts to mitigate the annual cuts, short-term legislative
fixes only kick the can down the road without addressing the underlying
stability. Next year, when both the 1.25% statutory adjustment from the
Consolidated Appropriations Act, 2023 and the additional 1.68% relief
from this year's appropriations package are set to expire, physicians
are set to face yet another cut of 2.93% for 2025.
AAOS is supportive of legislation led by Reps. Greg Murphy (R-NC), Brad
Wenstrup (R-OH) and Michael Burgess (R-TX), ``The Provider
Reimbursement Stability Act of 2023,'' which would reform budget
neutrality and provide much needed stability within the MPFS for
orthopaedic surgeons and the larger physician community. As written,
the legislation would provide a full inflationary update to the MPFS
and limit positive or negative adjustments to Medicare reimbursements
to 2.5 percent. AAOS believes this legislation is another great step
that Congress can take towards more comprehensive payment reform.
Specialists' Role in the Transition to Value-Based Care
The original intent of Medicare Access and CHIP Reauthorization Act of
2015 (MACRA)--to incentivize the shift of U.S. healthcare spending and
delivery from a fee-for-service model to a value-based care model--has
been successfully implemented in some respects. However, it has failed
to create the abundance of opportunities for physicians to participate
in alternative payment models (APMs) that are necessary to make the
program successful.
As it relates to orthopaedic surgery, a shift to value-based models has
proven to be complicated and costly with limited return on investment.
Physicians are overloaded with administrative burden to comply with the
numerous value-based payment models and patients are often unaware that
they are participating in such arrangements, thus limiting the
effectiveness of such programs.
When considering the goals of MACRA, it is important to return to the
intent of the law and explore options for providing are in a way that
is of high value while remaining accessible to all patients. This may
look like a single system for designing and operating all value-based
payment models, with one platform for measure testing, approval, and
use, as well as the same single platform for submission. Such a
platform would be compatible with both government-operated and
privately-
operated value-based care programs.
AAOS is supportive of advancing value-based care and developed a value-
based care continuum (VBCC) to help orthopaedic practices better
understand and navigate various alternative payment models created to
achieve value-based care. AAOS also supports the creation of voluntary,
physician-led alternative payment models that expand access to quality
specialty care through wraparound approaches to musculoskeletal
disorders. This includes care teams that assess the clinical and social
factors that make surgical and nonsurgical interventions safe,
effective, and long-lasting. Orthopaedic surgeons should remain the
foremost leaders of these care teams which may include mid-level
practitioners, nurse navigators, and physical therapists. Essential to
improved access is reduced administrative burden which detracts from
time spent with the patient and slows the treatment process.
AAOS members are eager and willing participants in the transition to
value-based care and were early adopters of value-based payment models,
participating in the now partially mandatory Comprehensive Care for
Joint Replacement (CJR) and voluntary Bundled Payments for Care
Improvement-Advanced (BPCI-A) programs. Our members' work to optimize
patient care, increase value, and decreased costs resulted in an
estimated $61.6 million estimated net savings in the first three
performance years of the CJR program.\6\
---------------------------------------------------------------------------
\6\ https://innovation.cms.gov/data-and-reports/2022/cjr-fg-
thirdannrpt.
Any legislation passed by Congress must support surgeon-led models,
which are highly effective at achieving participation from physicians,
---------------------------------------------------------------------------
savings to the Medicare program, and patient engagement in their care.
Congress clearly demonstrated its commitment to surgeon-led models when
it created the Physician-focused Payment Model Technical Advisory
Committee (PTAC) to review and recommend stakeholder-designed APM
proposals. However, the committee has been plagued by years of turmoil
and resignations in protest of HHS' failure to adopt any of its
recommended models.\7\ In fact, PTAC has evaluated more than three
dozen models and recommended several to HHS and CMS, but none have been
adopted.
---------------------------------------------------------------------------
\7\ https://www.politico.com/newsletters/politico-pulse/2019/11/25/
a-closer-look-at-medicare-for-all-783041.
The problems with PTAC point to a broader issue with how CMS has been
exploring and evaluating options for alternative payment models and
cost savings in health care. Just last month, the Congressional Budget
Office issued a report estimating that the Center for Medicare &
Medicaid Innovation (CMMI)--the agency tasked with testing new APMs and
identifying potential cost savings--actually increased federal spending
by $5.4 billion between 2011 and 2020, and will continue to increase
net spending by $1.3 billion over the next decade. The spending
increase is a result of CMMI's failure to identify and expand models
that produce cost savings. The agency spent $7.9 billion to operate
models between 2011 and 2020. Of the 49 models it initiated, only 6
``generated statistically significant savings'' and only 4 have been
---------------------------------------------------------------------------
``certified for expansion'' by CMS and HHS.
As Congress considers ways to improve the pipeline of viable APMs,
particularly for specialty care, it should explore ways to bolster the
role of PTAC and give surgeons real input in developing and
implementing models that best suit the needs of their patients.
CMS has taken the initiative to create and support Accountable Care
Organization (ACO) models, which is a significant step in moving the
United States toward a population health approach to care. Ultimately,
we all want to create and participate in a model that helps patients
achieve good health outcomes and enable us to sustainably care for our
rapidly growing Medicare population. However, the current models are
designed to place the risk and cost management aspects of value-based
payments solely in the realm of primary care practitioners while
keeping the specialists and their teams in the fee-for-service world.
This is based on the premise that ACOs will be able to identify and
refer patients to high value specialists while providing most of the
care themselves.
Given the proportion of Medicare dollars spent on specialty care and
the prevalence of conditions that are treated by specialists, this is a
recipe for failure. The AAOS strongly recommends an approach that
allows risk sharing downstream with the specialists who provide care
for these conditions. Providing efficient, evidence-based treatments
for musculoskeletal conditions with an eye toward preventive care and
improving overall health can only be accomplished with deep and
expansive expertise in the most prevalent health conditions. To achieve
the shared savings that CMS aims for, it mandates that the experts who
work directly with patients on key decision making are incentivized
toward value. The most promising model to facilitate ACO/Specialist
collaboration is a condition-based payment mechanism as described in
the attached white paper developed by AAOS volunteers and staff. Thus,
AAOS urges the Center for Medicare and Medicaid Innovation (CMMI) to
explore and immediately pilot a program for the management of chronic,
prevalent conditions such as osteoarthritis of the knee, as delineated,
with plans to expand into other conditions as the reconciliation,
monitoring, and payment mechanisms are refined from this initial
experience.
Key factors that drive improvements in cost, quality and outcomes are
communication, collaboration, and the use of high-quality data to
inform clinical decision making. Successful population health
organizations maintain services to patients aimed at providing as much
on site and well-rounded care as possible. This may cost more upfront
for organizations but eventually help to avoid costly acute and post-
acute care. Such interventions will inevitably result in more value-
based revenue and more importantly, better outcomes and happier
patients. By utilizing high quality data and metrics, primary care
practitioners and their teams can adopt referral patterns that
correspond to population health and value-based care goals. They will
be able to identify and work with high quality, high performing
specialists. This will decrease stress and time for referral
appointments for the primary care while enhancing the patient's
experience and trust in the population-based organization.
Engaging specialists in episodic care management also reduces the
stress and strain on primary care. No single physician can know and
understand best practices for the management of every disease. By
engaging specialists who are familiar with best practices for any given
disease process, time and costly interventions can often be avoided. To
share an example, it is quite common for a patient to have waited a
lengthy period to be seen in an orthopaedic practice. They usually
present in pain and frustrated with an MRI that is positive for
meniscal tearing amid extensive osteoarthritis and their expectation is
that arthroscopic surgery will heal their meniscal tear. In such a
scenario, by engaging orthopaedic surgeons and other musculoskeletal
specialists earlier in the process the patient would be more satisfied
that their needs and fears were being addressed, the unnecessary MRI
would be avoided, the patient would be reassured that arthroscopy is
not indicated for meniscal tears in the setting of osteoarthritis and
that by undergoing physical therapy and other non-operative measures
they could potentially postpone or obviate the need for total knee
arthroplasty. Thus, saving the system money and further enhancing the
patient's experience with improved health outcomes.
We urge you to consider the profound impact that interoperability,
multi-payer alignment of measures, and administrative burden have on
the ability for physicians to successfully participate in alternative
payment models. It is incumbent upon Congress and CMS to ensure that
these perennial barriers are resolved in any future model. Likewise,
AAOS strongly encourages the agency to only consider voluntary models
that have incentives for participation. Mandatory models have
historically been unsuccessful in engaging physicians who are otherwise
eager to lead in the shift to value-based care. As in our earlier
comments on the Comprehensive Care for Joint Replacement (CJR) Model
and subsequent extension, a mandate to include all episodes,
physicians, and facilities in a designated Metropolitan Statistical
Area severely disadvantaged those surgeons, non-physician providers,
and facilities that either did not have the proper infrastructure to
optimize patient care under
episodes-of-care payment models and/or lacked adequate patient volumes
to create sufficient economies of scale. A voluntary program that
allows surgeons, facilities, and non-surgical providers to tailor their
episode-of-care models to their unique patient population would lead to
far better patient outcomes as well as more accurate and efficient
payments.
In conclusion, the American Association of Orthopaedic Surgeons urges
Congress to take immediate action to address the growing challenges
facing physicians and their patients in the U.S. healthcare system. By
stabilizing Medicare reimbursement, reforming budget neutrality, and
supporting the development of physician-led alternative payment models,
Congress can help to reverse the trend of consolidation, preserve
patient access to care, and promote the transition to value-based care.
We stand ready to work with the Committee and other stakeholders to
advance these critical priorities and ensure that our nation's
healthcare system remains robust, innovative, and patient-centered for
years to come. Thank you for the opportunity to submit this statement
for the record, and we look forward to continuing to engage with the
Committee on these important issues.
______
American Clinical Neurophysiology Society
555 East Wells St., Suite 1100
Milwaukee, WI 53202-3823
Phone: (414) 918-9803
Fax: (414) 276-3349
https://www.acns.org/
April 25, 2024
The Honorable Ron Wyden The Honorable Mike Crapo
Chair Ranking Member
U.S. Senate U.S. Senate
Committee on Finance Committee on Finance
Washington, DC Washington, DC
Dear Chair Wyden and Ranking Member Crapo:
On behalf of the American Clinical Neurophysiology Society (ACNS), we
appreciate the opportunity to provide input on the Senate Finance
Committee's April 11th hearing on ``Bolstering Chronic Care through
Medicare Physician Payment.'' We appreciate that Senators raised issues
related to the Medicare conversion factor, prior authorization, and
quality programs and we look forward to working with the Committee and
the bipartisan working group on legislative solutions to these issues.
Founded in 1946, ACNS is a professional society with more than 1,500
members comprised of physicians, researchers and allied health
professionals devoted to the establishment and maintenance of standards
of professional excellence in clinical neurophysiology under the
practice of neurology, neurosurgery, and psychiatry. ACNS members
utilize neurophysiology techniques in the diagnosis and management of
patients with disorders of the nervous system and in research examining
the function of the nervous system in health and disease.
Clinical neurophysiology is a neurology subspecialty. ACNS members
focus attention not just on electroencephalography (EEG), but also on
evoked potentials, electromyography, nerve conduction studies,
neurophysiologic intraoperative monitoring, polysomnography and other
sleep technology, quantitative neurophysiological methods,
magnetoencephalography, sleep disorders, epilepsy, neuromuscular
disorders, brain stimulation, brain-computer interfacing, and related
areas. Many of the patients we treat are Medicare beneficiaries;
consequently, an effective Medicare payment system is of particular
importance to our members.
While we appreciate the challenges of primary care, we want to note
that the patients with chronic conditions that our members treat
require long-term specialized care; indeed, ACNS members are the
medical home for patients with epilepsy a very common chronic
neurological condition, amongst others such as chronic neuromuscular
diseases. The solutions that the Committee develops should not be
limited to primary care but should support those physicians who manage
patients' complex, and often chronic, conditions, and we offer the
following recommendations as the Committee continues its work.
Recommendations to Improve the Medicare Payment System
Creating reimbursement stability must be a high priority for Congress
as you develop legislation to revise the payment system. We believe
that the current system is broken and unsustainable for Medicare
beneficiaries and providers. Each year the threat of cuts to physician
payments creates uncertainty and anxiety for physicians, who already
feel overwhelmed and undervalued. We already see workforce shortages
across specialties, including neurology where increasingly a dwindling
workforce takes care of an ever-expanding demographic of elderly
patients. Neurologists develop longitudinal relationships with their
patients to manage their complex health conditions.
As you know, the Medicare Access and CHIP Reauthorization Act (MACRA)
of 2015 eliminated the SGR's volume-based targets, which resulted in
annual decreases to the conversion factor; often Congress stepped in to
avert those required cuts. However, due to the retention of the
Physician Fee Schedule's statutory budget neutrality requirement and
lack of conversion factor updates, the last of 0.5 percent update was
applied in 2020, physicians again face significant payment cuts
requiring Congress to intervene. Under the SGR and MACRA, Medicare
physician payment has stagnated for the last 2 decades. Physicians have
struggled to keep pace as practice costs, the consumer price index, and
other factors have kept physician payments flat. Meanwhile, hospital
inpatient and outpatient reimbursement, which include a mechanism for
regular updates, have increased at a steady pace.
ACNS would support the development of a stable Medicare payment system
that eliminated the threat of yearly payment cuts, while also keeping
payments on pace with inflation and creating increases that were on par
with other payment systems under Medicare. Barriers to care will worsen
if the stability of maintaining a livelihood as a physician remains
threatened.
We believe that MACRA cannot be fixed without eliminating or adjusting
the budget neutrality requirement. While Congress and CMS would like to
transition to value-based payment models, it likely cannot be done
without increases to physician payments, given that the costs of
practicing medicine are increasing. Costs such as investment in
electronic health records, staff training, staff compensation, supplies
and other items needed to operate a practice are increasing with
inflation, yet physician payment remains flat.
The payment system cannot be updated or fixed unless the system
provides for regular updates to the underlying practice expense inputs.
Specifically, the indirect practice expense inputs of operating a
medical practice used in the calculation of physician payments for
Medicare services indirect are derived from survey data that is 16
years old. We believe that regularly updating the direct and indirect
practice expense is a key component of a stable Medicare payment system
that will include increases that are proportionate to economic changes.
CMS is aware that the Medicare Economic Index (MEI) weights need to be
updated. CMS had proposed to update the MEI using 2017 data from the
United States Census Bureau's Service Annual Survey but ultimately
decided not to make this change in CY 2023 due to the significant
redistributive effect of the policy. We implore Congress to work with
CMS to update the MEI and develop a mechanism to keep it current.
In addition to revising the budget neutrality adjustment, we believe
that the compliance and reporting requirements of the Quality Payment
Program (QPP) are extremely complex despite Congress' intention to
simplify quality reporting requirements under MACRA. The QPP includes
two separate, but equally complex payment systems--MIPS and advanced
APMs; however, MIPS is not significantly more streamlined than the
programs it was intended to replace. Congress must strive to revise the
QPP such that its requirements support the delivery of truly value-
based care and improved quality and do not create new check the box
exercises or administrative burden. Even though the program was created
to streamline quality reporting and to simplify it, many practices hire
staff simply to assist with meeting the reporting requirements.
Additionally, MACRA's statutory requirements have impeded Congress'
goals for the program. For instance, MACRA legislation dictated the
weights of the different MIPS categories--quality, cost, promoting
interoperability, and improvement activities. While the cost category
now comprises 30 percent of the physician's MIPS score, we believe it
does not accurately reflect a physician's performance. Measuring the
cost of physician care must be attributed appropriately, and account
for factors that are under the control of the physician. We encourage
Congress to take this into account when considering revisions to the
quality payment program.
Recommendations to Increase Provider Participation in Value-based
Payment Models
As you know, value-based care models were created to tie payment for
healthcare services to the quality of the care provided and not simply
the volume of care delivered, while rewarding physicians for efficiency
and effectiveness. However, the programs created under CMS have created
challenges for physicians and physician practices that do not translate
into value.
There is an increased administrative burden and financial risk involved
with participation in value-based payment models. There is a
significant investment in training staff at a time when there are
staffing shortages and high turnover rates. This training often takes
away time and resources that should be devoted to patient care. In
addition, with so many variations in practices, including practice
size, specialty type, practice location, and population demographics, a
one-size fits all model simply does not work. Flexibility is key to
provider participation as a model that is not adaptable will not take
hold. We also believe that payment models should decrease the risk to
the provider by limiting the penalty for those items out of control of
the provider (such as when a patient cannot afford a medication or does
not have access to transportation to attend appointments).
In summary, value-based payment models need to be tailored to
specialties and subspecialties, with associated meaningful quality
measures, and those payment models need to be easy for the provider to
enroll and navigate.
Recommendations to Improve MIPS and APM Programs
To improve the MIPS program, CMS needs to have the authority and
resources to create programs that are meaningful to all providers and
patients regardless of specialty type, while lowering the burden to
participate in these programs. We understand the constraints under the
current payment system. We believe that collaboration with stakeholders
will assist in creating more meaningful programs.
ACNS also believes there needs to be more meaningful quality measures
created for specialties. Often our members report on measures that have
little impact on the care provided, and providers may simply be
fulfilling administrative requirements. We would welcome the
opportunity to work with CMS and other stakeholders to create
meaningful, actionable measures for our specialty.
We also would like to see a quality program that produces measured
feedback that is timely and actionable. At present, we do not believe
that some of the information found in performance reports is relatable
to our practice patterns. Finally, many of the quality measures do not
focus on patient care and outcomes, therefore we again encourage CMS
and other stakeholders to consider creating more meaningful measures.
We would also recommend simplifying the reporting requirements and
reporting tools used in quality programs, while aligning rules and
administrative tasks across programs. In addition, we believe that
providers need more meaningful and useful educational resources so that
we are better equipped to meet the demands of quality payment programs.
Recommendations on Reducing the Burden of Prior Authorization
Prior authorization is a major barrier to the delivery of timely care
and treatments to patients and resulting in additional administrative
burdens for providers. People with chronic illnesses such as epilepsy
often experience prior authorization issues when accessing care. For
example, prior authorization requirements make it difficult to schedule
appointments for the Epilepsy Monitoring Unit (EMU). Our providers are
not able to receive prior authorization until the day of the scheduled
procedure, leaving no time to adequately counsel the patient on the
procedure or the cost of the service. If the prior authorization is
denied, the patient faces the difficult choice of going forward with
the procedure or rescheduling, which may not be medically advisable.
This also may strain the patient-provider relationship, which hinders
the practice of medicine.
Those staff responsible for approving prior authorizations often lack
the expertise on the areas of medicine that our members practice, which
can cause additional barriers to care. For example, a children's
hospital treating a pediatric patient with potential catastrophic
epilepsy may seek prior authorization for a procedure called a
hemispherectomy, the removal of half of a patient's brain. After
significant delay, the insurer approves the prior authorization for the
hemispherectomy but states that a separate authorization would have to
be given for performing the procedure on the other half of the brain.
The decision makers did not have the expertise to understand that you
would not perform two hemispherectomies on the same patient, which took
additional provider time to explain to the insurer. It would reduce the
burden on providers if there were subject matter experts reviewing the
prior authorization request to ensure timely and appropriate
authorization.
Thank you again for the opportunity to provide our feedback as the
Finance Committee develops legislation to address physician payment and
improve care for patients with chronic conditions, such as epilepsy. We
look forward to working with the Committee and the bipartisan working
group led by Senators Stabenow and Thune as this process moves forward.
Please reach out to Stefanie Rinehart at srinehart@dc-crd.com with any
questions.
Sincerely,
Meriem Bensalem-Owen, M.D., FACNS
President
______
American College of Allergy, Asthma, and Immunology Advocacy Council
85 W. Algonquin Road
Arlington Heights, IL 60005
847-427-1200
https://college.acaai.org/
April 16, 2024
Hon. Ron Wyden Hon. Mike Crapo
Chair Ranking Member
U.S. Senate Senate
Committee on Finance Committee on Finance
221 Dirksen Senate Office Building 239 Dirksen Senate Office Building
Washington, DC 20510 Washington, DC 20510
RE: ACAAI Statement for the Record in Response to U.S. Senate Committee
on Finance Committee Hearing: Bolstering Care through Medicare
Physician Payment--Thursday, April 11, 2024
The American College of Allergy, Asthma, and Immunology's (ACAAI's)
Advocacy Council appreciates the Senate Committee on Finance holding a
hearing on improving chronic care through Medicare physician payment.
We hope this hearing highlighted the insufficiency of Medicare
reimbursement for physicians who care for patients with chronic
conditions.
ACAAI represents more than 6,000 board-certified allergists and
healthcare professionals. Allergists specialize in treating both adult
and pediatric patients with chronic conditions such as asthma, food
allergies, hives or urticaria, stinging insect hypersensitivity, sinus
problems, allergic rhinitis, anaphylaxis, immune deficiencies, and
atopic dermatitis or eczema, among other things.
Chronic conditions generally cannot be cured. They require ongoing care
from a trusted and skilled clinician to effectively manage the
patient's condition. Chronic care for a condition such as asthma
requires regular office visits and medication adherence and management.
Modern technology makes it possible to track symptoms outside of the
exam room and allows patients to communicate with clinicians more
regularly through portal messages. The current reimbursement model does
not adequately account for these advances. Improvements are needed so
that clinicians are reimbursed in a way that incentivizes care
management and supports modern clinical approaches to chronic care
management.
Recent policy changes such as revised evaluation and management (E/M)
code values and documentation requirements have helped allergy
practices receive more adequate reimbursements. However, more is
needed.
Overall, we agree with many of the key issues brought up in the
hearing, including low physician payments, the fragmented system of
services produced by the Physician Fee Schedule, and the lack of
meaningful value or clinical relevance in the metrics used in value-
based payment programs such as the Medicare's Merit-Based Incentive
System (MIPS).
The ACAAI agrees with the Finance Committee that physician payment
reform is necessary to improve treatment for patients with chronic
conditions. To achieve this goal, ACAAI recommends:
Permanently preventing various Medicare reimbursement reductions
from taking effect at the start of each calendar year. ACAAI is
appreciative of Congress' efforts to avert reductions to Medicare
reimbursement rates, but the annual cycle of physicians advocating
against cuts to the Conversion Factor to prevent Medicare reimbursement
reductions highlights the need for a sustainable solution. We encourage
the Senate to introduce and pass a companion version of Pass H.R. 2474,
the Strengthening Medicare for Patients and Providers Act, and H.R.
6371, the Provider Reimbursement Stability Act of 2023.
Congress must permanently waive the 4% PAYGO reduction put into
place when passing the American Rescue Plan of 2021. Moreover, the
continuous extension of the 2% Medicare sequestration reduction,
initially intended to be only for 10 years when it was implemented in
2011, has created an enduring challenge for healthcare providers. This
reduction, in combination with the expiration of the MIPS exceptional
performance bonus and other policies, has made it difficult for many
allergists to receive meaningful Medicare reimbursement adjustments.
Creating greater financial certainty for allergy practices is not just
a solution but a lifeline for the healthcare workforce serving patients
facing chronic conditions, ultimately ensuring access to quality care
for those who need it most.
Congress should pass S. 3805, No Fees for EFTs Act, which would
close the EFT fee loophole by specifying that fees are prohibited for
transactions occurring directly between health plans and providers,
including EFT transactions facilitated on behalf of health plans by
covered entities or third parties. Additionally, Congress should
prohibit automatic Virtual Credit Card (VCC) payments unless providers
give advanced consent, effectively changing VCCs from opt-out to opt-in
payment options. HIPAA has established a standard electronic
transaction for Electronic Funds Transfer (EFT) payments to healthcare
providers, promoting the transition away from paper checks. These EFT
payments are akin to an employer directly depositing an employee's
paycheck into their bank account and have been increasingly adopted,
with 75% of claims payments utilizing the standard EFT transaction as
of 2022. However, certain commercial payers exploit a loophole that
allows them to charge healthcare providers additional fees for EFT
transactions.
In addition, some commercial health plans attempt to reimburse
physicians using Virtual Credit Cards (VCCs). These are electronic
numbers provided to physicians for payment, similar to credit card
transactions, but they often entail payment fees. Physicians should
have the option to opt out of VCC payments and receive a standard EFT
transaction, which is free of additional charges. However, the opt-out
process can be administratively burdensome for healthcare practices,
and the alternative EFT payment may also carry fees when facilitated by
third-party payment vendors. While CMS can regulate HIPAA transaction
standards, it lacks the authority to address VCC-related issues.
Congress therefore needs to act to protect practices from VCC payment
fees.
Simplifying Merit-Based Incentive Payments (MIPS) and Advanced
Payment Models. Value-based payments, while well-intentioned, can be
burdensome for allergists treating chronic conditions. As currently
constructed, programs such as MIPS require significant investment of
resources to effectively participate but have limited opportunities for
physicians to receive significant payment increases as a reward for
this investment. Allergists would benefit from less burdensome and more
meaningful requirements to succeed in these programs, with a reformed
payment incentive system to increase the benefits of succeeding in
value-based payment programs.
Additionally, physicians would have more success in value-based
payment models if they were specifically tailored to the conditions
they treat. We are disappointed that CMS has not tested any of the
physician-focused payment models (PFPM) recommended by the PFPM
Technical Advisory Committee (PTAC). In the MACRA legislation that
created MIPS, Congress intended for PFPMs to serve as a physician-led
alternative pathway to value-based care for chronic conditions to
supplement MIPS and Advanced APMs. ACAAI's model, the
Patient-Centered Asthma Care Payment Model,\1\ was among the dozens of
models that the PTAC recommended to CMS. Our model is an example of an
innovative reimbursement model to reward effective chronic care
management for asthma. Congress should direct CMS to dedicate a portion
of CMMI's budget to implement PFPM recommended by PTAC.
---------------------------------------------------------------------------
\1\ https://college.acaai.org/sites/default/files/Resources/
Advocacy/apm_exec_summary-complete_model.pdf.
Continuing bipartisan efforts to reform prior authorization,
particularly in the Medicare Advantage program by reintroducing the
Improving Seniors Timely Access to Care Act originally considered in
the 117th Congress. Requiring health plans to streamline their prior
authorization processes will benefit physicians treating chronic care.
Prior authorization, often used excessively by health plans, creates
immense administrative challenges for physicians. It is essential that
providers treating advanced chronic conditions, particularly amid
widespread physician shortages, care for as many patients as possible.
The barriers put in place due to prior authorization exacerbate
---------------------------------------------------------------------------
challenges for patients with chronic conditions when accessing care.
While a recent CMS final rule implements much of this policy, gaps
continue to exist. For example, the final rule for prior authorization
does not apply to drugs. Medications are an essential component of a
patient's chronic care management. Delaying a patient's access to their
medication can disrupt their care.
Congress should move to pass the Improving Seniors Timely Access
to Care Act to help close these gaps. Congress should also further
limit health plans' use of prior authorization and penalize plans for
improperly denying claims. ACAAI also recommends that Congress explore
a program that requires health plans to adopt a ``fast-track'' for
physicians who have a high amount of their prior authorization claims
approved.
Curtailing the influence of Pharmacy Benefit Managers (PBM) in
dictating which medications treating chronic conditions (such as
inhalers for treating asthma) are included in formularies. To address
and improve how physicians treat chronic care, they should be able to
prescribe medications that, according to their expert opinion, would
best improve the quality of life for someone living with a chronic
condition. This is especially true for treating chronic conditions such
as asthma where the popular and effective inhaler Flovent was recently
removed from the market. Now, PBMs are refusing to include the cheaper,
generic version on their formularies. The influence PBMs have on drug
availability should be put into question, especially for treating
chronic conditions. The Advocacy Council has endorsed the Senate
Finance Committee's efforts to reform PBMs. We urge the Committee to
continue its strong push to pass a law that would reign in the
influence of PBMs and improve patient access to medications. We applaud
the bipartisan efforts this committee has taken thus far to achieve
this goal.
In conclusion, the ACAAI Advocacy Council expresses our deep
appreciation for the Senate Committee on Finance's commitment to
bolstering chronic care through Medicare physician reimbursement. Our
recommendations span key areas, including reforming Medicare
reimbursement, eliminating fees on electronic fee transfers (EFTs), and
reigning in PBMs. We believe that these measures, if implemented, would
go a long way in improving the care patients receive for their chronic
conditions.
We look forward to working with the Committee to address these vital
issues to ensure that allergy patients dealing with chronic conditions
receive the care they deserve. Please do not hesitate to contact Matt
Reiter (reiterm@capitolassociates.com) if you wish to discuss our
recommendations further. Thank you for your consideration.
Sincerely,
Gailen Marshall, Jr., M.D., Ph.D.,
FACAAI Travis A. Miller, M.D., FACAAI
President, ACAAI Chair, Advocacy Council
______
American College of Lifestyle Medicine
P.O. Box 6432
Chesterfield, MO 63006-6432
https://lifestylemedicine.org/
April 24, 2024
Statement for the Record
On behalf of the 11,000 medical professional members of the American
College of Lifestyle Medicine (ACLM) who are dedicated to treating and
reversing lifestyle-related chronic disease, we would like to thank the
Senate Finance Committee for holding its April 11th hearing
``Bolstering Chronic Care through Medicare Physician Payment'' and
appreciate this opportunity to submit this Statement for the Record. As
the nation's only medical professional association dedicated to such an
approach to chronic disease, we wholeheartedly agree that chronic care
needs bolstering--chronic disease creates human suffering among both
adults and a growing number of children, lowered workforce
productivity, clinician burnout, and financial unsustainability for
families and the nation as a whole.
The incidence trajectory is alarming: According to the CDC, 51.8% of
U.S. adults have at least one diagnosed chronic condition. Some 27.2%
of U.S. adults suffer from multiple chronic conditions.\1\ Chronic
diseases are responsible for 7 out of every 10 deaths in the U.S.,
resulting in over 1.7 million fatalities annually. According to NIH
data \2\ the adult obesity rate in 1980 in this country was 13.4%, and
now stands at over 40%. This has led to similar large increases in the
incidence of a wide range of comorbidities including cardiovascular
disease, type 2 diabetes and pre-
diabetes, chronic kidney disease and certain forms of cancer, most
notably an increase in colon cancer among younger Americans. Only
recently have we seen policy makers begin to call these comorbidities
by their proper name: ``diet-related chronic disease.''\3\
---------------------------------------------------------------------------
\1\ https://www.cdc.gov/pcd/issues/2020/20_0130.htm.
\2\ https://www.ncbi.nlm.nih.gov/books/NBK44656/
#::text=The%20prevalence%20of%20
obesity%20changed,children%20during%20the%20same%20period.
\3\ https://www.gao.gov/products/gao-21-593.
The financial impact is sobering: CDC reports 90% of the $4.1 trillion
in U.S. healthcare costs can be attributed to chronic or mental health
conditions. Chronic disease accounts for 81% of all hospital
admissions, 91% of all prescriptions filled, and 76% of all doctor
visits. Furthermore, it's estimated that employees with chronic
conditions cost employers $153 billion in lost wages each year.\4\ With
the surge of demand for GLP-1 drugs and expansion of label usage, these
costs will explode.
---------------------------------------------------------------------------
\4\ https://news.gallup.com/poll/150026/unhealthy-workers-
absenteeism-costs-153-billion.aspx
#::text=WASHINGTON%2C%20D.C.%20%2D%2D%20Full%2Dtime,billion%20in%20lost
%20
productivity%20annually.
And the effect on society is unmistakable: Americans are living
shorter, less healthy lives. According to recent a Commonwealth Fund
report, The U.S. has an obesity rate nearly double the average of the
38 member countries of the Organization for Economic Cooperation and
Development (OECD) with a life expectancy at birth 3 years lower on
average and more than 7 years lower than leading member nations, all
while spending nearly twice as much on health care per capita as any of
them.\5\ As a result of its growing prevalence in the population,
chronic disease now even threatens U.S. national security, affecting
military recruitment eligibility and active-duty readiness. What's
more, it is a matter of health equity, as communities of color suffer
more instances of chronic disease, face more social barriers to care
such as transportation, and are vulnerable to more complication rates
as a result, notably amputations.
---------------------------------------------------------------------------
\5\ https://www.commonwealthfund.org/publications/issue-briefs/
2023/jan/us-health-care-global-perspective-2022.
As patient disease, suffering and the associated financial impact
continues its unsustainable upward trajectory, the need for improved
primary care payment is unquestionable. Physician burnout has created
primary care physician shortages with yearly Medicare payments cuts
only add to the workforce retention issue. The U.S. is already running
low on primary care physicians, according to the American Medical
Association, with an estimated shortage of between 17,800 and 48,000
predicted by 2034. The shortage of physicians has negative consequences
for patients and communities, such as delays in access to care, poorer
health outcomes, higher costs, and lower satisfaction.\6\ Nearly $1
billion in annual excess health care expenditure are due to turnover of
primary care physicians.
---------------------------------------------------------------------------
\6\ https://www.msn.com/en-us/health/medical/where-have-all-the-
doctors-gone-exploring-the-causes-and-consequences-of-the-physician-
shortage-in-the-united-states/ar-AA1|EqpZ.
We believe taking steps to expand and reward the practice of lifestyle
medicine is an absolutely necessary part of any strategy that hopes to
stem this epidemic tide of chronic disease, improve patient outcomes,
reverse the trend of physician burnout and contain the growth of health
care spending in this country.
What is lifestyle medicine?
Lifestyle medicine is a medical specialty that uses therapeutic
lifestyle interventions as a primary modality to treat chronic
conditions including, but not limited to, cardiovascular diseases, type
2 diabetes, and obesity. Lifestyle medicine certified clinicians are
trained to apply evidence-based, whole-person, prescriptive lifestyle
change to treat and, when used intensively, often reverse such
conditions. Applying the six pillars of lifestyle medicine--a whole-
food, plant-predominant eating pattern, physical activity, restorative
sleep, stress management, avoidance of risky substances and positive
social connections--also provides effective prevention for these
conditions.\7\
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\7\ https://lifestylemedicine.org/about-us/.
You will notice the word you do not find in that definition: manage.
When most practitioners--and policy makers, for that matter--discuss
chronic care that is the term they use, reflecting the belief that
managing such conditions to ensure patients are prescribed and take
their medications and care is coordinated to avoids gaps in care that
can result in hospitalizations and emergency rooms is the best we can
do, that patients are consigned to having these conditions for life and
the best we can do is slow the progression and mitigate the harmful
side effects. ACLM and its members believes our health care system can
---------------------------------------------------------------------------
and must do better.
To be clear, ACLM physicians are not anti-prescription drugs. Our
members recognize the important role they play and often do prescribe
such treatments. They simply do not believe they are the only or even
the best answer for many patients. As ACLM member and practicing
preventive cardiologist Cliff Morris described it, ``Dr. Morris
believes that in many instances medications are appropriate in
maintaining the health of an individual; however, his goal is to treat
the root cause of disease itself so the body no longer needs the
medication, and thus does not have to live with the side effects of
medications. If by adopting healthy lifestyle habits you can bring your
numbers down naturally, then you will essentially no longer rely on the
medication for your health. At that point, and only then, your provider
will take you off of your medication. At Morris Cardiovascular we
celebrate this moment as you take back your health.''
Despite wide recognition that all of this is directly related to
significant dietary changes in our country and other lifestyle
elements, the health care system has simply not evolved nearly enough
to create a work force or payment systems equipped to address these
conditions their patient populations most often present with. Most
notably, our physicians receive little to no training in nutrition or
exercise science in most of our medical schools and residency programs,
with data showing that an overwhelming majority feel ill equipped to
provide the kind of expert guidance their patients need in these
areas.\8\ According to a recent article in STAT,\9\ ``The average
medical school student spends less than a day \10\ learning about
obesity, despite the fact that over 40% of adults and 1 in 5 children
\11\ in the U.S. have it, according to some estimates.'' The health
care system did not cause this problem and there are major policy areas
outside the system and the scope of the Finance Committee that need to
be addressed, but the health care system does need to play a much
larger and more direct role in addressing this epidemic if we are ever
going to make real progress in improving outcomes.
---------------------------------------------------------------------------
\8\ https://www.congress.gov/bill/117th-congress/house-resolution/
784/text.
\9\ https://www.statnews.com/2023/03/20/childhood-obesity-
guidelines-eating-disorders-data-concerns/.
\10\ https://www.wgbh.org/news/national-news/2023/01/31/scant-
obesity-training-in-medical-school-leaves-docs-ill-prepared-to-help-
patients.
\11\ https://www.cdc.gov/mmwr/volumes/67/wr/
mm6706a3.htm?s_cid=mm6706a3_w.
---------------------------------------------------------------------------
This education and training does not need to be developed from scratch.
ACLM, which has championed food as medicine and other lifestyle
``pillars'' to address existing chronic disease since its inception in
2004, provides hundreds of hours of undergraduate, graduate (residency)
and continuing medical education (CME) courses. We support student- and
trainee-initiated Lifestyle Medicine Interest Groups at 132 academic
and health institutions. Some 302 lifestyle medicine residency programs
exist across 135 sites, with 6,900+ enrollees.
In support of the 2022 White House Conference on Hunger, Nutrition, and
Health and to date, ACLM has committed $44.1 million in complimentary
coursework to 200,000 clinicians until September 2025, and lifestyle
medicine certification support to one primary care provider in each of
the nation's 1,400 Federally Qualified Health Centers.
We help prepare physicians and other clinicians for that certification.
Since certification began in 2017 by the American Board of Lifestyle
Medicine, 3,085 physicians in the U.S. have become board certified in
lifestyle medicine, along with 1,263 other health professionals.
Worldwide, across 72 countries, 5,017 physicians and 1,671 other
clinicians are certified for a total of 6,688.
Lifestyle medicine training also has the ability to support better
health behaviors for clinicians who are delivering care. One study, has
shown that clinicians who practice LM are at a lower risk for burnout,
which could help address the healthcare workforce shortages cited
above.
The time for change in this area is long past due. The situation has
become so dire, that in 2023, the American Academy of Pediatrics began
recommending Intensive Health Behavior and Lifestyle Treatment (IHBLT)
for children as young as 2 years old (while also recognizing that it is
not ``universally available''), obesity drugs for children as young as
12 years old and bariatric surgery for children as young as 13 years
old.\12\
---------------------------------------------------------------------------
\12\ https://www.aap.org/en/news-room/news-releases/aap/2023/
american-academy-of-pediatrics-issues-its-first-comprehensive-
guideline-on-evaluating-treating-children-and-adolescents-with-obesity/
#::text=Physicians%20should%20offer%20adolescents%20ages,health%20behav
ior%20
and%20lifestyle%20treatment.
Those same obesity drugs, glucagon-like peptide 1 (GLP-1) agonists, are
changing the landscape of obesity treatment with demand surging and
cost projections raising great concerns over their systemic impact on
Medicare Part D costs, as well as their impact on Medicaid and
commercial insurance costs. Even with Medicare statutorily precluded
from covering GLP-1s for treatment of obesity, Ozempic alone was the
sixth most costly Part D drug in 2022 with its indication only for
treatment of type 2 diabetes.\13\ With recent FDA of approval \14\ of
Wegovy for treatment of cardiovascular disease, the potential Medicare
patient pool is likely to continue grow regardless of whether Congress
takes action to allow Medicare to cover these drugs for obesity.
---------------------------------------------------------------------------
\13\ https://www.kff.org/policy-watch/medicare-spending-on-ozempic-
and-other-glp-1s-is-skyrocketing/?utm_campaign=KFF-
Medicare&utm_medium=email&_hsenc=p2ANqtz-8kEPIry
T_Rgwgla_cOILCS3V1DDRlML5TJgT1LDuQBBKidrwenLhpzNajdUHx2CYsnJiR74102VRS
_Cdixy24f2h_n6w&_hsmi=299684398&utm_content=299684398&utm_source=hs_emai
l.
\14\ https://www.fda.gov/news-events/press-announcements/fda-
approves-first-treatment-reduce-risk-serious-heart-problems-
specifically-adults-obesity-or.
ACLM believes there is a role for the GLP-1s and is heartened by the
positive short term impact they are having for patients not only in
addressing obesity but also some of its most damaging comorbidities;
however, given the high incidence of short term side effects, the
potentially enormous systemic costs and the legitimate questions about
the long term health effects to patients from taking appetite
suppressants for a lifetime, we believe these drugs are best
administered in combination with lifestyle medicine, to give patients a
pathway to eventually no longer taking these drugs without quickly
reversing the gains they have made. Again, the system is simply not
equipped to offer that alternative right now with the rigor and at the
---------------------------------------------------------------------------
scale that is required.
So what are the policy prescriptions we recommend the Finance Committee
pursue to meet this goal of building a health care system equal to the
challenge of addressing this epidemic and truly ``Bolstering Chronic
Care''?
As mentioned earlier, we believed it starts with dramatically
increasing the time and quality of the nutrition education our doctors
receive in Undergraduate Medical Education (UME) and Graduate Medical
Education (GME). This was an area of focus at the 2022 White House
Conference on Hunger, Nutrition and Health and the Department of Health
and Human Services (HHS) has taken up the mantle as well, working with
stakeholders like ACLM to drive desperately needed change in this area.
It is long past time for the Finance Committee to get involved in this
as well. We recognize there are limits to how far Congress will go in
dictating to schools and residency programs the content of their
curriculum; however, there are clear steps the Committee can and must
take to continue to help elevate this issue. We think that starts with
the Committee simply holding hearings on the issue, bringing
stakeholders such as that American Association of Medical Schools
(AAMC) and the American Council for Graduate Medical Education (ACGME)
up for questioning about what they are doing to address this glaring
deficiency and, most importantly, an organization such as ACLM which is
already offering scalable curriculum across the spectrum of medical
education in this area. Given the number of hearings the committee has
held to address issues related to chronic care such as the prices of
the drugs used to treat the diseases, we think it is past time for the
Committee to hold hearings on solutions that can reduce the need for
those same medications.
The Committee could also legislate to require the Government
Accountability Office (GAO) to report on the status of nutrition
education in our residency programs, including best practices that the
majority of residency programs are falling far short of in this area
and could seek to replicate.
Along with creating a work force that is educated to work with patients
to prevent and also to treat and reverse chronic conditions where
possible, we also need payment models that incentivize models designed
to reward physicians for taking such an approach. For instance, we have
models where reducing hospitalizations is a quality measure. Why can't
we also have quality measures that include reducing the need for
prescription drugs while improving measurables for conditions such as
high cholesterol, hypertension, and type 2 diabetes? In the fee-for
service system, CPT codes that address lifestyle modifications are
reimbursed far less than CPT codes for drug prescriptions and surgical
procedures. This is despite the fact that lifestyle interventions have
been proven to achieve better health outcomes than prescription drugs
alone and often require more time and effort from the clinical care
team than a prescription drug or surgical procedure might. Behavior
change interventions also have far less harmful side effects.
The current quality and payment models also don't reward medication de-
escalation as the result of improved health outcomes or even reversed
chronic conditions. As an example, in the Medicare Advantage insurance
space, a large number of the measures in the Quality Bonus Program are
focused on medication adherence as end result and punish plans whose
physicians work with patients to improve or reverse their chronic
conditions through lifestyle change. Success on these measures is what
determines whether plans receive their 5% bonus payment for achieving
four or five start status, so we know they ``teach to the test'',
meaning these incentives flow through to their physician contracts.
In the direct physician payment space, for instance, we have payment
models where reducing hospitalizations is a quality measure. Why can't
we also have quality measures that include reducing the need for
prescription drugs while improving measurables for conditions such as
high cholesterol, hypertension and type 2 diabetes?
There was some discussion during the hearing, including from Ranking
Member Mike Crapo (R-ID), about the role that was envisioned for the
Physician-Focused Payment Model Technical Advisory Committee (PTAC)
created as part of the Medicare Access and CHIP Reauthorization Act
(MACRA) of 2015 in providing medical specialists an avenue to develop
and advance payment models through a rigorous process that would to
many of those recommended by the PTAC being implemented by the Center
for Medicare and Medicaid Innovation (CMMI). In fact, none of the
models recommended were ever implemented and as result the PTAC has
withered on the vine. This process needs to be reinvigorated either
through a renewed PTAC or some other model the committee creates.
In addition, there are bills already introduced that the committee
should advance that would represent some progress in advancing
lifestyle medicine solutions to chronic disease. Those include the
Medical Nutrition Therapy Act (S. 3297) led by Senators Susan Collins
and Gary Peters. This bill expands Medicare coverage of medical
nutrition therapy services. Currently, Medicare covers such services
for individuals with diabetes or kidney disease under certain
circumstances; such services must also be provided by a registered
dietitian or nutrition professional pursuant to a physician referral.
The bill extends coverage to individuals with other diseases and
conditions, including obesity, eating disorders, cancer, and HIV/AIDS;
such services may also be referred by a physician assistant, nurse
practitioner, clinical nurse specialist, or (for eating disorders) a
clinical psychologist. ACLM support passage of the Medically Tailored
Meals Act (S. 2133) led by Senators Debbie Stabenow and Roger Marshall,
which would create a medically-tailored meals home delivery
demonstration program.
Lastly, efforts at long term behavior change and maintenance
interventions are often not as effective or efficient when delivered in
the traditional, infrequent 1:1 provider-to-patient ratio, 15-minute
medical appointment. A best practice for the delivery of lifestyle
medicine and support of the necessary behavior change is through shared
medical appointments (SMAs) in which patients receive both individual
care and group education by a team of clinicians about therapeutic
lifestyle changes that can treat or reverse their disease(s). SMAs are
not new models, but have been very effective for our members in the
delivery of therapeutic lifestyle interventions. SMAs have been shown
to help patients learn and support each other in behavior change,
increase access to care, achieve better health outcomes and alleviate
provider burnout. However, there are a number of challenges related to
the delivery of SMAs for both providers and patients. On the provider
side, challenges include compliance concerns related to the number and
frequency of E&M visits coded back-to-back as is common in an SMA
model, place of service issues for delivering care in community-based
settings where patients live and work, challenges in getting approval
for the use of modifier 33 to waive patient copays. On the patient
side, the number and frequency of SMA programs to address lifestyle-
related behaviors can be financially unviable if they require a patient
co-pay each visit.
Winston Churchill is believed to have once observed ``You can always
count on Americans to do the right thing--once they have tried
everything else''. We urge the Committee as it considers policies to
help ``bolster chronic care'' to take the steps we have recommended and
others to address the root causes of this epidemic. It truly is the
right thing and when it comes to chronic disease, we have tried
everything else.
For questions related to feedback and recommendations from the American
College of Lifestyle Medicine, please contact Kaitlyn Pauly, Deputy
Director of Practice Advancement and Administration, at
kpauly@lifestylemedicine.org
Regards,
Beth Frates, M.D., DipABLM Susan Benigas, BS
President Executive Director
______
American College of Physicians
25 Massachusetts Avenue, NW, Suite 700
Washington, DC 20001-7401
202-261-4500
800-338-2746
https://www.acponline.org/
On behalf of the American College of Physicians (ACP), we appreciate
this opportunity to share our recommendations to improve the delivery
of chronic care in Medicare. We applaud Chairman Wyden and Ranking
Member Crapo for hosting this hearing on Bolstering Chronic Care
through the Medicare Physician Fee Schedule (MPFS) and their
willingness to consider policies to enhance care for seniors with
chronic conditions. We were pleased to work with this Committee several
years ago to strengthen chronic care through the passage of S. 870, the
Creating High-Quality Results and Outcomes to Improve Chronic (CHRONIC)
Care Act and look forward to working with you to ensure that the MPFS
provides the support necessary for physicians to provide high quality
chronic care for our seniors.
ACP is the largest medical specialty organization and the second
largest physician membership society in the United States. ACP members
include 161,000 internal medicine physicians, related subspecialists,
and medical students. Internal medicine physicians are specialists who
apply scientific knowledge, clinical expertise, and compassion to the
preventive, diagnostic, and therapeutic care of adults across the
spectrum from health to complex illness.
Although the Chronic Care Act made important changes in improving care
for seniors with chronic conditions, additional steps are needed to
ensure that our patients have access to high quality chronic care. Six
in 10 American adults \1\ have at least 1 chronic disease and 4 in 10
have 2 or more, and at $3.3 trillion in annual health costs, chronic
disease is responsible for 75% of aggregate national health care
spending and is the largest cause of disability and death.\2\
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\1\ https://www.cdc.gov/chronicdisease/resources/infographic/
chronic-diseases.htm.
\2\ https://www.mdpi.com/1660-4601/15/3/431.
General internal medicine physicians assume principal responsibility
for coordinating and managing patients' overall care, particularly for
those with multiple complex chronic conditions.\3\ As the Senate
Finance Committee examines policies to bolster chronic care, we urge
you to adopt the following measures to ensure lower costs and improve
the quality of chronic care in this country:
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\3\ https://www.acpjournals.org/doi/10.7326/0003-4819-159-9-
201311050-00710.
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Strengthen and Stabilize the MPFS
Revise Requirements for Budget Neutral Payment Cuts in the MPFS
Ensure Accurate Estimates of Utilization of New Codes in the
MPFS
Remove Beneficiary Cost Sharing for Chronic Care Management
Services
Support Increased Access to Telehealth Services
Support the Implementation of Medicare Code G2211
Expand the Primary Care Physician Workforce
Support the Elimination of Cost Sharing for Primary Care
Services
Support Increased Payment for Primary Care Physicians
Strengthen the Medicare Physician Fee Schedule
It is unrealistic to assume that the current MPFS provides the adequate
stability and resources necessary for our physicians to deliver high
quality chronic care for our patients. Unlike nearly every other
segment of the Medicare payment system, the MPFS does not include
annual inflationary adjustments. As a result, when accounting for
inflation, current Medicare physician payment rates have decreased by a
staggering 26% since 2001. The failure of Congress to provide
consistent, positive, and stable payment updates is contributing to
staffing shortages and service limitations that potentially result in
longer wait times or other disruptions impacting patient care.
We urge Congress to approve H.R. 2474, the Strengthening Medicare for
Patients and Providers Act, which preserves access to care for Medicare
beneficiaries by providing an annual inflation update equal to the
Medicare Economic Index (MEI) for Medicare physician payment. This
legislation is essential to physicians' ability to make needed
investments in their practice that help ensure they can continue
delivering high quality care to their patients.
Revise Requirements for Implementing Budget Neutral Payment Cuts in
the MPFS
In addition to a lack of inflationary updates, each year physician
practices face arbitrary payment cuts due to budget neutrality
requirements in the annual fee schedule that, unless addressed in a
comprehensive way, will continue to plague physicians in the years to
come. Although we appreciate that Congress has provided some financial
relief to physicians to mitigate the impact of these payment cuts,
these measures do not provide the consistency and stability for
physicians to meet their expenses and provide high quality care to
seniors.
We urge the Finance Committee to approve legislation H.R. 6545, the
Physician Fee Schedule Update and Improvements Act, which would update
the threshold for implementing budget neutral payment cuts in the MPFS.
It would raise the budget neutrality threshold to $53 million and would
use cumulative increases in the MEI to update the threshold every 5
years afterwards. We believe that this is a practical approach, which
would help account for inflation.
ACP also supports the provisions in the bill that would require CMS to
update the direct costs associated with practice expenses (clinical
labor, the prices of equipment, and the prices of medical supplies)
simultaneously at least once every 5 years.
We also support provisions in this bill that would allocate 3 percent
to the 2024 Medicare conversion factor, as well as extend incentive
payments for participation in eligible advanced alternative payment
models (APMs) through 2026 and would tier bonuses according to how long
a physician has participated in an APM, to account for increased
upfront costs. The bill includes a provision that would provide the
Secretary of Health and Human Services (HHS) with flexibility for
tiering bonuses. ACP supports extending incentive payments for APMs to
support physicians' transition from a volume-based fee-for-service
health care system to one that is based on the value of health care
delivered to the patient. Instead of having a tiered approach for
bonuses, we recommend that Congress considers freezing the revenue
threshold increase for 5 years to encourage more physicians to
transition from fee-for service into APMs and maintain financial
viability for those already participating in such programs.
Ensure Accurate Calculation of Utilization of New Medicare Payment
Codes
ACP is requesting that Congress directs the Government Accountability
Office (GAO) to conduct a study and report back to Congress on the
utilization estimates and actual payments incurred from the
implementation of new Medicare codes by the Centers for Medicare and
Medicaid Services (CMS). This language is needed to more accurately
determine how much money in Medicare Part B was unnecessarily held back
versus the actual amount needed to pay for those services within the
first year of implementation. The concern is that money is often
withheld from the fee schedule due to budget neutrality and if the
estimates are above the actual code utilization, that money doesn't get
put back into the fee schedule to fund other service costs. If there is
an overestimation in utilization of new codes, it can lead to
unnecessary physician payment cuts, which ultimately can hinder
patients' access to timely care.
Remove Beneficiary Cost Sharing for Chronic Care Management Services
We remain concerned that many seniors have failed to access chronic
care management services due to a patient cost-sharing requirement
associated with this care. Current law mandates that Medicare
beneficiaries are subject to a 20% coinsurance requirement to receive
chronic care management services. This cost-sharing requirement creates
a barrier to care, as beneficiaries are not accustomed to cost-sharing
for care management services and may forego the services altogether as
a result. The latest data \4\ reveals that only 4% of Medicare
beneficiaries potentially eligible for chronic care management received
these services. That amounts to 882,000 out of a potential pool of 22.5
million eligible beneficiaries.
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\4\ https://aspe.hhs.gov/sites/default/files/documents/
31b7d0eeb7decf52f95d569ada0733b4/CCM-TCM-Descriptive-Analysis.pdf.
We urge you to approve H.R. 2829, the Chronic Care Management
Improvement Act of 2023. This legislation would remove the cost sharing
requirement for patients to access chronic care management services. We
also support allowing the physician that performs chronic care
management services to waive the requirement that the patient pay the
20% coinsurance fee associated with this service.
Support Increased Access to Telehealth Services for Medicare
Beneficiaries
We support the expanded role of telemedicine as a method of health care
delivery that will improve the health of patients with chronic
conditions by enabling and enhancing patient-physician collaborations,
increasing access to care and members of a patient's health care team,
and reducing medical and resource costs when used as a component of a
patient's longitudinal care.
Telehealth flexibilities from the pandemic-era public health emergency
(PHE) have been instrumental in improving access to care for patients
across the U.S. We were pleased that the Consolidated Appropriations
Act of 2023 extended many of those flexibilities through the end of
2024.
ACP believes that the following existing flexibilities should be
continued--and not allowed to expire--to support making telehealth an
ongoing and continued part of medical care now and in the future. We
urge the Finance Committee to make these existing flexibilities
permanent or to provide long-term extensions for them.
Expand originating sites and lift geographic requirements for
telehealth services
Allow federally qualified health centers (FQHCs) and rural
health clinics (RHCs) to continue to provide telehealth services
Allow the furnishing of audio-only telehealth services for
evaluation and management services
ACP Supports S. 2016/H.R. 4189, the Connect for Health Act of 2023
We urge Congress to approve S. 2016/H.R. 4189, the Connect for Health
Act of 2023. This legislation would permanently expand access to
essential telehealth services including expanding originating sites and
lifting geographic requirements for telehealth services and allowing
FQHCs and RHCs to continue to provide telehealth services. We urged the
Finance Committee to include this legislation in the original CHRONIC
Care Act and urge you to act to continue to ensure that seniors have
access to these vital telehealth services after they expire at the end
of this year.
Ensure Access to Audio-only Telehealth Services
We also support S. 1636/H.R. 3440, the Protecting Rural Telehealth
Access Act, a bill that would ensure that seniors may continue to
access audio-only telehealth consults with their physician after this
option expires at the end of this year. ACP strongly supports the use
of audio-only telehealth as an effective modality to address gaps in
health equity. Primary care and other evaluation and management
services delivered via telephone have become essential to a sizable
portion of Medicare beneficiaries who lack access to the technology
necessary to conduct video visits. These services are instrumental for
patients who do not have the requisite broadband/cellular phone
networks or have privacy concerns and do not feel comfortable using
video visit technology or do not possess the digital literacy to use
video technology.
Support the Implementation of Medicare Code G2211
We are pleased that at the beginning of this year, CMS implemented
Healthcare Common Procedure Coding System (HCPS) add on code G2211 to
compensate physicians for the extra work and resource costs required
for the coordination of care for complex or serious conditions. This
new Medicare code is essential to provide our physicians with the
resources necessary to provide high quality care for patients with
chronic conditions, and to ensuring that patients have access to a
holistic, dynamic, and integrated \5\ system. With implementation,
clinicians can now receive payment for services like chronic disease
management tracking, review of consultative or diagnostic reports, and
medication monitoring that would otherwise be unaccounted for in the
current E/M coding structure.
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\5\ https://assets.acponline.org/acp_policy/policies/
beyond_the_referral_position_paper_2022.
pdf.
A report by the National Academy of Sciences, Engineering, and Medicine
\6\ calls on policymakers to increase the investment in primary care as
evidence shows that it is critical for ``achieving health care's
quadruple aim: enhancing patient experience, improving population
health, reducing costs, and improving the health care team
experience.'' The report urges reforms to ensure that the Medicare
physician payment system no longer undervalues primary and cognitive
care, and more adequately incentivizes the type of quality, value-based
care that patients need. ACP greatly appreciates the changes by CMS and
Congress to help patients and physicians to establish and maintain
longitudinal relationships that improve health outcomes. The College
looks forward to continuing to work with CMS and Congress to ensure
patients have access to continuous and comprehensive care.
---------------------------------------------------------------------------
\6\ https://www.nationalacademies.org/our-work/implementing-high-
quality-primary-care.
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Expand the Primary Care Workforce
It is estimated that there will be a shortage of 17,800 to 48,000
primary care physicians by 2034.\7\ As our population ages with higher
incidences of chronic diseases, it is especially important that
patients have access to physicians trained in comprehensive primary and
team-based care for adults--a hallmark of internal medicine GME
training. It is worth noting that the federal government is the largest
explicit provider of GME funding (over $15 billion annually), with most
of the support coming from Medicare.
---------------------------------------------------------------------------
\7\ https://www.aamc.org/media/54681/download?attachment.
ACP appreciates Congress' continued GME expansion with the Consolidated
Appropriations Act, (CAA), 2023, H.R. 2617, adding an additional 200
GME slots, 100 for psychiatry and psychiatric subspecialties and 100
for other physician specialties. We urge Congress to continue this
momentum through the passage of the Resident Physician Shortage
Reduction Act of 2023, H.R. 2389/S. 1302, which would gradually raise
the number of Medicare-supported GME positions by 2,000 per year for 7
years.
Support the Elimination of Cost Sharing for Primary Care Services
We support waiving beneficiary cost sharing for primary care services.
We believe that cost sharing creates barriers to evidence-based, high
value, and essential care and should be eliminated, particularly for
low-income patients and patients with certain defined chronic
illnesses. Evidence \8\ shows that even very low Medicaid copayments
are associated with decreased use of necessary care. High deductibles
may serve as a barrier to receiving high-value, preventive care and
treatment after diagnosis.
---------------------------------------------------------------------------
\8\ https://www.kff.org/medicaid/issue-brief/the-effects-of-
premiums-and-cost-sharing-on-low-income-populations-updated-review-of-
research-findings/.
---------------------------------------------------------------------------
Support Sufficient and Sustained Increases in Medicare Payments for
Primary Care Services in a Manner that is not
Limited by Current Budget Neutrality Constraints
It is essential that Congress develop policies to provide the financial
stability needed to help physicians improve the quality and value of
care they furnish. As indicated above, a first step would be modifying
the current laws that impose arbitrary payment cuts in the MPFS every
year. ACP also encourages Congress to develop policies to ensure that
the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
fulfills its goal as intended to transform Medicare physician payment
from a fee-for-service (FFS) model that pays physicians based on the
number of services provided to a value-based model that incentivizes
the quality and outcome of care delivered to patients. Yet, concern is
growing that these programs have fallen far short of truly shifting
payments away from a still predominant FFS model or moving the needle
toward achieving greater equity in the delivery of health care.
Based on the 2020 ACP paper, Envisioning a Better U.S. Health Care
System for All: Health Care Delivery and Payment System Reforms,\9\ we
recommend that all payment systems substantially increase relative and
absolute payments for primary care commensurate with its value in
achieving better outcomes and lower costs. Inappropriate disparities in
payment levels between complex cognitive care and preventive services,
relative to procedurally oriented services, should be eliminated. It is
essential that payment policies recognize the value of primary care,
and that payment is sufficient to reverse the primary care physician
shortage. Access to primary care has consistently been associated with
higher quality of care,\10\ lower mortality rates,\11\ higher patient
satisfaction,\12\ and lower total system costs.\13\ Compared with other
developed countries, the United States ranked lowest in primary care
functions as well as health outcomes, yet highest in health
spending.\14\ Moreover, studies have shown health outcomes \15\ are
better in states with higher ratios of primary care physicians \16\
within the population than in those with lower ratios. Increasing one
primary care physician per 10,000 people in one state was associated
with a rise in that state's quality rank by more than 10 places and a
reduction in overall spending \17\ by $684 per Medicare beneficiary.
---------------------------------------------------------------------------
\9\ https://www.acpjournals.org/doi/epdf/10.7326/M19-2407.
\10\ https://pubmed.ncbi.nlm.nih.gov/16202000/.
\11\ https://jamanetwork.com/journals/jamainternalmedicine/
fullarticle/2724393.
\12\ https://pubmed.ncbi.nlm.nih.gov/9752374/.
\13\ https://pubmed.ncbi.nlm.nih.gov/22418570/.
\14\ https://pubmed.ncbi.nlm.nih.gov/11965331/.
\15\ https://jhu.pure.elsevier.com/en/publications/when-doctors-
share-visit-notes-with-patients-a-study-of-patient-a.
\16\ https://jhu.pure.elsevier.com/en/publications/when-doctors-
share-visit-notes-with-patients-a-study-of-patient-a.
\17\ https://pubmed.ncbi.nlm.nih.gov/15451981/c.
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Conclusion
We appreciate the Senate Finance Committee's efforts to bolster chronic
care in Medicare and their support for strengthening the MPFS to
provide physicians with the resources to provide high-quality care to
our seniors. We look forward to working with the Committee to implement
these policies as outlined in our statement. Should you have any
questions, please do not hesitate to contact Brian Buckley, Senior
Associate for Legislative Affairs at bbuckley@acponline.org.
______
American College of Radiology
1892 Preston White Drive
Reston, VA 20191
(703) 648-8900
https://www.acr.org
The American College of Radiology (ACR), representing approximately
41,000 radiologists, radiation oncologists, medical physicists, and
imaging professionals, appreciates the opportunity to submit a
statement for the record in response to the Senate Finance Committee
hearing titled ``Bolstering Chronic Care Through Medicare Physician
Payment'' held April 11, 2024.
As a physician medical specialty society, we are acutely aware of the
many challenges our members face as they provide high quality care to
Medicare beneficiaries. These challenges have been exacerbated by a
long-broken Medicare physician payment system, which has failed to keep
pace with the true cost of physician practices. According to an
American Medical Association analysis of Medicare Trustees data, when
adjusted for inflation, physician reimbursement has declined 26 percent
from 2001 to 2023. Failure to address this basic underlying
reimbursement deficiency threatens the continued ability of physicians
to care for their patients.
For many patients, especially those with chronic conditions, teams of
physician specialists work in concert with the primary care provider to
provide treatments for their patients. This coordinated, teamwork model
of care is disincentivized in the Medicare Physician Fee Schedule
(MPFS) due to statutorily required budget neutrality.
Additionally, physicians have singularly been excluded in the Medicare
system from any kind of annual inflation adjustment that directly
impacts the costs of running their practices. Congress must act to add
a Medicare Economic Index (MEI) based inflationary update to the MPFS.
With the passage of the Medicare Access and CHIP Reauthorization Act of
2015 (MACRA), Congress intended to encourage and incentivize a
transition from traditional fee-for-service to a value-based care
model, via either an alternative payment model (APM) or the Merit-based
Incentive Payment System (MIPS). Much of diagnostic radiology is non-
patient facing, however numerous significant exceptions are found in
the provision of breast imaging, and in interventional radiology
procedures. As largely non-patient facing physicians, as with a number
of other medical specialties, diagnostic radiologists have found it
extremely difficult to meaningfully participate in the MACRA statutory
programs. Recent studies show that one third to nearly one half of
radiologist interactions with Medicare beneficiaries are single,
isolated interactions.\1\ In addition, outdated and contested CMS
regulations prohibit diagnostic radiologists from billing evaluation
and management codes,\2\ the codes most frequently billed for patient
encounters. These two factors severely limit the ability of
radiologists to participate in any value-based payment model. As
Congress considers MACRA reform, the nature of practice for all
physicians, including radiologists and other non-patient facing
physicians, must be considered for true reform to take place.
---------------------------------------------------------------------------
\1\ Eric W. Christensen, et al.; Prevalence of ``One-Off Events''
in Radiology: Implications for Radiology in Episode-Based Alternative
Payment Models, https://www.sciencedirect.com/science/article/abs/pii/
S0363018823001238.
\2\ Medicare Benefit Policy Manual, Ch. 15, Sec. 80.6.1, https://
www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/
bp102c15.pdf.
As a specialty, diagnostic radiology is at the forefront of medical
technological innovation and use. The science of radiology is the major
component in the diagnosis of most injuries and diseases. If services
are provided in a privately owned, non-hospital based practice, the
cost and maintenance of the equipment used, the cost of owning or
renting space to provide these services, employment of staff and
dedicated technologists can only survive like all businesses if there
is sufficient reimbursement to cover these expenses. Unfortunately,
adequate reimbursement of the practice expense component of the MPFS,
which is intended to account for both direct practice expense (clinical
labor, supplies, and equipment) and indirect practice expense (rent,
administration, and other overhead), falls grievously short of
appropriate and necessary reimbursement to allow community based,
---------------------------------------------------------------------------
privately owned practices to survive.
In particular, collecting accurate indirect practice expense data has
been challenging due to the complex nature of data sets while having to
take into consideration of different specialties' practice patterns.
The indirect practice expense data needs to be routinely updated to
ensure it is accurate and representative to avoid potentially large
swings in reimbursement due to redistributive effects in a budget
neutral system.
These reimbursement reductions are felt hardest by smaller, independent
practices, like those in rural and underserved areas that continue to
face significant health care access challenges. In response, many
practices have been acquired by larger healthcare entities, including
hospitals, health systems, and corporate healthcare networks,
permanently impacting patient access to care. Private practices that
have not consolidated are forced to make very difficult decisions when
considering investing in technology, potentially hindering innovation
and quality of care delivered to patients.
The continued downward spiral of the MPFS and resulting changes in the
practice of medicine have contributed to a workforce shortage that is
being experienced by the entire physician community, radiology
included. Recent data from the American Association of Medical Colleges
(AAMC), projects a shortfall of up to 86,000 physicians by 2036. This
is extremely concerning, especially considering an ageing population
that has benefited from diagnostic imaging technological advances that
have enabled patients to live longer with chronic conditions.
Although many patients do not have a face-to-face encounter with their
radiologist, radiologists care for more Medicare beneficiaries per year
than any other physician, which indicates radiology's prominent role in
patient care.\3\ As a result, the demand for imaging services continues
to rise and the supply of radiologists is increasingly unable to meet
that demand. One way to reduce the increasing demand for imaging
services is to implement Section 218(b) of the Protecting Access to
Medicare Act of 2014 (PAMA) which requires all ordering providers to
consult appropriate use criteria (AUC) via a clinical decision support
mechanism prior to the ordering of advanced diagnostic imaging services
for Medicare beneficiaries. This educational tool is critical,
particularly in areas where non-physician providers order advanced
imaging to both educate the provider and ensure patients receive the
right test at the right time. The program can also help eliminate ``low
value'' imaging which can inconvenience the patient, cost both the
patient and the Medicare system money and often be of little to no
clinical relevance. Although Congress required the PAMA program be
implemented by 2017, the Centers for Medicare and Medicaid Services
(CMS) has faced significant logistical difficulty during the regulatory
process and in the 2024 MPFS final rule indefinitely paused
implementation pending statutory changes. CMS also reiterated their
support for the program and estimated that if implemented, the PAMA AUC
program could save the Medicare system approximately $700 million
annually.
---------------------------------------------------------------------------
\3\ Andrew B. Rosenkrantz et al.; Unique Medicare Beneficiaries
Served: A Radiologist-Focused Specialty-Level Analysis, Journal of the
American College of Radiology, https://www.
sciencedirect.com/science/article/abs/pii/S1546144018300462.
In order to move forward with AUC implementation, the ACR has proposed
significant administrative simplification language to the Senate
Finance Committee. We urge the swift adoption of the revised, updated
legislative text to provide CMS with the statutory changes needed to
implement the AUC program. These changes will first and foremost
improve patient care by decreasing unnecessary utilization and
associated copayment costs and provide a utilization management tool
far superior to any prior authorization process. Winnowing down the
number of unnecessary advanced imaging studies will also have a direct,
dramatic impact on unnecessary imaging studies which will advantage the
---------------------------------------------------------------------------
current status of workforce shortages in diagnostic radiology.
The ACR encourages swift Congressional action to increase both the
current and future supply of radiologists. To address current supply,
the expansion of the Conrad 30 program (S. 665) would allow more
physicians who have trained in the United States on a J-1 visa to
continue to practice medicine in the U.S. without having to return to
their home country post residency. The Healthcare Workforce Resilience
Act (S. 3211) would recapture unused immigrant visas for physicians and
nurses, which will ultimately lead to an increase in currently
practicing physicians to meet the needs of our population. To address
future supply, the ACR encourages passage of the Resident Physician
Shortage Reduction Act (S. 1302), and add Medicare funded graduate
medical education (GME) slots and help close the projected physician
shortfall.
We are encouraged that Congress is recognizing the need for substantive
Medicare physician payment reform and look forward to future
discussions. If you have any questions, please contact Cindy Moran,
Executive Vice President, Government Relations, Economics and Health
Policy, at cmoran@acr.org.
Thank you,
Cynthia R. Moran
Executive Vice President
______
American College of Surgeons
Statement of Firpo Carr, Ph.D., Health Psychologist
As a Health Psychologist who is an Affiliate Member of the American
College of Surgeons (ACS), I listened with rapt attention to testimony
by a panel of experts appearing before The Senate Finance Committee on
April 11, 2024, about ``Bolstering Chronic Care through Medicare
Physician Payment.'' There was an abundance of rich, invaluable
information to digest.
Of course, I watched the proceeding through the lens of a psychologist
interested in studying surgeons' mental health and well-being.
However, I surmised that the challenges confronting surgeons and
physicians treating chronic care patients and navigating the morphing
puzzle pieces of the Medicare Physician Payment system are daunting and
inescapably cause significant stress. In this regard, self-care must be
emphasized.
Undoubtedly, all had a vested interest in the subject matter. For
instance, it was reassuring to witness Senators tincture their
observations on chronic care with experiences of family members'
interactions with the medical system. In doing so, they made themselves
relatable to their constituents and sensitive to the American people's
general needs.
Accolades aside, there was also reason for pause.
For example, it was concerning to learn from Senator Elizabeth Warren
that a particular American Medical Association (AMA) committee has an
overrepresentation of specialty physicians who, by sheer numbers,
overwhelm primary care physicians (PCP) when voting on payments.
Specialists vote to pay themselves considerably more than PCPs. This
disparity, which negatively impacts physicians in private practice and
their patients, should be addressed.
Moving forward, I was pleased to observe the alertness, acuity, and
measured passion of Senators and panelists alike. Self-care should not
be underestimated, particularly when politicians and panelists wrestle
with the nuts and bolts of effective ways of bolstering chronic care
through Medicare physician payment.
Unsurprisingly, I was keenly interested in what ACS Executive Director
& CEO Patricia L. Turner, M.D., MBA, FACS, had to say and was pleased
to see her emphasize how the ACS is a pacesetter for high-quality,
evidence-based surgical care as substantiated by its 13 quality
programs.
Additionally, I especially appreciated that, along with Dr. Turner's
insightful expert testimony, she showed deference to the profound
thoughts of her fellow expert panelists--each representing their
respective organizations--stating that all the boats in the harbor can
rise together.
The main takeaway for me was that, while there is still plenty of work
to be done, the perseverance of the Senate Finance Committee should be
applauded. The endurance and stick-to-itiveness of panelists
representing their colleagues should be celebrated.
To be sure, the issues are formidable and can only be dealt with
through a concerted effort. All will do well to be mindful that the
first step to resolution is self-care as reflected in the maxim
expressed in Latin, Medice, cura te ipsum, that is, ``Physician, heal
thyself'' (Luke 4:23).
Humble thanks to Senator Ron Wyden and the rest of the Senate Finance
Committee, as well as to all the esteemed panelists.
______
American Diabetes Association
2451 Crystal Drive, Suite 900
Arlington, VA 22202
tel: 800-342-2383
https://diabetes.org/
Statement of Lisa Murdock, Chief Advocacy Officer
Thank you, Chairman Wyden, Ranking Member Crapo, and distinguished
members of the Finance Committee, for providing the American Diabetes
Association (ADA) the opportunity to submit written comments regarding
the impact of Medicare physician reimbursement policy on care for
Americans with diabetes and other chronic conditions. We appreciate you
considering this important topic at this critical time.
The ADA is the nation's leading voluntary health organization fighting
to bend the curve on the diabetes epidemic and help people living with
diabetes thrive. For more than 80 years, the ADA has been driving
discovery and research to treat, manage and prevent diabetes, while
working relentlessly for a cure. We help people with diabetes thrive by
fighting for their rights and developing programs, advocacy and
education designed to improve their quality of life.
Access to care for the 38.4 million Americans with diabetes is critical
to effective management of this condition and to preventing
unnecessary, dangerous and often life-threatening complications. That
access is at risk as our country faces shortages of physicians--and in
particular endocrinologists and primary care doctors--who are crucial
to the treatment of diabetes.
Adequate Medicare reimbursement across physician specialties is a
necessary step toward addressing this country's shortage of physicians
and other health workers. Since the beginning of the COVID-19 pandemic,
nearly one in five health care workers has resigned, and surveys
suggest that nearly 50 percent of the U.S. health care workforce has
considered or is considering leaving within the next 2 years.\1\ This
situation is dire for people with diabetes, who outnumber practicing
endocrinologists by a ratio of 40,000 to 1.\2\ Partly as a result, the
diabetes community relies overwhelmingly on primary care providers--who
care for some 90 percent of people with Type 2 diabetes, the fastest-
growing subset of the diabetes population--to oversee their insulin
regimens, provide diabetes education, and prescribe continuous glucose
monitors and other diabetes management tools. Nearly 70 percent of
outpatient visits for all adults with diabetes take place in primary
care settings, and 76 percent of visits are scheduled specifically due
to diabetes.\3\ The post-pandemic ``great resignation'' is having an
impact here too. In 2021 and 2022, this wave of clinician resignations
already included 145,213 physicians and 34,834 nurse practitioners,
coming predominantly from internal medicine and family practice.\4\
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\1\ Ethan Popowitz, ``Addressing the Healthcare Staffing
Shortage,'' Definitive Healthcare, September 2023, https://
www.definitivehc.com/sites/default/files/resources/pdfs/Addressing-the-
healthcare-staffing-shortage-
2023.pdf?utm_source=newsletter&utm_medium=email&utm_
campaign=newsletter_axiosvitals&stream=top.
\2\ ``Number of People per Active Physician by Specialty, 2021.''
\3\ Scott J. Pilla, MD, MHS, Jodi B. Segal, MD, MPH, and Nisa M.
Maruthur, MD, MHS, ``Primary Care Provides the Majority of Outpatient
Care for Patients with Diabetes in the US,'' Journal of General
Internal Medicine, July 2019, https://www.ncbi.nlm.nih.gov/pmc/
articles/PMC6614213/
#::text=Among%20non%2Dhospital%2Dbased%20office,a%20patient%20reason%
20for%20visit.
\4\ Popowitz, ``Addressing the Healthcare Staffing Shortage.''
To improve the stability of primary care practitioners, the federal
government should increase Medicare reimbursement rates and especially
focus payments on expanding under-resourced primary care teams. Team-
based care is a critical part of the answer to the problems of
physician shortage and increased workload. Research shows that nurse
practitioners, physician assistants and other advanced care providers,
in addition to pharmacists and community health workers, help patients
reduce A1C, begin and adjust medications without physician approval,
and generally improve clinical outcomes for patients with type 2
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diabetes in primary care settings.
This approach does not require Medicare to reinvent the wheel. Congress
and the administration can encourage team-based care delivery in
primary care practices by increasing reimbursement rates through
existing federal health care programs for providers and their community
partners. The Centers for Medicare and Medicaid Services (CMS) is
already doing some of this important work. CMS proposed changes to its
Physician Fee Schedule for calendar years 2023 and 2024 to increase
reimbursement rates for primary care clinicians and chronic care
management services and pay for services provided by ``auxiliary
personnel'' such as community health workers. CMS has also launched a
series of demonstration projects that use prospective-based payments to
incentivize advanced primary care delivery. Its recently announced
project--the ACO Primary Care Flex Model--will test whether and how
these payment models can improve outcomes and reduce costs in the
Medicare Shared Savings Program, especially for those Medicare
beneficiaries living in medically underserved communities. Congress and
the patient community stand to learn a great deal from the outcome of
this primary care payment model in particular, as the findings from ACO
Primary Care Flex can inform how Medicare reimbursement affects
outcomes for patients living with chronic conditions.
Medicare can also reduce expensive complications from diabetes by using
reimbursing policy to encourage more preventive care services. ADA
recently launched the Amputation Prevention Alliance to spread
awareness about preventive interventions, including those that can be
performed in a primary care office, to limit diabetes-related
amputations. Eighty-five percent of diabetes-related amputations are
preventable, and amputees with diabetes experience a significantly
elevated risk of mortality following the loss of a limb--one in 10 dies
within 30 days of surgery, and one in six dies within 90 days.\5\
Minimally invasive procedures to diagnose cases of peripheral artery
disease (PAD) and critical limb ischemia (CLI) are generally not
covered by federal health care programs like Medicare. The ADA urges
Medicare to cover PAD screening for at-risk beneficiaries without cost-
sharing requirements.
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\5\ Jason K. Gurney, James Stanley, Juliet Rumball-Smith, Steve
York, ``Postoperative Death After Lower-Limb Amputation in a National
Prevalent Cohort of Patients with Diabetes,'' Diabetes Care, April 5,
2018, https://care.diabetesjournals.org/content/41/6/1204.
Congress may also consider a value-based payment model in which
reimbursement rates for primary care providers are adjusted based on
access to diabetic foot ulcer and PAD assessments and patient-reported
outcome metrics (e.g., wound healing time, wound free time, wound
recurrence rates and low to high amputation ratios). Ultimately,
achievable Medicare reimbursement reforms that prioritize all members
of the primary care team and focus on chronic care management and
preventive care can improve patient outcomes and significantly reduce
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long-term costs to the U.S. health care system.
Thank you for the opportunity to submit this testimony for the record.
The ADA looks forward to continuing to work with Congress to make sure
our community has access to the health care providers and resources
they need to effectively manage their diabetes.
______
American Geriatrics Society
40 Fulton Street, Suite 809
New York, NY 10038
212-308-1414 tel
https://www.americangeriatrics.org/
The American Geriatrics Society (AGS) greatly appreciates the
opportunity to provide feedback to the Senate Committee on Finance as
it begins its efforts to develop legislation to reform the Physician
Fee Schedule and update MACRA.
The mission of the AGS, a nationwide not-for-profit organization
comprised of nearly 6,000 geriatrics clinicians is to improve the
health, independence, and quality of life of all older adults. Our
members are pioneers in advanced-illness care for older individuals,
with a focus on championing interprofessional teams, eliciting personal
care goals, and treating older people as whole persons. AGS believes in
a just society, one where we all are supported by and able to
contribute to communities where ageism, ableism, classism, homophobia,
racism, sexism, xenophobia, and other forms of bias and discrimination
no longer impact healthcare access, quality, and outcomes for older
adults and their caregivers. AGS believes increased payment accuracy
for clinicians paid under the Physician Fee Schedule and through the
Quality Payment Program (QPP), established by the Medicare Access and
CHIP Reauthorization Act (MACRA) is a cornerstone to improving access
to care in rural and historically minoritized communities. AGS is
actively engaged in efforts to advance value-based, high-quality care
for older Americans, and we appreciate the committee's willingness to
listen to our concerns and experience with these programs.
MACRA replaced the unworkable cost control mechanism of the
Sustainable Growth Rate (SGR) with a new payment system intended to
incentivize value-based care. However, MACRA--particularly the
provisions establishing the Merit-based Incentive Payment System
(MIPS)--uses an ``accountability'' mechanism that is largely siloed by
individual disease states and conditions, focuses disproportionately on
performance and payment at the individual clinician and individual
specialty level, and, as a result of its budget neutrality
requirements, picks clinician ``winners'' and ``losers.'' We cannot
achieve the promise of value-based care with this fragmented approach,
which is organized around organ-specific care and does not take a whole
person approach to health and well-being. In our view, a high-quality,
cost-effective healthcare system results from care that is person-
centered, team-based and grounded in strong primary care--the payment
system must reflect, reinforce, and incentivize this type of care.
Specifically, the AGS believes that truly value-based care
requires:
Multi-disciplinary teams of physicians and non-physician
practitioners caring for patients, with the primary care
practitioner central to facilitating care coordination.
Strong primary care, as envisioned in the report of the
National Academies of Sciences, Engineering and Medicine:
``Implementing High Quality Primary Care,''\1\ with meaningful
education for beneficiaries on the importance of every person
having an established source of primary care.
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\1\ National Academies of Sciences, Engineering, and Medicine.
2021. Implementing High-
Quality Primary Care: Rebuilding the Foundation of Health Care.
Washington, DC: The National Academies Press. doi: 10.17226/25983.
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A whole-person orientation with input from patients and
their families, where areas of quality measurement focus on
patient goals and experiences, person-oriented outcomes, and
the total cost of care for that patient rather than on
condition- or specialty-specific outcomes as a metric for
higher reimbursement.
An intentional commitment to equitable care and reducing
disparities by, among other strategies, financially supporting
organizations embedded in underserved communities, including
rural and urban Health Professional Shortage Areas, and
providing financial incentives for care management services,
particularly to historically minoritized and rural communities
(e.g., support for self-care or navigating complex health
systems). Importantly, the payment system must not financially
``punish'' those who care for communities with less advantage
or people with greater complexity.
A regulatory, payment, and technological framework that
permits providers flexibility to establish practice
organizations that are best for the people they care for and
that reduces the financial, legal, and regulatory burdens that
have led to the rapid consolidation and monetization of
healthcare in the United States. Nearly three-quarters of U.S.
doctors work for corporate entities such as private equity
firms, health insurers and hospitals in 2022, up from 69
percent in 2021.\2\ Rather than driving system efficiencies and
savings, studies show that private equity acquisitions of
physician practices are associated with increased healthcare
spending and patient utilization, with the average charge per
claim increasing 20 percent and the average allowed amount per
claim up 11 percent post-acquisition.\3\
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\2\ Physicians Advocacy Institute, COVID-19's Impact on
Acquisitions of Physician Practices and Physician Employment 2019-2021,
a study prepared by Avalere Health, April 2022, http://
www.physiciansadvocacyinstitute.org/Portals/0/assets/docs/PAI-Research/
PAI%20Avalere%20
Physician%20Employment%20Trends%20Study%202019-
21%20Final.pdf?ver=ksWkgjKXB_yZfI
mFdXlvGg%3d%3d.
\3\ Singh Y, Song Z, Polsky D, Bruch JD, Zhu JM. Association of
Private Equity Acquisition of Physician Practices With Changes in
Health Care Spending and Utilization. JAMA Health Forum.
2022;3(9):e222886. doi:10.1001/jamahealthforum.2022.2886.
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Accessible care settings for people, including care that is
accessible to patients in their homes through telemedicine and
programs such as ``hospital at home'' and ``Independence at
Home,'' when clinicians deem it appropriate based on shared
decision-making with their patients.
Administrative expertise and analytic support for clinical
teams, with an overall goal of reducing administrative burden,
so that clinicians can both maintain focus on care and still
have ownership and involvement in quality measurement (and
prevent unnecessary consolidation of physician practices).
Electronic health information exchanges and electronic
health records (``EHR'') systems that are helpful, not a
hassle, and that easily permit patient information to be shared
across different entities that care for the patient to support
clinical decision-making and care coordination and mitigate
patient risk and waste (including through use of data-driven
tools that take advantage of artificial intelligence
technologies).
Both stability and flexibility whereby investments in value-
based care transformation can be confidently made, but with
enough flexibility to correct for the inevitable
miscalculations and missteps inherent in any change.
Greater diversity in the health care professions through
more reasonable cost of education and greater consideration of
programs like the National Health Services Corps.
Payments that include:
Incentives that are generally positive,
with limited negative incentives for maintaining the
fee-for-service status quo.
Reasonable payment updates that reflect
changes in the cost of providing care as well as
inflation. Adjusted for inflation in medical practice
costs, as measured by the Medicare Economic Index
(MEI), Medicare physician payment rates declined 20
percent from 2001 to 2021.
The AGS believes that these are attainable goals and ones that must
be reflected in any legislative effort that considers the future of
physician payment. It is also critical that Congress recognize that the
long-term vision of developing a better performing health care system
at times may be in tension with saving Medicare dollars in the short
run. Congress should not preoccupy itself with short-term savings to
the detriment of long-term goals. As with any system seeking
transformation, we must be willing to make upfront investments in order
to achieve long-term efficiencies and quality improvements.
With these goals in mind, we recommend that the Committee take a
holistic approach to reviewing physician payment under Medicare. At a
minimum, Congress must establish a stable, annual Medicare physician
payment update that keeps pace with inflation and practice costs and
allows for innovation to ensure Medicare patients continue to have
access to multi-disciplinary team-based care across specialties.
Our recommendations for steps that Congress could take that
stabilize the payment system include:
1. Foster performance-based care that values and supports
geriatrics care teams for complex and high-cost patients.
The Center for Medicare and Medicaid Innovation has
comprehensive primary care programs. These programs allow the
physician practice to increase capacity and skill sets by
providing a monthly fee that is designed to allow practices to
bring in nurse care managers, pharmacists, integrated
behavioral health, staff to support assistance in patients with
disadvantaged social determinants of health, for example. This
promotes more effective panel management and greater access to
primary care. It allows practices to be ready to assume the
obligations of accountable care payment programs. They also
promote partial capitation for primary care services, so
practices are not just focused on visit volumes. These programs
should be rapidly expanded for practices that wish to enroll in
them. They implement the National Academies of Sciences,
Engineering, and Medicine \4\ recommendations to strengthen
interprofessional teams and ensure that care teams reflect the
diversity of the communities they serve. However, expansion
will require infrastructure support, funding, and attitudinal
shift.
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\4\ National Academies of Sciences, Engineering, and Medicine.
2021. Implementing High-
Quality Primary Care: Rebuilding the Foundation of Health Care.
Washington, DC: The National Academies Press. https://doi.org/10.17226/
25983.
Comprehensive Primary Care Plus (``CPC+'') is a national
advanced primary care medical home model that aims to
strengthen primary care through regionally-based multi-payer
payment reform and care delivery transformation. This program
not only strengthens primary care for all beneficiaries but is
also designed to meet the specific needs of the chronically ill
patient. Currently, participation is limited to certain
geographic regions and not all practices that hoped to
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participate were selected.
Beyond CPC+, there are many successful models and innovations
that help achieve the goal state for primary health care. We
urge the Committee to review ``Complexities of Care: Common
Components of Models of Care in Geriatrics'' (2022)\5\ as well
as the models listed in the NASEM's report, ``Implementing
High-Quality Primary Care: Rebuilding the Foundation of Health
Care (2021).''\6\ Complexities of Care, published in the
Journal of the American Geriatrics Society explored the common
components of models of care in geriatrics when caring for
older adults with ``care complexity.'' The article defines care
complexity in older adults, reviews healthcare models and the
most common components within them and identifies potential
gaps that require attention to reduce the burden of care
complexity in older adults. While these models show great
promise, most are, unfortunately, limited in scope and not
universally available.
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\5\ https://agsjournals.onlinelibrary.wiley.com/doi/full/10.1111/
jgs.17811.
\6\ https://www.nationalacademies.org/our-work/implementing-high-
quality-primary-care.
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2. Reinstate the Primary Care Bonus Payment
As part of the Affordable Care Act (ACA), Medicare
implemented a 10 percent bonus payment for primary care
physicians for 5 years. The bonus payment expired at the end of
2015. The AGS urges Congress to consider restoring the payment
indefinitely, which would help create a more stable environment
and provide an incentive for new physicians, advanced practice
nurses, and physician assistants to enter and stay in primary
care, including geriatrics. The current shortage is the result
of under-funding of primary care, which has made careers in
primary care medicine unattractive to graduating physicians
because of the relatively low incomes they generate compared to
other medical fields. Primary care also has greater levels of
responsibility between visits, in quality reporting, and in
dealing with the shortcomings of electronic health records
(EHRs).
3. Expand Telehealth
Medicare beneficiaries need permanent access to telehealth
and practices need adequate payment for it. We have learned
telehealth can improve safety and access for Medicare
beneficiaries when they receive healthcare services. We also
have experienced the need to cover audio only services due to
issues with patients' technology management challenges and
broadband access. These services can effectively substitute for
in person visits \7\ and create access for those that
previously lacked the ability to get medical and behavioral
healthcare needs met. Payment must be adequate for these
services. These services require the use of clinical staff and
indirect practice expenses. Insufficient payment undermines a
practice's ability to provide the services.
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\7\ Cuellar A, Pomeroy JML, Burla S, Jena AB. Outpatient Care Among
Users and Nonusers of Direct-to-Patient Telehealth: Observational
Study. J Med Internet Res. 2022 Jun 6;24(6):e37574. doi: 10.2196/37574.
PMID: 35666556; PMCID: PMC9210206.
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4. Revamp Quality Measurement
AGS strongly encourages the development and deployment of
quality metrics related to patient goals and treatment burden.
Medicare should create and adopt a more holistic approach to
quality measurement in older adults with multiple chronic
conditions that does not rely on single disease payments.
Elements of such a system could be modeled upon the 4Ms of age-
friendly care with an emphasis on what matters to the
person.\8\
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\8\ Institute for Healthcare Improvement. ``Age-Friendly Health
Systems: Guide to Using the 4Ms in the Care of Older Adults'' (2020).
https://www.americangeriatrics.org/sites/default/files/inline-files/
IHIAgeFriendlyHealthSystems_GuidetoUsing4MsCare.pdf.
Thank you for your leadership and commitment to reforming MACRA to
stabilize physician practices and strengthen primary care, particularly
for older adults living with chronic conditions and/or functional
limitations. The AGS believes that traditional Medicare must remain a
strong, viable option to help balance market forces in Medicare
Advantage and preserve beneficiary choice and access. It is crucial
that reforms to MACRA ensure that we have a robust primary care
workforce that is equipped and able to deliver the person-centered care
that Medicare beneficiaries deserve; that is, assuring the primacy of
individuals' health and life goals in their care planning and in the
care they receive. The AGS looks forward to working collaboratively
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with you to achieve these goals as you develop legislative solutions.
______
American Medical Association
25 Massachusetts Avenue, NW, Suite 600
Washington, DC 20001
(P) 202-789-7426
The American Medical Association (AMA) appreciates the opportunity to
submit this Statement for the Record for the U.S. Senate Finance
Committee hearing entitled ``Bolstering Chronic Care through Medicare
Physician Payment.'' This hearing signifies a critical step forward in
the ongoing endeavor to modernize traditional Medicare, focusing on the
management and treatment of chronic illnesses and the payment
structures for physicians and other health professionals. The AMA
commends the Committee for its dedication to enhancing Medicare's
support for individuals with chronic conditions, such as cancer,
diabetes, and heart disease. This commitment was exemplified by the
passage of the CHRONIC Care Act in 2018, which instituted comprehensive
policy improvements to better meet the complex health care needs of
seniors. The AMA is fully supportive of these efforts to update and
strengthen Medicare and looks forward to collaborating with the
Committee to aid in shaping policies ensuring high-quality, sustainable
care for future generations.
CHRONIC CARE MANAGEMENT IMPROVEMENT ACT OF 2023
The AMA supports H.R. 2829, the Chronic Care Management Improvement Act
of 2023, which is a critical avenue for enhancing chronic disease
management within the Medicare program. This legislation, aimed at
eliminating patient cost-sharing for Chronic Care Management (CCM)
services, addresses a significant barrier that has hindered the
widespread adoption of these essential services. Despite the
demonstrated benefits of CCM in improving patient outcomes and reducing
hospitalizations, the latest data points to a stark underutilization,
with only 4 percent of eligible Medicare beneficiaries receiving CCM
services representing only 882,000 out of an estimated 22.5 million.
In addition to the legislative removal of cost-sharing obligations, a
concerted effort by the Centers for Medicare & Medicaid Services (CMS)
to partner with states could further increase access to CCM services.
This could be achieved through the inclusion of CCM services in state
Medicaid plans. Such measures would not only amplify the reach of CCM
but also enhance patient engagement in self-management of their health
conditions to prevent exacerbations, particularly for those managing
chronic diseases.
Waiving patient cost-sharing for CCM services is an important step
towards removing obstacles to care management services, including
patient-initiated navigation (PIN), and ensuring that Medicare
beneficiaries receive the comprehensive care coordination they require.
This legislative action, coupled with enhanced CMS and state
collaboration, can improve the use of CCM services and health outcomes
for millions of Americans living with chronic conditions.
AMA'S COMMITMENT TO PREVENTING AND TREATING CHRONIC DISEASE
Chronic disease is a leading cause of death and disability in the
United States (U.S.). According to the Centers for Disease Control and
Prevention (CDC), each year more than 877,500 Americans die of heart
disease or stroke, more than 1.7 million people are diagnosed with
cancer, and more than 37.3 million Americans have diabetes, with an
additional 98 million adults diagnosed with prediabetes, which puts
them at risk for type 2 diabetes.\1\ CDC estimates indicate that these
diseases, along with other conditions such as obesity, Alzheimer's, and
mental health issues, place a significant burden on the economy,
accounting for 90 percent of our nation's $4.1 trillion in annual
health care spending. These figures will undoubtedly worsen as the
population ages.\2\
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\1\ https://www.cdc.gov/chronicdisease/about/costs/index.htm.
\2\ Id.
The AMA is committed to improving the health of the nation and reducing
the burden of chronic diseases. Our primary focus is preventing
cardiovascular disease (CVD), the leading cause of death in the U.S.,
accounting for one in four deaths among adults. Two major risk factors
for CVD are hypertension and type 2 diabetes. CVD risk factors and
associated morbidity and mortality inequitably impact Black, Hispanic/
Latinx, Indigenous, Asian/Pacific Islanders, and other people of color.
While specific causes of the inequities vary by each respective group,
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structural and societal barriers are attributed as primary reasons.
To prevent CVD and address related health inequities, the AMA is
developing and disseminating CVD prevention solutions in collaboration
with health care and public health leaders. These solutions educate
clinical care teams and patients, guide health care organizations
(HCOs) in clinical quality improvement and promote policy changes to
remove barriers to care. The AMA disseminates these solutions through
strategic alliances with various organizations, including the CDC, the
American Heart Association (AHA), and West Side United in Chicago.
Another CVD risk is obesity which is associated with cardiovascular
disease mortality independent of other cardiovascular risk factors. The
AMA is working with other medical societies, including the American
College of Physicians and the Obesity Medicine Association, to identify
opportunities to improve access to evidence-based obesity treatments.
The AMA supports S. 2407/H.R. 4818, the Treat and Reduce Obesity Act,
which would provide Medicare beneficiaries with access to safe,
effective, and life-saving treatments. The bill aims to effectively
treat and reduce obesity in older Americans by enhancing Medicare
beneficiaries' access to health care professionals who are best suited
to provide intensive behavioral therapy and by allowing Medicare Part D
to cover Food & Drug Administration (FDA)-approved anti-obesity
medications.
PREVENTIVE HEALTH SAVINGS ACT
Allowing Congress the ability to look at the financial impact of
preventive health legislation beyond the 10-year CBO scoring window is
another important tool that is critical for addressing chronic
conditions in this country. Consequently, the AMA has endorsed \3\ S.
114/H.R. 766, originally named as the Preventive Health Savings Act,
and renamed in the House of Representatives as the ``Dr. Michael C.
Burgess Preventive Health Savings Act.'' Congress should be able to
consider the long-term economic benefits of legislation that promotes
wellness and disease prevention and reduces the incidence of chronic
conditions, yet it is constrained from doing so by the 10-year CBO
scoring window. This legislation will importantly provide the Chair and
Ranking Member of either budget or health-related committees in the
House and Senate with the ability to request an analysis of the two 10-
year periods beyond the existing initial 10-year window. Furthermore,
the legislation's definition of ``preventive health'' appropriately
captures the unique nature of this concept by including actions that
focus on the health of the public, individuals, and defined populations
to protect, promote, and maintain health and wellness, as well as
prevent disease, disability, and premature death as demonstrated in
credible, publicly available studies and data. It is widely recognized
that preventing a chronic condition will improve health outcomes,
reduce costs to our health care system and provide patients with a
better quality of life. It is well past time for the CBO to have a
scoring methodology that accurately accounts for these long-term
economic benefits.
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\3\ https://searchlf.ama-assn.org/letter/
documentDownload?uri=%2Funstructured%2Fbinary%2
Fletter%2FLETTERS%2Flfcts.zip%2F2024-2-5-Letter-to-Chair-Arrington-and-
Ranking-Member-Boyle-re-HR-766-Preventive-Health-Savings-Act-118th-
Congress-v3.pdf.
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PREVENT DIABETES ACT
The CDC's National Diabetes Prevention Program (DPP), which has the
objective of decreasing the incidence of patients developing Type 2
diabetes by incorporating behavioral counseling, exercise, and
nutrition counseling, is a proven program that has demonstrated a
decrease in the incidence of patients with pre-diabetes, thereby
reducing the incidence of Type 2 diabetes. This successful program was
the first pilot approved by the Centers for Medicare and Medicaid
Innovation (CMMI) for expanded Medicare coverage and is known as the
Medicare Diabetes Prevention Program (MDPP). The limitations Medicare
has placed on the MDPP have reduced uptake of these important diabetes
prevention services and thereby limited the success of the program in
preventing the incidence of Medicare beneficiaries with pre-
diabetes. As of the end of 2022, cumulative MDPP enrollment stood at
4,848 Medicare beneficiaries, which is striking considering more than
half a million individuals participate in the CDC's National DPP
program when offered through their health plan or employer. Many
Congressional districts lack in-person MDPP locations to serve the tens
of thousands of at-risk constituents otherwise eligible for these
services under Medicare. Almost one in three adults aged 65 and older
have diabetes. According to CMS, medical care for seniors with diabetes
and its complications cost the U.S. $205 billion in 2022, most of it
paid by Medicare. According to the CDC, some 98 million Americans have
prediabetes, including 27.2 million who are aged 65 and older. Without
a significant course correction, those numbers will only grow.
Consequently, the AMA has endorsed H.R. 7856, the PREVENT DIABETES Act.
This legislation, which would broaden access to diabetes prevention
services by aligning the MDPP with the CDC's DPP, make MDPP a permanent
benefit in Medicare, ensure seniors can participate in the program more
than once, and expand access to all CDC-recognized delivery modalities,
including virtual diabetes prevention platforms in the program, will
help ensure that the full potential of this program to reduce the
incidence of Medicare beneficiaries with pre-diabetes, and prevent Type
2 diabetes, is realized.
PRESERVING PATIENT ACCESS TO CARE THROUGH PHYSICIAN FINANCIAL
STABILITY
Need for an Inflation-Based Update to Physician Payment
For services provided to Medicare beneficiaries in the first 2 months
of the year, physicians' payments were cut 3.37 under current law. We
appreciate Congress for acting to partially mitigate that reduction,
however as of March 9th, physicians are still experiencing a Medicare
cut of nearly 2 percent. At the same time, the cost of practicing
medicine is rising at the fastest rate in decades, as CMS estimated the
cost to run a medical practice increased by 4.6 percent in 2024. An
inflation-based update to physician payment is critical to change the
unsustainable trajectory of the current payment system, which not only
jeopardizes patients' access to physician services but also poses
significant challenges in managing chronic conditions effectively. The
consequences of the continued real-dollar cuts to Medicare payments,
exacerbated by the absence of statutory updates aligned with the
inflation in medical practice costs and the problems with Medicare's
budget neutrality rules has resulted in a 29 percent decline in
physician payments adjusted for inflation in medical practice costs
since 2001.
Physician practices cannot continue to absorb increasing costs while
their payment rates dwindle. In multiple annual reports, the Medicare
Trustees have stated that they ``expect access to Medicare-
participating physicians to become a significant issue in the long
term'' unless Congress takes steps to bolster the system. The Trustees
noted in 2023, for example, that ``the law specifies the physician
payment updates for all years in the future, and these updates do not
vary based on underlying economic conditions, nor are they expected to
keep pace with the average rate of physician cost increases.'' The
current Medicare physician payment system--with its lack of an adequate
annual update--is particularly destabilizing as physicians, many of
whom are small business owners, contend with a wide range of shifting
economic factors when determining their ability to provide care to
Medicare beneficiaries.
Hospitals, skilled nursing facilities, and nearly every other Medicare
provider receive an automatic annual update tied to inflation.
Physicians compete in the same marketplaces as these providers for
clinical and administrative staff, equipment, and supplies. Yet
physicians are at a significant disadvantage due to payment cuts and
because their payments have failed to keep up with inflation.
Furthermore, hospitals have multiple sources of relief during times of
high inflation, including the 340B program and Disproportionate Share
Hospital (SDH) payments to account for uncompensated care. It is no
wonder that these trends are driving consolidation, which is highly
likely to increase future Medicare costs as these other providers
receive increasingly higher payments than the diminishing number of
independent medical practices. A recent AMA analysis \4\ shows that by
far, the most cited reason that independent physicians sell their
practices to hospitals or health systems had to do with inadequate
payment. Next were the need to better manage payers' regulatory and
administrative requirements and the need to improve access to costly
resources. The AMA strongly supports policies that promote market
competition and patient choice. Payment adequacy is necessary for
physicians to continue to have the ability to practice independently.
---------------------------------------------------------------------------
\4\ https://www.ama-assn.org/system/files/2022-prp-practice-
arrangement.pdf.
In its recent March Report \5\ to Congress, the Medicare Payment
Advisory Commission (MedPAC) called for a physician payment update tied
to the Medicare Economic Index (MEI) in 2025, following a similar
recommendation \6\ for increasing physician payment in 2024. Unlike the
temporary patches that Congress has adopted in recent years, MedPAC
calls for permanent updates to physician payment that would be built
into subsequent years' payment rates. While the AMA has commended the
Commission for taking this significant step, we note that implementing
an inflation-based update based on only half of the full MEI growth
rate, as recommended, would be a missed opportunity to meaningfully
address the perennial issue of Medicare physician underpayment that
threatens stable access to care for millions of Medicare beneficiaries.
---------------------------------------------------------------------------
\5\ https://www.medpac.gov/wp-content/uploads/2024/03/
Mar24_Ch4_MedPAC_Report_To_
Congress_SEC.pdf.
\6\ https://www.medpac.gov/wp-content/uploads/2023/03/
Ch4_Mar23_MedPAC_Report_To_
Congress_SEC.pdf.
We continue to believe that MedPAC's rationale that half of MEI is
sufficient because the practice expense component of physician payment
accounts for approximately half of total Medicare physician payments
reflects an incomplete picture of the cost of running a medical
practice. It is well understood that the practice expense component
does not cover all practice costs. For example, in the 2024 Medicare
Physician Payment Schedule (MPS) final rule, the Centers for Medicare &
Medicaid Services (CMS) applies a direct cost scaling adjustment of
0.4637. In other words, for a supply that costs $100, CMS will include
$46.37 or a reduction of $53.63 from the invoice cost of the item in
the direct expense allocation for the service. Additionally, practice
expense is only one component of a multifactorial formula to compensate
physicians for the total costs of running a medical practice and caring
for Medicare beneficiaries. Payment for physician work--the time,
energy, and expertise devoted to treating patients by physicians, nurse
practitioners, physician assistants and other qualified health care
professionals--is no less important, also contributes to total cost in
the provision of a service and is equally impacted by inflation.
Therefore, an inflation-based payment update is equally warranted for
physician work and other aspects of total physician payment, all of
which could be addressed by finalizing an update that is tied to full,
---------------------------------------------------------------------------
rather than half, of MEI.
We appreciate that Congress passed legislation that, again, mitigated
severe Medicare payment cuts. However, these temporary, partial patches
are a distraction, exacerbate budgeting challenges for practices, and
divert resources that both medicine and Congress could be spending on
other meaningful health care policies and innovations. Therefore,
organized medicine is united in support of a long-term payment solution
that centers on annual inflationary updates. Specifically, we ask
Congress to pass H.R. 2474, the ``Strengthening Medicare for Patients
and Providers Act,'' which provides a permanent annual update equal to
the increase in the MEI. Such an update would allow physicians to
invest in their practices and implement new strategies to provide high-
value, patient centered care and enable CMS to prioritize advancing
high-quality care for Medicare beneficiaries without the constant
specter of market consolidation or inadequate access to care.
Improvements to Budget Neutrality
Another way to help ensure physicians have ample resources to provide
more care in the home is via reforms to statutory budget neutrality
requirements within the Medicare Physician Fee Schedule. The AMA urges
the Senate Finance Committee to introduce companion legislation to H.R.
6371, the Provider Reimbursement Stability Act. The House Energy and
Commerce Committee has taken action on a portion of this legislation
when it passed H.R. 6545, the Physician Fee Schedule Update and
Improvement Act, out of committee in December 2023. The reality is that
physician payments are further eroded by frequent and large payment
redistributions caused by these budget neutrality adjustments. CMS
actuaries have on occasion overestimated the impact of Relative Value
Units (RVUs) changes in the fee schedule. When these misestimates are
not adjusted in a timely way, it results in permanent removal of
billions of dollars from the payment pool. Given the statutory
authority for budget neutrality adjustments to be made ``to the extent
the Secretary determines to be necessary,'' current law allows CMS to
account for past overestimates of spending when applying budget
neutrality. Congress should consider requiring a look-back period (as
have been implemented in other payment systems) that would allow the
Agency to correct for misestimates and adjust the conversion factor to
reflect actual claims data. In addition, the $20 million threshold that
establishes whether RVU changes trigger budget neutrality adjustments
was established in 1989--3 years before the current physician payment
system took effect. There have been no adjustments for inflation. As a
result, the amount should be increased to $53 million to best account
for past inflation. Further, Congress should limit the year-to-year
variance in the Physician Fee Schedule conversion factor due to budget
neutrality to a no greater than 2.5 percent increase or decrease. This
would help to add more stability and predictability to the physician
payment system.
Reduce Burdens in Merit-based Incentive Payment System (MIPS) and
Provide Access to Key Data
Since the enactment of the Medicare Access and CHIP Reauthorization Act
of 2015 (MACRA), the AMA has worked closely with Congress and CMS to
promote a smooth implementation of MIPS. We supported MACRA's goals to
harmonize the separate, burdensome, and punitive Meaningful Use,
Physician Quality Payment System, and Value-Based Payment Modifier
programs. However, the implementation of a new Medicare quality and
payment program for CMS and physicians has been a significant
undertaking, which was drastically disrupted by the COVID-19 pandemic
and the Change Healthcare cyberattack. Further refinements are urgently
needed to achieve the goals of MACRA and reduce the administrative
burden for physicians. Worse, there is a growing body of evidence that
the program is disproportionately harmful to small, rural, safety net,
and independent practices, as well as devoid of any relationship to the
quality of care provided to patients.
While CMS has tried to improve the program, such as by introducing the
MIPS Value Pathways (MVPs) option, these changes are superficial as the
agency believes it does not have statutory authority to remedy these
problems directly. Congress must step in and act to prevent
unsustainable penalties, particularly on small, rural, and underserved
practices; ensure access to timely data; reduce unnecessary burdens;
and increase clinical relevance to physicians and their patients.
Specifically, we recommend the following legislative changes:
1. Mitigate steep MIPS penalties following the COVID-19 pandemic
and Change Healthcare cyberattack that disrupted MIPS implementation
and prevent financial disaster for small, rural, and underserved
practices.
2. Hold CMS accountable for timely and actionable MIPS and claims
data.
3. Enhance measurement accuracy and validity, align cost and
quality performance, and promote clinical data registries and other
promising technology to making MIPS more clinically relevant while
reducing burden.
We urge Congress to consider these recommendations and look forward to
collaborating closely on these critical issues to ensure that health
care providers, especially those in rural and underserved areas, are
supported effectively through the MIPS framework.
Alternative Payment Models
Value-based alternative payment models (APMs) have a successful track
record of improving health outcomes and reducing costs. The AMA
supports S. 3503/ H.R. 5013, the Value in Health Care (VALUE) Act,
introduced by Senators Whitehouse (D-RI) and Barrasso (R-WY.) in the
Senate and Representatives Darin LaHood (R-IL) and Suzan DelBene (D-WA)
in the House that would extend the 5 percent APM bonus and maintain the
50 percent revenue threshold for 2 years.
This bipartisan legislation would help ensure that physicians in
communities across the country have meaningful incentives to
participate in alternative payment models that will deliver high
quality, coordinated health care for patients. APMs have played a key
role in providing high-quality care for Medicare beneficiaries while
producing billions of dollars in savings for taxpayers over the past
decade.
The AMA urges Congress to build on the success of current APMs by
finding additional pathways to help develop a more robust pipeline of
APMS available to all types of physicians in all geographic locations
in the country.
ELIMINATING EFT FEES TO STREAMLINE HEALTH CARE PAYMENTS
The AMA urges the Committee to consider the passage of the ``No Fees
for EFTs Act'' as a crucial step towards enhancing the efficiency and
effectiveness of chronic care management across the U.S. By addressing
this legislative issue, the Committee would not only be supporting the
financial sustainability of health care practices but also contributing
to the broader goal of improving care for patients with chronic
conditions.
The burden of electronic funds transfer (EFT) fees, as outlined in our
support for H.R. 6487, the ``No Fees for EFTs Act'' in the House, and
support for S. 3805, the corresponding Senate bill, highlights a
significant barrier to the efficient operation of health care
practices. EFT fees, often amounting to 2 to 5 percent of the claim
payment, are levied by certain health plans and their intermediaries
without a clear agreement from health care practices. This not only
exacerbates the financial strain on these practices but also diverts
valuable resources away from patient care and resources that are
crucial for the management of chronic illnesses. In addition, for
health care providers in rural and underserved areas, where chronic
conditions are prevalent and resources are scarce, the impact of these
fees is even more pronounced. These areas frequently face challenges in
accessing comprehensive care, and administrative inefficiencies only
serve to exacerbate these disparities.
By eliminating EFT fees, the ``No Fees for EFTs Act'' would
significantly reduce administrative complexities, freeing up resources
that could be better allocated toward patient care. This is especially
important in chronic care management, where continuous, comprehensive
care is necessary for managing long-term health conditions. The
reduction of administrative burdens would allow health care providers
to invest more time caring for patients.
TELEHEALTH ACCESS THROUGH LEGISLATIVE REFORM
The AMA supports the role of telehealth in managing chronic illnesses
and advocates for the permanent removal of restrictions limiting
Medicare patients' access to these services. Through legislative
proposals such as the Creating Opportunities Now for Necessary and
Effective Care Technologies (CONNECT) for Health Act (S. 2016/H.R.
4189) and the Telehealth Modernization Act (S. 3967/H.R. 7623), there
is a pathway for permanency of the advances made in telehealth
accessibility, particularly vital for patients managing chronic
conditions.
Introduced by Senators Schatz (D-HI) and Wicker (R-MS), the CONNECT for
Health Act is bipartisan legislation that would permanently extend many
important COVID-19 telehealth flexibilities that have significantly
improved access to care for patients in rural and underserved areas.
More specifically, the bill repeals the existing Medicare geographic
site restrictions and permanently modifies the originating site
requirements to allow patients to receive telehealth services wherever
the patient can access a telecommunications system, including, but not
limited, to the home. These COVID-19 policies have allowed patients to
obtain telehealth services at home instead of having to travel to a
medical facility to receive virtual care from a distant site. They have
also allowed Medicare patients located in urban and suburban areas to
have access to telehealth services for the first time. COVID-19
flexibilities also enabled patients to access health care services
through audio-only visits when they do not have reliable access to two-
way audio-video telecommunications technology.
Passage of the Telehealth Modernization Act (S. 3967/H.R. 7623), which
was introduced by Senators Tim Scott (R-SC) and Brian Schatz (D-HI) in
the Senate, and Representatives Buddy Carter (R-GA), Lisa Blunt
Rochester (D-DE), Greg Steube (R-FL), Terri Sewell (D-AL), Mariannette
Miller Meeks (R-IA), Jeff Van Drew (R-NJ), and Joe Morelle (D-NY) in
the House, is also crucial because in addition to eliminating the
originating and geographic restrictions of Medicare coverage for
telehealth, it would permanently continue the ability to use audio-only
telehealth services beyond the current statutory deadline of December
31, 2024. Access to two-way audio-visual telehealth and audio-only
services has lowered or eliminated barriers that many patients in rural
and underserved areas face when trying to obtain in-person care, such
as functional limitations that make it difficult to travel to physician
offices, long travel times, workforce shortages, the need for a
caregiver to accompany the patient, and patients experiencing unstable
housing and lack of transportation and childcare.
Permanently removing the antiquated geographic restrictions and the
originating site requirements means patients will no longer have to
travel, counterintuitively, to a limited set of brick-and mortar
medical sites to access virtual care. In an effort to boost access to
virtual mental health services, The Connect for Health Act also repeals
the requirement within the Consolidated Appropriations Act, 2021,
requiring patients to see a physician in-person within 6 months of an
initial telehealth visit for a mental health condition.
The integration of this legislation would be a forward-thinking
approach to the way health care is delivered, particularly for chronic
disease management. These acts collectively aim to dismantle outdated
barriers that restrict telehealth's potential to enhance patient care.
By permanently removing these restrictions. This is especially
important for chronic care management where the need for regular and
convenient access to health care services is necessary.
Telemental Health Care Access Act
Federal lawmakers have also introduced stand-alone bills, specifically
S. 3651/H.R. 3432, the Telemental Health Care Access Act, to remove
these in-person visit requirements that will only stifle access to
mental health services. While federal lawmakers have, thus far, passed
legislation delaying the mandate for patients to receive an in-person
visit within 6 months of receiving an initial telemental health service
from taking effect, it is crucial this policy is permanently removed to
ensure patients retain ample access to virtual mental health services.
Absent Congressional intervention, the in-person telemental health
requirements will go into effect on January 1, 2025, so it is crucial
legislative action occurs expeditiously.
The dramatic increase in the availability of telehealth services has
catalyzed the development and diffusion of innovative hybrid models of
care delivery utilizing in-
person, telehealth, and remote monitoring services so that patients can
obtain the optimal mix of service modalities to meet their health care
needs. These models can also reduce fragmentation in care by allowing
patients to obtain telehealth services from their regular physicians
instead of having to utilize separate telehealth-only companies that
may not coordinate care with patients' medical home. Now, all
Americans, including rural, underserved, minoritized and marginalized
patients, can receive a combination of in-person and virtual care,
which is crucial for patients with chronic diseases. Congress should
not permit these flexibilities to expire as it will run counter to its
goals of promoting more home-based care.
In closing, the AMA looks forward to working with the Senate Finance
Committee to pass the above-mentioned proposals that help promote
prevention, the use of telehealth for chronic care management and
continuity of care, provides for the solvency of independent physician
practices (which form the bedrock of care for rural and underserved
communities and our health care system in general), and eliminates the
burdens many physician practices face to receive electronic payments
for services rendered. The more we can stabilize the Medicare program
and reduce the burdens that physician practices face, the more time and
resources there are available to dedicate to improving patient care. We
stand ready to work with the Committee to improve the Medicare program
for the patients struggling with chronic conditions and the physicians
who treat them.
______
American Medical Women's Association
Two Woodfield Lake
1100 E Woodfield Road, Suite 350
Schaumburg, IL 60173
Telephone (847) 517-2801
Fax: (847) 517-7229
https://www.amwa-doc.org/
April 10, 2024
The Honorable Ron Wyden
Chairman
Senate Committee on Finance
219 Dirksen Senate Office Building
Washington, DC 20510
The Honorable Mike Crapo
Ranking Member
Senate Committee on Finance
219 Dirksen Senate Office Building
Washington, DC 20510
Dear Senator Wyden and Senator Crapo,
I am writing to share perspectives on the upcoming Senate Finance
Committee hearing ``Bolstering Chronic Care through Medicare Physician
Payment Reform'' scheduled to take place in the Senate Finance
Committee on April 11, 2024. This discussion represents a critical
opportunity to enhance the quality of care for individuals living with
chronic conditions and to address systemic challenges within our
healthcare system. Thank you for holding this discussion.
Chronic diseases present formidable challenges for both patients and
healthcare providers, necessitating ongoing management and support. By
reforming Medicare physician payment structures to incentivize
comprehensive, coordinated care for chronic conditions, we can
revolutionize how we approach chronic care management. Adequately
compensating physicians for their time and resources invested in
managing chronic conditions is essential to ensuring that patients
receive the comprehensive support they need to lead healthier lives.
Moreover, implementing payment reforms aligned with the goals of
chronic care management has the potential to reduce healthcare costs in
the long term by minimizing hospitalizations, emergency room visits,
and complications associated with unmanaged chronic conditions.
Prioritizing preventive care and proactive management is crucial for
creating a more sustainable and efficient healthcare system.
Additionally, I urge the Senate Finance Committee to recognize the
growing impact of obesity as a chronic disease and to consider the
implications of Medicare coverage for anti-obesity medications under
the Treat and Reduce Obesity Act (TROA). Currently, Medicare Part D
does not provide coverage for these medications, despite their proven
efficacy in helping individuals achieve significant weight loss and
reducing the risk of developing chronic diseases such as diabetes and
heart disease. TROA would address this gap by providing coverage for
anti-obesity medications as well as the full range of obesity
treatments, including nutrition counseling, behavioral therapy, and
community-based programs.
I commend the Senate Finance Committee for taking proactive steps to
address these pressing issues and for their dedication to advancing
healthcare. I hope that you will share these points with the committee
members during the upcoming discussion. I eagerly anticipate the
livestream of the hearing and look forward to the progress that will be
made in bolstering chronic care and addressing the needs of patients
with chronic conditions.
Thank you for your attention to these important matters.
Sincerely,
Eliza Chin, M.D., MPH
Executive Director
______
American Nurses Association
8515 Georgia Ave., Suite 400
Silver Spring, MD 20910
https://www.nursingworld.org/
April 23, 2024
The Hon. Ron Wyden The Hon. Mike Crapo
Chairman Ranking Member
United States Senate United States Senate
Committee on Finance Committee on Finance
219 Senate Dirksen Office Building 219 Senate Dirksen Office Building
Washington, DC 20510 Washington, DC 20510
Dear Chairman Wyden and Ranking Member Crapo,
On behalf of the American Nurses Association (ANA), I would like to
thank you for holding the hearing, ``Bolstering Chronic Care through
Medicare Physician Payment,'' on April 11, 2024. While physician
payment has been discussed for decades, there also needs to be focus
placed on how public payers such as Medicare ensure access to nursing
care. The roles registered nurses (RN) and advanced practice registered
nurses (APRN) play in health care delivery has changed significantly
since the inception of the Medicare program.
ANA appreciates the Committee's recognition that more fully valuing
primary care providers is essential to helping the Medicare program
better address chronic conditions. The shortage of primary care
physicians in the United States is projected to be between 20,200 and
40,400 physicians by 2036.\1\ Consequently, APRNs will be needed to
fill this void in primary care, and they stand ready to be utilized to
the fullest extent of their education and clinical training--Nurse
Practitioners (NP), for example, already make up around 50 percent of
the primary care workforce. Appropriately, Medicare rules and
statements increasingly refer to Qualified Health Practitioners (QHP),
in addition to physicians, in order to be more inclusive of APRNs. ANA
would appreciate the Committee's urging of the Centers for Medicare and
Medicaid Services (CMS) to continue to do so. Moreover, RNs are
significant providers of care coordination and related services that
render team-based care effective for patients with chronic conditions.
We appreciate this opportunity to share with you how several of our
policy priorities align with the Committee's goals for physician
payment reform.
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\1\ https://www.aamc.org/media/75231/download?attachment.
ANA is the premier organization representing the interests of the
nation's over 5 million registered nurses, through its constituent and
state nurses associations, organizational affiliates, and individual
members. RNs serve in multiple direct care, care coordination, and
administrative leadership roles, across the full spectrum of health
care settings. RNs provide and coordinate patient care, educate
patients and the public about various health conditions, and provide
advice and emotional support to patients and their family members. ANA
members also include those practicing in the four advanced registered
nurse roles: NPs, clinical nurse specialists (CNS), certified nurse-
midwives (CNM), and certified registered nurse anesthetists (CRNA). ANA
is dedicated to partnering with health care consumers to improve
practices, policies, delivery models, outcomes, and access across the
health care continuum.
National Provider Identifier (NPI) Numbers for All Practitioners
NPIs remain the gold standard for determining eligibility and
reimbursing the health care clinicians for care provided to patients.
RNs are integral parts of the health care team and spend significant
time with patients providing clinical services. However, though they
are eligible to receive them, NPIs are not required for RNs and they do
not typically obtain them. In the current health care financing system,
RN work is generally not accounted for, other than in the practice
expense (PE) component of the relative value unit (RVU). The time spent
by the RN is the main element of RN work that is captured in the PE of
billing providers. The lack of NPIs for nurses makes it extremely
difficult to record, measure, and value the services they provide and
their impact on patient outcomes.
Obtaining an NPI is a first step to recognizing and evaluating the
value of the nurse in the health care delivery system. Obtaining and
recording RNs' NPIs in relevant health care data systems would allow
health systems, payers, and enterprise resource planning systems to
distinguish the value of nursing services from that of other providers.
This would allow for a quantitative analysis and substantive
demonstration of the nurse's role and value as an integral member of a
patient's health care team. As such, ANA urges the Committee to explore
utilization of the NPI for RNs as a means of better capturing the
significant contributions of RN care. NPIs would not change RN
reimbursement or pay as RN times and services provided are now included
in the PE component of relative value unit RVUs.
Recognizing RN Value
As the Committee looks at ways to evolve and reform the health care
system, ANA strongly advocates for changes in current reimbursement
models to recognize the value of the nurse. The American Medical
Association (AMA) created the CPT and RUC systems to value the work
done by physicians and other qualified healthcare providers. While
APRNs and other non-physician providers have NPIs and bill for services
attributed to them, patient care provided by RNs is not billed and
identified separately. The result is that RNs have historically been
included as part of PE when the RUC either establishes or modifies the
value of procedures in the CPT code set. However, this only captures
the time it takes rather than fully capturing the scope of services
that RNs provide to patients. Payment innovations centered on value
should encompass the expertise of RNs and the clinical services they
provide. As such, ANA encourages the Committee to explore reimbursement
models that would capture the actual value of the RN as part of any
broader Medicare payment reforms.
Incident To Billing
In the same vein as assigning NPI numbers to RNs, MedPAC has
recommended for several years that Congress should require APRNs and
physician assistants to bill the Medicare program directly, eliminating
``incident to'' billing for services they provide.\2\ ANA agrees with
MedPAC. Because of incident to billing, it is unknown what care is
being delivered by physicians directly or by other practitioners. The
data generated by eliminating incident to billing would give Congress
and other policymakers a more complete understanding of how our health
care system is working and will help uncover efficiencies and cost
savings. Not only would eliminating incident to billing generate cost
savings, but we believe the benefits of the data derived will provide
significant value to policymakers, particularly with respect to
appropriately valuing primary care.
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\2\ https://www.medpac.gov/recommendation/issues-in-medicare-
beneficiaries-access-to-primary-care-5-1-june-2019/.
Discounted Reimbursement for Nurse Practitioners and Clinical Nurse
Specialists
Under current law, NPs and CNSs receive 85 percent of the Physician Fee
Schedule for the same work as their physician colleagues. In addition,
only physicians receive a 10 percent bonus if they work in designated
health professional shortage areas (HPSA), meaning NPs and CNSs receive
less than 78 percent of the reimbursement as their physician colleagues
for the same work in HPSAs. Furthermore, practice expenses do not
change based on your professional designation. There is no reason the
discounted reimbursement should include a discount on practice expenses
when a difference between practice expenses of those of a physician and
those of another qualified provider does not exist.
APRNs are educated under the nursing model, where clinical training is
integrated into their core curriculum. APRN programs are competency-
based, not time-based. A student must demonstrate mastery of content
before advancing. While the nursing and medical models of training are
different, the safety and quality of APRN competency-based education is
consistently demonstrated in more than 40 years of patient care
research. For example, the American Enterprise Institute released a
report that found that ``beneficiaries who received their primary care
from NPs consistently received significantly higher-quality care than
physicians' patients in several respects. While beneficiaries treated
by physicians received slightly better services in a few realms, the
differences were marginal.''\3\ ANA appreciates the Committee's
recognition of the need to bolster primary care in rural and
underserved areas and expanding the 10% HPSA bonus eligibility for
APRNs is a commonsense way to help address this growing challenge.
---------------------------------------------------------------------------
\3\ https://www.aei.org/research-products/report/nurse-
practitioners-a-solution-to-americas-primary-care-crisis/.
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Improving Care and Access to Nurses (ICAN) Act (S. 2418/H.R. 2713)
ANA reiterates our staunch support for the ICAN Act, which contains a
host of provisions that would increase access to cost-effective, high-
quality care for Medicare and Medicaid beneficiaries. This legislation
would increase patient access to care by removing outdated and
unnecessary federal barriers on services provided by APRNs under the
Medicare and Medicaid programs, further benefiting beneficiaries,
especially those with chronic care conditions that must be closely
monitored.
Recognizing the importance of APRNs to our health care workforce, and
for patient access to care, the Institute of Medicine (IOM) issued The
Future of Nursing: Leading Change, Advancing Health report in 2010,
which called for the removal of laws, regulations, and policies that
prevent APRNs from providing the full scope of health care services
they are educated and trained to provide. In 2021, this position was
reaffirmed by the National Academy of Medicine (previously named the
IOM) in their 2021 The Future of Nursing 2020-2030: Charting a Path to
Achieve Health Equity.
Unfortunately, there are still Medicare and Medicaid policies that have
not been modernized to reflect the growing and essential role of APRNs.
Various federal statutes and regulations remain which prevent APRNs
from practicing to the full extent of their education and clinical
training. Many of these policies were written before APRNs could
participate in Medicare. These provisions reduce access to care,
disrupt continuity of care, increase health care costs, and undermine
quality improvement efforts. Removal of these outdated barriers should
serve as a bedrock of Medicare reimbursement reform.
The purpose of the ICAN Act is to increase access, improve quality of
care, and lower costs in the Medicare and Medicaid programs by removing
federal barriers to practice for APRNs, consistent with state law. We
urge Congress to pass this important legislation. It will move our
health care system forward in an effective and efficient manner for the
benefit of patients and providers. More than 240 organizations have
endorsed this legislation, including the National Rural Health
Association, AARP, the American Health Care Association, and Leading
Age.
In closing, I would like to thank you for your leadership and for your
willingness to consider our perspective on this critical issue to
ensure that patients have access to qualified, high-quality providers.
ANA stands ready to work with the Finance Committee to implement policy
solutions to comprehensively address the nation's challenges addressing
chronic care. If you have any questions, please contact Tim Nanof, Vice
President of Policy and Government Affairs, at (301) 628-5081 or
Tim.Nanof@ana.org.
Sincerely,
Debbie Hatmaker, Ph.D., RN, FAAN
Chief Nursing Officer/EVP
______
American Occupational Therapy Association
6116 Executive Boulevard, Suite 200
North Bethesda, MD 20852-4929
301-652-6611
https://www.aota.org/
The American Occupational Therapy Association (AOTA) is the national
professional association representing the interests of more than
230,000 occupational therapists, occupational therapy assistants, and
students of occupational therapy. The science-driven, evidence-based
practice of occupational therapy enables people of all ages to live
life to its fullest by promoting participation in daily occupations or
activities. In so doing, growth, development, and overall functional
abilities are enhanced, and the effects associated with illness,
injuries, and disability are minimized.
Crucial Role of Occupational Therapy in Supporting Chronic Conditions
Occupational therapy (OT) can contribute to the overall effectiveness
of a primary care program focused on managing and supporting chronic
conditions. However, OT has faced increasing challenges providing
services under the Medicare Physician Fee Schedule over the last
decade, even as more and more evidence emerges about the efficacy of OT
in improving the overall health and wellness of Medicare Beneficiaries.
At its most basic, the goal of occupational therapy is to evaluate the
person, their needs, and their capabilities to optimize their ability
to perform day-to-day activities and to maximize health. Occupational
therapy self-management interventions can improve the health outcomes
in type 2 diabetes and provide a cost-effective option for reducing the
burdens placed on patients and healthcare systems.\1\ Supporting self-
management facilitates individuals' ability to function in their
desired environment, often preventing higher utilization of more costly
care.
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\1\ Self-Management Support Interventions Integrated into
Occupational Therapy Practice With People Having Type 2 Diabetes.
https://natsci.upit.ro/issues/2019/volume-8-issue-16/self-management-
support-interventions-integrated-into-occupational-therapy-practice-
with-people-having-type-2-diabetes.
Occupational therapy enables individuals with a chronic condition to
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have healthier, productive, and meaningful lives by:
Addressing performance deficits in daily self-care (ADLs) and
home management tasks (instrumental ADLs), resulting from specific
chronic conditions, to sustain or improve current status in these
areas.
Developing strategies to incorporate energy conservation and
activity modification techniques into daily activities to cope with
physical demands and reduce the fatigue associated with many chronic
conditions.
Individualizing adaptations to perform health management tasks
effectively (e.g., ensuring that someone with hand weakness can manage
daily insulin shots for diabetes).
Teaching and incorporating health management tasks into existing
habits and routines, so they become part of the daily routine (e.g.,
setting up a schedule and reminder system to take medications).
Developing coping strategies, behaviors, habits, routines, and
lifestyle adaptations to support physical and psychosocial health and
well-being.
Building Routines and Habits for Overall Self-Management of Conditions
Living with a chronic condition can bring with it changing physical
and/or mental abilities. In addition, the environment, both physical
and psychosocial (e.g., family dynamics), may need to be addressed.
Occupational therapy practitioners analyze the demands of activities
meaningful to the client and evaluate the fit between abilities and
challenges.
Self-management is about taking charge of one's life and managing one's
condition instead of being controlled by that condition and is
recognized as an effective approach to chronic health conditions by
``empowering patients to understand their conditions and take
responsibility for their health'').\2\ The client-centered nature of
occupational therapy is ideal for supporting self-management. Whether a
client is newly diagnosed or has lived with a chronic condition for
many years, occupational therapy supports patients in managing the
disease with positive behaviors and strategies while also engaging in
daily life activities.
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\2\ https://www.ninr.nih.gov/sites/files/docs/ninr-focus-self-
management.pdf.
Occupational therapy practitioners analyze the demands of meaningful
activities to the client and evaluate the fit between client abilities
and challenges imposed by those activities and the environment. They
may make recommendations on conserving energy, decreasing or preventing
pain, simplifying activities, and improving the safety and ease of
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functioning in a given environment (e.g., home, school, work).
Managing chronic conditions also involves learning specific health-
management skills. These may include regularly monitoring blood
pressure or weight; planning, shopping for, and preparing meals
according to specific requirements or restrictions; monitoring blood
glucose; administering oral, injected, or inhaled medications; or
increasing physical activity. It is not enough for clients to learn and
demonstrate these skills. To be effective, they must be consistently,
habitually, and correctly performed and the client must successfully
integrate those skills into existing routines. Occupational therapy
practitioners look at barriers that prevent clients from integrating
health management tasks into their daily routines and, if necessary,
incorporate adaptations to overcome these barriers. They are
particularly skilled in helping clients manage chronic conditions in a
way that fits with existing routines and patterns, so changes feel less
disruptive and are more likely to be consistently integrated into the
daily routine.
Focus on Developing Medication Management Strategies
Medication non-adherence in patients with chronic conditions results in
higher hospitalization rates, poorer outcomes, and dramatically
increased health care costs. Studies have shown that between 50-70% of
older adults fail to take medications according to physician
instructions--resulting in an estimated 3 million older adults being
admitted to skilled nursing facilities each year and causing as many as
125,000 deaths annually.\3\
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\3\ https://pubmed.ncbi.nlm.nih.gov/14717268.
As experts in the development of habits and routines, as noted above,
occupational therapy practitioners play a pivotal role in helping
patients develop medication management routines. Working with
occupational therapy practitioners to establish daily practices aimed
at significantly improving medication compliance have proven to
increase overall health and functional status, decrease the risk of
falls, improve cognition, and increase driver safety for older
adults.\4\
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\4\ https://www.researchgate.net/publication/
284362391_Relationship_of_Number_of_Medica
tions_to_Functional_Status_Health_and_Quality_of_Life_for_the_Frail_Home
-Based_Older_
Adult.
Studies in this area indicate that medication habits need to be
customized to the individual to promote integration into existing life
routines. This finding is consistent with client-centered practice.
Evidence also strongly suggests that patients would significantly
benefit from skilled interventions, such as developing cues, arranging
for equipment, assessing the environment, or arranging for monthly
refills. These findings substantiate occupational therapy
practitioners' role in developing specific, individualized, concrete
plans for integrating med es, thus exponentially increasing the
patient's odds of adherence.
Alarming Trends in the Occupational Therapy Workforce
Threaten Future Access to Care
Occupational therapy (OT) services are provided by both occupational
therapists (who are trained either through a 2-year master's program or
a 3-year doctoral program) and occupational therapy assistants (who
either receive an associate's degree or a bachelor's degree).
Since 2018, there has been a steady decrease in the number of
applicants (-33%) and total applications (-41%) to OT programs.
Occupational therapy assistant programs have seen the most significant
of these declines. In 2015 these programs filled 85% of their available
seats. In 2022, only 66% of seats were filled--a 19% decrease.
However, the U. S. Bureau of Labor Statistics projects an increase in
the need for occupational therapy practitioners (OTPs) over the next 10
years; projecting a 14% increase in employment for occupational
therapists \5\ and a 25% increase in employment of occupational therapy
assistants.\6\
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\5\ https://www.bls.gov/ooh/healthcare/occupational-
therapists.htm#tab-6.
\6\ https://www.bls.gov/ooh/healthcare/occupational-therapy-
assistants-and-aides.htm#tab-6.
[GRAPHIC] [TIFF OMITTED] T1124.009
.epsThe following recommendations focus on ways Congress can increase
access to innovative programs under Medicare, ensure adequate payment
for occupational therapy services, ensure that occupational therapy
practitioners are included in future payment models that focus on
beneficiary outcomes, and ensure beneficiary access to occupational
therapy services in rural and medically underserved areas.
Congress Must Increase Access to Innovative Programs
Cost Savings Through Supporting Aging in Place and Reducing Falls.
Multiple programs and studies have demonstrated the effectiveness and
cost savings of an occupational therapy led home-safety evaluation
centered on a client's identified goals and preferences and followed by
suggested low-cost home modifications and adaptive equipment. Despite
demonstrated cost savings and improved quality of life, there is no way
for these types of services to be provided to Medicare beneficiaries
outside of grant funding and demonstration projects.
The CAPABLE Model, which was developed through funding by the Center
for Medicare and Medicaid Innovation (CMMI) and the National Institutes
of Health is the most well-known of these interventions. This 5-month,
interprofessional, team-based intervention is delivered by an
occupational therapist (six visits), a nurse (four visits), and a
handy-person (up to 1 day). The handy-person will make home repairs,
install assistive devices, and make home modifications as prescribed by
the occupational therapist. CAPABLE as American Occupational Therapy
Association Page 2 of 5 a model promotes safe and effective aging in
place by addressing Medicare beneficiary issues that directly drive
healthcare costs yet are not addressed in current care models. The
model has resulted in reduced disability, healthcare cost savings, and
the promotion of aging in place. Studies have demonstrated that the
CAPABLE model produced $922 per Medicare beneficiary per month in
savings for up to 2 years \7\ and $867 per month for up to a year in
Medicaid savings \8\ due to a reduction in hospitalizations and other
institutional based care.
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\7\ Ruiz S, Snyder LP, Rotondo C, Cross-Barnet C, Colligan EM,
Giuriceo K. Innovative Home Visit Models Associated with Reductions in
Costs, Hospitalizations, and Emergency Department Use. Health Affairs.
2017;36(3):425-432.
\8\ Szanton SL, Alfonso YN, Leff B, et al. Medicaid Cost Savings of
a Preventive Home Visit Program for Disabled Older Adults. Journal of
the American Geriatrics Society. 2018;66(3):614-620.
While the CAPABLE model has undergone multiple clinical trials and
studies, there is other ample evidence for the cost-effectiveness of
low cost, high intensity home modifications directed by an occupational
therapist. A study in the American Journal of Preventative Medicine
identified ``home modifications delivered by an occupational
therapist'' as the intervention with the greatest potential to help
older adults by preventing falls. The study estimated a cost savings of
$38.2 million and estimated that 45,164 falls would be prevented.\9\
Another study combined weatherization/energy services with a home
safety assessment conducted by an occupational therapist and subsequent
home modifications/repairs. The study group saw a significant reduction
in falls (from 94% to 9%) and calls for assistance (from 23% to 3%)
within a 6-month period.\10\
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\9\ Stevens, Judy A. and Robin Lee. ``The Potential to Reduce Falls
and Avert Costs by Clinically Managing Fall Risk.'' Am J Prev Med 55
no. 3 (2018): 290-297. doi:10.1016/j.amepre.2018.04.035.
\10\ Tohn, Ellen, Jonathan Wilson, Tracy Van Oss, and Michael
Gurecka. ``Incorporating Injury Prevention into Energy Weatherization
Programs.'' J Public Health Manag Pract (2019) doi:10.1097/
PHH.0000000000000947.
When Congress directed the Department of Housing and Urban Development
(HUD) to establish a grant program to help enable low-income elderly
persons to remain in their primary residence, HUD chose OT to lead home
modifications as the intervention with the most evidence of success and
cost savings and also based the Older Adults Home Modification Grant
Program (OAHMP) around this intervention model.\11\ The grant program
highlights that occupational therapy practitioners are ``trained to
evaluate clients' functional abilities and the home environment'' and
have ``knowledge of the range of low-cost, high-impact environmental
modifications and adaptive equipment used to optimize the home
environment and increase independence.''
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\11\ https://www.hud.gov/program_offices/spm/gmomgmt/grantsinfo/
fundingopps/oahmp.
Occupational therapy practitioners (OTPs) also play a distinct role in
helping those with Alzheimer's and dementia continue to engage in the
activities that are most meaningful to them, thereby helping to
optimize their quality of life. A crucial component of supporting
meaningful engagement for a person with dementia, is supporting and
training the caregiver, as well as promoting caregiver wellness, a
focus of both Skills2Care and COPE. While these programs are supported
by the Administration on Aging and some state Medicaid programs, there
is currently no pathway to reimbursement for these interventions under
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Medicare.
Congress has established the Physician-Focused Payment Model Technical
Advisory Committee (PTAC) so that ideas on value-based care could be
generated from the diverse provider community. The ability of the PTAC
to approve smaller, innovative Alternative Payment Models (APMs) is now
more important than ever, as CMMI has pledged to focus on fewer, larger
APMs. Despite the promise of the PTAC, however, it has failed to create
a pathway for meaningful participation in APMs. The CAPABLE model is an
example of an evidence-based intervention, approved by the PTAC, that
was never implemented by CMS even though it was first developed through
funding from CMMI research grants.
Recommendations:
Congress could allow healthcare practitioners to pilot test PTAC-
approved APM models: This is not allowed under current law, but
granting such permission would allow participants to show CMS and other
policymakers how the model would work and perform in real-world
settings for the benefit of Medicare beneficiaries. Once the pilot
period concludes and an appropriate amount of data was collected and
analyzed, CMS could make its final approval or denial decision. If
approved, this would allow for other providers to more easily replicate
real-world use of the piloted model and build upon lessons learned to
allow for more effective, broad-scale implementation.
Congress must be able to look beyond current CBO analysis when judging
potential savings for innovative programs: Under current rules, CBO
would not take into account the massive savings which would be
generated by a national roll-out of CAPABLE or a similar program.
Therefore, the cost would be prohibitively high, and real savings would
not be realized as patients would continue to suffer preventable
accidents which result in costly emergency room visits,
hospitalizations and institutionalization.
Eroding Reimbursement under Medicare Part B
Occupational therapy practitioners and other therapy providers have
been particularly hard hit by the recent redistribution of resources on
the Physician Fee Schedule to increase payments for Evaluation &
Management (E/M) codes as a result of budget neutrality requirements.
Unlike other medical specialties, therapy providers are not allowed to
bill evaluation and management codes, meaning therapy practitioners
have taken and will continue to face the full reduction in the
conversion factor caused by these payment changes. In addition to the
decreases in the conversion factor caused by changes to the E/M values,
payment for therapy services received additional cuts in 2024 after the
Congressional moratorium on implementation of the G2211 code ended. We
appreciate Congressional action to phase these cuts in, however at the
end of this phase in, payment for occupational therapy services will
have been reduced by as much as 9%.
The negative impacts of past and future budget neutrality cuts on OT
are felt nationally; however, rural providers face greater challenges
given that they serve smaller and often shrinking patient populations.
Total Medicare payments for OT services increased nationwide from $1.1B
to $1.6B from 2009-21 which represents a 37 percent increase; however,
this was driven by a 48% increase in patient volume, not the number of
services per beneficiary which actually dropped by 6.9% during this
time. Given that the rural population in the U.S. has declined from
nearly 59.5 million to 56.8 million during this time, downward
pressures on reimbursement cannot be addressed by increased patient
volume, which would be difficult to achieve anyway given decreases in
applications for OT programs, OTA reimbursement cuts and other factors.
While the challenges of the current payment system cut across multiple
specialties, they have been particularly difficult for therapy
providers, including occupational therapy practitioners. From the
beginning, the Quality Payment Program (QPP) offered few options for
participation for therapy practitioners, and outpatient therapy
services provided in facility-based settings were never eligible for
the QPP. Occupational therapy practitioners in private practice have
limited or no options to receive bonus payments. As Congress considers
policies to create a more affordable, patient-centered health care
system focused on overall health, policies must include all Medicare-
eligible professionals equally. Further, we ask that Congress consider
updating legacy Medicare payment policies that continue to harm therapy
providers and threaten access to care for Medicare beneficiaries.
Recommendations:
End the Multiple Procedure Payment Reduction (MPPR) for therapy
services: The multiple procedure payment reduction (MPPR), is a payment
policy that was first implemented in 2011, and applies to physical
therapy (PT), occupational therapy (OT) and speech language pathology
(SLP) services provided under Medicare Part B. Because of MPPR, when a
beneficiary receives more than one 15-minute therapy services on the
same day, all subsequent therapy services beyond the first, across
therapy disciplines, are cut. Under this policy, the therapy service
with the highest practice expense value is reimbursed at 100%, and the
practice expense values for all other subsequent therapy services are
reduced by 50%.
The MPPR is a flawed policy that was never based on actual data backing
the 50% reduction. The Centers for Medicare & Medicaid Services (CMS)
initially proposed a 25% reduction, even while acknowledging that this
number was not backed up with concrete data. Later Congress moved the
25% reduction to 50% in order to pay for a month's long patch to the
Sustainable Growth Rate. As a result, therapy services received, whit
is now estimated to be a 15.8% cut to payments, only a few years before
their payment rates were frozen under MACRA.
The application of MPPR to the ``always therapy'' codes results
in an excessive reduction of these codes and is having a significant
impact on the financial viability of therapy practices and the
occupational therapy workforce--ultimately impacting access to vital
therapy services. We strongly recommend that Congress end this policy
or reduce the level of cuts.
MACRA and the Medicare Quality Payment Program: In order to move to a
payment system that truly values quality and patient outcomes, all
providers must be engaged from the outset. CMS's current one-size-fits
all development of MIPS eligible quality measures has focused primarily
on physicians and does not reflect the services (and outcomes) of many
providers paid through the Medicare Physician Fee Schedule.
CMS must provide a way for all providers to participate in
current and future payment programs throughout their development. This
includes identification of cost measures that occupational therapy
practitioners can participate in, outcomes measures that are reflective
of the services provided by occupational therapy practitioners and
other non-physician providers, and outcomes measures that are not
limited to the use of a specific outcomes management systems.
Allow Occupational Therapy Practitioners to Opt Out of Medicare: Unlike
many other health providers, occupational therapy practitioners cannot
opt out of being a Medicare enrolled provider, if they provide services
to Medicare-eligible beneficiaries. This prevents Medicare
beneficiaries from exercising their right should be empowered to select
the health care professional of their choice, including allowing
beneficiaries to privately contract with occupational therapists. As
discussed below, Medicare's inflexible policies have stifled the
ability to implement innovative programs that can support the long-term
health and wellness of Medicare beneficiaries. There are evidence-based
therapy interventions that cannot be reimbursed under current Medicare
payment policies, but could be provided under private pay, if that were
allowed.
Allowing therapy providers to opt out would give Medicare
beneficiaries the opportunity to benefit from these critical
interventions to which they are currently denied access, and improve
overall health outcomes, thus keeping people out of the acute
healthcare system.
Ensuring Access to Occupational Therapy Services
in Rural and Underserved Areas
Telehealth
OT interventions delivered via telehealth have enabled patients to
develop, regain, and build functional independence in everyday life.
Telehealth has also demonstrated advantages over in-person visits in
some situations, especially for people in rural and underserved areas,
and for the large number of seniors in all communities who face
transportation and mobility issues, especially those with disabilities.
Telehealth is also an ideal platform for conducting home safety
evaluations as it provides a window into the person's home and often
greater access to their caregivers. However, occupational therapy
practitioners are only allowed to provide Medicare telehealth services
under temporary waivers.
Recommendation:
Enact legislation such as S. 2880--the Expanded Telehealth Access Act
in order to make therapy practitioners permanent Medicare telehealth
providers. Congressional action is essential to enable Medicare
beneficiaries to continue to receive OT services via telehealth when
appropriate. Passage of the Expanded Telehealth Access Act (S.2880)
would enable OT professionals as well as PTs, SLPs, and audiologists to
provide services via telehealth under Section 1834(m) of the Social
Security Act. Unless Congress acts, Medicare beneficiaries will face a
telehealth ``cliff'' on December 31, 2024, whereby beneficiaries who
are now accustomed to receiving some OT services via telehealth
suddenly lose access to such services. We urge Congress to prevent this
outcome.
Support Occupational Therapy Assistants
Access to occupational therapy in rural, medically underserved areas is
directly dependent on the availability of occupational therapy
assistants. An analysis of 2021 Medicare Part B claims \12\ shows that
46% of all occupational therapy services provided in rural and
medically underserved areas are provided by OTAs, compared to 34% in
all other geographic areas. The recent trends in enrollment for
occupational therapy assistant programs are particularly worrisome for
rural and medically underserved areas, where beneficiaries already tend
to receive fewer minutes of therapy in settings such as skilled nursing
facilities, and where occupational therapy assistants provide a much
higher percentage of those minutes.\13\
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\12\ https://acrobat.adobe.com/link/
track?uri=urn:aaid:scds:US:afa395e4-8b46-30fc-9687-fd85
ecb1aa95.
\13\ https://www.aota.org/-/media/corporate/files/advocacy/federal/
otaworkforceinsnfsfinal
report922.pdf.
Current enrollment trends and projected workforce needs paint an
alarming picture for the future of the occupational therapy workforce
and people's ability to access occupational therapy services in rural
and medically underserved areas. Compounding the enrollment challenge
is a recent reimbursement cut for services provided by OTAs. On January
1, 2022, Medicare outpatient services provided by occupational therapy
assistants and physical therapist assistants (PTAs) began receiving a
15% reduction in payment. This cut is the result of a provision in the
Balanced Budget Act of 2018, and is separate from, and in addition to,
other cuts to therapy payments under the Medicare Physician Fee
Schedule that have been imposed over the last several years.
Recommendation:
Enact the Enabling More of the Physical and Occupational Workforce to
Engage in Rehabilitation (EMPOWER) Act (H.R. 4878/ S. 2459): The
EMPOWER Act would change the Medicare supervision requirement for OTAs
and PTAs in private practice so that it cannot exceed requirements
under State law. Currently, private practice is the only setting under
Medicare Part B that requires ``direct'' supervision instead of
``general'' supervision. Therapy providers in all settings must comply
with their state practice act if state or local practice requirements
are more stringent than Medicare, and currently 48 states require
general supervision of physical therapist assistants, and 49 states
require general supervision of occupational therapy assistants. This
Medicare regulation, which only applies to private practices, is also
more burdensome than in all other settings including those where more
acute patients are generally seen, i.e., hospital outpatient/SNF, etc.
Enacting this bill would remove barriers to care provided by
OTAs in a private practice setting and would reinforce the important
role of occupational therapy assistants as part of the care team,
especially in rural areas. The bill also requires the Government
Accountability Office (GAO) to examine the impact of the 15% payment
cut to OTAs and PTAs on access to services in rural and medically
underserved areas. AOTA believes strongly that these cuts have already
impacted access to services in rural and underserved areas, but more
data is needed.
Thank you for your attention to this crucial issue. AOTA looks forward
to working with the Senate Finance Committee as you seek to improve
payments for Medicare services and support beneficiaries with chronic
conditions.
______
American Osteopathic Association
511 2nd Street, NE
Washington, DC 20002
312-202-8000
https://osteopathic.org/
On behalf of the American Osteopathic Association (AOA), and the more
than 186,000 osteopathic physicians (DOs) and medical students we
represent, we write to express our appreciation for the Committee's
interest in improving patient access to care and making meaningful
strides toward addressing the substantial gaps in Medicare fee for
service payment. This is a particularly important opportunity to
provide insight on matters impacting osteopathic physicians and our
patients.
Among the core principles of osteopathic medicine are providing
patient-centered, coordinated care across the health care spectrum. We
recognize that health care stakeholders across the United States share
the responsibility of promoting reforms and policies that ensure
individuals with chronic diseases have access to high-
quality, continuing and comprehensive care when and where they need it.
As such, the AOA unequivocally believes that the current Medicare
physician payment model cannot sufficiently provide the stability
physicians need to be able to deliver coordinated, longitudinal care--
particularly for patients with chronic diseases.
Medicare Payment and Patient Access
Nearly 95 percent of adults aged 60 and older have at least one chronic
illness or condition, and nearly 80 percent of the same cohort have two
or more chronic conditions.\1\ Over the next decade, the projected
number of patients with at least one chronic condition is expected to
double and encompass more than 142 million Americans by 2050, placing
increasing strain on the U.S. healthcare system and workforce.\2\ At
the same time, the United States could see a shortage of as much as
124,000 physicians by 2034 if the current trends are not reversed.\3\
The current structure and unsustainable rates for physician payment is
a key driver in practice closures and physician shortages, particularly
in rural areas.
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\1\ National Council on Aging. Chronic Inequities: Measuring
Disease Cost Burden Among Older Adults in the U.S. A Health and
Retirement Study Analysis. Page 5, Figure 2. April 2022. Accessed
online at: https://ncoa.org/article/the-inequities-in-the-cost-of-
chronic-disease-why-it-matters-for-older-adults.
\2\ Ansah JP, Chiu CT. Projecting the chronic disease burden among
the adult population in the United States using a multi-state
population model. Front Public Health. 2023 Jan 13;10:1082183. doi:
10.3389/fpubh.2022.1082183. PMID: 36711415; PMCID: PMC9881650.
\3\ Association of American Medical Colleges: Report Reinforces
Mounting Physician Shortage. June 11, 2021. Accessed online at: https:/
/www.aamc.org/news/press-releases/aamc-report-reinforces-mounting-
physician-shortage.
Physicians across the country face ongoing uncertainty regarding the
payment they will receive for services rendered year after year. This
year, in the Medicare Physician Fee Schedule CMS finalized a 3.37% cut
to Medicare's physician payments, which was only able to be partially
mitigated by Congress. This cut coincides with ongoing increases in
costs to practice medicine--which CMS acknowledges, as the projected
increase in the Medicare Economic Index (MEI) for 2024 will be 4.6%.
Unlike nearly all other Medicare providers and suppliers, physicians do
not receive an annual inflationary payment update. Changing this would
provide stability to independent physician practices facing unique
economic challenges in rural areas. This type of reform has previously
been proposed through the bipartisan Strengthening Medicare for
Patients and Providers Act (H.R. 2474), and the AOA strongly urges the
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Senate Finance Committee to consider this legislation further.
The AOA also recommends further supplementing support for rural
physicians by utilizing economic levers that would make practicing in
rural and underserved communities more accessible and appealing to a
broader base of physicians. These levers include increasing Physician
Health Professional Shortage Area incentives and/or creating new means
of improving payment specifically for rural physicians. For example, in
its March 2024 report, MedPAC recommended creating an add-on payment
for physicians caring for low-income patients to better support
physicians working with rural and underserved populations.\4\ Without
predictable inflationary payment updates and additional incentives for
rural and underserved areas, the physician workforce in these
communities is likely to decline.
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\4\ MedPAC. ``March 2024 Report to Congress.'' April 18 2024.
Accessed online at: https://www.medpac.gov/wp-content/uploads/2024/03/
Mar24_Ch4_MedPAC_Report_To_Congress_
SEC.pdf.
Furthermore, Medicare's current budget neutrality obligations within
the physician payment schedule exacerbate the lack of inflationary
updates. A provision within the Omnibus Budget Reconciliation Act of
1989 mandated that any adjustments to the MPFS due to upward payments
or new procedures in one category that increase costs by $20 million or
more must be offset by cuts in other areas of the fee schedule. This
issue is reflected in the implementation of a new and controversial
care complexity add-on code (G2211). Improved payment for longitudinal,
coordinated primary care is necessary for physicians, but those payment
improvements should not come at the expense of payment reductions in
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other specialties that would limit the benefits the new code provides.
In comparing the United States with nine other high-income nations, the
United States has significantly lower rates of patients reporting a
longstanding relationship with a primary care physician.\5\ At the same
time, evidence shows that longitudinal relationships, which are
integral to both the philosophy of osteopathic medicine and delivering
high-quality care, lead to better management of chronic conditions and
improved patient outcomes.\6\ Investment in the physician workforce,
especially in primary care, is needed to build capacity across the
country. To help alleviate building pressure on the physician workforce
and subsequent access impacts upon patients, the AOA strongly urges the
Committee to consider the Resident Physician Shortage Reduction Act
(H.R. 2389). The bill would increase the number of residency positions
funded by Medicare, with particular emphasis on hospitals in rural
areas and Health Professional Shortage Areas (HPSAs).
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\5\ Gumas ED et al. ``Finger on the Pulse: The State of Primary
Care in the U.S. and Nine Other Countries,'' March 28, 2024. The
Commonwealth Fund. Accessed online at: https://
www.commonwealthfund.org/publications/issue-briefs/2024/mar/finger-on-
pulse-primary-care-us-nine-countries.
\6\ Jennifer Arnold, ``Fostering Long-Term Doctor-Patient
Relationships to Improve Outcomes,'' Duke Health, January 17, 2017.
Additionally, the Committee should evaluate proposals such as the
bipartisan Rural Physician Workforce Production Act (H.R. 834), which
would allow certain hospitals to receive additional payments from
Medicare for employing resident physicians in rural areas. This would
increase the number of physicians practicing in rural communities and
would provide financial support to make these residencies more
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accessible.
Continued patient access to high-quality care, particularly for chronic
conditions, is contingent upon the confluence of all three factors:
sustainable and predictable updates to physician payment under the
Medicare Physician Fee Schedule, adjustments to the budget neutrality
threshold, and investment in the physician workforce, particularly in
rural and underserved communities.
Aligning Sites of Service and Medicare Payment
Differences in payment predicated upon the site of service create
fundamental inequities in the care delivery landscape, and the MPFS
cuts that went into effect January 1, 2024, would exacerbate existing
site of service differences for services that are demonstrably similar.
AOA supports policies that would require payments to physicians that
reflect the resources required to provide patient care in each setting.
These changes would also ensure that physicians delivering longitudinal
care to patients with chronic conditions are not disadvantaged compared
to Hospital Outpatient Departments (HOPDs) delivering urgent care for
emerging issues related to chronic conditions. Not only would more
equitable payment lower costs, but it would support better outcomes for
patients.
The inequities, in the current payment model, allow for HOPDs to net
higher payments for certain services, driving up costs to both Medicare
and patients, while driving consolidation and reducing competition in
the care delivery ecosystem. As the Committee considers policies that
will align payments for various sites of service, it should prioritize
payment models that account for costs incurred to the provider while
also taking into account the nature of the patient population being
served. Payment policies should also include factors such as the
provision of care coordination, after-hours care, emergency care,
quality-based payments, and other costs.
MedPAC recommended Congress implement site-neutral payment policies in
its July 2023 report, and the AOA strongly echoes that
recommendation.\7\
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\7\ MedPAC. ``Health Care Spending and the Medicare Program: July
2023 Data Book.'' 2023.
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Value and Innovation
The AOA has long advocated for payment predicated upon delivering high-
quality, value-based care rather than the volume-based nature of the
current fee-for-service payment model. Despite that, transitions to
value-based payments must account for the unique needs of different
specialties, practices current capacities, and the ways physicians
deliver care. It also must not create additional barriers to entry,
result in reduced or inequitable payment, or increase administrative
burden. To better promote high-value care and reduce burdens, the
Committee should look at Advanced alternative payment models (APMs)
rather than the Merit-based Incentive Payment System (MIPS) when
building new policies.
Advanced APM pathways include Accountable Care Organizations (ACOs),
including those under the Medicare Shared Savings Program (MSSP), and
Centers for Medicare and Medicaid Innovation (CMMI) models. Many AAPMs
are well suited for physicians helping patients manage chronic
conditions, as they include added incentives for providers who take on
additional risk when treating patients as they deliver high quality,
coordinated, and efficient care. Ultimately, in considering any shifts
towards expanding existing APMs or seeking to accelerate physician
participation in such models, efforts must:
Support practices in making the necessary infrastructure
investments to succeed under such models;
Ensure sufficient flexibility in the range of models available
to account for differences across specialties and the ways different
physicians deliver care;
Minimize administrative burden to enable physicians who commit
to value-based models to focus on patient care; and
Ensure adequate payment for the range of services the particular
physician provides, and in the case of primary care, support the
comprehensive services that advanced primary care seeks to deliver.
Ensuring that financial support is available to incentivize this
transition is essential, and the AOA applauds Congress' extension of
AAPM bonuses for PY2024, despite our disappointment at the reduced
bonus rate.
When Congress passed the Medicare Access and CHIP Reauthorization Act
(MACRA) it clearly intended to deliver an accelerated pathway for
physicians to participate in APMs. The transition to value-based
payment has not materialized as Congress had hoped because practices
have not been paid enough to be able to reinvest to have the capacity
to succeed in APMs. It is important to note that most APMs are built
upon the foundation of our FFS system, and continuously declining
payment rates in FFS create a vicious cycle that only makes it more
challenging to transition as revenue, and funds available to make
investments, declines.
Moreover, the current structure of MIPS does not effectively measure
performance on meaningful outcomes or accurately predict care quality,
and it is not an effective means of delivering value and penalizes
small and rural practices.
Further, the Committee should consider additional funding for the
Quality Payment Program's Small Practice, Underserved, and Rural
Support (QPP-SURS) program. This program ensures small and rural
physicians can participate in quality payment models that will improve
patient outcomes and access while lowering costs. Most small and rural
providers do not have access to the technical or administrative staff
necessary to ensure proper participation in the MIPS, which currently
disadvantages small and independent physician practices. Physicians in
small and rural practices consistently receive below-average MIPS
scores, demonstrating that practice size and resources are better
indicators of MIPS performance than patient outcomes. Research shows
that association with large hospital systems and provider networks
receive better MIPS performance ratings, despite large health systems
not delivering demonstrably better quality of care.\8\ Physician-owned
practices deliver high-quality and cost-effective care regardless of
health system affiliation, and this research demonstrates the technical
and administrative disadvantage small and independent physician
practices are currently facing. Ensuring physicians at small or rural
practices can participate in APMs that incentivize high-quality, cost-
effective care is integral to improving patient access to care for
chronic conditions.
---------------------------------------------------------------------------
\8\ Johnston K, Wiemken T, Hockenberry J, et al. Association of
Clinician Health System Affiliation with Outpatient Performance Ratings
in the Medicare Merit-based Incentive Payment System. JAMA Netw Open.
2020;324(10):984-992.
Value-based payment is an important tool that can be used to enhance
access to primary care, particularly for patients with chronic
conditions. The AOA applauds the Committee's interest in taking steps
to ensure physician payment reform drives patients access to high-
quality, affordable, coordinated care, and we look forward to working
with the committee further.
Conclusion
Again, thank you for the opportunity to submit comments for the record.
The Committee's work on these important issues will support the
stability of both the physician workforce and patient access to
affordable, high-quality care. The AOA and our members stand ready to
assist the Committee at large as you consider new policies and
legislation to improve patient access to care and minimize red tape for
doctors. If you have any questions or if the AOA can be a resource,
please contact AOA Vice President of Federal Affairs and Public Policy,
John-Michael Villarama, MA, at jvillarama@osteopathic.org, or (202)
349-8748.
______
American Physical Therapy Association
3030 Potomac Ave., Suite 100
Alexandria, VA 22305-3085
703-684-2782
https://www.apta.org/
The Honorable Ron Wyden The Honorable Mike Crapo
Chair Ranking Member
U.S. Senate U.S. Senate
Committee on Finance Committee on Finance
219 Dirksen Senate Office Building 219 Dirksen Senate Office Building
Washington, DC 20510 Washington, DC 20510
Dear Chairman Wyden and Ranking Member Crapo,
On behalf of our more than 100,000 member physical therapists, physical
therapist assistants, and students of physical therapy, the American
Physical Therapy Association appreciates the opportunity to submit
comments for the hearing ``Bolstering Chronic Care through Medicare
Physician Payment.''
APTA is dedicated to building a community that advances the physical
therapy profession to improve the health of society. As experts in
rehabilitation, prehabilitation, and habilitation, physical therapists
play a unique role in society in prevention, wellness, fitness, health
promotion, and management of disease and disability for individuals
across the age span, helping individuals improve overall health and
prevent the need for avoidable health care services. Physical
therapists' roles include education, direct intervention, research,
advocacy, and collaborative consultation. These roles are essential to
the profession's vision of transforming society by optimizing movement
to improve the human experience.
``The Economic Value of Physical Therapy in the United States''\1\ a
recently released APTA report, showcases the cost-effectiveness and
economic value of physical therapist services for a broad range of
common conditions. The report compares physical therapy with
alternative care across a suite of health conditions commonly seen
within the U.S. health care system. The report underscores and
reinforces the importance of including physical therapists and physical
therapist assistants as part of multidisciplinary teams focused on
improving patient outcomes and decreasing downstream costs.
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\1\ https://www.valueofpt.com/.
While the report highlights the economic value that physical therapy
brings to the U.S. health care system, such value is not maximized due
to the unique challenges faced by physical therapists under the
Medicare Physician Fee Schedule (MPFS). Physical therapist and physical
therapist assistants play a critical in the delivery of services to
beneficiaries who have chronic care conditions; however, therapists and
other non-physician providers who are paid under the MPFS are often
overlooked when it comes to enacting meaningful reforms to payment and
administrative burden challenges. To improve chronic care services,
broader reforms to the current fee schedule to address these challenges
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must be made.
APTA's comments below offer a series of policy recommendations for the
committee's consideration to decrease health care costs and reduce
administrative burden that are supported by APTA's recent economic
report.\2\ Our comments also mirror the recommendations laid out in the
``Policy Principles of Outpatient Therapy Reform Under the Medicare
Physician Fee Schedule''\3\ that provides a roadmap offering
recommendations specific to outpatient therapy that need to be made for
the continued sustainability of physical therapy under Medicare. The
``Policy Principles of Outpatient Therapy Reform Under the Medicare
Physician Fee Schedule'' are endorsed by APTA, APTA Private Practice,
the American Speech-Language-Hearing Association, and the American
Occupational Therapy Association.
---------------------------------------------------------------------------
\2\ https://www.valueofpt.com/globalassets/value-of-pt/
economic_value_pt_u.s._report_from_
apta-policy_paper-policymakers.pdf.
\3\ https://apta1111-my.sharepoint.com/personal/
justinelliott_apta_org/Documents/Desktop/Policy Principles for
Outpatient Therapy Reform under the Medicare Physician Fee Schedule
(apta.org).
---------------------------------------------------------------------------
Background
The 2015 Medicare Access and CHIP Reauthorization Act, known as MACRA,
replaced the flawed Sustainable Growth Rate formula with the Quality
Payment Program, or QPP. The QPP comprises two tracks: the Merit-based
Incentive Payment System, or MIPS, and Advanced Alternative Payment
Models, also known as AAPMs. The Centers for Medicare & Medicaid
Services began implementing the QPP in 2017, with the eventual goal of
moving providers out of MIPS and into AAPMs. There are a number of
foundational issues with MACRA and the QPP that disproportionately
impact nonphysician qualified health care providers such as physical
therapists. In addition, there are logistical and operational barriers
for therapists to participate in MIPS and AAPMs. Some of the current
challenges facing therapy providers include:
MACRA Has Not Stabilized Payment Under the Medicare Physician Fee
Schedule. MACRA sought to stabilize payments by repealing
the Sustainable Growth Rate formula and providing payment
adjustments under the QPP. Despite that goal, these changes
replaced relief from the growth rate cuts with payment cuts
to the conversion factor--as a result, budget neutrality
requirements limit the effectiveness of payment incentives
provided under MIPS and have required annual legislative
intervention to stave off untenable cuts to payment.
Further, nonphysician providers, including therapists, have
few options to receive payment adjustments under the QPP
that would otherwise serve to offset payment cuts. In 2021,
the average payment per therapy claim was the same as it
was in 2010. Since 2021, therapy services have been cut
further because of reductions to the conversion factor. An
additional 15% cut to services provided by physical
therapist assistants was implemented in 2023. This decrease
in payment is simply not sustainable if we are to have a
robust workforce that supports access to rehabilitation
therapy services nationwide. Providers are suffering under
a workforce shortage and MACRA policies are reducing
resources needed for adequate therapists to meet patient
access needs.
Inability of facility-based outpatient therapy providers to
participate in bonus payment structures. While outpatient
private practice therapy services are paid under the
Medicare Physician Fee Schedule, or MPFS, services provided
in facility-based settings, such as hospital outpatient
departments, rehabilitation agencies, and skilled nursing
facilities are not considered to be a part of the MPFS.
Rather, the 1997 Balanced Budget Act required that payments
for facility-based outpatient therapy services be ``based-
on'' the value of those services as set forward in the
MPFS. While therapy services provided under the fee
schedule are billed through an individual's National
Provider Identifier, all facility-based outpatient therapy
services are billed through the facility, and not the
individual therapist. This distinction is not
insignificant. According to MedPAC,\4\ 63% of all Medicare
outpatient therapy services are provided in facility-based
settings, yet facility-based outpatient therapy providers
have had no way to receive payment updates or bonus
payments. However, these services are subject to budget
neutrality cuts and any other policy affecting therapy
payments through the physician fee schedule--such as the
multiple procedure payment reduction, also known as MPPR,
and cuts to services provided by physical therapist
assistants.
---------------------------------------------------------------------------
\4\ https://www.medpac.gov/wp-content/uploads/2022/10/
MedPAC_Payment_Basics_22_OPT_
FINAL_SEC.pdf.
QPP Does Not Promote Value-Based Care or Effectively Measure
Quality of Care. The QPP does not allow for adequate
participation for therapists in either MIPS or AAPMs. The lack
of appropriate quality metrics and a failure to include all
outpatient providers of therapy services in MIPS and AAPMs have
prevented the shift to value-based care. These problems are
compounded by slow and ineffective mechanisms used to innovate
within the QPP. This means physical therapists who were not
fully considered in the QPP's design still cannot meaningfully
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participate.
Barriers to Therapist Participation in MIPS. Most physical
therapists are not required to participate in MIPS but are
encouraged to opt in to the program. However, extremely limited
payment incentives serve to dissuade optional participation
given that the cost of compliance outweighs even the highest
historical incentives earned under the programs. Without
specialty measurement sets, therapy cost measures, or otherwise
comparable options available to most physicians, therapists
have few reasons to participate under the program and suffer
compounding pay cuts under the MPFS without any opportunity for
mitigation through the QPP.
CEHRT is a Threshold Barrier for Therapists in MIPS and
AAPMs. Promoting interoperability through Certified Electronic
Health Record Technology, or CEHRT, was part of MACRA's
original vision. AAPMs promote this by requiring CEHRT as a
prerequisite for AAPM opportunities, and under MIPS providers
are scored on the ``promoting interoperability'' measure
category. CEHRT options are simply not available for physical
therapists, as their requirements are costly, burdensome, and
contain many requirements that are specific only to physicians.
As a result, physical therapists cannot participate in AAPMs,
and will receive scores of zero under MIPS in the
interoperability category. Without vendors working to develop
CEHRT for therapists (in part because there aren't enough
potential users to justify vendors' expense of CEHRT
development), these providers will never be able to participate
meaningfully. Requirements must be relaxed or modified,
otherwise physical therapists will continue to be assessed on
an uneven playing field.
Barriers to Participation in AAPMs. In addition to CEHRT as
a threshold barrier to participation, the Qualifying
Participant, or QP, threshold to earn incentives under the
program also is not realistically achievable for physical
therapists. Further, while there is a Partial QP designation,
it does not offer any incentives to participate, and serves
more to prepare clinicians who believe they would meet the QP
threshold in the future. AAPMs could have therapist-specific
thresholds or offer incentives for partial QPs to incentivize
participation by therapists.
The challenges that MACRA has created for therapy providers are
compounded by the current budget neutrality policies under the MPFS
that have resulted in year-over-year cuts. Despite Congress's annual
intervention since 2020 to provide additional funding to the fee
schedule to mitigate the impact of the cuts, therapy providers still
had to absorb multiple payment reductions. The challenges associated
with budget neutrality threaten to re-create the decades-long problems
created by the Sustainable Growth Rate; an urgently needed solution is
necessary to prevent increased spending associated with temporary,
year-end fixes.
Recommendations
To provide greater stability under the MPFS for nonphysician providers
such as physical therapists, and to help account for a decade of cuts
to payments to therapy services, we recommend the following policies be
included in any legislative package aimed at reforming the Medicare
Physician Fee Schedule to ensure patient access to care and stability
of providers.
Eliminate the Multiple Procedure Payment Reduction Policy
The MPPR Policy, first implemented in 2011, applies to physical
therapy, occupational therapy, and speech-language pathology services
provided under Medicare Part B. Because of MPPR, when therapists bill
more than one ``always therapy'' service (identified by CPT code) on
the same day for the same patient, all therapy services beyond the
first are subject to a reduction in the practice expense portion of
that code.
Under this policy, the therapy service with the highest practice
expense value is reimbursed at 100%, and the practice expense values
for all subsequent therapy services, provided by all therapy
clinicians, are reduced by 50%. The work and malpractice components of
the therapy service payment are not reduced. In the 2011 Medicare
Physician Fee Schedule, CMS first proposed the implementation of a 25%
MPPR across therapy services. Congress reduced this reduction amount to
20% in the Physician Payment and Therapy Relief Act of 2010 (H.R.
5712). This 20% MPPR was in place from January 1, 2011, to March 31,
2013. Without any further analysis demonstrating a need to increase the
MPPR, Congress implemented a permanent 50% MPPR in the American
Taxpayer Relief Act of 2012, which was implemented by CMS on April 1,
2013. The average payment per therapy claim in 2013 (after MPPR) was
8.5% less than the average therapy claim in 2010 (before MPPR).
Our organizations have opposed the MPPR policy since its inception. It
is inherently flawed, because the American Medical Association Relative
Value Scale Update Committee, which assigns values to CPT codes,
already ensures that any potential duplication in work or practice
expense is addressed as part of the code valuation process. Certain
efficiencies that occur when multiple therapy services are provided in
a single session were explicitly taken into account when relative
values were established for these codes. The application of MPPR to the
``always therapy'' codes results in a duplicative and excessive
reduction of these codes and is having a significant impact on the
financial viability of therapy practices--ultimately impacting access
to vital therapy services.
The percentage of payment reduction was arbitrarily decided by the
112th Congress and does not reflect actual utilization data regarding
how many units of a therapy service are typically delivered in a
treatment session, and it does not recognize that OT, PT, and SLP
interventions are separate and distinct from each other. When CMS first
proposed the MPPR, they purposefully did not consider how therapy
services are provided in facility-based settings, even stating that it
does ``not believe it would have been appropriate for us to consider
institutional patterns of care.''\5\ (See page 70.)
---------------------------------------------------------------------------
\5\ https://www.govinfo.gov/content/pkg/FR-2010-11-29/pdf/2010-
27969.pdf.
With the potential exception of greeting the patient, clinical staff
activities that are elements of the practice expense are not
duplicative in nature and should not be reduced in value, especially
when delivering different services during the therapy session. For
instance, if therapeutic exercises using hand weights are provided for
one unit, followed by self-care retraining in the kitchen for one unit,
then the equipment, supplies, and clinical staff activities are
entirely separate for each of these procedures. Each requires its own
disinfection, patient positioning, and other set-up and clean-up
processes before and after the procedure. Under the current policy,
despite those services being separate and distinct, and having a
separate and distinct practice expense, payment for the second unit is
reduced even though the values of the two codes do not include any
---------------------------------------------------------------------------
duplicative cost.
MPPR also applies across therapy disciplines delivered on the same date
regardless of the distinct services and supplies provided to the
patient. While the first therapy discipline (e.g., physical therapy)
would receive payment under MPPR at 100% for the first unit and 50% of
the practice expense for all other units, a second or third discipline
(e.g., occupational therapy or speech-language pathology) delivering
services on that date would have all provided service units reduced.
This occurs even though the expertise, equipment, clinical staff, and
supplies utilized for one therapy service have no overlap with the
other services provided. This policy penalizes providers when
scheduling multiple therapies on the same date, which
disproportionately affects beneficiaries in rural and underserved
communities where transportation issues may require therapy services to
be delivered on the same day to reduce the need for repeat visits to
the clinic.
Provide Flexibility in the Supervision of Physical Therapy Assistants
to Alleviate the Challenges Facing the Physical Therapist
Workforce in Rural and Underserved Areas
Medicare allows for general supervision of occupational therapy
assistants (OTAs) by occupational therapists, and physical therapist
assistants (PTAs) by physical therapists in all settings, except for
outpatient private practice under Part B, which requires direct
supervision. While therapy providers must comply with their state
practice act if state or local practice requirements are more stringent
than Medicare's, the standard in 49 states is general supervision of
PTAs, making this an outdated Medicare regulation--which arbitrarily
applies only to private practice--more burdensome than almost all state
requirements. Standardizing a general supervision requirement for
private practices will help ensure continued patient access to needed
therapy services and give small therapy businesses more workforce
flexibility to meet the needs of beneficiaries.
The inconsistency of supervision policies between settings jeopardizes
employment opportunities for OTAs and PTAs as well as the needs of
Medicare beneficiaries in medically underserved and rural communities
that rely so heavily on their services. Standardizing the supervision
requirement from direct to general for private practices will help
ensure continued patient access to needed therapy services and give
private practices more flexibility in meeting the needs of
beneficiaries. This small modification would better promote timely
access to therapy services.
Congress should enact the Enabling More of the Physical and
Occupational Workforce to Engage in Rehabilitation Act, or EMPOWER Act
(H.R. 4878/S. 2459),\6\ bipartisan legislation \7\ that would assist
the therapy workforce by permitting general supervision of physical
therapist and occupational therapy assistants under Medicare Part B
outpatient practices. According to an independent report published by
Dobson DaVanzo & Associates in September 2022, this change in
supervision is estimated to save up to $271 million over 10 years.
---------------------------------------------------------------------------
\6\ https://www.apta.org/advocacy/issues/medicare-physician-fee-
schedule/position-paper-pta-differential.
\7\ https://www.congress.gov/bill/118th-congress/senate-bill/2459.
The EMPOWER Act also direct the Government Accountability Office to
conduct an analysis of how the Medicare Part B 15% payment differential
for services provided by OTAs and PTAs, which went into effect in 2022,
has impacted access to occupational therapy and physical therapy
services in rural and medically underserved areas, across all Medicare
Part B settings. Beneficiaries in those areas are twice as likely to
receive OT or PT services from an assistant. Rehabilitation therapy
providers report that rural areas suffer significantly from the ongoing
workforce shortage. A GAO report will provide greatly needed
information and data regarding the impact of this payment differential
and how it disproportionately impacts these regions.
Reform MACRA to Allow Broader Participation by Therapy Providers
Within MACRA, the QPP has posed significant challenges to nonphysician
providers, including PTs, OTs, and SLPs. Therapists in particular have
struggled to meaningfully participate in MIPS or engage in AAPMs, in
part because CMS has failed to pilot or implement several alternative
payment and delivery models applicable to therapy providers. Congress
must enact meaningful reforms to the QPP that recognize the value of
therapy providers and allow them to provide effective oversight of the
QPP to determine its effectiveness at measuring therapy performance and
outcomes.
The value of any quality program depends on the ability of all
providers to participate. To address the current shortcomings of the
QPP including limited opportunities for therapists' participation in
the program, Congress should authorize a stakeholder workgroup to
identify barriers and develop recommendations for the Secretary of the
Department of Health and Human Services on rulemaking to ensure that
the QPP comprehensively measures the impact of all care received by
Medicare beneficiaries.
Reduce the Impact of Inflation on Providers and the Patients They Serve
Providers paid under the Medicare Physician Fee Schedule do not receive
the annual inflationary update upon which virtually all other Medicare
providers can rely on to better weather periods of fiscal uncertainty.
Providing an annual inflationary payment update to the Medicare
Physician Fee Schedule's conversion factor based on the Medicare
Economic Index, or MEI, will provide much-needed stability to the
Medicare payment system. The MEI is a measure of inflation faced by
health care providers with respect to their practice costs and general
wage levels.
Health care providers, including rehabilitation therapists, continue to
face increasing challenges as they seek to provide Medicare
beneficiaries with access to timely and quality care. Congress has
taken action to mitigate some of the recent MPFS cuts on a temporary
basis, nevertheless, reimbursement continues to decline. According to
an American Medical Association analysis of Medicare Trustees data,\8\
when adjusted for inflation, Medicare payments to clinicians have
declined by 26% from 2001 to 2023. The failure of the MPFS to keep pace
with the true cost of providing care, combined with year-over-year cuts
resulting from the application of budget neutrality, sequestration, and
alternative payment and value-based care models that are unavailable to
therapists, clearly demonstrates that the fee schedule is broken.
Increasingly thin operating margins disproportionately affect small,
independent, and rural practices, as well as those treating low-income
or other historically under-resourced or marginalized patient
communities--undermining efforts to improve equity in health care and
social determinants of health.
---------------------------------------------------------------------------
\8\ https://www.ama-assn.org/system/files/medicare-updates-
inflation-chart.pdf.
An inflationary update will provide budgetary stability to clinicians--
many of whom are small business owners--as they contend with a wide
range of shifting economic factors such as increasing administrative
burdens, staff salaries, office rent, and purchasing of essential
technology. Providing an annual inflation update equal to the MEI for
fee schedule payments is essential to enabling practices to better
absorb payment distributions triggered by budget neutrality rules,
performance adjustments, and periods of high inflation. A more stable
payment system will also help providers to invest in their practices
---------------------------------------------------------------------------
and implement new strategies to provide high-value care.
APTA strongly support the Strengthening Medicare for Patients and
Providers Act (H.R. 2474),\9\ legislation that would provide such an
annual inflationary update to the Physician Fee Schedule's conversion
factor based on the Medicare Economic Index to help ensure patient
access to the critical services our members provide. H.R. 2474 was
introduced by Reps. Raul Ruiz, D-CA, Larry Bucshon R-IN, Ami Bera, D-
CA, and Mariannette Miller-Meeks, R-IA.
---------------------------------------------------------------------------
\9\ https://www.apta.org/advocacy/issues/medicare-physician-fee-
schedule/strengthening-medicare-for-patients-and-providers-act.
---------------------------------------------------------------------------
Reduce Administrative Burden for Therapy Services Provided Under
Medicare
Part B
Medicare Part B guidelines permit Medicare beneficiaries to receive
therapy evaluation and treatment services with or without a physician
order. The PT, OT, or SLP may evaluate that patient, formulate a plan
of care, and commence treatment in either instance. However, under
current certification requirements, the therapy provider must submit
the plan of care to the patient's physician and have it signed within
30 days in order to receive payment. If the deadline is approaching and
the referring physician still hasn't returned the signed plan of care,
the rules say it's up to the therapist to obtain that signature;
without it, the PT is faced with halting treatment or face the prospect
of not getting paid by Medicare.
Given the current pressures on therapy providers, including recent
year-over-year fee schedule cuts, we are united in seeking
opportunities to reduce administrative burden without compromising
patient safety or quality of care as a way to mitigate the impact of
these payment cuts for therapy providers and our physician colleagues,
as well as to best serve our patients expeditiously and without
financial risk to their therapy providers. The time and resources spent
by both therapists and physicians in procuring a timely signature when
a physician order is already present adds unnecessary cost, potentially
delays essential services, and fails to contribute to improved quality
of care.
Congress should enact legislation that would clarify a new care
coordination model such that when outpatient therapy services are
provided under a physician's order, the plan of care certification
requirements shall be deemed satisfied if the qualified therapist
submits the plan of care to the patient's referring physician within 30
days of the initial evaluation. The order would confirm the physician's
awareness of the therapy episode and proof of submission of the plan of
care would demonstrate the coordination and collaboration between the
physician and the therapist called for by CMS.
APTA strongly supports the Remove Duplicative Unnecessary Clerical
Exchanges Act, or the REDUCE Act (H.R. 7279).\10\ This bipartisan bill
would streamline the current plan of care certification requirement
under Medicare Part B to reduce administrative burden and paperwork for
physical therapists and physicians. The REDUCE Act was introduced in
the U.S. House of Representatives by Reps. Don Davis, D-NC, and Lloyd
Smucker, R-PA.
---------------------------------------------------------------------------
\10\ https://www.apta.org/advocacy/issues/administrative-burden/
remove-duplicative-unnecessary-clerical-exchanges-act.
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Provide Patient Choice Under Medicare
Currently, PTs, OTs, and SLPs may not opt out of being Medicare-
enrolled providers if they provide services to Medicare-eligible
beneficiaries. This prevents Medicare beneficiaries from exercising
their right to select the health care professional of their choice,
including allowing beneficiaries to privately contract with these
therapists for their care regardless of whether the therapist has
elected to enroll in Medicare. To provide true patient choice and
ensure access to the most appropriate care, PTs, OTs, and SLPs must be
able to opt out of the established enrollment rules set by the Medicare
program and federal law along with physicians, physician assistants,
dentists, podiatrists, optometrists, social workers, psychologists,
nurse midwives, dietitians, and other eligible providers. Denying a
patient access to a therapist with expertise because that provider is
not enrolled in Medicare also negatively impacts patients' clinical
outcomes and can lead to increased downstream costs to the system.
It is imperative that Medicare enrollees have the opportunity to choose
the most appropriate provider and model of care to meet their needs.
Medicare's inflexible policies have stifled implementation of
innovative programs that can support the long-term health and wellness
of Medicare beneficiaries. Certain evidence-based therapy interventions
cannot be reimbursed under current Medicare payment policies. Allowing
therapy providers to opt out would give Medicare beneficiaries the
opportunity to benefit from these critical interventions to which they
are currently denied access.
According to an independent report published by Dobson & Davanzo in
October 2023, allowing physical therapists, occupational therapists,
and speech-language pathologists the option to opt-out is estimated to
save $139.6 million over 10 years. The American Physical Therapy
Association urges Congress to enact legislation that would provide
physical therapists and other therapy providers with the ability to
privately contract with Medicare beneficiaries.
Enact a Permanent Medicare Policy for Therapy Services Delivered via
Telehealth
In response to the coronavirus public health emergency in 2020,
Congress passed and the President signed into law legislation that
authorized CMS to significantly expand Medicare's coverage of
telehealth services during the public health emergency to protect the
health and safety of Medicare patients. Under the authority of Section
1135 of the Social Security Act, CMS permitted virtually all medical
providers, including physical therapists, occupational therapists, and
speech-language pathologists, to provide services via telehealth to
Medicare beneficiaries. In late 2022, Congress approved legislation
that extended Medicare's telehealth flexibilities for another 2 years;
Medical providers will be permitted to treat Medicare patients via
telehealth until December 31, 2024. After that date, unless Congress
acts, Medicare patients may lose coverage of telehealth visits.
Continued access to telehealth services provided by physical
therapists, occupational therapists, and speech-language pathologists
would allow Medicare beneficiaries to maintain access to critical
health care services utilizing the method of delivery in-person or
telehealth of their choice. The June 2023 MedPAC Report highlighted
that over 90% of Medicare beneficiaries surveyed who had at least one
telehealth visit with a clinician stated that they were very or
somewhat satisfied. Additionally, clinicians surveyed by MedPAC
indicated that, on average, less than 10% of their services were
delivered via telehealth. Finally, a report by the HHS Office of
Inspector General found that less than 0.2% of Medicare telehealth
claims were considered high risk. Telehealth presents a way to provide
access to care for patients both in rural and urban areas who may have
trouble getting to appointments due to distance, mobility or
transportation issues, or who cannot afford to take time off of work.
Services delivered using telehealth also provide access to therapy in
areas of our country where there simply are no therapists available.
Telehealth has been demonstrated to be a service delivery mechanism
that is used judiciously by health care providers in consultation with
their patients who maintain high levels of satisfaction. Furthermore,
initial data indicates concerns over fraud, waste, and abuse may not be
as significant as initially feared.
APTA supports the Expanded Telehealth Access Act (H.R. 3875/S.
2880),\11\ bipartisan legislation that would add therapy providers in
private practice, as well as facility-based outpatient therapy
providers under Medicare Part B, as permanent authorized providers of
telehealth services under Medicare. H.R. 3875 was introduced by Reps.
Mikie Sherrill, D-NJ, and Diana Harshbarger, R-TN, S. 2880 was
introduced by Senators Steve Daines, R-MT, and Tina Smith, D-MN.
---------------------------------------------------------------------------
\11\ https://www.apta.org/advocacy/issues/telehealth/expanded-
telehealth-access-act.
---------------------------------------------------------------------------
Conclusion
APTA appreciates the opportunity to share our perspective and
recommendations to the committee that will provide long-term stability
and reform to the Medicare Physician Fee Schedule. Should you have any
questions, please contact justinelliott
@apta.org. Thank you for your time and consideration.
Sincerely,
Roger Herr, PT, MPA
President
______
American Psychological Association Services, Inc.
750 First Street, NE
Washington, DC 20002-4242
202-336-5800
202-336-6123 TDD
https://www.apa.org/
April 25, 2024
The Honorable Ron Wyden The Honorable Mike Crapo
Chair Ranking Member
U.S. Senate U.S. Senate
Committee on Finance Committee on Finance
219 Dirksen Senate Office Building 219 Dirksen Senate Office Building
Washington, DC 20510 Washington, DC 20510
Dear Chairman Wyden and Ranking Member Crapo:
On behalf of the American Psychological Association Services (APA
Services), we are writing to share comments and recommendations for
consideration as part of your committee's April 11th hearing,
``Bolstering Chronic Care through Medicare Physician Payment.'' APA
Services is the companion organization of the American Psychological
Association, which is the nation's largest scientific and professional
nonprofit organization representing the discipline and profession of
psychology, as well as over 157,000 members and affiliates who are
clinicians, researchers, educators, consultants, and students in
psychological science.
We applaud your committee's attention to improving Medicare healthcare
provider reimbursement policies, as they are not adequately supporting
high-quality, cost-
effective health care for the program's beneficiaries. We share the
concerns of the broad provider community regarding the consistent
failure of payment updates for Part B providers to keep pace with
inflation. Steadily eroding reimbursement rates are increasingly making
Medicare participation unsustainable for psychologists and other
providers. We strongly support proposals to raise the budget neutrality
cap on adjustments to the Medicare Physician Fee Schedule (PFS), and to
connect annual conversion factor increases to the Medicare Economic
Index or similar measures of inflation. However, our comments today
will focus on aspects of the Medicare fee schedule and proposed payment
policies that specifically impact psychological services.
Because of their foundational importance, it is important for
policymakers to understand that Medicare PFS payment formula
methodologies for both work and practice expenses have consistently
undervalued psychologists' services. This situation has been
exacerbated by the statutory requirement that annual updates to the PFS
be made in a budget neutral manner.
Work Valuation
As the committee has recognized, the Medicare fee schedule tends to
undervalue cognitively intensive services, and psychologists' services
are cognitively intensive. Thankfully, the Centers for Medicare and
Medicaid Services (CMS) has recognized the need to set more appropriate
work values for psychologists' services, and in the 2024 fee schedule
CMS initiated a 19.1% increase in work relative value units (RVUs) for
psychotherapy services over the next 4 years. However, CMS has not
adopted a similar increase for psychological and neuropsychological
testing and assessment services, which are as cognitively demanding as
psychotherapy services.
Psychological assessment is the process of systematically collecting
reliable and valid information about behavior from multiple sources to
inform decisions about a patient's mental or behavioral functioning,
typically for the purpose of diagnoses, treatment planning, or
treatment evaluation. Domains assessed in a psychological assessment
typically consist of mood/emotional conditions and symptoms, mental
status, adaptive functioning, and behavioral and interpersonal
adjustment, with evaluation of acuteness vs. chronicity, severity,
degree of functional impairment, comorbidity, and prognosis where
information is available. Psychological testing has been shown to
provide both clinical and financial benefit in treating psychiatric
disorders.\1\
---------------------------------------------------------------------------
\1\ Durosini, I., & Aschieri, F. (2021). Therapeutic assessment
efficacy: A meta-analysis. Psychological Assessment, 33(10), 962-972.
https://doi.org/10.1037/pas0001038.
Neuropsychological assessments provide measurements of behavioral
manifestations of central nervous system (CNS) disorders using
techniques that provide objectivity, validity, and reliability.
Information acquired from neuropsychological assessments can directly
inform medical decisions by providing data relevant to diagnosis,
progression or course of conditions, prognosis, and treatment of
disorders. In addition, neuropsychological assessments can aid in
making accurate predictions about functional abilities across a variety
of disorders.\2\, \3\ Neuropsychological tests are
administered in the context of a comprehensive evaluation that
synthesizes data from clinical interviews, record review, medical
history, and behavioral observations. Where appropriate, these
evaluations consider neuroimaging, other neuro-diagnostic studies, and
other lab/diagnostic studies to inform neuropsychologically oriented
interventions.\4\
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\2\ Chaytor, N. & Schmitter-Edgecombe, M. (2003). The ecological
validity of neuropsychological tests: A review of the literature on
everyday cognitive skills. Neuropsychology Review, 13, 181-197.
\3\ Gure, T. R., Kabeto, M. U., Plassman, B. L., Piette, J. D., &
Langa, K. M. (2010). Differences in functional impairment across
subtypes of dementia. Journals of Gerontology: Biological Sciences and
Medical Sciences, 65, 434-441.
\4\ Board of Directors. (2007). American Academy of Clinical
Neuropsychology (AACN) practice guidelines for neuropsychological
assessment and consultation. The Clinical Neuropsychologist, 21, 209-
231.
Neuropsychological evaluation remains the most sensitive cognitive
testing method for discriminating pathophysiological dementia from age-
related cognitive decline, cognitive difficulties that are depression-
related, and other related disorders, and are the gold standard in both
reliably establishing a diagnosis and developing treatment plans by
clinically justifying relevant therapies and interventions.\5\ This is
important in dementia care, as medications used to treat Alzheimer's
disease have virtually no benefit for patients with other forms of
dementia. An estimated 17% of Medicare beneficiaries with vascular
dementia and 8% with Parkinson's disease are initially misdiagnosed
with Alzheimer's disease, resulting in unnecessary treatment costs
until they are accurately diagnosed.\6\
---------------------------------------------------------------------------
\5\ Weintraub S. Neuropsychological Assessment in Dementia
Diagnosis. Continuum (Minneapolis, Minn.). 2022 Jun 1;28(3):781-799.
doi: 10.1212/CON.0000000000001135. PMID: 35678402; PMCID: PMC9492323.
\6\ Hunter CA, Kirson NY, Desai U, Cummings AK, Faries DE, Birnbaum
HG. Medical costs of Alzheimer's disease misdiagnosis among US Medicare
beneficiaries. Alzheimer's Dement. 2015 Aug;11(8):887-95. doi: 10.1016/
j.jalz.2015.06.1889. Epub 2015 Jul 21. PMID: 26206626.
CMS stated in the CY 2024 proposed rule, ``because the physician/
practitioner work RVU is developed based on the time and intensity of
the service, the issues regarding the valuation of these types of
services are particularly pronounced for services that are billed in
time units (like psychotherapy codes) that directly reflect the
practitioner time inputs used in developing work RVUs, compared to
other services that are not billed in time units in which work RVUs are
based on estimates of typical time, usually based on survey data.''\7\
---------------------------------------------------------------------------
\7\ Medicare and Medicaid Programs; CY 2024 Payment Policies Under
the Physician Fee Schedule and Other Changes to Part B Payment and
Coverage Policies. 88 Fed. Reg. 52262. (proposed August 7, 2023).
As with psychotherapy services and their corresponding codes, all
psychological and neuropsychological testing services are time-based
services and meet CMS' rationale for the proposed increase in value. We
believe that parallel increases in the work RVUs for all psychological
and neuropsychological testing and assessment services are warranted to
maintain relativity across the current procedural terminology (CPT)
codes, and to avoid disincentivizing provision of these services.
Practice Expense (PE) Valuation
As CMS has noted, behavioral health services have very little to no
direct expenses, and additionally, clinical psychology has the lowest
Indirect Practice Cost Indices (IPCI) of all specialties. CMS has
recognized that the methodology used to allocate practice expense RVUs
produces an anomaly for services with very low direct practice expense
inputs, and that psychologists' services are also disadvantaged under
the formula for allocating indirect practice expenses. CMS began to
address this issue in 2018 by modestly increasing the indirect PE RVUs
for services falling below the indirect PE valuation for a physician
office visit.
APA appreciates CMS's alternative methodology and efforts to establish
a reasonable minimum value in the allocation of indirect PE RVUs. CMS
has made important progress to help ensure beneficiary access to these
vital services through review and update of payment policies and
continues to request recommendations to systematically address how
behavioral health services are valued under the Medicare PFS. However,
further adjustments to reimbursement for behavioral health services are
needed to shift market dynamics and increase participation, and
ultimately to achieve the CMS Behavioral Health Strategy. APA is urging
CMS to close the gap in practice expense valuations between
psychologists and other healthcare provider specialties.
It is important for Congress to understand these valuation issues since
alternative payment models (APMs) and bundled payments are frequently
based upon PFS reimbursement rates.
Supporting Behavioral Health Integration in Alternative Payment Models
In order to effectively respond to the ongoing mental health crisis, it
is imperative that new payment models and incentives adequately support
integrated primary and behavioral healthcare. Integrated primary care,
in which primary care and behavioral health clinicians work together as
a team to care for patients and their families, can improve patient
outcomes and satisfaction with care and reduce overall treatment costs.
It can also increase access to mental health treatment, since as many
as 80% of patients with a mental illness visited a primary care
provider within the last year, and up to 75% of primary care visits
include mental or behavioral health components, including behavioral
factors related to chronic disease management and patient health and
well-being.\8\, \9\ In addition to improving the
identification and treatment of individuals with behavioral disorders
and care of patients' chronic conditions, research shows that
integrated care can reduce treatment costs. One study found that
integrating a psychologist into a primary care practice resulted in
cost savings of $860 per member per year.\10\ We applaud the
Committee's approval of the Better Mental Health Care, Lower-Cost
Drugs, and Extenders Act, and its provisions in Sec. 104 to support
adoption of evidence-based models of integrated care. We urge the
Committee to continue to support integrated care in its development of
new payment models and policies.
---------------------------------------------------------------------------
\8\ Jetty, A., Petterson, S., Westfall, J. M., & Jabbarpour, Y.
(2021). Assessing primary care contributions to behavioral health: a
cross-sectional study using medical expenditure panel survey. Journal
of primary care & community health, 12, 21501327211023871.
\9\ Robinson, P. J., & Reiter, J. T. (2007). Behavioral
consultation and primary care: A guide to integrating services. New
York: Springer.
\10\ Ross, K. M., Klein, B., Ferro, K., McQueeney, D. A., Gernon,
R., & Miller, B. F. (2019). The cost effectiveness of embedding a
behavioral health clinician into an existing primary care practice to
facilitate the integration of care: A prospective, case--control
program evaluation. Journal of Clinical Psychology in Medical Settings,
26, 59-67.
Without a clear and sustained effort to track, report, and make
progress on behavioral health, new payment models and value-based
payment initiatives risk hindering, not improving, access to behavioral
health services. One recent study found that beneficiaries who were
assigned to an Accountable Care Organization (ACO) had worse mental
health outcomes than those who remained outside ACOs. The authors
concluded, ``Among patients not enrolled in ACOs at baseline those who
newly enrolled in ACOs in the following year were 24% less likely to
have their depression or anxiety treated during the year than patients
who remained unenrolled in ACOs, and they saw no relative improvement
at 12 months in their depression and anxiety symptoms.''\11\ A recent
report issued by the Bipartisan Policy Center on integrated primary
care concluded:
---------------------------------------------------------------------------
\11\ Hockenberry, J. M., Wen, H., Druss, B. G., Loux, T., &
Johnston, K. J. (2023). No Improvement in Mental Health Treatment or
Patient-Reported Outcomes at Medicare ACOs for Depression and Anxiety
Disorders: Study examines mental health treatment and patient outcomes
at Medicare ACOs. Health Affairs, 42(11), 1478-1487.
Payment models, such as CPC+ were intended to incorporate care
coordination and behavioral health integration as cost
effective means of improving health outcomes. However, these
models remain based in Medicare's fee for service structure and
lack accountability for behavioral health outcomes and
integration. The CMMI Primary Care First model builds on CPC+
and moves practices closer to taking on full risk, while
focusing on high need, seriously ill patients. Yet, like CPC+
and Patient Centered Medical Homes, it focuses on physical
health rather than behavioral health outcomes. Without adequate
quality metrics, there is limited accountability and assessment
of the value of integration.\12\ (p. 51)
---------------------------------------------------------------------------
\12\ Hartnett, T., Loud, G., Harris, J., Curtis, M., Hoagland, G.
W., Serafini, M., Glassberg, H., Chung, H. (2023). Strengthening the
Integrated Care Workforce. Bipartisan Policy Center. https://
bipartisanpolicy.org/report/strengthening-the-integrated-care-
workforce/.
Access to psychological services is critical to the overall success of
several CMS Innovation Center model: Innovation in Behavioral Health
(IBH) Model; Making Care Primary (MCP) Model; Integrated Care for Kids
(InCK) Model; Primary Care First Model Options; Maternal Opioid Misuse
(MOM) Model; and Transforming Maternal Health (TMaH) Model. Integrating
behavioral health screening and management services into these models
allows more frequent psychological testing to assist with differential
diagnosis and treatment recommendations. This is especially important
in the classification of severe and persistent mental illness.
Identification of these conditions is uniquely important due to high
co-morbidity rates, significant negative impacts on mental and physical
well-being, and financial burden (e.g., lost income, healthcare
---------------------------------------------------------------------------
spending) associated with the conditions.
To highlight a specific example, neuropsychological testing services
will be vitally important to the success of the CMS Innovation Center's
Guiding an Improved Dementia Experience (GUIDE) Model, designed to
support people living with dementia and their unpaid caregivers. In the
GUIDE model, the first recommendation in identifying beneficiaries is
to utilize an interdisciplinary approach to the ``Initial Comprehensive
Assessment Visit,'' which includes a cognitive assessment. We are also
urging CMS to revise the ACO Primary Care Flex model to better
incentivize and scale integrated primary and behavioral health
treatment, and to establish behavioral health spending reporting
requirements to help assess the model's impact on access to behavioral
health services.
We appreciate the opportunity to provide comments on this critical
issue, and we look forward to working with the committee to establish
more effective Medicare payment policies for the benefit of the
program's millions of beneficiaries.
Sincerely,
Katherine B. McGuire, MSc
Chief Advocacy Officer
______
American Society of Health-System Pharmacists
April 11, 2024
The Honorable Ron Wyden
Chairman
United States Senate
Committee on Finance
219 Dirksen Senate Office Building
Washington, DC 20510-6200
The Honorable Mike Crapo
Ranking Member
United States Senate
Committee on Finance
219 Dirksen Senate Office Building
Washington, DC 20510-6200
Re: Senate Finance Committee Hearing on Bolstering Chronic Care Through
Medicare Physician Payment.
Dear Chairman Wyden and Ranking Member Crapo:
We applaud the Senate Finance Committee for examining how to bolster
chronic care through the Medicare physician payment. The American
Society of Health-
System Pharmacists (ASHP) is the largest association of pharmacy
professionals in the United States, representing over 60,000
pharmacists, student pharmacists, and pharmacy technicians in all
patient care settings, including hospitals, ambulatory clinics, and
health-system community pharmacies. Our members play a critical role,
as part of a comprehensive care team, assisting physicians in their
treatment of Medicare beneficiaries suffering from chronic medical
conditions. We recommend Congress require the Centers for Medicare &
Medicaid Services (CMS) to clearly enable physicians to bill for the
entirety of services pharmacists provide incident to the physician.
In inpatient and outpatient settings, pharmacists have traditionally
provided team-based clinical services, working collaboratively with
physicians, nurses, and other healthcare professionals to enable safe
and effective medication. This collaborative approach is necessary
because drug therapy is involved in 76% of physician office visits and
is the sole treatment for many acute and chronic conditions.\1\
Unfortunately, a 2020 CMS policy change limited physicians to billing
only the lowest-level evaluation and management (E/M) code for
pharmacist-provided incident-to services, regardless of the duration
and complexity of the E/M services provided.\2\ This policy shift
undermines care models that enable clinical pharmacists to support
physicians and the care teams on which they participate in providing
comprehensive care to seniors, thereby threatening patient access to
critical services, such as comprehensive medication management. This is
particularly worrisome for patients suffering from chronic conditions
requiring extensive medication management, such as diabetes,
hypertension, or Parkinson's disease.
---------------------------------------------------------------------------
\1\ Budnitz DS, Pollock DA, Weidenbach KN, et al. National
surveillance of emergency department visits for outpatient adverse drug
events. JAMA. 2006;296:1858-1866; See also Watanabe JH, McInnis T,
Hirsch JD. Cost of Prescription Drug--Related Morbidity and Mortality.
Annals of Pharmacotherapy 2018, Vol. 52(9) 829-837.
\2\ Centers for Medicare & Medicaid Services, Physician Fee
Schedule CY 2021 Final Rule, 85 Fed. Reg. 84592-3 (Dec. 28, 2020),
available at https://www.govinfo.gov/content/pkg/FR-2020-12-28/pdf/
2020-26815.pdf (Limiting physicians supervising pharmacist-provided
incident-to services to billing code 99211 for those services, despite
the fact that many of the services provided by pharmacists meet the
complexity and duration criteria set forth for code 99212-14).
Problems associated with medication use, such as non-adherence,
polypharmacy errors, and adverse events, result in 500,000 emergency
room visits and 100,000 hospitalizations yearly, costing the health
system over an estimated five billion dollars.\3\ Pharmacists educate
patients and caregivers about their medications, monitor drug therapy,
and coordinate communication between patients, insurers, and
interdisciplinary specialty providers. Pharmacists' management of
medication therapy such as this has been shown to improve transitions
of care and reduce hospital readmissions.\4\, \5\
---------------------------------------------------------------------------
\3\ Budnitz DS, Pollock DA, Weidenbach KN, et al. National
surveillance of emergency department visits for outpatient adverse drug
events. JAMA. 2006;296:1858-1866; See also Watanabe JH, McInnis T,
Hirsch JD. Cost of Prescription Drug--Related Morbidity and Mortality.
Annals of Pharmacotherapy 2018, Vol. 52(9) 829-837.
\4\ Ni, W., Colayco, D., Hashimoto, J., Komoto, K., Gowda, C.,
Wearda, B., McCombs, J. Budget Impact Analysis of a Pharmacist Provided
Transition of Care Program. Journal of Managed Care & Specialty
Pharmacy. Feb 2018.
\5\ Budlong, H, Brummel, A, Rhodes, A, Nici, H. Impact of
Comprehensive Medication Management on Hospital Readmission Rates.
Population Health Management 2018. 21(5): 395-400.
In order for it to be financially feasible for care teams to use their
pharmacists to provide medication and chronic disease services, ASHP
recommends that physicians be allowed to bill for E/M codes for
established patients (99211-99215), including when provided by a
---------------------------------------------------------------------------
pharmacist, if the incident-to requirements are met.
ASHP thanks you for your work on this issue. We look forward to
continuing to work with you on this issue. If you have questions or if
ASHP can assist in any way, please contact Frank Kolb at
fkolb@ashp.org.
Sincerely,
Tom Kraus
Vice President, Government Relations
______
American Society of Pediatric Nephrology
6728 Old McLean Village Drive
McLean, VA 22101
ph. 703-556-9222
fax 703-556-8729
April 25, 2024
The Honorable Ron Wyden The Honorable Mike Crapo
Chair Ranking Member
U.S. Senate U.S. Senate
Committee on Finance Committee on Finance
Washington, DC 20510 Washington, DC 20510
Dear Chair Wyden and Ranking Member Crapo:
On behalf of the American Society of Pediatric Nephrology (ASPN) we
appreciate the opportunity to provide this statement for the record on
the Senate Finance Committee's April 11th hearing on ``Bolstering
Chronic Care through Medicare Physician Payment.'' Pediatric
nephrologists serve as the medical home for children with kidney
disease who need specialized care for this chronic condition. We would
like to provide input on several of the issues raised during the
hearing, including improvements to the Medicare Physician Fee Schedule
(MPFS), increasing provider participation in value-based care models,
and prior authorization. We also want to raise issues related to
Medicaid, as one-third of pediatric patients with end-stage kidney
disease (ESKD) are covered by this program.
Founded in 1969, ASPN is a professional society composed of pediatric
nephrologists whose goal is to promote optimal care for children with
kidney disease and to disseminate advances in the clinical practice and
basic science of pediatric nephrology. ASPN currently has over 700
members, making it the voice for pediatric kidney disease. Our members
strive to ensure that affected infants, children, adolescents, and
young adults receive appropriate and high-quality care. Approximately
one third of pediatric patients with ESKD are covered by Medicare,
making reforms to the Medicare Access and CHIP Reauthorization Act
(MACRA) critical to pediatric nephrologists.
Recommended Changes to the Conversion Factor
Children with end-stage renal disease (ESRD) are automatically eligible
for Medicare, and one-third of our patient population has Medicare
coverage. Most of the care billed to Medicare falls under the ESRD
Prospective Payment System (PPS). However, care delivered to children
who receive kidney transplants as part of the Medicare program receive
3 years of post-transplant care under the MPFS, making the stability of
the payment system a concern for our members. MACRA provided 0.5%
updates to the MPFS conversion factor from 2015-2019. Since then, the
lack of statutory updates to the conversion factor combined with the
system's budget neutrality requirements has created significant
downward pressure on payment.
Children with kidney disease, including those post-transplant, are
medically complex and require high levels of care coordination to
support their continued growth, development, and health that is not
recognized under the MPFS. To support high-quality care for medically
complex patients, the Finance Committee must first stabilize the MPFS
by providing inflationary updates to the conversion factor and update
the budget neutrality factor for the first time since 1992. Once these
changes that benefit all physicians are in place, the Finance Committee
and the Centers for Medicare & Medicaid Services (CMS) can implement
policies to provide incentives to provide high-quality coordinated
care.
Increasing Provider Participation in Value-based Payment Models
As discussed, pediatric nephrologists and pediatric ESKD centers serve
as the medical home for many children with kidney disease. Since only
one-third of children with ESKD have Medicare coverage, the potential
for reimbursement for care coordination is low and contributes to the
scarcity of pediatric ESRD resources by disincentivizing programs from
offering such pediatric care. This reimbursement issue must be
addressed both to prevent the loss of existing ESKD resources due to
ongoing financial pressures and to allow for consideration of their
expansion in a cost-conscious environment. The medical home is
particularly important for pediatric ESKD patients, as they also
receive hypertension care, which is an important screening for this
vulnerable population.
Most pediatric nephrologists practice at children's hospitals. ESKD
patients are these institutions only exposure to the Medicare program,
which makes participation in value-based programs and models a
challenge. To truly incentivize value-based care, quality measures and
requirements should be harmonized across payers to reduce confusion and
burden. It is also critical that institutions have the staff to be able
to participate in data tracking and in reporting measures, which can be
difficult for small practices.
The quality programs should be integrated into the existing electronic
medical record (EMR) to collect data. There are multiple pain points
with silos of care and integrating quality structures into EMRs that
need to be addressed. It would also help to increase the number of
pediatric measures if they spanned payers beyond Medicare. Measures
could look at the entire pediatric ESKD population and better reflect
the quality of care.
Recommendations Related to Medicaid Coverage
While the recent hearing did not address the Medicaid program, ASPN
urges the Finance Committee to explore improvements to the Medicaid
program to improve care coordination and chronic care delivery. As
stated earlier, one-third of pediatric ESKD patients are on Medicaid,
and so any policy changes must ensure that these patients are able to
access the same quality of care as patients on Medicare or private
insurance. Medicaid reimburses at approximately 80% of the Medicare
rate and rates vary across states and services.
Many medically complex children, including those with chronic kidney
disease and ESKD, are covered by Medicaid. While covered by Medicaid,
medical care supports their growth and development and manages their
disease. The program needs to support this complex, coordinated care.
Therefore, the solutions that the Finance Committees present should not
be limited to Medicare, or we risk creating health disparities based on
the patient's insurance coverage.
Recommendations to Improve Prior Authorization
Children and adolescents undergoing dialysis or transplants are unique,
and very different from adults. The causes for ESKD in children
predominantly include congenital abnormalities, glomerular diseases and
rare genetic disorders, not hypertension and diabetes as seen in adults
undergoing the same treatment. Children with ESKD also suffer from
impaired growth and development, including impaired neurocognitive
development. They also have different drug metabolism, which changes
over time as they grow to be adults.
These differences between children and adults with kidney disease, and
specifically ESKD, are particularly important when considering prior
authorization policies, which may delay access to medically appropriate
care and therapies for pediatric patients. These children regularly
require genetic testing, imaging studies, durable medical equipment,
including scales and blood pressure cuffs, 24-hour ambulatory blood
pressure monitoring, mental health services, special formulas and
feeding tube supplies. All may require prior authorization.
One member reported that prior authorization requirements resulted in a
significant delay for a 4-year-old patient suffering from severe
hypertension who required CT vascular imaging. When the provider
completed the peer-to-peer to complete the prior authorization, the
approval delay was because the imaging was to examine the patient's
aorta and vasculature rather than the lung parenchyma, which would be
examined in adults. Because of the delay, our member considered
admitting the child as an inpatient, which would have been at a
significantly higher cost to the health care system, to expedite the
testing, and ultimately, the necessary treatment. The delay in
diagnosis and surgical treatment put the child at risk for stroke and
seizure from uncontrolled hypertension. ASPN urges the Finance
Committee to consider the unique needs of pediatric ESKD patients when
considering prior authorization reforms. Additionally, we recommend
that reviewers of prior authorization requests for pediatric patients
have pediatric expertise. These vulnerable patients should not
experience unnecessary, and potentially dangerous, delays in care
because these requirements do not reflect the needs of these children
who are commonly covered by Medicare and Medicaid.
Thank you again for the opportunity to submit this statement for the
record to the Senate Finance Committee. We look forward to working with
the Committee and with the Bipartisan Working Group on Physician
Payment reform led by Senators Stabenow and Thune as you develop
legislative solutions to improve physician payment and care for
patients with chronic conditions. Please reach out to Erika Miller,
ASPN's Washington Representative, at emiller@dc-crd.com with any
questions or if we can provide additional information.
Sincerely,
Jodi Smith, M.D., MPH
President
______
American Society of Retina Specialists
20 North Wacker Drive, Suite 2030
Chicago, IL 60606
phone 312-578-8760
fax 312-578-8763
https://www.asrs.org/
The American Society of Retina Specialists (ASRS) is the largest retina
organization in the world, representing over 3,500 board-certified
ophthalmologists who have completed fellowship training in the medical
and surgical treatment of retinal diseases. The mission of the ASRS is
to provide a collegial open forum for education, to advance the
understanding and treatment of vitreoretinal diseases, and to enhance
the ability of its members to provide the highest quality of patient
care.
We appreciate this opportunity to provide input to the committee as it
begins its work on reforming and modernizing Medicare physician
payment. As physicians who care for a high volume of Medicare
beneficiaries with chronic and potentially-blinding eye disease, we are
pleased that the committee has begun its work by exploring how best to
meet the needs of these patients.
Among our key recommendations for the committee to ensure beneficiaries
have continued access to high-quality chronic care are the following:
Ensure beneficiaries suffering from chronic disease will have
continued access to the specialty care they need and physicians receive
adequate reimbursement for the care they provide by:
establishing regular, inflation-based updates to
the Physician Fee Schedule conversion factor, and
reforming budget neutrality requirements in the
fee schedule to allow for necessary value modifications to
existing services, and the adoption of new technologies and
treatment protocols without causing unwarranted reductions to
other unrelated services.
Eliminate or modify the Merit-based Incentive Payment System
(MIPS) to focus on clinically-relevant measures that address identified
gaps in care, particularly to target improving measurement of chronic
care services.
Require the Center for Medicare and Medicaid Innovation (CMMI)
to engage with specialists caring for chronic disease patients and work
toward implementing alternative payment models (APMs) that address
these needs.
Provide additional funding to physicians and other stakeholders
to develop APMs.
Fee Schedule Reform and Modernization
Retina specialists and other physicians are committed to providing the
highest quality of care to Medicare beneficiaries with chronic disease.
In return, Medicare must provide an adequate and predicable baseline
payment level that ensures physicians will have the resources to care
for these patients. Two elements of the physician fee schedule--the
lack of inflation-based payment updates and outdated budget neutrality
limits--are limiting those resources. Thus, practices are having a
difficult time staying financially solvent while making necessary long-
term investments and meeting growing patient demand. ASRS recommends
Congress focus its work on modifying these elements to prevent the need
for yearly payment ``fixes'' and ensure long-term stability.
Inflation-Based Updates
For more than 2 decades, Medicare physician payments have not kept pace
with inflation. According to the American Medical Association (AMA),
physicians' purchasing power has eroded by approximately 30% since
2001, while during that time all other Medicare payment systems have
realized payment updates that have kept pace with or even surpass the
Medical Economic Index (MEI), the chief measure of inflation in
healthcare. In fact, the Medicare Physician Fee Schedule is the only
payment system without a built-in inflationary adjustment. It is far
past time for Congress to act to bring payments in line with current
prices and provide assurances that future payment will be adequate.
ASRS recommends implementing regular, inflation-based updates to the
fee schedule to meet that need.
Budget Neutrality Limits
In addition, Congress must increase the current $20 million budget
neutrality threshold on the Medicare Physician Fee Schedule. It has
created unintentional inequities in payment, disrupted the relativity
of the fee schedule, and unnecessarily pitted procedural and non-
procedural specialists against each other in a fight for value.
As physician services are regularly reviewed by the RUC and CMS, even
minor adjustments in a particular service's value can cause ripple
effects across the fee schedule, increasing or decreasing other
specialties' reimbursement without any coordinating change in the
services they are providing. Relative value units (RVUs) are
painstakingly assigned to account for the unique work and practice
expense for each physician service relative to all others. But the
annual neutrality adjustments caused by the low threshold are
disrupting that balance.
Most concerning is when CMS acts outside of the current relative value
system and adds new services to the fee schedule, such as the new E/M
add-on code G2211, which necessitate budget neutrality adjustments.
Specifically, G2211 was not valued through the RUC process to maintain
relativity in the fee schedule and more accurately gauge the potential
utilization of the code. Almost half of the initial 2024 cut to the fee
schedule was due to the implementation of this code. It required
Congress to act well past the beginning of the year to modify the
conversion factor which, unlike prior fixes, was not backdated. As a
new and un-tested service, the add-on code should have been phased-in
over several years without impacting budget neutrality until its full
impact was known. ASRS recommends that Congress increase the dollar
threshold that triggers budget neutrality adjustments and empower CMS
with authority to override budget neutrality in certain circumstances.
Problems with the fee schedule are borne out in the reimbursement for
retina procedures. A 2022 study looked at the trends in reimbursement
for 15 procedures commonly performed by retina specialists over 2011 to
2020 and found that the average reimbursement change over that time was
a decrease of 8.2%. Adjusted for inflation, the decrease grew to
20.7%.\1\ This decline in reimbursement is directly attributable to
both the lack of inflationary adjustment and budget neutrality factors
that Congress must remedy.
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\1\ Trends in Medicare Reimbursement for Common Vitreoretinal
Procedures: 2011-2020. Shriji Patel, MD MBA, et al. Ophthalmology. 2022
Jul;129(7):829-831.
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Key Cost Pressures on Retina Specialists' Practices
Retina practices are no different from other physician specialties or
other small businesses operating in this period of high inflation.
Rising equipment, supply, utility and labor prices are putting retina
practices at a disadvantage. In 2023, 84% of U.S.-based retina
specialists reported difficulty finding clinical staff for their
practices, with 63.5% saying this led to mild or severe
understaffing.\2\ Many retina specialists reported losing qualified
staff to hospitals or other industries that can afford to pay more
competitive wages.
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\2\ 2023 ASRS Preferences and Trends Survey, available: https://
www.asrs.org/content/documents/_asrs-2023-pat-survey-for-website.pdf.
Understaffing is troubling considering how important technicians and
administrative staff are in the care of patients with chronic retinal
disease. The high prevalence of diseases such as age-related macular
degeneration (AMD), diabetic retinopathy, and diabetic macular edema
(DME) in the Medicare population coupled with the frequency of
necessary visits for these patients--approximately every 4-6 weeks--
means that retina practices must run efficiently. Retina specialists
rely on their clinical staff to help patients navigate through the
process of imaging, exams and preparation for intravitreal injections
so the physician can be solely focused on examining the patient,
interpreting the imaging, performing the injections and managing the
patient's individual care plan. For Medicare Advantage patients and
those with commercial insurance, additional administrative staff is
needed to deal with the onerous step therapy and prior authorization
policies implemented by these payers. Without adequate reimbursement to
pay clinical staff, retina specialists may have to reduce their patient
load, thereby threatening the vision of patients with potentially-
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blinding conditions.
While the lack of adequate reimbursement is immediately felt in the
day-to-day operations of the practice, payment that does not keep pace
with inflation also has a negative long-term impact on patients.
Without assurance that payments will keep up, retina specialists are
hesitant to expand their practices or invest in new equipment that
would allow them to serve patients better. COVID-era delays and
increased construction costs have prevented practices from expanding or
opening new offices. Declining reimbursement makes it less likely the
cost of new clinical or imaging equipment will be recouped.
Like the COVID-19 pandemic, outside influences continue to impact
physician practices. Retina specialists have been particularly hard hit
by the recent cyberattack on Change Healthcare. This incident has
ceased or significantly disrupted reimbursements to retina practices
and negatively impacted cashflow--thereby over-
extending their credit and forcing many to take out loans to purchase
the Part B drugs that patients with chronic retinal disease rely on.
This single incident demonstrates how fragile the healthcare
infrastructure is and underscores that without sufficient physician
payment, beneficiaries will lose access to care.
Patient Demand and Administrative Costs Projected to Grow
Evidence suggests that these long-term investments to expand access to
care are imperative. The U.S. population will continue to age into
chronic retinal disease necessitating even more care from retina
specialists. A 2022 study found that currently about 20 million
Americans over 40 have AMD with about 1.49 million suffering from late-
stage AMD \3\--figures significantly higher than previous estimates.
According to the American Diabetes Association, the number of Americans
with diabetes is also projected to increase 165%, from 11 million in
2000 to 29 million in 2050--which will likewise increase the number of
people suffering from diabetic eye disease who will require care from
retina specialists.
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\3\ ``Prevalence of Age-Related Macular Degeneration in the U.S. in
2019.'' David B. Rein, Ph.D., MPA; John S. Wittenborn, BS; Zeb Burke-
Conte, BS; et al; JAMA Ophthalmol. Published online November 3, 2022.
doi:10.1001/jamaophthalmol.2022.440.
However, it is unclear whether those patients will be able to receive
the care they need in a timely manner. The projected shortage of
primary care physicians is well-documented, however, specialties--
including ophthalmology--also face shortages. A 2023 study found that
from 2020 to 2035, the supply of U.S. ophthalmologists will decrease
relative to demand and lead to a 30% shortfall.\4\ This shortage is
already being felt with some retina fellowship programs not being able
to fill all available slots. A recent increase in the number of
resident slots across medicine was a much-needed first step, but more
investment is required to ensure physician supply meets the demand over
the coming decades.
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\4\ ``Ophthalmology Workforce Projections in the United States,
2020 to 2035.'' Sean T. Berkowitz, MD, MBA; Avni P. Finn, MD, MBA; Ravi
Parikh, MD, MPH; et al.; Ophthalmology. V.131, Issue 2, p. 133-139,
February 2024.
As mentioned above, the administration costs associated with MA and
other private payers have skyrocketed in the last decade with the rise
in utilization management. Care for nearly every non-original Medicare
patient with chronic retinal disease is subject to some form of step
therapy and/or prior authorization. Retina specialists employ dedicated
employees to investigate benefits, determine the specifics of the
insurer's step therapy policy, and submit authorizations. While the
delay in care and potential poor outcomes for patients are the most
concerning aspect of utilization management, the extra labor costs are
endangering practices' ability to stay afloat. A 2022 study conducted
by ASRS members found that 56.8% of patients experience delays in
treatment and practices spend an average of 47 minutes per
authorization request, all while 96.3% of prior authorization requests
are ultimately approved.\5\ These costs are not associated with
original Medicare beneficiaries, but since most private contracts are
based on Medicare rates, the additional work required to take care of
these patients is not compensated.
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\5\ Dang, S. ``Anti-VEGF Injection Prior Authorization Impacts on
Retina Practices.'' 2022 ASRS Annual Meeting, July 16, 2022.
Congress needs to take immediate action to tie physician payment to
inflation and modify budget neutrality to address the current and
future pressures that limit access to care.
Repeal MIPS
At its inception, the MIPS program seemed to include laudable goals,
however, it has become clear that Congress should sunset this program.
MIPS still functions as four separate and unrelated individual programs
that are tedious to implement and do not relate to specialty care.
Perhaps the most telling indicator of the program's failure is the lack
of evidence to indicate it is improving care. A recent search of PubMed
turned up no results of peer-reviewed literature that found a
correlation between the MIPS program and improved quality.
CMS' Flawed Implementation of MIPS
At its core, CMS has failed to conceive of and implement MIPS as a
unique program that would serve as a bridge between previous disparate
reporting programs and new APMs. Each of the categories retains
measures and structure from its predecessor and has individual, complex
scoring methodologies. Rather than integrating the elements of the
programs it replaced, MIPS simply aligns the performance periods and
reporting deadlines and combines the scores to translate to one final
payment adjustment. CMS' ever-shifting requirements complicate the
program and insufficient specialty-specific measures mean retina
specialists are typically reporting on primary care measures not
meaningful to their practices.
Considering the lack of documented improved outcomes, the significant
cost practices incur to participate in MIPS becomes concerning.
Infrastructure costs of EHR and hardware are added to the practice
staff labor--and oftentimes that of outside consultants--to comply with
MIPS. The recent bonus payments of 1-2% associated with MIPS are not
significant enough to make the cost to participate worthwhile. For
example, a large retina practice of 21 physicians recently analyzed
their cost of participating in MIPS. The practice has two staff members
each working about 10 hours per week to oversee the practice's
participation in MIPS and found that documenting MIPS for each visit
takes about 2 minutes. Added to the direct costs of consultants, the
total cost of participating in MIPS is $13,000 per physician.
Barriers to Specialty-Specific Measure Reporting
Not only is it burdensome for physicians to participate in the program,
but CMS largely outsources the creation of measures and infrastructure
necessary to run the MIPS program. It relies on the work of non-
government entities, such as medical societies, spending considerable
resources to enable physicians' participation in the program. In our
case, ASRS has acted to address the lack of retina-focused measures by
developing three new MIPS quality measures that were implemented for
the 2024 performance year. The multi-year process we undertook to
develop these measures cost approximately $335,000, not counting our
physicians' uncompensated time, and required multiple attempts to have
them accepted by CMS. The physician experts developing these measures
felt that the concepts they identified would address gaps in care that
were within the power of the individual retina specialist to remedy.
While we appreciated feedback from CMS throughout the process, the
development was influenced by ensuring that the measures fit within the
confines of the program, rather than solely on what was clinically-
relevant. Chiefly, we were not able to even draft or test measure
concepts around some of the chronic diseases retina specialists treat
most frequently, such as AMD and diabetic retinopathy, because it was
difficult to identify measurable endpoints for treatments that may last
for many years.
The ASRS investment in developing three quality measures pales in
comparison to the investment required to establish a qualified clinical
data registry (QCDR). The cost to start-up a fully-functional QCDR that
includes MIPS reporting is estimated at upwards of $1 million with
additional annual maintenance costs. Unfortunately, some societies that
have made this investment have had significant problems. Some
established registries, such as those run by the American College of
Surgeons and the Society of Thoracic Surgeons, have left the QCDR
program because of CMS' onerous programmatic requirements to
participate in MIPS, as well as testing and validation criteria. Others
have suffered from lack of participation or insufficient return on
investment. Even when QCDRs are able to comply with CMS' regulations,
the resulting system can be unworkable for practices to use, often
forcing them to drop out. These examples show that on top of the cost
to participate, MIPS is not only not contributing to improved quality
of care, but it may be impeding efforts to collect and analyze clinical
data.
Given the lack of evidence that MIPS has improved outcomes, now is the
time to repeal MIPS and rethink how to improve quality and value in the
Medicare program.
Increase Opportunities and Incentives for Specialty-Focused APMs
CMS did not use any of the money Congress allocated in MACRA to fund
grants to specialties to develop APMS. As Congress looks to reform the
system, we recommend it make grants available to fund the
infrastructure physician organizations need to develop and implement
new models. In addition, CMS and CMMI must be required to review
physician-submitted models and incorporate specialists' feedback in new
models.
Under the current system, no physician-developed model has been
implemented by CMS or CMMI, even though MACRA created the Physician-
Focused Payment Model Technical Advisory Committee (P-TAC) as a vehicle
for physicians to submit their APM concepts. Given this situation many
organizations are reluctant to invest time and money in developing new
models. P-TAC's website lists dozens of clinician-
submitted proposals it has reviewed and made recommendations on to
CMS.\6\ However, we are not aware of any such proposal endorsed by P-
TAC that has been tested or implemented by CMS to date. After seeing so
many other specialty societies and physician groups fail to gain
traction with their APM concepts, we are skeptical that CMS would take
action on them without further Congressional intervention. Congress
must take action to arm the P-TAC with more authority and require CMS
to at least test and evaluate the feasibility of recommended models.
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\6\ Physician-Focused Payment Model Technical Advisory Committee,
https://aspe.hhs.gov/collaborations-committees-advisory-groups/ptac/
ptac-proposals-materials#1081. Accessed April 18, 2024.
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Conclusion
As experts in chronic disease, retina specialists develop strong bonds
with their patients over many years. They are focused on customizing
each patient's care to help maintain their vision and allow them to
continue living independently. The long-term erosion in physician
payments, coupled with the rise of administrative burdens and
irrelevant pay-for-reporting makes achieving that goal harder every
year. We recommend Congress take this opportunity for full-scale reform
and invest in the long-term stability of practices providing care to
Medicare beneficiaries by implementing inflation-based updates,
ameliorating the impact of budget neutrality adjustments, and truly
working toward value-based care by removing MIPS and investing in
efforts to develop specialty-specific models.
We thank the committee for holding this hearing and appreciate the
particular focus on chronic care. We would be happy to provide you with
any assistance or additional information you may need. Please contact
Allison Madson, vice president of health policy, at
allison.madson@asrs.org for assistance.
______
American Urological Association
1000 Corporate Boulevard
Linthicum, MD 21090
Phone: 410-689-3700
Fax: 410-689-3800
https://www.auanet.org/
https://urologyhealth.org/
April 23, 2024
The Honorable Ron Wyden, Chair
U.S. Senate
Committee on Finance
221 Dirksen Senate Office Building
Washington, DC 20510
The Honorable Michael Crapo, Ranking Member
U.S. Senate
Committee on Finance
239 Dirksen Senate Office Building
Washington, DC 20510
RE: Statement for the Record, Hearing on ``Bolstering Chronic Care
through Medicare Physician Payment''
Dear Chair Wyden and Ranking Member Crapo:
The American Urological Association (AUA) applauds the Senate Finance
Committee for holding the recent hearing, Bolstering Chronic Care
through Medicare Physician Payment. The Medicare program, its
sustainability, and its payment policies are of great importance to our
members and the Medicare beneficiaries they treat. The AUA commends the
Committee for holding this hearing to examine policies to update and
strengthen the Medicare program to improve beneficiary access to high-
quality care.
The AUA is a globally engaged organization with more than 22,000
physicians, physician assistants, and advanced practice nursing members
practicing in more than 100 countries. Our members represent the
world's largest collection of expertise and insight into the treatment
of urologic disease. Of the total AUA membership, more than 15,000 are
based in the United States and provide invaluable support to the
urologic community by fostering the highest standards of urologic care
through education, research, and the formulation of health policy.
Urologists play a crucial role in the care of patients with both
chronic and acute urologic conditions, providing vital services that
improve quality of life and often prevent serious complications.
Despite the critical nature of urologists' work in enhancing patients'
well-being, the existing Medicare reimbursement structure often fails
to adequately compensate urologists for the advanced and specialized
care they deliver. This discrepancy not only undermines the financial
viability of urology practices but also jeopardizes patient access to
high-quality care and innovative treatments.
Physician payments have stagnated for the last 2 decades while
hospitals and physician practices must continue to pay market rate for
supplies, equipment, and staff wages.
For the last several years, Congress has intervened to prevent or
mitigate cuts to the Medicare Physician Fee Schedule (MPFS), and the
AUA is grateful for these actions. However, our members and the
patients they treat deserve better than the unstable and uncertain
reimbursement and access environment the annual threat of cuts creates.
The statutory constraints placed on the Centers for Medicare & Medicaid
Services (CMS), including the lack of statutory updates and the budget
neutrality requirement, limits the agency's ability to stabilize the
MPFS and ensure appropriate access to the full range of specialty care
without Congressional intervention. To address these constraints and
protect Medicare beneficiary access to care, we recommend the following
solutions.
Implement Inflationary Updates
According to an American Medical Association (AMA) analysis of Medicare
Trustees data, Medicare physician payment has declined by approximately
30% percent when adjusted for inflation from 2001-2024. The MPFS does
not receive necessary increases or adjustments for inflation, in
contrast to other Medicare fee schedules with the last statutory update
of 0.5% implemented in 2019. The decline in reimbursement over the last
2 decades undermines physicians' ability to deliver essential medical
services, jeopardizing patient access to timely and high-quality care.
Therefore, AUA recommends Congress provide a statutory update to the
MPFS based on the Medicare Economic Index (MEI) to reflect the
inflation in practice costs, including but not limited to clinical
staff, rent, medical supplies and equipment, and insurance. It is
important to note that greater financial stability will lead to
improved physician retention ensuring patients have access to timely
and high-quality care, and allowed investments in infrastructure, which
can contribute to improved efficiency and quality of care delivery.
Address Budget Neutrality
Current Medicare statute requires changes to the MPFS be implemented in
a budget neutral manner, which means that policies that increase or
decrease Medicare spending by more than $20 million require that upward
or downward adjustments be made by that excess amount to all physician
services. Budget neutrality places unreasonable constraints on MPFS
payments and potential policies. Therefore, AUA recommends that
Congress consider raising the budget neutrality threshold from $20
million to $53 million to accommodate changes in Medicare spending
since this threshold has not been increased since 1992. This will allow
for more flexibility in adjusting physician payments and prevent
different specialties from being pitted against one another.
Additionally, it will mitigate the dynamic where specialties feel they
are pitted against each other when new codes are added to the MPFS or
values for existing codes are proposed to be increased. Congress should
also provide for an increase equal to the cumulative increase in the
MEI every 5 years to allow this threshold to keep pace with inflation.
Improving Quality Payment Programs
AUA was pleased that the Committee is interested in improving the
Merit-based Incentive Payment System (MIPS) and identifying strategies
to bolster more widespread adoption of advanced alternative payment
models (APMs). The Medicare Access to CHIP Reauthorization Act (MACRA)
authorized the CMS Quality Payment Program (QPP) in to encourage
physicians', including specialists like urologists, engagement in
innovative healthcare delivery models, fostering a system that rewards
improvements in the quality of care delivered. AUA believes that APMs,
if implemented well, can incentivize improved quality and better care
coordination, which can be especially valuable for conditions like
prostate and bladder cancer that may require surgery, radiation, and
medical oncology to treat. Unfortunately, MACRA's statutory
requirements have impeded Congress' goals for the program and Congress
must strive to revise the QPP such that its requirements support the
delivery of value-based care and improved quality.
There is a significant administrative burden and financial risk
involved with participation in MIPS and APMs. Additionally, the large
investment in training takes away time and resources that should be
devoted to patient care. In addition, with so many variations in
practices, including practice size, specialty type, practice location,
and population demographics, a one-size fits all model simply does not
work. To improve the MIPS program, CMS must have the authority and
resources to create programs that are meaningful to all providers and
patients regardless of specialty type, while lowering the burden to
participate in these programs. Specialty physicians looking to
participate in these programs will find few physician-focused APMs are
available for them.
Additionally, CMS has stated its intent to sunset traditional MIPS and
move to MIPS Value Pathways (MVPs). The agency is continuing to roll
out new pathways each year; however, specialties like urology do not
yet have MVP options to participate. While we understand the
constraints under the current payment system, we believe that
collaboration with stakeholders will assist in creating more meaningful
programs and reducing burden for providers.
Additionally, the AUA recommends that quality payment incentives be
large enough to cover the costs of the time and resources that are
devoted to participating in a quality program while also rewarding
physicians for their participation. This is important because it
ensures that healthcare providers are adequately compensated for the
efforts they put into improving patient care. Not only can financial
incentives be used to improve patient care, but this can also be used
to provide incentives to urologists and other physicians to practice in
underserved areas. Therefore, Congress must ensure that quality payment
incentives are commensurate with the investment of time and resources
necessary for sustaining effective quality improvement efforts and
ultimately enhancing the quality of care delivered to patients.
The AUA appreciates your leadership and welcomes the opportunity to
work with you to improve Medicare beneficiary access to care and ensure
the care delivered by urologists and other physicians is reimbursed
equitably. For any questions please contact paymentpolicy@auanet.org.
Sincerely,
Eugene Rhee, M.D., MBA
Chair, Public Policy Council
______
Association for Clinical Oncology
2318 Mill Road, Suite 800
Alexandria, VA 22314
T: 571-483-1300
F: 571-366-9530
https://asco.org/
Statement of Everett E. Vokes, M.D., FASCO, Board Chair
The Association for Clinical Oncology (ASCO) is pleased to submit this
statement for the record of the hearing entitled, ``Bolstering Chronic
Care through Medicare Physician Payment.'' ASCO appreciates the
Committee holding today's hearing to discuss a more sustainable
Medicare physician reimbursement system that improves care for
beneficiaries, including those with cancer. ASCO is a national
organization representing nearly 50,000 physicians and other health
care professionals who care for people with cancer. ASCO members are
dedicated to conducting research that leads to improved patient
outcomes and are also committed to ensuring that evidence-based
practices for the prevention, diagnosis and treatment of cancer are
available to all Americans, including Medicare beneficiaries.
ASCO supported the passage of the Medicare Access and CHIP
Reauthorization Act of 2015 (MACRA) as a replacement for the flawed
Sustainable Growth Rate (SGR) formula for Medicare physician
reimbursement. Since its enactment, ASCO has provided extensive
education to its members as well as significant input to the Centers
for Medicare and Medicaid Services (CMS) around necessary refinements
to the program to ensure its efficacy in the agency and for Medicare
beneficiaries they serve. Unfortunately, physicians still face the same
uncertainty MACRA was intended to address--financial instability within
the Medicare payment system.
We are encouraged by the Committee's interest in addressing current
challenges and look forward to collaborating on ways to ensure long-
term stability in the Medicare payment system. ASCO offers to be an
ongoing resource for you as you evaluate the financial sustainability
and patient impact of the Medicare physician payment system, MACRA's
effectiveness and the continued transition to a value-based payment
system.
ASCO's History of Quality Improvement
Since its founding over 50 years ago, our affiliate organization, the
American Society of Clinical Oncology (the Society), has been dedicated
to the delivery of high-quality, high-value care for every patient with
cancer--every day, everywhere. The Society has a wide range of
resources and programs aimed at improving the standard of cancer care
received by patients in the United States and around the world.
Oncology care is entering a time of unprecedented progress in both the
understanding and treatment of cancer. However, today's medical
practice environment is facing significant disruption, which threatens
oncologists' ability to deliver the high-quality cancer care that
patients deserve. Ongoing consolidation of physician practices,
escalating cost of care, workforce shortages and physician burnout are
on the rise and administrative burden has never been greater. As cancer
care professionals navigate these challenges, they are looking for
models that enable the delivery of high-quality, high-value cancer care
and a framework that supports success regardless of payment
arrangements and other administrative policies.
In response to this need,\1\ in July 2021, the Society launched its
ASCO Patient-
Centered Cancer Care Certification initiative. This program promotes
the oncology medical home as an effective approach to assuring every
patient with cancer achieves the best possible outcome for their
disease. It offers oncology group practices and health systems a single
set of comprehensive, expert-backed standards for patient-centered care
delivery.
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\1\ https://practice.asco.org/quality-improvement/quality-programs/
asco-certified.
The now permanent program (ASCO Certified) is based on Oncology Medical
Home (OMH) standards \2\ from the American Society of Clinical Oncology
and the Community Oncology Alliance (COA). These standards establish
core elements needed to deliver equitable, high-quality cancer care and
offer all stakeholders clarity on elements they should expect to see
from cancer care teams. The OMH standards focus on seven different
domains of cancer care, including patient engagement; availability and
access to care; evidence-based medicine; equitable and comprehensive
team-based care; quality improvement; goals of care, palliative and
end-of-life care discussions; and chemotherapy safety.
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\2\ https://ascopubs.org/doi/full/10.1200/OP.21.00167.
The pilot included 95 cancer care sites and nearly 500 oncologists from
12 participating practice groups and health systems in a variety of
settings, including community, hospital, and academic settings. Two
commercial insurers participated, and others expressed strong interest.
Participating practices use the ASCO Quality Reporting Registry (AQRR)
for ongoing measurement of quality, outcomes, and utilization measures.
Performance data are derived from electronic health records, insurance
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claims, patient satisfaction surveys, and clinical pathways systems.
Practices meeting the rigorous ASCO-COA Oncology Medical Home Standards
are certified by the ASCO Certification Program. Certified practices
are expected to sustain adherence to the ASCO-COA OMH standards
demonstrated through ongoing assessment and improvement activities
monitored and evaluated by the ASCO Certification Program.
Additionally, ASCO's Quality Oncology Practice Initiative (QOPI)
Certification Program \3\ provides a three-year certification
recognizing high-quality care for outpatient hematology-oncology
practices within the United States and certain other countries. Its
primary focus is the safe delivery of chemotherapy in the outpatient
setting. Practices receive QOPI Certification based on their full
compliance with QOPI Certification Standards as assessed during an on-
site survey.
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\3\ https://practice.asco.org/quality-improvement/quality-programs/
qopi-certification-program.
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Enhancing Oncology Model
In June 2022, the Center for Medicare and Medicaid Innovation (CMMI)
announced a new, 5-year voluntary oncology payment model, the Enhancing
Oncology Model (EOM),\4\ which began on July 1, 2023. Participating
oncology practices are taking on financial and performance
accountability for episodes of care surrounding systemic chemotherapy
administration to patients with seven common cancer types: breast
cancer, chronic leukemia, small intestine/colorectal cancer, lung
cancer, lymphoma, multiple myeloma, and prostate cancer. EOM
participants are responsible for the total cost of care during a 6-
month episode and elect to participate in one of two, two-sided
financial risk arrangements.
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\4\ https://www.cms.gov/priorities/innovation/innovation-models/
enhancing-oncology-model.
EOM employs specific design elements, including comprehensive,
coordinated cancer care; data-driven continuous improvement; payment
incentives, including a Monthly Enhanced Oncology Services (MEOS)
payment and a performance-based payment (PBP) or a performance-based
recoupment (PBR); an aligned multi-payer structure; and focused efforts
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to identify and address health disparities.
EOM participants are required to implement participant redesign
activities, including 24/7 access to care, patient navigation, care
planning, use of evidence-based guidelines, use of electronic Patient
Reported Outcomes (ePROs), screening for health-related social needs,
use of data for quality improvement, and use of certified electronic
health record technology. As part of the data reporting for quality
improvement, EOM participants will submit health equity plans to CMS,
where participants detail evidence-based strategies to mitigate health
disparities identified within their beneficiary populations.
ASCO is pleased that EOM is a voluntary model and that practices were
able to choose to participate based on their level of readiness and
ability to assume financial risk. We fully support CMMI's focus on
equity and coordinated cancer care. The cancer care delivery
requirements of the CMMI EOM have many similarities with ASCO-COA
Oncology Medical Home Standards and ASCO Certified. Practices achieving
ASCO Patient Centered Cancer Care Certification will be well positioned
to succeed in the EOM.
We are concerned, however, that CMMI significantly reduced MEOS
payments compared to similar payments in the earlier Oncology Care
Model (OCM). This is especially concerning given that there was a 1-
year gap between the end of OCM and the start of EOM, during which time
practices received no additional support for the mechanisms instituted
during OCM to enhance patient access and care coordination that are
continuing under EOM. The limited MEOS may not cover the practice
redesign efforts needed in this model with financial risk.
While OCM prompted practice changes that enhanced patient-centered
care, those changes cannot be sustained or broadened to other practices
without a regulatory and payment framework that supports them. We are
eager to work with CMS and Congress to enable the practice
transformation critical to practices surviving and thriving in the
years ahead, so patients receive the care they need and deserve.
Below are areas of improvement we believe are vital to achieving high-
value, high-quality care for all patients with cancer.
Medicare Physician Payment Reform
In repealing the SGR, MACRA specified a 0% update to the Medicare
Physician Fee Schedule (MPFS) Conversion Factor (CF) for a period of 6
years, followed by a 0.25% annual increase for Merit Based Incentive
Payments System (MIPS) participants and a 0.75% annual increase for
Advanced Alternative Payment Model (APM) participants thereafter. While
Congress provided temporary relief in 2021 and 2022, physician
reimbursement was cut in 2023 and again in 2024. In the Consolidated
Appropriations Act of 2024, passed on March 9, 2024, Congress included
a +1.68% adjustment to the MPFS CF for the remainder of 2024. This
increase resulted in a 1.68% reduction to the 3.37% CF. This did not
apply retroactively, with claims with dates of service prior to March 9
reimbursed using the original conversion factor.
Failure of the MPFS to keep up with increasing labor, supplies, rent,
and other practice expenses influences a growing site-of-service shift
from independent physician practices to off-campus outpatient hospital
departments paid for by the Outpatient Prospective Payment System
(OPPS). Rather than addressing the lack of sufficient payment under the
MPFS, Congress directed CMS to reduce payments to new off-campus
outpatient hospital departments, thereby encouraging further shifts
into on-campus departments. Instead of encouraging value-based care,
this consolidation results in reduced beneficiary access to community-
based healthcare services. Congress must ensure that future payment
updates within the MPFS are sufficient to sustain beneficiary access to
community-based physician care.
While we appreciate Congress' efforts to help stabilize physician
payment, ASCO hopes to see a longer-term solution. We strongly support
and encourage lawmakers to support the Strengthening Medicare for
Patients and Providers Act (H.R. 2474), not yet introduced in the
Senate. This legislation aims to provide an annual update to a single
conversion factor under the MPFS that is based on the Medicare Economic
Index (MEI). This inflationary increase will help providers keep up
with rising healthcare costs. Moreover, ASCO supports the Providing
Relief and Stability for Medicare Patients Act of 2023 (H.R. 3674) and
the Provider Reimbursement Stability Act of 2023 (H.R. 6371),
legislation that would increase resources across all Medicare service
codes. Following the initial increase, the fee schedule would see
annual adjustments based on the MEI. ASCO appreciates the inclusion of
the provision to update direct costs associated with practice expense
relative value units (RVUs) once every 5 years. Lastly, both bills
would address over- and under-utilization estimates, which impacts
budget neutrality in the MFPS. These consistent investments in Medicare
services are crucial to the vitality of our profession and the quality
of care we provide.
MIPS Budget Neutrality and the Exceptional Performance Bonus
For performance year 2021, there were a total of 954,664 MIPS-eligible
clinicians under the Quality Payment Program (QPP) MIPS track.6 Of that
total number, 951,744 (99.7%) avoided a negative payment adjustment.
Almost 84% achieved exceptional performance and earned positive payment
adjustments ranging from +0.09% to +1.79%. Only those clinicians
scoring high enough to earn an exceptional performance bonus actually
received any positive payment adjustment. Clinicians who received a
positive score, but did not reach the exceptional threshold, received a
payment adjustment of 0% due to the budget neutrality requirement of
MIPS as established by MACRA (i.e., absent the ``exceptional
performance'' bonus, the number of negative adjustments equals the
number of positive adjustments). As only 0.31% of clinicians received a
score below the threshold (and received a 7% penalty), the only real
source for a positive payment adjustment came from the $500 million
annual ``exceptional performance'' bonus. With the sunsetting of the
ability to earn this bonus in performance year 2022, it is very likely
that high-scoring clinicians participating in MIPS going forward will
receive little to no positive adjustment through MIPS; this is
compounded by the 0% statutory update to the MIPS track until 2026 and
the lack of an inflationary update to the MPFS.
When the MIPS track of the QPP was originally envisioned, it was
thought that a budget-neutral system would provide rewards to high
performers, while penalizing low performers. Experience has shown us
that small and rural practices disproportionately bear the burden of
growing penalties, which in the aggregate are far too small to result
in any meaningful distribution to higher performers. The budget-neutral
nature of MIPS should be re-examined, as should the exceptional
performance bonus. We urge the Subcommittee to consider legislation to
not only address budget neutrality in the MPFS as outlined above but
also in MIPS.
Provider Participation in APMs
MACRA provided for a time-limited, annual payment incentive to
Qualifying APM Participants (QPs) equal to 5% of estimated aggregate
payment amounts for covered professional services. The incentive
payment was intended to encourage participation in advanced APMs and
has been critical in assisting physicians to develop the infrastructure
necessary for the transition to value-based payment models.
Unfortunately, the combination of a lack of specialty-specific advanced
APMs, financial uncertainty throughout the COVID-19 pandemic, and
delays in the rollout of certain APMs (e.g., Oncology Care First, now
named Enhancing Oncology Model) has resulted in many physicians being
unable to qualify for this incentive. The payment incentive for
advanced APMs was extended by 1.8% under the Consolidated
Appropriations Act of 2024. While we appreciate Congress' efforts to
ensure providers can successfully participate in value-based payment
models in the short term, longer-term solutions are necessary to
address the incentive gap we are nearing. Specifically, we encourage
Congressional support for S. 3503/H.R. 5013 the Value in Health Care
Act of 2023 to extend incentive payments for eligible APMs for an
additional 2 years. Additionally, Congress should consider long-term
solutions, beyond the 5-year cap outlined in the legislation to ensure
financial stability in the program.
Further, to qualify for the APM incentive, physicians must meet either
the Medicare Payment Threshold Option or Medicare Patient Threshold
Option. These thresholds are meant to ensure that physicians
meaningfully participate in alternative payment models. Many specialty
physicians will find it difficult to qualify under the currently
specified thresholds. For example, oncologists who participate in a
Medicare Shared Savings Program (MSSP) Accountable Care Organization
(ACO) naturally have lower payment and patient threshold scores due to
receiving referrals from primary care physicians outside of the ACO. As
a result, many ACOs are considering whether to remove specialists from
their participating physician lists so that the remaining physicians
may be deemed QPs.
Even within specialty-specific models, specialists may find that the
limited scope of models--the EOM includes only seven cancer types--
makes it difficult to meet the specified thresholds. Congress should
extend the current 50% payment threshold and 35% patient threshold and
should also direct CMS to remove barriers to participation in multiple
APMs, such as allowing a single practice (identified by a Tax
Identification Number) to participate in multiple ACOs.
Conclusion
Thank you for your commitment to improving the Medicare program and
cancer care delivery. ASCO stands ready to serve as a resource as you
continue this much needed dialogue around reforms to the physician
reimbursement system. Please contact Kristine Rufener at
Kristine.Rufener@asco.org with any questions.
______
Letter Submitted by A. Joseph Borelli, Jr., M.D.
April 11, 2024
Senator Ron Wyden
Chairman
U.S. Senate
Committee on Finance
221 Dirksen Senate Office Building
Washington, DC 20510
Senator Mike Crapo
Ranking Member
U.S. Senate
Committee on Finance
239 Dirksen Senate Office Building
Washington, DC 20510
Subject: Revision of Medicare MRI Reimbursement Rates
Dear Chairman Wyden and Ranking Member Crapo,
Please accept this statement for the record regarding the U.S. Senate
Finance Committee Hearing titled Bolstering Chronic Care through
Medicare Physician Payment on April 11, 2024. Having served as the
former Chair of the Committee on MRI Accreditation for the American
College of Radiology, which established the MR Accreditation Program in
2011--a program now integral to CMS's efforts to guarantee the quality
and safety of MRI procedures to our seniors nationwide--I possess an
in-depth understanding of the financial and operational challenges that
MRI facilities encounter. This is particularly true for facilities like
ours, operating in non-hospital, freestanding settings and serving a
high volume of Medicare beneficiaries.
Our current Medicare reimbursement structure does not adequately
accommodate the operational costs of MRI facilities, especially those
like ours that incur about $100,000 per month in fixed costs, including
the lease and maintenance of a modern 3T MRI scanner of about $35,000
per month. The cost of providing healthcare insurance for our employees
has increased by 50% in the last 7 years, while Medicare reimbursement
has been repeatedly cut. Currently, the typical technical reimbursement
rate of approximately $100 per MRI procedure is insufficient to cover
these expenses given the capacity limitations of MRI scanners, which
typically perform about 300-500 scans per month. Hospitals, on the
other hand, are reimbursed at nearly twice that amount.
To address these challenges, I propose two key budget-neutral
adjustments to the Medicare MRI reimbursement rates for independent,
non-hospital-affiliated facilities:
1. Equipment-Based Reimbursement Scale: Establish a committee to
annually adjust reimbursements in a budget-neutral manner based on the
resale value of MRI equipment. This would ensure that facilities using
higher-quality equipment receive a reimbursement rate that reflects
their greater diagnostic capabilities and higher operational costs,
while facilities with lesser equipment receive correspondingly adjusted
rates. This would also eliminate the financial incentive to purchase
the cheapest available equipment in the self-referred setting (e.g.,
orthopedic offices).
2. Geographic and Demographic Considerations: Implement
adjustments for facilities in regions with a high proportion of
Medicare beneficiaries, like Beaufort County, South Carolina, where 75%
of our patients are seniors. This would help facilities in high-demand
areas maintain a high standard of care without financial strain.
Regions with a lower proportion of Medicare beneficiaries would see
reduced reimbursement, to maintain budget neutrality.
These proposals aim to create a more equitable and sustainable
reimbursement model that reflects both the quality of diagnostic
equipment and the demographic realities of different regions. My
extensive experience in developing MRI accreditation standards informs
these recommendations, emphasizing a commitment to the quality, safety,
and sustainability of diagnostic imaging services.
I am eager to collaborate with your committee to refine and implement
these proposals. Thank you for considering these urgent adjustments,
and I look forward to your partnership in enhancing healthcare services
for our senior population.
Sincerely,
A. Joseph Borelli, Jr., M.D.
Former Chair
Committee on MRI Accreditation
American College of Radiology
President and Medical Director
3T MRI at Belfair
______
Coalition of State Rheumatology Organizations
555 East Wells Street, Suite 1100
Milwaukee, WI 53202 3823
Phone: 414-918-9825
https://csro.info/
CSRO is comprised of over 40 state and regional professional
rheumatology societies whose mission is to advocate for excellence in
the field of rheumatology, ensuring access to the highest quality of
care for the management of rheumatologic and musculoskeletal disease.
Our coalition serves the practicing rheumatologist. We thank the
Committee for its bipartisan interest in the topic of physician
reimbursement. We offer several initial ideas for reform herein and
would welcome the opportunity to discuss these in more detail.
Rheumatologic disease is systemic and incurable, but innovations in
medicine over the last several decades--primarily the development of
biologics and biosimilars--have enabled rheumatologists to better
manage these conditions. With access to the right treatment early in
the disease, patients can generally delay or even avoid damage to their
bones and joints, as well as reduce reliance on pain medications and
other ancillary services, thus improving their quality of life.
However, rheumatoid arthritis (RA) and other autoimmune conditions are
extremely complex. Although rheumatology is beginning to benefit from
more precise diagnostics, we still cannot predict with absolute
accuracy which medication will work for a particular patient, because
of RA's varied signaling pathways. Even where these tools are
available, developing value-based care metrics or episode-based
measures remains difficult. Within the confines created by these
challenges, CSRO nonetheless continues to engage in efforts to define
episodic care and appropriate cost measures.
For rheumatology and every other Medicare-heavy specialty, a major
barrier to the exploration of additional value-based care initiatives
is reimbursement instability in the Medicare Physician Fee Schedule and
its downstream effects on reimbursements from Medicare Advantage plans.
Practices with high numbers of Medicare beneficiaries are faced with a
large and growing gap between their reimbursement and their costs,
which leaves little to no room to invest in the systems and
infrastructure that modern medicine demands or to incur the financial
risk that many value-driven models require. For that reason, we urge
the Committee to focus congressional efforts on five policy areas that
will provide immediate and long-term stability to the Fee Schedule, as
described below.
I. Inflation Update
Unlike all other major Medicare payment systems, the Fee Schedule lacks
a mechanism to incorporate inflationary increases into its
reimbursement rates. That has created an ever-growing disconnect
between the cost of providing care to Medicare beneficiaries and the
program's reimbursement for that care. The medical community's
endorsement of the Medicare Access and CHIP Reauthorization Act (MACRA)
was rooted in the belief that it would replace the unpredictable
Medicare payment landscape with a stable, quality-rewarding system.
Unfortunately, this shift has not materialized as anticipated.
According to the American Medical Association, reimbursement for
Medicare physicians declined by 26% from 2001 to 2023, when one adjusts
for inflation in practice costs. That is not a sustainable payment
system and, inevitably, will lead to beneficiaries experiencing
difficulty finding physicians who accept Medicare.
The bipartisan Strengthening Medicare for Patients and Providers Act
(H.R. 2474) would provide an annual Fee Schedule update based on the
Medicare Economic Index (MEI), which is the most relevant inflation
metric for medical practices. CSRO urges the Congress to enact this
legislation.
II. Budget Neutrality
The Fee Schedule is subject to a statutory budget neutrality
requirement, whereby increases in spending over a certain threshold
must be offset by equivalent reductions in spending that same year.
That threshold is $20 million, a level set by Congress in 1992 and
never updated since. The Centers for Medicare and Medicaid Services
(CMS) has no authority to change this statutory requirement, though its
policy decisions have in the past ``triggered'' the threshold, thereby
resulting in commensurate reimbursement reductions across the Fee
Schedule. The concept of budget neutrality has turned the Fee Schedule
into a fixed pie, while the outdated threshold amount will result in
the threshold being triggered more and more as time goes by. The budget
neutrality requirement is a main contributor to the annual pattern of
Congress averting or mitigating reimbursement reductions at the last
minute.
CSRO urges the Congress to enact Section 5 of the bipartisan Physician
Fee Schedule Update and Improvements Act (H.R. 6545), which would
update the budget neutrality threshold to $53 million and establish
inflationary indexing on a 5-year basis from there.
III. Practice Expense Data Input Updates
In 2022, CMS updated clinical labor practice expense (PE) inputs for
the first time in two decades. Although that was a welcome update, the
long delay meant that large increases were necessary to reflect twenty
years of wage growth. That in turn triggered budget neutrality
reductions once implemented.
As part of long-term Fee Schedule stabilization, CMS must be directed
to update data inputs on a more frequent and regular basis. CSRO urges
the Congress to enact section 6 of the legislation mentioned above
(H.R. 6545), which would require CMS to update direct costs to
calculate PE RVUs every five years at a minimum.
IV. Stop Extensions of Medicare Sequestration
After a temporary reprieve during the public health emergency, the 2%
Medicare sequestration was fully phased back in as of July 1, 2022.
When the Medicare sequester was first created, it was scheduled to
occur from FY 2013 through FY 2021. However, Congress has since
extended Medicare sequestration to pay for other priorities, so that it
currently extends through FY 2032--a full decade past its originally
envisioned end date. Extending the Medicare sequester to offset new
spending exacerbates the long-term underfunding of the Fee Schedule. We
urge Congress to reject any further extensions of the Medicare
sequester.
V. Unique Situation of Buy-and-Bill Part B Clinicians
The new Medicare Drug Price Negotiation Program (MDPNP) will become
fully applicable to the pricing of selected Part B drugs in 2028, which
is expected to result in large reductions to average sales prices
(ASPs) for the selected medications. That in turn will result in
reductions to reimbursement for the physicians who buy these
medications at-risk for in-office administration, because reimbursement
for selected drugs would be based on the maximum fair price (MFP)
established via the MDPNP plus 6%, instead of the current ASP plus 6%.
(Note that, in either scenario, the reimbursement amount would be
subject to the 2% Medicare sequester.)
In the legislative process leading up to enactment of the MDPNP,
several provider groups expressed concern that this program could have
unintended consequences on the financial stability of practices who
acquire medication for in-office administration. The legislation tried
to guarantee the MFP price point for provider acquisition, but that
guarantee will be difficult to operationalize in the complex world of
drug acquisition, which features several layers of middlemen. If MFP-
based reimbursement drops below acquisition costs for selected drugs,
medical practices will suffer financial instability and may have to
stop offering the selected drugs until acquisition costs can meet
reimbursement levels. There is also a lack of clarity on the extent of
the impact that MFPs will have on commercial ASPs and on the additional
administrative burden that practices will have to incur to manage the
different reimbursement rates for the same medication.
For these reasons, CSRO urges you to include the Protecting Patient
Access to Cancer and Complex Therapies Act (S. 2764/H.R. 5391) as part
of comprehensive physician payment reform. That legislation would leave
intact the MDPNP process, but would make changes to the mechanics of
how Medicare obtains its savings. More specifically, the bill would
remove Part B providers from the middle by requiring the drug
manufacturers of selected drugs to reimburse Medicare directly for the
difference between ASP and MFP on their selected products. Notably, the
bill keeps intact the two major goals of the MDPNP: Medicare would
still obtain significant savings on Part B drugs and the bill would
still guarantee beneficiaries access to MFP-based cost-sharing. This
``best of both worlds'' approach would keep in place the benefits of
the MDPNP yet would also ensure that Part B providers are not
inadvertently harmed in the process, ultimately protecting their
Medicare patients' access to needed medication in the lowest-cost site
of care.
Thank you again for holding a hearing on Medicare physician
reimbursement and for affording stakeholders the opportunity to provide
input for the record. If you need additional information, please don't
hesitate to contact us.
______
College of American Pathologists
1001 G Street, NW, Suite 425 West
Washington, DC 20001
800-392-9994
https://www.cap.org/
April 24, 2024
Chairman Ron Wyden Ranking Member Mike Crapo
U.S. Senate U.S. Senate
Committee on Finance Committee on Finance
Washington, DC 20510 Washington, DC 20510
Dear Chairman Wyden and Ranking Member Crapo:
The College of American Pathologists (CAP) appreciates the opportunity
to share our views with the Senate Finance Committee regarding chronic
care and the Medicare Physician Payment System. As the world's largest
organization of board-certified pathologists and leading provider of
laboratory accreditation and proficiency testing programs, the College
of American Pathologists (CAP) serves patients, pathologists, and the
public by fostering and advocating excellence in the practice of
pathology and laboratory medicine worldwide.
As you are aware, pathologists are physicians who specialize in the
diagnosis of disease. On any given day, pathologists impact nearly all
aspects of patient care, from diagnosing cancer to managing chronic
diseases such as diabetes through accurate laboratory testing. Often,
they guide primary care and other doctors, determining the right test,
at the right time, for the right patient. Pathologists in hospitals and
independent laboratories around the country are also responsible for
developing and/or selecting new test methodologies, validating, and
approving testing for patient use, and expanding the testing
capabilities of the communities they serve to meet emergent needs.
Pathologists assure compliance with laboratory regulatory and
accreditation standards, while preventing overuse or improper
application of tests. Although patients may never meet the pathologist
on their care team, they can be assured that these experts deliver
quality and care at every step. Indeed, the influence of pathology
services on clinical decision-making is pervasive and constitutes a
critical infrastructure and foundation of appropriate care.
To help bolster the provision of chronic care services, the CAP
recommends Congress work to stabilize the physician payment system,
grow the health care workforce, increase oversight of insurer-imposed
policies that impact patient care, and look at meaningful sources of
health spending.
Sustainable Provider Financing
Inflationary Update
Over the last 5 years payments to pathologists have decreased by
approximately 4.6 percent, while physician practice costs (medical
supplies, lab personnel costs, professional liability insurance) have
increased by nearly 13.8 percent. In 2024 alone, pathologists are
anticipated to experience a net 5.7 percent reduction in Medicare
Physician Fee Schedule reimbursement as payments are expected to fall
by close to 1.1 percent while expenses are expected to increase by over
4.6 percent. The lack of an annual inflationary update for
pathologists, especially those that operate small businesses, compounds
the wide range of shifting economic factors impacting the practice of
pathology, such as increasing administrative burdens, staff salaries,
office rent, and purchasing of essential technology when determining
their ability to provide care to Medicare patients. The absence of an
annual inflationary update, combined with the Physician Fee Schedule's
statutory budget neutrality requirements and ongoing Medicare payment
cuts, further compounds the difficulties pathologists face in managing
resources to continue caring for patients in their communities.
Therefore, the CAP requests that the Committee pass legislation to
provide an inflationary update to the Medicare Physician Fee Schedule.
[GRAPHIC] [TIFF OMITTED] T1124.010
----------------------------------------------------------------------------------------------------------------
5-Year Yearly
2020 2021 2022 2023 2024 Total Average
----------------------------------------------------------------------------------------------------------------
Pathology Medicare Payments 0.03% -1.75% -0.65% -1.16% -1.11% -4.64% -0.93%
----------------------------------------------------------------------------------------------------------------
Medicare Economic Index (MEI) for 1.9% 1.4% 2.1% 3.8% 4.6% 13.80% 2.76%
Inflation
----------------------------------------------------------------------------------------------------------------
Difference -1.87% -3.15% -2.75% -4.96% -5.7% -18.44% -3.69%
----------------------------------------------------------------------------------------------------------------
Since 2020, reimbursement rates for pathology services have gone down by approximately 4.6%, while physician
practice costs (medical supplies, lab personnel, professional liability insurance) have increased by nearly
13.8% over the same timeframe. In 2024 alone, pathologists are anticipated a net 5.7% reduction in Medicare
Physician Fee Schedule reimbursement as payments are expected to fall by 1.1% while costs are expected to rise
by 4.6%. Currently, it is too early to predict an MEI for 2025. Therefore, it is not included in above chart.
Budget Neutrality
Budget neutrality is another barrier to achieving high-quality, high-
value health care. These requirements lead to arbitrary reductions in
reimbursement unrelated to the cost of providing care, forcing
physicians and other health care providers into adversarial roles,
leading to an unpredictable reimbursement system from year to year. The
CAP acknowledges that budget neutrality is a politically appealing
option to control rising health care costs. However, the CAP urges
Congress to think more creatively and expansively about ways to manage
health care costs which do not generate such significant instability
for health care providers, threatening beneficiary access to essential
health care services.
Because of the continuous reimbursement cuts caused by the Physician
Fee Schedule's budget neutrality requirements and the lack of an
inflationary update, the cost of providing patient care is becoming
unsustainable. As costs exceed revenues, laboratory workforce shortages
will worsen. The result: increased wait times in the emergency
department, longer time before receiving a diagnosis of cancer,
potential for increased errors in testing and delays in specimen
collection and turnaround time for laboratory results. Therefore, the
CAP requests that the Committee pass legislation to eliminate, revise,
or replace the budget neutrality requirements in Medicare.
Effectiveness of MACRA
MACRA was originally passed to end a cycle of Medicare payment cuts and
reward value-based care, yet today we are faced with continued
financial instability within the Medicare physician payment system and
value-based care that is not incentivized or attainable for most
physicians.
There has been a chorus of dissatisfaction with the Merit-based
Incentive Payment System (MIPS). The Medicare Payment Advisory
Commission (MedPAC) has questioned the value of the MIPS program due to
its design and measurement methods. Indeed, the Government Accounting
Office's (GAO) 2021 report on Provider Performance and Experiences
under the Merit-based Incentive Payment System described many of the
challenges physicians experience in the MIPS program, including the
question of whether MIPS meaningfully improved quality of care or
patient outcomes. It further indicated that the design of the program
may incentivize reporting over quality improvement. CMS's response to
the GAO report was that a new pathway in MIPS, called MIPS Value
Pathways (MVPs) would address many of these challenges. Unfortunately,
both the MIPS and MVP quality programs continue to pose challenges,
including for the care of chronic conditions. Alternative payment
models (APMs) have similar issues, while the burden of data entry and
other administrative requirements continue to impede the effectiveness
of MACRA instead of improving care for patients.
1. Quality Programs
The MIPS and MVP programs incentivize silos of care rather
than rewarding integration of the care team. Because CMS scores
individual clinicians on quality measures that apply only to
individuals, there is no incentive to foster collaboration. The
proposed future of MIPS, MIPS Value Pathways or MVPs,
exacerbate this problem because most current and proposed MVPs
are specialty-specific rather than condition or procedure-
specific. For instance, instead of a Melanoma MVP that includes
quality measures for the entire care team (primary care
clinicians, pathologists, dermatologists, Mohs' surgeons,
etc.), the Dermatological Care MVP includes quality measures
for a variety of unrelated dermatological conditions. Thus,
only dermatologists are eligible for this MVP and the disparate
quality measures within it do not incentivize collaboration
among dermatologists.
This problem is even worse for patients with chronic
conditions who may require ongoing and episodic care;
integration among the care team is even more important for
these beneficiaries. However, the MIPS program only permits
quality measures that cover a single calendar year, which does
not align with how patients with chronic conditions experience
care.
CMS should not remove or disincentivize process measures,
especially for patients with chronic conditions. Since outcomes
may be few and far between for these patients (e.g., diabetes
will never be fully resolved for a patient), process measures
are critical to ensure patients are receiving appropriate
ongoing care. While we understand CMS' desire to measure
outcomes, under the belief that is what matters most to
patients, for chronic conditions especially, process measures
are critical.
Further, the CMS-proposed ``upsides'' of MIPS participation
have not materialized, even for the highest performers. The
seemingly promised 9 percent potential positive payment
adjustments in return for flat PFS have not been realized and
the cost and burden of participation in MIPS has been higher
than anticipated. Thus, within MIPS, the administrative and
financial burden of participating far outweighs any marginal
improvements in cost and quality that could possibly be
ascribed to MIPS participation.
2. Advanced Alternative Payment Model (APM)
Within the APM track, there is an equivalent lack of
meaningful results, with increased and unnecessary complexity
built into the system. CMS recently acknowledged in its own
Synthesis of Evaluation Results across 21 Medicare Models,
2012-2020 that most of the current models created by the Center
for Medicare and Medicaid Innovation (CMMI) are not meeting
quality and savings goals. In fact, according to the CMS report
only two APMs on CMS's list of 21 improved the patient
experience of care.
Additionally, despite there being hundreds of APMs, there
have been very limited options for physicians to participate,
much less for them to receive Qualifying APM Participant status
from meeting the Advanced APM participation threshold. Per the
recently released MedPAC data book (July 2022), most clinicians
participating in Advanced APMs were in accountable care
organizations (ACOs) participating in the Medicare Shared
Savings Program (MSSP). In fact, of the clinicians who
qualified for the 5 percent Advanced APM bonus, over 75 percent
were in MSSP. Four other Advanced APMs made up most of the rest
of the eligible clinicians, while just 3.4 percent participated
in an Advanced APM other than the top four or MSSP. One look at
the CMS website for available APMs, their associated rules,
dates for sign-up, data reporting and other requirements,
demonstrates an extraordinary amount of complexity for models
that are hardly being utilized.
Further, many single-specialty practices are disenfranchised
from being able to participate in APMs altogether. As currently
envisioned by the CMS, APMs significantly favor multispecialty
practices, including larger systems in urban settings. And
while the CMS wants to see all Medicare beneficiaries and most
Medicaid beneficiaries enrolled in an accountable care
relationship by 2030, it is unclear how single-specialty,
community-based practices can effectively participate in CMS's
vision. The CMS has not explicitly articulated how this
transition will occur, nor what they see as the primary
accountable care relationship model for specialists. The CMS
has acknowledged broad concerns among participants that the
path to APMs remains unclear, particularly for specialties
other than primary care. For example, of the Advanced APMs
currently available, we believe pathologists are only able to
participate in at most three models, and only to a very limited
extent. Clearly, more opportunities are needed for specialty
physicians to participate in Advanced APMs and incentives must
recognize that high-value care is provided by both small
practices and large systems, in both rural and urban settings.
3. Reduce Health IT Administrative Burdens
Another major barrier concerning implementation of MACRA is
the associated administrative burden, particularly as it
relates to the current state of health care data. While
electronic health records are critical for advancing care
accuracy, speed, and coordination, one size does not fit all
with respect to health information technology (health IT). Even
within a single specialty, different physician practices may
have different levels of fluency with technology, and between
specialties, maturity of health IT can vary widely. Therefore,
when it comes to implementing the requirements of a system-wide
program like MACRA, we suggest that regulations should
acknowledge the varying states of data and encourage
flexibility to accommodate different health IT readiness.
Furthermore, rather than impose health IT requirements across
the board, CMS and other agencies should work with stakeholders
to move from the current state to an improved future state that
promotes greater health data interoperability.
Data entry remains a major burden to complete implementation
of MACRA, as it requires significant time and effort on the
part of physicians and/or administrative staff, an average of
more than 200 hours a year in one study.\1\ However, one
proposed alternative is quality measurement based on
administrative claims. While these measures reduce data entry
burden, they do not represent a complete fix; downsides of
administrative-claims-based measurement include limited
available data, retrospective evaluation, and oftentimes
limited clinician control over the processes being measured.
The CMS acknowledges the need for real-time evaluation and
feedback, which cannot be accomplished with administrative-
claims-based measurement.
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\1\ Khullar D, Bond AM, O'Donnell EM, Qian Y, Gans DN, Casalino LP.
Time and Financial Costs for Physician Practices to Participate in the
Medicare Merit-based Incentive Payment System: A Qualitative Study.
JAMA Health Forum. 2021;2(5):e210527.
The underlying PFS has created significant financial instability for
physician practices, and dissatisfaction with MACRA may further
discourage participation in value-based care models in the future. The
long-term consequence of failing to avert the cuts and improve the
effectiveness of MACRA is decreased patient access to care. The CAP
urges the Committee to improve the provision of chronic care services
to patients by minimizing physician administrative, financial, and
technological burdens of participation in MACRA. To further improve the
effectiveness of MACRA and provision of chronic care, the CAP asks the
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committee to take the following actions:
1. Pass legislation to maintain meaningful quality measures. The
CMS is attempting to replace process measures: measures that look at
whether the clinician did what he or she was supposed to do (example:
annual hepatitis screening for active drug users) with outcome
measures: what was the outcome of the procedure (example: decrease in
lower back pain). This is an issue for pathologists because there are
not relevant outcome measures for pathology. Pathologists do not have
direct attributable control over the outcome of most procedures.
Process measures have been and remain very important in all aspects of
health care and efforts should be taken to protect them.
2. Pass legislation to improve stakeholder participation in the
development of new payment models. The CAP remains concerned that
models are being developed by CMMI that dramatically change providers'
clinical decision-making without considering the input of those
specialties impacted by the model. Thus, the CAP has sought to ensure
physicians, especially the societies that represent physicians
participating in and affected by new payment models, have input into
new model development. Specifically, in carrying out its statutory
duties of testing innovative health care payment and delivery models
that lower costs while ``preserving or enhancing the quality of care,''
CMMI is required to consult clinical and analytical experts with
expertise in medicine and health care management. Amongst those
clinical experts and those with expertise in medicine and health care
management, CMMI should be required to include associations
representing physician specialties whose services are impacted directly
in both primary and supporting roles by the Center's models.
Consultation with specialty associations will help ensure that models
developed in a manner that is transparent and focused on the best
interests of the patient consistent with sound clinical input and
practices.
Additionally, the fact that CMS has yet to take up any of the
models recommended by the Physician Focused Payment Model Technical
Advisory Committee (PTAC) demonstrates the complexity in creating
appropriate physician-developed APMs as envisioned under MACRA. Having
physician input and buy-in is critical to effective delivery system
reform. More innovative health care payment and delivery models must be
developed in an open and transparent fashion with the input of those
specialties impacted by the models.
3. Pass legislation requiring PTAC model submitters to consult
participating and affected specialties prior to model submission. The
PTAC provides an important opportunity for specialists to develop their
own models and submit them for review and recommendation to the
Secretary. However, at least three models submitted to the PTAC have
included pathology services, yet the CAP was not consulted or even
aware they encompassed pathology services until the models were posted
for public comment. Model submitters should be required to provide
evidence of consultation and concurrence from specialties participating
in their models prior to submission so that the PTAC can make
recommendations on models that are truly physician-focused and enable
meaningful contribution of their participants in enhancing the care of
patients.
4. Pass legislation requiring that traditional MIPS options be
maintained for single specialty practices to ensure that private/
independent practices of all sizes remain a viable option for
physicians. Traditional MIPS, though burdensome, allows single
specialty pathology practices to be accurately measured on relevant
quality activities and obtain full incentives without pressure to
consolidate. Many pathologists in independent practice choose to stay
in MIPS for that reason. The CAP believes the replacement of
traditional MIPS with MVPs and Advanced APMs incentivizes larger,
multispecialty practices, as the clinical alignment envisioned by these
programs is often achieved via physician employment or practice
consolidation. Indeed, consolidation among physician practices and
between hospitals and physician practices has accelerated in the past
decade, with participation in APMs cited as reasons for
consolidation.\2\ This kind of consolidation is bad for ensuring access
to quality care for patients in rural and underserved communities.
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\2\ Medicare Payment Advisory Commission. 2022. March 2022 Report
to the Congress: Medicare Payment Policy; Ch 4. Washington, DC: MedPAC.
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Addressing the Health Care Workforce Shortage
As you know, older adult patients require higher levels of care due to
greater incidence of chronic disease, which will increase the demand
for physician services on a smaller pool of available physicians.
Therefore, it is imperative to grow the physician workforce. The
Association of American Medical Colleges (AAMC) is projecting that the
United States will face a shortage of up to 124,000 physicians by 2034.
The CAP appreciates that Congress made a critical initial investment in
the physician workforce by providing 1,000 Medicare-supported graduate
medical education (GME) positions in the Consolidated Appropriations
Act of 2021 and 200 Medicare-supported GME positions in the
Consolidated Appropriations Act of 2023. However, these should be
viewed as a down payment for a much larger documented need.
The demand for trained pathologists continues to far exceed the supply
provided by the number of existing residency positions. Data from the
CAP's 2021 Practice Leader Survey is suggestive of a nationwide demand
of 1,000-1,200 pathologists to fill open positions in the United States
in recent years, and these numbers are substantially lower than the
demand that is being reported for 2022. In contrast, over the last
decade or so, there have been approximately 620 pathologist residency
positions available each year. To meet the increased demand for
pathologists and other physicians, there must be a larger investment in
training. As such, the CAP asks the Committee to support the following
bills:
1. Pass S. 1302, The Resident Physician Shortage Reduction Act. S.
1302 would provide 14,000 new Medicare-supported GME positions over 7
years. While these 14,000 positions would not be enough to remedy the
over 100,000 plus physician shortage, they are a critical step in the
right direction. These positions would be targeted at hospitals with
diverse needs, rural teaching hospitals, hospitals currently training
over their Medicare caps, hospitals in states with new medical schools,
and hospitals serving patients in health professional shortage areas.
2. Encourage committee members to support S. 665; the CAP supports
the Conrad State 30 and Physician Access Reauthorization Act. S. 665
will increase the number of waivers for a state from 30 to 35 and
incentivize qualified IMGs who are citizens of other nations to work in
underserved communities. For agreeing to these terms, physicians will
not have to leave the U.S. for 2 years before they are eligible to
apply for an immigrant visa or permanent residence, thus allowing them
to begin to provide necessary patient care in rural and underserved
areas upon finishing their residency. IMGs are an important part of our
nation's health care system and currently represent 25% of the
physician workforce.
Insurer-Imposed Policies Impacting Patient Care
Increasingly, our members are experiencing instances of improper
practices by insurers, which has direct implications for patient care,
including those with chronic conditions, and coverage. With the passage
of federal legislation to address surprise billing, health insurance
plans are increasingly relying on narrow and often inadequate networks
of contracted physicians, hospitals, and other providers to shift
medically necessary health care costs onto their enrollees, which can
be especially burdensome to those with multiple chronic conditions. For
example, although it has made changes to the program, in 2021
UnitedHealthcare tried to roll out a ``benefit design'' that requires
laboratories to meet UnitedHealthcare-determined efficiency and quality
requirements to become a ``Designated Diagnostic Provider'' or DDP.
Facilities that did not meet these requirements (non-DDP facilities)
would ``remain in network,'' but UnitedHealthcare would not cover
outpatient diagnostic laboratory services provided by these facilities,
leaving patients ``liable for charges.'' Even with recent
modifications, the CAP believes UnitedHealthcare policies that subject
patients to an increased payment for services received at in-network,
but non-DDP facilities, is counter to efforts to protect patients and
eliminate surprise medical bills.
Other insurers are keeping facilities in-network but imposing
restrictive referral requirements that result in fractured care and
added burden for patients and their physicians. For example, in
situations where a biopsy leads to further hospital-based care,
requiring patient samples to be sent outside the health system either
prevents participation of the pathologist who is part of the
multidisciplinary team or adds a second physician to the diagnosis, as
the hospital-based pathologist will have to confirm the diagnosis and
assume responsibility for the patient. There are also logistical
challenges and risks in dividing diagnostic material for a single
patient. Further, these kinds of requirements can adversely affect
appropriate response to acute developments in a patient's care, and
possibly cause significant delay in diagnosis. Some conditions may
require rapid evaluation and treatment--not always possible when
sending samples to outside laboratories--in order to prevent serious,
even life-threatening complications. Additionally, for patients who
live further away from the health system/hospital, returning to receive
care after the results have been returned may be difficult and more
likely to result in delayed care and poorer health outcomes.
Finally, other health insurance plans are slashing reimbursement across
the board--or ceasing reimbursement for critical services altogether--
without any individual physician/practice consideration, leaving many
pathologists in serious financial jeopardy across the nation. Blanket
rate cuts that lower reimbursement below the cost to provide the
services threaten the financial viability of many smaller and/or rural
laboratories and pathology practices. And many pathologists have little
leverage or ability to opt out-of-networks with powerful insurers
because of consolidation and insurer control in their health systems
and communities. Further, as the American Medical Association recently
wrote to the FTC and Department of Justice, ``mergers of market power
health insurers tend to result in lower than competitive payments to
health care providers, but there is no evidence the cost savings are
passed through to consumers in the form of lower premiums.'' Hindering
access to high-quality pathology services through reduced rates or lack
of payment for pathology and laboratory services, which adversely
affects patient diagnosis, treatment, and outcomes.
Insurers' increasing adoption of abusive practices and/or reliance on
inadequate networks results in adverse consequences for access to
quality patient care to benefit the financial interest of the payer.
Now more than ever, patients--especially those with chronic
conditions--and their treating physicians are relying on the expertise
of pathologists and the availability of appropriate testing.
Meaningful Sources of Health Care Spending
Finally, the CAP realizes that the policies we are advocating for cost
money. However, the health of our country's citizenry, more than
anything else, impacts all facets of our nation--from national security
to its economic vitality, requiring significant financial investments.
Therefore, we encourage the Committee look at waste and consolidation
in the health care system as a source potential source of revenue to
stabilize the payment system and grow the workforce in lieu of site
neutral policies. For example, the largest source of health care
spending in the U.S. is administrative, with over $265 billion a year
in waste according to some studies.\3\ On the other hand, site neutral
payment proposals fail to take into consideration the technical costs
associated with specific individual codes and fail to recognize the
distinct costs of physician services. Arbitrarily accepting hospital
outpatient rates instead of the carefully reviewed inputs is a step
backwards. The CMS has stated that comparisons between the Physician
Fee Schedule (PFS) and the out-patient prospective payment system
(OPPS) payments for services are inappropriate because of the different
nature of the cost inputs and has explicitly refused to impose one
payment system on the other.
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\3\ ``The Role of Administrative Waste in Excess U.S. Health
Spending,'' Health Affairs Research Brief, October 6, 2022.
OPPS data is hospital data and does not reflect the actual resource
costs of physicians in their offices or laboratories. It reflects the
average costs of ``buckets'' of services rather than resource costs for
individual services performed by physicians. The monies are then
distributed by case-mix. Complete accuracy of this data is practically
impossible. OPPS rate setting allows for meaningful comparison of
resource-intensiveness and costs of services within the OPPS system.
But the methodology is not designed to allow for comparisons to
services outside the OPPS. Current law requires physician services to
be resource-based and ambulatory payment classifications are not
resource-based. In short, site-neutral proposals could result in
billions of dollars being shifted between sites of service, and
potentially out of the health care system, resulting in major
disruptions in health care revenue at a time when consolidation is on
the rise and practices in rural and underserved areas are struggling or
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closing.
In closing, the CAP appreciates the opportunity to provide these
comments for the record. Please contact Darren Fenwick at
dfenwic@cap.org or 202-354-7135 if you have any questions regarding
these comments.
Sincerely,
Donald S. Karcher, M.D., FCAP
President
______
Emergency Department Practice Management Association
1660 International Drive, Suite 600
McLean, VA 22102
The Emergency Department Practice Management Association (EDPMA) is the
nation's only professional trade association focused on the delivery of
high-quality, cost-effective care in the emergency department. EDPMA's
membership includes emergency medicine physician groups of all sizes
and billing, coding, and other professional support organizations that
assist healthcare clinicians in our nation's emergency departments.
Together, EDPMA members see or support approximately 60% of all annual
emergency department visits in the country. For more info, please visit
https://edpma.org/.
Re-envisioning a plan for improving the quality of and access to
physician services provided to Medicare beneficiaries can only occur
after Congress first stabilizes the Medicare Physician Fee Schedule
(MPFS) through two policies: (1) the creation of an annual inflationary
update and (2) the modernization of budget neutrality requirements.
Although there are additional substantive reforms that would benefit
the MPFS, indexing the MPFS for inflation and modernizing the budget
neutrality requirement are critically important, foundational steps
that must be taken first. Each of these critical steps is described in
turn below. However, we would first like to emphasize the unique impact
that Medicare payment instability has on emergency medicine practices.
EMTALA's Unique Impact on Emergency Physicians
Although Medicare reimbursement issues affect all clinicians in the
program, emergency medicine providers are in a unique situation
compared to nearly every other medical specialty, due to the
longstanding federal law EMTALA (Emergency Medical Treatment and Labor
Act). Since 1987, EMTALA has provided a statutory guarantee that every
patient who presents to an emergency department must be evaluated and
medically stabilized regardless of the patient's insurance status or
ability to pay for their care. Essentially, 100% of all emergency
patients benefit from EMTALA's protections and 100% of emergency care
is provided under EMTALA before the physician knows what payment--if
any--will be rendered for clinical care. EMTALA is a critical feature
of our nation's safety net and emergency care system. EDPMA members are
proud to be a pivotal part of that safety net.
As a direct result of EMTALA, emergency physicians see a broad
representation of patients, including uninsured, Medicaid, Medicare,
and commercially insured patients (the average proportions are roughly
25% for each payor). It is well established that the ultimate
reimbursement for uninsured, Medicaid, and Medicare services is less
than the actual cost of providing clinical care to these patients. As a
result, on average, EMTALA's requirements create a significant unfunded
gap for approximately 75% of the patients seen in our nation's
emergency departments. Coupled with significant workforce challenges in
recent years, this results in a substantial strain on emergency care
practices.
These dynamics also mean that emergency physician practices are highly
sensitive to downward movements, fluctuations, and the absence of
inflation adjustments for reimbursement rates of all payors, including
Medicare. Emergency physician practices cannot adjust to reimbursement
decreases in the same way that other specialties can. When
reimbursement rates go down or are not adjusted for inflation, other
specialties not subject to EMTALA have more flexibility to adjust
processes for patient financial screening or patient scheduling to
ensure the economic stability of their practices. For example, they can
first inquire about patients' ability to pay, require insurance
information or payments before care is delivered, or refuse to see
patients at all in response to reductions or changes in reimbursement.
Emergency physician practices have the unique opportunity, but also the
affirmative challenge of providing clinical care first, and only
afterwards collecting appropriate reimbursement to attempt to sustain
patient access to care. This makes emergency care uniquely vulnerable
to the downward trend in Medicare reimbursements. To avoid stretching
the safety net beyond its breaking point, the emergency medicine
community needs the MPFS to be on stable ground before enactment of
additional substantive reforms.
Inflationary Update: Medicare Economic Index
Unlike Medicare's other major payment systems, the MPFS lacks a
mechanism to reflect annual inflation, leaving physicians to absorb
annual increases in the cost of practice on top of any additional
reimbursement reductions. Not surprisingly, this has resulted in
physician reimbursement falling significantly behind inflation metrics,
behind the reimbursement of all other providers, and well behind the
reimbursement of other sectors of health care, as this graph by the
American Medical Association illustrates:
[GRAPHIC] [TIFF OMITTED] T1124.011
.epsIt is imperative that Congress provide a mechanism for physician
reimbursement to keep pace with the rising costs of providing medical
care. The Medicare Economic Index (MEI) is specifically designed to
measure annual increases in the cost of practice. It provides the most
relevant inflation metric for the MPFS. For 2024, the MEI is +4.6%.
Failure to do so will inevitably result in serious beneficiary access
challenges, as noted in the Medicare Trustees' 2023 Report to
Congress,\1\ which warned that access to Medicare physicians would
become ``a significant issue in the long term,'' absent a change in the
delivery system or in the level of update. The bipartisan Strengthening
Medicare for Patients and Providers Act (H.R. 2474)\2\ would provide an
annual inflationary update to the MPFS based on the MEI. This is a
basic, foundational policy that will provide stability to the Medicare
program. We urge the Congress to enact this legislation.
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\1\ https://www.cms.gov/oact/tr/2023.
\2\ https://www.congress.gov/bill/118th-congress/house-bill/2474/
text?s=1&r=1&q=%7B%22
search%22%3A%22HR2474%22%7D.
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Budget Neutrality Threshold
The MPFS is subject to a budget neutrality requirement, by which
payment changes over a certain threshold must be offset by reductions
in spending that same year. Over the years, certain policy decisions by
the Centers for Medicare and Medicaid Services (CMS) have added to
reimbursement instability by triggering the statutory requirement for
budget neutrality. Most recently, CMS' creation and implementation of a
new add-on code (G2211) highlighted the ``winners versus losers''
dynamic created by this policy: by triggering a Fee Schedule-wide
budget neutrality adjustment, implementation of this code alone was
responsible for a -2% reduction in Medicare payments for most
physicians in 2024 relative to 2023.
Although repeal of budget neutrality in its entirety may not be
feasible due to budgetary and scoring implications, Congress must
update the threshold at which budget neutrality is triggered. That
threshold is set in statute at $20 million, a number that has never
been updated since its enactment in the early 1990s. Unless this
threshold is updated and then indexed from the updated level, budget
neutrality will be triggered more and more frequently as time goes by.
That not only creates instability for Medicare clinicians, but it will
also make it more difficult for CMS to implement policies to keep pace
with innovation, as even minor policy changes will begin to trigger the
need for budget neutrality reductions. To avoid across-the-board
reductions in the future, we urge Congress to modernize the threshold
at which budget neutrality is triggered. Updating the threshold to $53
million would reflect the three decades of inflation since the
threshold was first created. Additionally, indexing the new level on a
regular basis is a crucial long-term reform that will avoid recreation
of the same problem in the future. To accomplish both of these goals,
we urge Congress to enact section 5 of the bipartisan Physician Fee
Schedule Update and Improvements Act (H.R.6545).\3\
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\3\ https://www.congress.gov/bill/118th-congress/house-bill/6545/
text?s=3&r=1&q=%7B%22
search%22%3A%22H.R.6545%22%7D.
We hope this feedback is helpful to the Committee as it considers next
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steps for Medicare physician reimbursement.
______
Healthy Aging Coalition
4031 Aspen Grove Drive, Suite 250
Franklin, TN 37067
The Healthy Aging Coalition appreciates the opportunity to provide this
Statement for the Record in connection with the Senate Committee on
Finance hearing entitled, ``Bolstering Chronic Care through Medicare
Physician Payment.'' The Healthy Aging Coalition consists of multiple
stakeholder organizations that are committed to ensuring that all older
adults live their best lives with equity, vitality, dignity, and
purpose, serving as a catalyst for education, action and change. We
work to build national awareness around the key challenges and issues
that impact aging adults with a focus on those in rural, underserved
and minority communities and to identify opportunities for
stakeholders, including policymakers, to advance equitable, evidence-
based, and innovative solutions.
We appreciate the Committee's commitment to examining revisions to
physician reimbursement in traditional Medicare and Medicare Advantage
(MA) to enhance support for older adults managing chronic conditions.
One of the Healthy Aging Coalition's priorities is to support
initiatives to reduce the prevalence of chronic conditions such as
obesity, diabetes, heart disease, and Alzheimer's Disease that promote
healthy longevity by promoting wellness and prevention programs. The
U.S. cannot address chronic diseases without addressing drivers of
chronic conditions, such as health disparities and social determinants
of health (SDOH). We are concerned that current Medicare reimbursement
does not provide adequate payment for the services and support provided
by physicians along with those in communities that address these
drivers and, in turn, address chronic conditions. It is also important
to recognize the need to stabilize Medicare Advantage and the
significant progress being made via supplemental benefits. These
health-related services are important to chronic care as was recently
issued by CMS for the Supplemental Benefits for the Chronically Ill.
As the Committee explores changes to Medicare physician payment as a
means of addressing chronic conditions, we urge that due consideration
be given to ensuring reimbursement for the community services and
supports that address and reduce chronic conditions. This would provide
older adults a greater opportunity to achieve health and wellness.
Thank you for your leadership in taking steps to support older adults
managing chronic conditions. The Healthy Aging Coalition is committed
to working with the Committee to reach this goal. Please contact Vicki
Shepard at vicki.shepard
@tivityhealthcom should you have questions or need more information.
NAMES OF COALITION MEMBERS
American College of Lifestyle Medicine
American Society on Aging
Ashtabula County YMCA (Ohio)
Archelle Georgiou, MD
Better Medicare Alliance
Bitewell
BloomingHealth
Determined Health
DoucetSolutions
Debbie Witchey
Gerontological Society of America
Grantmakers in Aging
Healthcare Leadership Council
Health Policy Source
Home Care Genie
Jefferson College of Population Health
Julianne Holt-Lunstad, PhD
Lois Drapin, The Drapin Group LLC
Medical Fitness Association
Mercy Community Healthcare
Milken Institute
Motion Picture & Television Fund
NashvilleHealth
National Association of Nutrition and Aging Services Programs
National Council on Aging
National Minority Quality Forum
Open Source Wellness
PreferCare
Sharecare
Spark Living and Learning, LLC
Tivity Health, SilverSneakers
UsAgainstAlzhiemer's
USAging
YMCA of Portage (Indiana)
Vivo
______
Infectious Diseases Society of America
4040 Wilson Blvd., Suite 300
Arlington, VA 22203
Statement of Steven K. Schmitt, M.D., FIDSA, FACP, President
On behalf of the Infectious Diseases Society of America (IDSA), which
represents more than 13,000 physicians, scientists, public health
practitioners and other clinicians specializing in infectious diseases
prevention, care, research and education, I thank the Committee for its
focus on physician payment issues, highlighting the needs of patients
with chronic conditions. IDSA asks the Committee to recognize the link
between chronic diseases and infectious diseases and the critical need
to reform Medicare physician payment policies to support access to
infectious diseases prevention, diagnosis and treatment that can
especially impact patients with chronic diseases.
The Connection Between Chronic Disease and Infectious Disease
Chronic diseases and infectious diseases are inextricably linked. Some
chronic diseases are caused by infections. Patients with chronic
conditions are often at greater risk of contracting infectious diseases
and suffering more serious illness from infections, as we saw with
COVID-19. These issues demonstrate that infectious diseases (ID)
physicians play a key role in caring for patients with chronic
diseases. As the percentage of the U.S. population that is
immunosuppressed (due to transplants, use of certain biologics,
cancers, etc.) continues to grow, so will the need for a robust ID
workforce and a payment system that enables ID recruitment and access
to ID care.
Recent research has shown that many chronic illnesses result from
infectious agents and can be exacerbated by infectious pathogens.\1\
For example, infectious agents such as viruses, bacteria and parasites
can cause cancer or increase the risks of developing cancer. Certain
viruses can also disturb the signals in the body that moderate cell
growth and can lead to cancer developing. Cancer patients also have a
much weaker immune system due to the spread of cancer to the bone
marrow, thereby stopping the production of blood cells that can help in
fighting infections. Furthermore, cancer treatments such as
chemotherapy, steroids and radiation can weaken the immune system,
making cancer patients more susceptible to infections.
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\1\ Knobler, S.L., O'Connor, S., Lemon, S.M., & Najafi, M. (2018).
OVERVIEW. The Infectious Etiology of Chronic Diseases--NCBI Bookshelf.
https://www.ncbi.nlm.nih.gov/books/NBK8
3680/.
The human immunodeficiency virus (HIV) is now regarded as a chronic
disease that patients live with for multiple decades due to the use of
antiretroviral therapy (ART).\2\ Health care systems across the country
now treat HIV patients with chronic care management models. However,
ART can cause multiple complications over time. Cumulative exposure
over time to antiretroviral drugs has demonstrated that HIV-infected
adults are at a much higher risk for the development of cardiovascular
disease, kidney disease, osteoporosis and neurocognitive disease.
Patients that have been diagnosed with viruses such as HIV have weaker
immune systems and are less able to fight infections that may cause
cancer. HIV patients are at a higher risk for many different forms of
cancer, including Kaposi sarcoma, Hodgkin's lymphoma and liver and lung
cancer.\3\
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\2\ Deeks, S.G., Lewin, S.R., and Havlir, D.V. (2013). ``The end of
AIDS: HIV infection as a chronic disease,'' The Lancet, 382(9903), pp.
1525-1533. doi:10.1016/s0140-6736(13)61809-7.
\3\ Risk factors: infectious agents. (2019, March 4). National
Cancer Institute. https://www.cancer.gov/about-cancer/causes-
prevention/risk/infectious-agents.
The number of immunosuppressed adults in the United States has been
increasing over time due to wider use of new immunosuppressive
treatments for a broad range of conditions that are immunocompromising,
including cancer, organ transplants, autoimmune disorders, rheumatoid
arthritis, psoriasis and more. Immunosuppression greatly increases the
risks and severity of infections. A review of 2021 data found that 6.6%
of U.S. adults are immunosuppressed, a significant increase from the
2.7% reported in 2013.\4\, \5\ Additionally, the numbers of
immunocompromised infants and children have also increased, and
pediatric ID physicians provide care to a significant number of these
patients who are at a much higher risk for developing serious
infections.
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\4\ Martinson, Melissa L., and Lapham, J. ``Prevalence of
immunosuppression among U.S. adults.'' JAMA, vol. 331, no. 10, 12 Mar.
2024, p. 880, https://doi.org/10.1001/jama.2023.
28019.
\5\ Harpaz, R., Dahl, R., & Dooling, K. (2016). Prevalence of
immunosuppression among U.S. adults, 2013. JAMA, 316(23), 2547. https:/
/doi.org/10.1001/jama.2016.16477.
Over the past 4 years, the medical community has seen an increase in
hospitalizations and deaths due to COVID-19 in patients with chronic
conditions, such as heart disease, diabetes and more.
Antimicrobial Resistance and Risk of Complications
The prevalence of antimicrobial resistance (AMR) is a growing threat to
patients, including those with chronic diseases. Millions of Americans
per year develop
hospital-acquired infections due to antibiotic-resistant pathogens.\6\
The inappropriate use of antibiotics over decades has resulted in
antibiotic resistance rates that continue to rise, with recent progress
hampered by the COVID-19 pandemic.
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\6\ Clinical Infectious Diseases, ciad428. ``AMR Guidance.'' IDSA
Home, https://www.idsociety.
org/practice-guideline/amr-guidance/.
To address the threat of AMR, IDSA greatly appreciates the leadership
of Senators Michael Bennet (D-CO) and Todd Young (R-IN) in sponsoring
the bipartisan PASTEUR Act, which would strengthen the antibiotic and
antifungal pipeline by changing the way the federal government pays for
novel antibiotics and antifungals that address unmet needs--paying for
value instead of volume used. Under PASTEUR, the federal government
would enter into contracts with novel antibiotic/antifungal developers
to pay a set fee for a supply of new drugs regardless of the quantity
used. PASTEUR would also provide grants to hospitals to support
antimicrobial stewardship programs, with priority given to rural,
critical access and safety net hospitals (which may partner with
academic institutions for stewardship). Successful implementation of
PASTEUR would require more ID physicians to ensure patients with
resistant infections receive optimal treatment, lead clinical trials
for novel antimicrobials and ensure that new antimicrobials are used
appropriately.
Current Medicare Reimbursement Concerns
Currently, nearly 80% of counties in the United States do not have a
single ID physician, and this poses significant patient access
problems.\7\ Recruitment within the specialty continues to decline. In
last year's fellowship match, only about 51% of ID training programs
filled (down from 56% the year before), whereas most specialties filled
90%-100% of their training programs. These shortages are driven in part
by reimbursement disparities that negatively impact infectious disease
physicians.
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\7\ Walensky, Rochelle P., et al. ``Where is the ID in COVID-19?''
Annals of Internal Medicine, vol. 173, no. 7, 6 Oct. 2020, pp. 587-589,
https://doi.org/10.7326/m20-2684.
Many medical students and residents are very interested in this field
but cite financial reasons for pursuing specialties that have much
higher reimbursement rates. Only three other medical specialties fall
below ID in terms of compensation, according to Medscape. Two of
those--pediatrics and public health--are primarily paid outside of the
Medicare system. The shortage of ID physicians is very worrisome from a
patient care and public health perspective, given the unique roles ID
physicians play. ID is uniquely part of the foundation of modern health
care. Cancer chemotherapy, organ transplants and other surgeries carry
significant risk of infection and require ID expertise. Many hospital
quality measures, conditions of participation (antimicrobial
stewardship, infection prevention and control) and other metrics upon
which hospital payments hinge (hospital readmissions, health care-
associated infections) all fundamentally require ID physicians. ID
physicians are at the forefront of leading preparedness and responses
to outbreaks and pandemics. Patients with serious infections have
better outcomes, shorter hospital stays and lower health care costs
when cared for by an ID physician.\8\
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\8\ McQuillen, Daniel P., and MacIntyre, Ann T. ``The value that
infectious diseases physicians bring to the healthcare system.'' The
Journal of Infectious Diseases, vol. 216, no. suppl--5, 15 Sept. 2017,
https://doi.org/10.1093/infdis/jix326.
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IDSA's Proposals to Improve ID Capacity and Reimbursement
As the Finance Committee considers Medicare Physician Fee Schedule
reforms, we strongly urge you to include provisions that target
specialties, like ID, that are at the bottom of the payment scale and
are experiencing recruitment challenges and workforce shortages
directly linked to inadequate reimbursement. IDSA recommends a
provision that would provide a temporary 10% incentive payment to ID
physicians, modeled after similar previous efforts for primary care and
general surgery. This approach would provide a critical, rapid boost
that would impact the specialty decisions of current medical students
and residents. It would also serve as a bridge to provide time to
develop and implement longer-term solutions.
Over the last several years, IDSA has repeatedly engaged with the
Centers for Medicare & Medicaid Services (CMS) to ask for assistance in
addressing the reimbursement challenges that are impeding recruitment
of ID physicians. Initially, we focused on urging CMS to improve the
values of inpatient evaluation and management (E/M) codes, the codes
mainly used by ID physicians, to maintain their historic relativity
with outpatient E/M codes (whose values were increased in 2021). The
historic relativity was based upon the fact that inpatient care is
inherently more complex than outpatient care. Patients with serious
infections often have underlying chronic illnesses, require more
complex medical decision making and are at greater risk of adverse
outcomes. CMS has not accepted this recommendation.
In January 2024, IDSA provided a list of services performed by ID
physicians that are not adequately captured by existing E/M codes, in
response to a request from CMS. At the end of February 2024, IDSA
submitted to CMS draft code descriptors \9\ for infectious diseases
complex prevention, infectious diseases, complex investigation/
diagnosis, complex antimicrobial therapy and infectious diseases
complex care management. IDSA also shared two draft code descriptors
that refer more generally to complex care, to provide CMS with options
that are not ID-specific: complex medication management and inpatient
complex care management. The six code descriptors align with the six
categories of activities routinely performed by ID physicians not
adequately captured by current E/M codes. IDSA encouraged CMS to
include these new codes and/or add-on codes in the upcoming CY 2025
Medicare Physician Fee Schedule rulemaking.
---------------------------------------------------------------------------
\9\ https://www.idsociety.org/globalassets/idsa/policy--advocacy/
current_topics_and_issues/
antimicrobial_resistance/strengthening_us_efforts/letters-manually-
added/idsa-add-on-codes-letter-and-descriptors_feb2024.pdf.
Several members of Congress are increasingly concerned about the ID
physician workforce shortage and ID reimbursement issues. Last fall, a
bipartisan group of representatives sent a letter \10\ to CMS asking
for the agency to incentivize more medical students to enter the
infectious diseases field by modifying its reimbursement policy.
---------------------------------------------------------------------------
\10\ https://www.idsociety.org/contentassets/
2b7de28c54ae43f098838c12b2783a1f/congressman-van-drews-letter-to-cms-
on-infectious-diseases-medicare-reimbursement-final.pdf.
Like many medical specialties, IDSA is supportive of broad reforms to
the Medicare physician payment system, including tying payment updates
to a measure of inflation, such as the Medicare Economic Index;
revising budget neutrality requirements, including raising the budget
neutrality threshold; and requiring ongoing updates to the practice
expense inputs that inform the value of services. These reforms are
essential to addressing some of the foundational challenges that
persist in the physician payment mechanism. However, these reforms
alone are not sufficient to address the significant payment disparities
facing ID that are driving ID recruitment challenges.
Conclusion
Thank you for your attention to physician payment issues and for
considering our requests regarding the need to bolster access to ID
treatment and prevention of infectious diseases through Medicare
reimbursement reforms. While Medicare primarily covers adults,
pediatric ID physicians face similar reimbursement and recruitment
challenges that we hope to discuss in the future. We look forward to
working with the Committee on these critical topics.
Should you have any questions or wish to discuss our requests further,
please contact Amanda Jezek, IDSA's senior vice president for public
policy & government relations, at ajezek@idsociety.org.
______
Medical Group Management Association
1717 Pennsylvania Ave., NW, #600
Washington, DC 20006
T 202-293-3450
F 202-293-2787
mgma.org
April 10, 2024
The Honorable Ron Wyden The Honorable Mike Crapo
Chairman Ranking Member
U.S. Senate U.S. Senate
Committee on Finance Committee on Finance
215 Dirksen Senate Office Building 215 Dirksen Senate Office Building
Washington, DC 20510 Washington, DC 20510
Re: MGMA Statement for the Record--Senate Committee on Finance's April
11th Hearing, ``Bolstering Chronic Care through Medicare Physician
Payment''
Dear Chairman Wyden and Ranking Member Crapo:
On behalf of our member medical group practices, the Medical Group
Management Association (MGMA) would like to thank the Committee for the
opportunity to provide feedback on bolstering chronic care through
Medicare physician payment. We appreciate your leadership in holding
this important hearing as it is vital that Medicare adequately
reimburse physicians for their chronic care services. Significant
reforms are needed to the Medicare physician payment system to stop the
harmful yearly cuts and support medical groups' ability to offer high-
quality care to patients with chronic conditions.
With a membership of more than 60,000 medical practice administrators,
executives, and leaders, MGMA represents more than 15,000 group medical
practices ranging from small private medical practices to large
national health systems, representing more than 350,000 physicians.
MGMA's diverse membership uniquely situates us to offer the following
policy recommendations.
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was
enacted to repeal the flawed Sustainable Growth Rate (SGR) formula,
stabilize payment rates to physicians in Medicare fee-for-service, and
incentivize physicians' transition to value-based care models. While
well-intentioned, MACRA's methodology for updating the Medicare
Physician Fee Schedule (PFS) does not keep pace with rising practice
costs and inflation, and simultaneously cuts reimbursement for
physicians.
The Centers for Medicare & Medicaid Services (CMS) finalized a 3.37%
cut to the Medicare conversion factor in its 2024 Medicare Physician
Fee Schedule (PFS). From January 1st to March 8th of this year, medical
groups absorbed a 3.37% reduction to reimbursement. Following
congressional action to partially mitigate 1.68% of the cut in the
Consolidated Appropriations Act of 2024 (CAA, 2024), physician
practices are left with a 1.69% reduction for the rest of the year.
Medicare physician reimbursement is on a dire trajectory, and these
annual cuts continue to undermine the ability of medical group
practices to keep their doors open and function effectively. MGMA
offers the following recommendations to strengthen Medicare payment and
sustainably support medical groups providing care to patients with
chronic conditions.
Key Recommendations
Pass legislation to implement an annual inflation-based
physician payment update tied to the Medicare Economic Index (MEI) to
ensure medical groups have a functioning reimbursement system moving
forward that keeps pace with rising costs. Without providing an annual
inflationary update for physicians--similar to other payment systems
under Medicare--medical groups will continue to face financial barriers
to providing access to care for patients with chronic conditions in
their communities. The Strengthening Medicare for Patients and
Providers Act would provide this long-needed annual MEI-based update to
Medicare physician reimbursement.
Reform the budget neutrality aspect of the Medicare Part B
payment system to avoid continued across-the-board payment cuts harming
medical groups' financial viability.
Pass the Chronic Care Management Improvement Act of 2023 to
ensure Medicare patients with chronic conditions are able to access
high-
quality care.
Provide positive financial incentives to support practices
transitioning into value-based care. The Value in Health Care Act of
2023 would reinstate the advanced alterative payment model (APM)
incentive payment at 5%, allow CMS to set the qualifying APM
participant (QP) thresholds at an appropriate level, and institute
additional polices to properly incentivize and assist practices
transitioning to value-based care arrangements.
Pass an Annual Medicare Inflationary Payment Update
This year's cut to the conversion factor is entirely untenable as the
cost of running a medical practice continues to rise--89% of MGMA
members reported an increase in operating costs in 2023.\1\ According
to MGMA data, physician practices saw total operating cost per FTE
physician increase by over 63% from 2013-2022, while the Medicare
conversion factor increased by only 1.7% over the same timeframe.
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\1\ MGMA Stat Poll, July 12, 2023. https://www.mgma.com/mgma-stat/
higher-costs-persist-for-medical-groups-even-as-inflations-growth-
slows.
In our 2023 Annual Regulatory Burden Report, MGMA surveyed over 350
medical groups and 87% of respondents reported that reimbursement not
keeping up with inflation impacts current and future Medicare patient
access.\2\ This aligns with what the Medicare Trustees recently said in
their 2023 report:
---------------------------------------------------------------------------
\2\ MGMA 2023 Annual Burden Report, November 13, 2023. https://
www.mgma.com/federal-policy-resources/mgma-annual-regulatory-burden-
report-2023.
While the physician payment system put in place by MACRA
avoided the significant short-range physician payment issues
resulting from the SGR system approach, it nevertheless raises
important long-range concerns that will almost certainly need
to be addressed by future legislation. In particular,
additional payments totaling $500 million per year and annual
bonuses are scheduled to expire in 2025 and 2026, respectively,
resulting in a payment reduction for most physicians. In
addition, the law specifies the physician payment updates for
all years in the future, and these updates do not vary based on
underlying economic conditions, nor are they expected to keep
pace with the average rate of physician cost increases. The
specified rate updates could be an issue in years when levels
of inflation are high and would be problematic when the
cumulative gap between the price updates and physician costs
becomes large. Absent a change in the delivery system or level
of update by subsequent legislation, the Trustees expect access
to Medicare-participating physicians to become a significant
issue in the long term.\3\
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\3\ Medicare Board of Trustees, 2023 Annual Report of the Board of
Trustees of the Federal Hospital Insurance and Federal Supplementary
Medical Insurance Trust Funds, March 31, 2023. https://www.cms.gov/
oact/tr/2023.
Practices have seen significant cuts to Medicare physician payment over
the past 4 years, which have a heightened impact in the face of
inflationary pressures (CMS projected a 4.6% increase to the MEI for
2024) and other economic factors such as staffing shortages. Failing to
stop this downward spiral in physician payment will continue to
threaten the financial viability of medical groups, hasten negative
repercussions to this nation's healthcare system, and hurt group
---------------------------------------------------------------------------
practices' ability to treat patients with chronic diseases.
Other Medicare payment systems receive annual positive updates--even
hospitals that received a 3.1% increase in the Medicare hospital
outpatient prospective payment system (OPPS) for 2024 have decried the
insufficient nature of their positive increase given financial
constraints and thin margins in the current environment. How does the
Committee expect physicians to keep their doors open in the same
environment if Congress allows these cuts to continue?
A permanent solution is critical to stabilize Medicare physician
payment. The Strengthening Medicare for Patients and Providers Act,
which was introduced by a bipartisan group of congressional doctors in
the House of Representatives and currently has 127 cosponsors, would
provide an annual Medicare physician payment update tied to inflation,
as measured by the MEI. This commonsense policy is long overdue to
bring physician payment in line with the costs of providing care and
should be enacted as soon as possible.
Modernize Medicare's Antiquated Budget Neutrality Policies
Compounding the lack of an inflation-based update are the annual
reimbursement cuts medical groups continue to face stemming from 2021
Medicare PFS changes, the phase-in of the E/M complexity add-on code
(G2211) that CMS implemented in 2024, and corresponding budget
neutrality requirements. The Provider Reimbursement Stability Act of
2023 would modernize many aspects of Medicare budget neutrality and
would make significant changes to alleviate the adverse effects
practices are experiencing. The legislation would increase the
triggering threshold from $20 million to $53 million (while adding an
update to keep pace with inflation), institute new utilization review
requirements to better reflect the reality of providers using certain
services compared to CMS' estimates, and more.
MGMA urges Congress to make changes to budget neutrality in unison with
the long-needed annual inflationary update. These policies work in
concert to undermine the financial viability of medical practices, as
medical groups will be facing another cut in 2025 absent congressional
intervention. Addressing both problems would go a long way towards
establishing an appropriate and sustainable Medicare reimbursement
system.
Support Patients With Chronic Conditions by Enacting the Chronic Care
Management Improvement Act of 2023
Chronic care management (CCM) is an integral part of care coordination
for patients with chronic conditions. Medicare started paying for CCM
services in 2015 for primarily non-face-to-face CCM services. While we
support this initiative to improve the ability to manage patients'
chronic conditions, theses services created a beneficiary cost-sharing
obligation.
The 20% coinsurance requirement for CCM services is a barrier to care
for beneficiaries who are not used to cost sharing for care management
services. The Chronic Care Management Improvement Act of 2023 would
waive this coinsurance requirement, thereby improving patients' ability
to receive the chronic care they need. We urge the Committee to pass
this important piece of legislation.
Support Physician Practices Transitioning Into Value-Based Care
Arrangements
Value-based care arrangements such as APMs can help physician practices
successfully treat patients with complex and chronic conditions, but
Congress needs to do more to ensure practices have adequate financial
support to voluntarily make the transition from fee-for-service.
Congress recently extended the APM incentive payment at 1.88% for
2024--a decrease from 3.5% in 2023, and 5% in 2022. MGMA strongly urges
Congress to reinstate the full 5% as this payment is necessary to cover
costs, support investments, and safeguard the financial viability of
medical groups in the program.
Congress also froze the QP thresholds at the 2023 level for the 2024
performance period in the CAA, 2024. This was a welcomed extension, as
CMS' increase of these thresholds would have made it extremely
difficult for many medical groups to reach QP status and qualify for
the APM incentive bonus and avoid onerous reporting requirements under
the Merit-based Incentive Payment System (MIPS). We suggest the
Committee give CMS the ability to adjust these thresholds under statute
to allow them to be set at reasonable levels, as drastic increases to
QP thresholds will make it impossible for many practices to join or
continue participating in APMs. The Value in Health Care Act of 2023
includes language to this effect and would implement additional
policies, such as extending the 5% APM incentive payment, to better
assist practices transitioning into value-based care arrangements.
Conclusion
MGMA thanks the Committee for its leadership in examining Medicare
payment for chronic care. We look forward to collaborating with the
Committee and its colleagues to craft sensible payment policies that
will reinforce practices' ability to offer high-quality care to
patients with chronic conditions. If you have any questions, please
contact James Haynes, Associate Director of Government Affairs, at
jhaynes@mgma.org or 202-293-3450.
Sincerely,
Anders Gilberg
Senior Vice President
Government Affairs
______
National Academy of Neuropsychology
7555 East Hampden Avenue, Suite 420
Denver, Colorado 80231
PH: 303-691-3694
FX: 303-691-5983
April 25, 2024
The Honorable Ron Wyden The Honorable Mike Crapo
Chair Ranking Member
U.S. Senate U.S. Senate
Committee on Finance Committee on Finance
219 Dirksen Senate Office Building 219 Dirksen Senate Office Building
Washington, DC 20510 Washington, DC 20510
Dear Chairman Wyden and Ranking Member Crapo:
On behalf of the National Academy of Neuropsychology (NAN), we are
writing to share comments and recommendations for consideration as part
of your committee's April 11th hearing, ``Bolstering Chronic Care
through Medicare Physician Payment.'' NAN is an organization that
represents neuropsychologists, who are doctoral experts in how brain
injuries and conditions affect behavior and functional abilities.
Neuropsychologists work closely with other medical specialists in the
assessment and treatment of people with a variety of brain injuries and
diseases, as well as promoting brain health.
You have received similar comments from our colleagues at the American
Psychological Association Services (APA Services), which we have
modified to identify specific considerations related to the practice of
neuropsychology.
We applaud your committee's attention to improving Medicare healthcare
provider reimbursement policies, as they are not adequately supporting
high-quality, cost-
effective health care for the program's beneficiaries. We share the
concerns of the broad provider community regarding the consistent
failure of payment updates for Part B providers to keep pace with
inflation. Steadily eroding reimbursement rates are increasingly making
Medicare participation unsustainable for psychologists and other
providers. We strongly support proposals to raise the budget neutrality
cap on adjustments to the Medicare Physician Fee Schedule (PFS), and to
connect annual conversion factor increases to the Medicare Economic
Index or similar measures of inflation. However, our comments today
will focus on aspects of the Medicare fee schedule and proposed payment
policies that specifically impact neuropsychological services.
Because of their foundational importance, it is important for
policymakers to understand that Medicare PFS payment formula
methodologies for both work and practice expenses have consistently
undervalued neuropsychologists' services. This situation has been
exacerbated by the statutory requirement that annual updates to the PFS
be made in a budget neutral manner.
Work Valuation
As the committee has recognized, the Medicare fee schedule tends to
undervalue cognitively intensive services, and neuropsychologists'
services are cognitively intensive. The Centers for Medicare and
Medicaid Services (CMS) has recognized the need to set more appropriate
work values for psychologists' services, and in the 2024 fee schedule
CMS initiated a 19.1% increase in work relative value units (RVUs) for
psychotherapy services over the next 4 years. However, CMS has not
adopted a similar increase for psychological and neuropsychological
testing and assessment services, which are as cognitively demanding as
psychotherapy services.
Psychological assessment is the process of systematically collecting
reliable and valid information about behavior from multiple sources to
inform decisions about a patient's mental or behavioral functioning,
typically for the purpose of diagnoses, treatment planning, or
treatment evaluation. Domains assessed in a psychological assessment
typically consist of mood/emotional conditions and symptoms, mental
status, adaptive functioning, and behavioral and interpersonal
adjustment, with evaluation of acuteness vs. chronicity, severity,
degree of functional impairment, comorbidity, and prognosis where
information is available. Psychological testing has been shown to
provide both clinical and financial benefit in treating psychiatric
disorders.\1\
---------------------------------------------------------------------------
\1\ Durosini, I., & Aschieri, F. (2021). Therapeutic assessment
efficacy: A meta-analysis. Psychological Assessment, 33(10), 962-972.
https://doi.org/10.1037/pas0001038.
Neuropsychological assessments provide measurements of behavioral
manifestations of central nervous system (CNS) disorders using
techniques that provide objectivity, validity, and reliability.
Information acquired from neuropsychological assessments can directly
inform medical decisions by providing data relevant to diagnosis,
progression or course of conditions, prognosis, and treatment of
disorders. In addition, neuropsychological assessments can aid in
making accurate predictions about functional abilities across a variety
of disorders.\2\, \3\ Neuropsychological tests are
administered in the context of a comprehensive evaluation that
synthesizes data from clinical interviews, record review, medical
history, and behavioral observations. Where appropriate, these
evaluations consider neuroimaging, other neuro-diagnostic studies, and
other lab/diagnostic studies to inform neuropsychologically oriented
interventions.\4\
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\2\ Chaytor, N. & Schmitter-Edgecombe, M. (2003). The ecological
validity of neuropsychological tests: A review of the literature on
everyday cognitive skills. Neuropsychology Review, 13, 181-197.
\3\ Gure, T. R., Kabeto, M. U., Plassman, B. L., Piette, J. D., &
Langa, K. M. (2010). Differences in functional impairment across
subtypes of dementia. Journals of Gerontology: Biological Sciences and
Medical Sciences, 65, 434-441.
\4\ Board of Directors. (2007). American Academy of Clinical
Neuropsychology (AACN) practice guidelines for neuropsychological
assessment and consultation. The Clinical Neuropsychologist, 21, 209-
231.
Neuropsychological evaluation remains the most sensitive cognitive
testing method for discriminating pathophysiological dementia from age-
related cognitive decline, cognitive difficulties that are depression-
related, and other related disorders, and are the gold standard in both
reliably establishing a diagnosis and developing treatment plans by
clinically justifying relevant therapies and interventions.\5\ This is
important in dementia care, as medications used to treat Alzheimer's
disease have virtually no benefit for patients with other forms of
dementia. An estimated 17% of Medicare beneficiaries with vascular
dementia and 8% with Parkinson's disease are initially misdiagnosed
with Alzheimer's disease, resulting in unnecessary treatment costs
until they are accurately diagnosed.\6\
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\5\ Weintraub S. Neuropsychological Assessment in Dementia
Diagnosis. Continuum (Minneapolis, Minn.). 2022 Jun 1;28(3):781-799.
doi: 10.1212/CON.0000000000001135. PMID: 35678402; PMCID: PMC9492323.
\6\ Hunter CA, Kirson NY, Desai U, Cummings AK, Faries DE, Birnbaum
HG. Medical costs of Alzheimer's disease misdiagnosis among U.S.
Medicare beneficiaries. Alzheimer's Dement. 2015 Aug;11(8):887-95. doi:
10.1016/j.jalz.2015.06.1889. Epub 2015 Jul 21. PMID: 26206626.
CMS stated in the CY 2024 proposed rule, ``because the physician/
practitioner work RVU is developed based on the time and intensity of
the service, the issues regarding the valuation of these types of
services are particularly pronounced for services that are billed in
time units (like psychotherapy codes) that directly reflect the
practitioner time inputs used in developing work RVUs, compared to
other services that are not billed in time units in which work RVUs are
based on estimates of typical time, usually based on survey data.''\7\
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\7\ Medicare and Medicaid Programs; CY 2024 Payment Policies Under
the Physician Fee Schedule and Other Changes to Part B Payment and
Coverage Policies. 88 Fed. Reg. 52262. (proposed August 7, 2023).
As with psychotherapy services and their corresponding codes, all
psychological and neuropsychological testing services are time-based
services and meet CMS' rationale for the proposed increase in value. We
believe that parallel increases in the work RVUs for all psychological
and neuropsychological testing and assessment services are warranted to
maintain relativity across the current procedural terminology (CPT)
codes, and to avoid disincentivizing provision of these services.
Supporting Neuropsychology Integration in Alternative Payment Models
In order to effectively respond to the needs of older adults with
chronic conditions, it is imperative that new payment models and
incentives adequately support integrated primary and behavioral/
cognitive healthcare. For example, Integrated primary care, in which
primary care and neuropsychologists work together as a team to assess
and care for patients and their families, can improve patient outcomes
and satisfaction with care and reduce overall treatment costs. It can
also increase access to mental health treatment, since as many as 80%
of patients with a mental illness visited a primary care provider
within the last year, and up to 75% of primary care visits include
mental or behavioral health components, including behavioral factors
related to chronic disease management and patient health and well-
being.\8\, \9\ In addition to improving the identification
and treatment of individuals with behavioral disorders and care of
patients' chronic conditions, research shows that integrated care can
reduce treatment costs. One study found that integrating a psychologist
into a primary care practice resulted in cost savings of $860 per
member per year.\10\ We applaud the Committee's approval of the Better
Mental Health Care, Lower-Cost Drugs, and Extenders Act, and its
provisions in Sec. 104 to support adoption of evidence-based models of
integrated care. We urge the Committee to continue to support
integrated care in its development of new payment models and policies.
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\8\ https://www.cms.gov/priorities/innovation/innovation-models/
guide.
\9\ Guterman EL, Kiekhofer RE, Wood AJ, et al. Care Ecosystem
Collaborative Model and Health Care Costs in Medicare Beneficiaries
With Dementia: A Secondary Analysis of a Randomized Clinical Trial.
(2023). JAMA Intern Med. 183(11):1222--1228. doi:10.1001/
jamainternmed.2023.4764
\10\ Robert John Sawyer et al. (2023). Making the Business Case for
Value-Based Dementia Care, NEJM Catalyst. DOI: 10.1056/CAT.22.0304.
Payment models, such as CPC+ were intended to incorporate care
coordination and behavioral health integration as cost effective means
of improving health outcomes. However, these models remain based in
Medicare's fee for service structure and lack accountability for
behavioral health outcomes and integration. The CMMI Primary Care First
model builds on CPC+ and moves practices closer to taking on full risk,
while focusing on high need, seriously ill patients. Yet, like CPC+ and
Patient Centered Medical Homes, it focuses on physical health rather
than behavioral health outcomes. Without adequate quality metrics,
there is limited accountability and assessment of the value of
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integration.'' (p. 51)
We were pleased to hear discussion of the CMS Innovation Center's
Guiding an Improved Dementia Experience (GUIDE) Model8 during the
hearing. The GUIDE model represents an innovative structure of care
management that recognizes the critical role caregivers play in
management of dementia and allows for provision of services that
benefit an individual patient directly and indirectly via caregiver
education, support, and respite services. As noted in the CMS
description, ``dementia affects more than 6.7 million Americans in
2023,'' and fragmentation in care leads to inaccurate or delayed
diagnosis and increased contact with emergency services and hospital
admissions, resulting in rising costs and poorer outcomes. Provider-
based, fee-for-service models do not take into account the value of
preventing unnecessary emergency and admission services. The GUIDE
model builds upon existing care management programs, some of which were
created by neuropsychologists.\9\ In the GUIDE model, the first
recommendation in identifying beneficiaries is to utilize an
interdisciplinary approach to the ``Initial Comprehensive Assessment
Visit,'' which includes a cognitive assessment. Such programs add value
via direct payments, improved diagnostic and risk specificity, and
savings due to reduction in costly intervention through case management
and caregiver support services.\10\
We appreciate the opportunity to provide these comments on this
critical issue, and we look forward to working with the committee to
establish more effective Medicare payment policies for the benefit of
the program's millions of beneficiaries.
Sincerely,
William Perry, Ph.D.
Executive Director and Past-President
______
National Association of ACOs
2001 L Street, NW, Suite 500
Washington, DC 20036
202-640-1985
www.naacos.com
The National Association of ACOs (NAACOS) appreciates the opportunity
to submit a statement to the Senate Committee on Finance in response to
the hearing ``Bolstering Chronic Care through Medicare Physician
Payment.'' NAACOS represents more than 430 accountable care
organizations (ACOs) in Medicare, Medicaid, and commercial insurance
working on behalf of health systems and physician provider
organizations across the nation to improve quality of care for patients
and reduce health care cost. NAACOS members serve over 9 million
beneficiaries in Medicare value-based payment models, including the
Medicare Shared Savings Program (MSSP) and the ACO Realizing Equity,
Access, and Community Health (REACH) Model, among other alternative
payment models (APMs). NAACOS appreciates the committee's leadership
and commitment towards improving the Medicare payment system. Our
statement reflects the shared goal of our members to advance value-
based care.
APMS ARE A PLATFORM FOR IMPROVING
CHRONIC CARE MANAGEMENT
A key aim of health care should be keeping patients healthy and
supporting them with getting the right services, at the right time, in
the right place. Unfortunately, Medicare's fee-for-service (FFS)
payment system can lead to care fragmentation that results in reactive,
sickness-based care. This means higher costs and less coordinated care
for patients. The current physician payment system also underinvests in
primary care and care coordination and does not account for adequately
paying providers as costs rise. As a result, physician practices have
limited funding or tools to proactively manage complex patient care.
Stabilizing Medicare's payment system and ensuring payment adequacy
along with strong incentives to adopt infrastructure and staffing
necessary for population health is needed to transition into payment
models that focus on outcomes.
APMs have proved to be the solution. Over the last 2 decades, the
growth of APMs has enabled health care providers to work as a team and
make necessary investments that result in better outcomes and reduced
costs. APMs are becoming more rooted in our health care system but
growth has been slower than Congress' original goal. It is essential to
remove barriers to participation and give additional flexibility and
tools to innovate care.
ACOs Are the Largest APM Leading Medicare's Value Transformation
The MSSP is the largest and most successful value-based care program in
Medicare, and as such it should be utilized as an innovation platform.
In 2024, there are 602 ACOs coordinating care for 13.4 million Medicare
beneficiaries. ACOs are a voluntary alternative to the fragmented FFS
system that gives doctors, hospitals, and other health care providers
the flexibility to innovate care and holds them accountable for the
clinical outcomes and cost of treating an entire population of
patients.
With primary care as the backbone, ACOs employ a team-based approach
that allows clinicians to ensure patients receive high quality care in
the right setting at the right time. ACOs improve quality while
controlling costs through primary care-focused initiatives such as
expanded primary care teams, care coordination strategies, and enhanced
data and analytics tools for primary care practices.\1\ The ACO model
also provides an opportunity for providers to work collaboratively
along the continuum while remaining independent.
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\1\ https://journals.lww.com/hcmrjournal/Fulltext/2019/04000/
Clinical_coordination_in_
accountable_care.5.aspx.
Importantly, ACOs provide shared savings opportunities and enhanced
regulatory flexibility that allows clinicians to maintain financial
security while practicing medicine more freely. For example, many
primary care practices were financially harmed by the effects of the
COVID-19 pandemic, and evidence showed that independent primary care
practices participating in ACOs were better-equipped to respond to the
crisis, supported by alternative revenue sources and workflow tools
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made available through ACO participation.
It's clear these payment system reforms have been a good financial
investment for the government. In the last decade, ACOs have generated
more than $22.4 billion in savings with $8.8 billion being returned to
the Medicare Trust Fund while maintaining high quality scores for their
patients. The growth of APMs has also produced a ``spill-over'' effect
on care delivery across the nation, slowing the overall rate of growth
of health care spending. Providers in APMs also help make the Medicare
program stronger by reducing improper payments. Using enhanced data and
analytics, ACOs regularly identify and report instances of fraud,
waste, and abuse.
Develop Solutions to Improve Physician Payment and Encourage the
Movement to Value
The Medicare Access and CHIP Reauthorization Act (MACRA) included
advanced APM incentive payments to encourage providers to move into
risk-based payment models while also providing funds that allow them to
cover services not reimbursed by traditional Medicare (e.g., meals
programs and transportation). These are the types of services that help
address patients' social needs, keep patients healthier, and lower
costs. MACRA also included a higher conversion factor update for
clinicians in advanced APMs, however this does not adequately address
inflation, creates more complexity for clinicians, and could make it
harder for clinicians in APMs to successfully meet program financial
targets.
While NAACOS is pleased that Congress passed another short-term
extension of MACRA's advanced APM incentives, it does not go far enough
to drive long-term movement to value-based care. The next year when
financial incentives favor clinicians that participate in risk based
APMs, over those who remain in FFS, will be 2032 (see graph below).
For clinicians in advanced APMs, the 1.88 percent incentive for 2024
and higher conversion factor is a lower incentive than the maximum
Merit-based Incentive Payment System (MIPS) adjustment, which is
estimated to be just over 3 percent. As the incentive structure shifts,
some clinicians may choose to voluntarily shift back to MIPS because
the program will continue to offer opportunities for high performing
clinicians in APMs to qualify for higher financial incentives.
[GRAPHIC] [TIFF OMITTED] T1124.012
.epsThe 1.88 percent advanced APM incentive will also expire at the end
of 2024. The expiration of APM incentives will mean a significant
incentive shift towards MIPS in the short term. APM adoption has been
steadily growing but still falls below Congress' original goals of
transitioning all clinicians into models with financial risk.
Going forward the committee should:
1. Develop approaches that account for inflation in payment
updates.
2. Maintain stronger financial incentives for physicians that move
into APMs.
3. Ensure that incentives do not impact a clinician's ability to
meet financial targets in APMs.
Reduce Program Complexity & Improve Scaling of Innovation
MACRA created nonfinancial incentives for clinicians in APMs by
exempting them from regulatory burdens associated with the FFS payment
system. Unfortunately, program complexity can lead to less
participation in value models. Additionally, clinicians can be hesitant
to participate in Innovation Center model tests because the models do
not have a predictable pathway to permanence.
Going forward the committee should:
Reduce program complexity by ensuring that clinicians in APMs
are not required to engage in duplicative quality reporting efforts.
Emphasize that MIPS should prepare clinicians for and encourage
adoption of APMs.
Ensure that promising aspects of innovative models have a more
predictable pathway for becoming permanent.
While updating Medicare's payment system and incentive structure will
take time, in the short term, the committee should advance the Value in
Health Care Act (H.R. 5013/S. 3503). This bipartisan bill was
introduced by Senators Sheldon Whitehouse (D-RI), John Barrasso, M.D.
(R-WY), Peter Welch (D-VT), Thom Tillis (R-NC), Bill Cassidy, M.D. (R-
LA), John Thune (R-SD), and Marsha Blackburn (R-TN). It makes several
important reforms to ensure that APMs continue to provide high-quality
care for Medicare beneficiaries, including:
1. Providing a multi-year commitment to reforming care delivery by
extending MACRA's original 5 percent advanced APM incentive for 2 years
to continue to encourage the movement to value.
2. Ensuring that qualifying thresholds remain attainable to
promote program growth by freezing them at 50 percent for 2 years and
giving the Centers for Medicare & Medicaid Services (CMS) authority to
adjust thresholds through rulemaking and set varying thresholds for
more targeted models where participants (e.g., specialists) cannot meet
the existing one-size-fits-all thresholds.
3. Removing the revenue-based designation in MSSP that penalizes
certain ACOs, especially those including rural and safety net
providers.
4. Establishing guardrails for CMS to ensure that the process to
set financial benchmarks is transparent and appropriately accounts for
regional variations in spending, to prevent arbitrary winners and
losers.
5. Directing CMS to establish a voluntary, full-risk track within
programs like the MSSP and has the U.S. Department of Health and Human
Services provide more technical assistance to new APM participants.
6. Directing the Government Accountability Office to evaluate the
potential of parity between APMs and Medicare Advantage (MA), so
policymakers can seek greater alignment between the programs to ensure
that both models provide attractive, sustainable options for innovating
care delivery, and to ensure that APMs do not face a competitive
disadvantage.
Build on the Innovation Center's Successes
As the Center for Medicare and Medicaid Innovation (CMMI) tests new
payment models, successful models, or key aspects of those models,
should be embedded as permanent parts of Medicare via the MSSP. While
the MSSP currently includes various participation options with
increasing levels of risk and reward, there is currently no full-risk
option for ACOs participating in MSSP. Congress should direct CMS to
create a separate full-risk option within MSSP to serve as a better
bridge between it and ACO REACH. This ``Enhanced Plus'' Track should
include greater flexibility in payment design and available waivers. As
the only permanent total cost of care model in Medicare, the MSSP
should be adapted to remain a viable option for more advanced ACOs and
further advance value-based care.
Population-Based Payments for Primary Care
More flexible payment mechanisms can support care delivery
transformation, strengthen primary care, and increase participation in
ACO initiatives. CMS recently launched the ACO Primary Care Flex model,
which will allow MSSP ACOs to offer prospective population-based
payments for primary care. NAACOS has been advocating for this
approach, which will bolster primary care practices in ACOs. Shifting
to prospective payments provides primary care practices with stable and
predictable cash flow needed to transform care delivery and provide
comprehensive, team-based care. For more than a decade, the ACO model
has improved beneficiary outcomes, generated savings to Medicare and
allowed practices to invest shared savings into innovation and patient
care. This model builds on the success of MSSP while recognizing we
must continue to evolve the program for growth to continue.
While we are extremely pleased with the model, we are concerned that
excluding high-revenue ACOs will prevent many independent primary care
practices who have partnered with their local health systems from
taking advantage of these much-needed innovations. The premise of ACOs
is to bring together providers from across the continuum of care to
provide improved care for beneficiaries. This is a primary example of
why the committee should support removing the revenue-based designation
in MSSP that continues to penalize certain ACOs.
Expand Waivers for APMs
Current law allows CMS to waive certain Medicare FFS requirements in
MSSP and other APMs. This is a critical component of APMs as it allows
providers to operate with fewer restrictions leading to a reduction in
provider burden and increased care innovation. However, the waivers to
date have been limited and can also be burdensome for providers. For
example, MSSP only has waivers for telehealth and the 3-day rule for
skilled nursing facility stays. Yet the ACO REACH model has access to
many more waivers. We believe all APMs should have access to all
available waivers and that those waivers shouldn't be limited to
certain models. Congress should direct CMS to establish a common set of
waivers for APMs.
Chronic care management (CCM) is also a critical part of coordinated
care. Unfortunately, Medicare's current CMM codes include a beneficiary
cost-sharing obligation that creates barriers to care. While APMs offer
opportunity to allow providers to reduce beneficiary cost sharing to
ensure patients receive enhanced care management, we encourage the
committee to look at legislative options to waive the beneficiary
coinsurance related to CCM. This would help ensure that more
chronically ill Medicare patients can receive access to high-quality
care.
Improve Approaches to Test and Scale Innovation
While CMMI has been successful in testing innovative payment
arrangements and increasing adoption of APMs, the success of these
models is not captured within current evaluation approaches. Congress
should work with CMS to ensure that promising models have a more
predictable pathway for being implemented and becoming permanent and
are not cut short due to overly stringent criteria. This includes
broadening the criteria by which CMMI models qualify for Phase 2
expansion and directing CMMI to engage stakeholder perspectives during
APM development.
Establish Parity Between APMs and Medicare Advantage Program
Requirements
Recognizing ACOs' and MA's shared goals of improving the quality of
care and cost savings to patients, it's imperative to build parity
between the two programs. Misaligned incentives are harmful to
advancing value as they increase provider burden, create confusion and
disincentives for patients, and generate market distortions that favor
one entity over another. Parity can be better provided in the programs'
benchmark and risk adjustment policies, quality measurement, and
marketing requirements. ACOs should be allowed to provide comparable
benefits to those offered to MA patients, such as telehealth visits,
transportation benefits, home visits, etc. Without parity, providers
are forced to spend time managing the various program requirements
rather than managing patient care. Congress should direct GAO to
evaluate how to create more parity between APMs and MA. Additionally,
Congress should explore opportunities to incentivize MA plans to enter
risk-bearing arrangements with providers.
We thank the committee for this opportunity to provide feedback on this
important hearing. NAACOS and its members are committed to providing
the highest quality care for patients while advancing population health
goals for the communities they serve. We look forward to our continued
engagement on bolstering CCM through payment system reforms. If you
have any questions, please contact Aisha Pittman, senior vice
president, government affairs at aisha--pittman@naacos.com
______
Obesity Care Advocacy Network
4511 North Himes Avenue, Suite 250
Tampa, FL 33614
April 24, 2024
U.S. Senate
Committee on Finance
Dirksen Senate Office Bldg.
Washington, DC 20510-6200
Dear Chair Wyden and Ranking Member Crapo,
The Obesity Care Advocacy Network (OCAN) appreciates the opportunity to
provide the following comments to the U.S. Senate Finance Committee in
response to its April 11th hearing on ``Bolstering Chronic Care through
Medicare Physician Payment.'' We are hopeful that the Committee will
include payment reforms in any legislation being considering to address
chronic disease care for Medicare beneficiaries, which promote greater
access to comprehensive obesity care.
Founded in 2015, OCAN is a diverse group of organizations focused on
changing how we perceive and approach obesity in the United States.
OCAN works to increase access to evidence-based obesity treatments by
uniting key stakeholders and the broader obesity community around
significant education, policy and legislative efforts. We aim to
fundamentally change how the U.S. healthcare system treats obesity, and
to shift the cultural mindset on obesity so that policymakers and the
public address obesity as a serious chronic disease.
Obesity is a progressive disease, and without treatment Medicare
beneficiaries with overweight or obesity risk further health
deterioration and an increased likelihood in the onset of related
comorbid conditions including obesity-related cancers, diabetes, and
end stage renal disease. Additionally, people with severe obesity have
a 48% higher risk of physical injury including falls which lead to
higher costs and mortality rates. Congress must take steps to address
this crisis now.
Medicare's Physician Payment System Must Recognize and Support
Coordinated Care for Patients Living with Obesity
Medicare must issue guidance that obesity should be a recognized
disease state for purposes of Medicare chronic care management codes.
Medicare payments for non-face-to-face chronic care management services
are traditionally not allowed for these services when they are utilized
to treat and manage obesity because obesity is not listed in the
Medicare Chronic Conditions Chartbook. The obesity community raised
this issue more than a decade ago when CMS proposed establishing the
chronic care management codes.
The Chartbook highlights the prevalence of chronic conditions among
Medicare beneficiaries and the impact of chronic conditions on Medicare
service utilization and spending. Since 2013, the obesity community has
argued that the Chartbook should include obesity especially given that
13 of the 15 conditions listed (high blood pressure, high cholesterol,
ischemic heart disease, arthritis, diabetes, heart failure, chronic
kidney disease, depression, COPD, atrial fibrillation, certain cancers,
asthma, and stroke) are commonly associated with obesity and/or are
exacerbated by obesity.
Obesity clearly meets the criteria CMS outlined in the proposed rule as
the rational for selecting the 15 conditions eligible for the chronic
care management payments. Specifically, (1) obesity is highly prevalent
among the Medicare population; (2) obesity is chronic, i.e., typically
lasts for more than 12 months; (3) obesity poses increased risk for
death, acute exacerbation/decompensation, or functional decline; (4)
obesity results in increased use of health care services; and (5)
successful care management of obesity can improve outcomes/reduce
costs.
The prevalence of obesity in older adults is high.
The obesity epidemic has had a negative impact on our nation's health
and economy. Among older adults (aged 60+), the prevalence of obesity
is 42.8%, similar to the level among younger and middle-aged adults.
The prevalence of severe obesity among those aged 60+ is 5.8%. More
than 20% of the population will be 65 years of age or older by 2030, up
from 15% today, highlighting the importance of addressing obesity among
older Americans.
Obesity is a chronic disease, which typically lasts well longer than 12
months.
Obesity is a chronic disease that poses lifelong challenges for many
individuals. In addition to the obesity community and the American
Medical Association, numerous other healthcare professional
organizations, such as the American Heart Association, American
Diabetes Association, and the American Association of Clinical
Endocrinologists define obesity as a chronic disease. Obesity is also
recognized as a chronic disease in the NHLBI Clinical Guidelines on the
Identification, Evaluation, and Treatment of Overweight and Obesity in
Adults, which state, ``Obesity is a complex multifactorial chronic
disease developing from interactive influences of numerous factors--
social, behavioral, physiological, metabolic, cellular, and
molecular.''
It is also important to note the broad recognition of obesity as an
independent, complex disease state by numerous federal agencies,
including the Social Security Administration (SSA), National Institutes
of Health (NIH), Food and Drug Administration (FDA), Veterans Affairs
(VA), Centers for Disease Control and Prevention (CDC), and the
Internal Revenue Service (IRS).
Obesity poses increased risk for death, acute exacerbation/
decompensation, or functional decline.
Studies \1\ have demonstrated that obesity results in higher morbidity
for a range of health conditions--including many on the list of 15
chronic conditions proposed by CMS--hypertension, type 2 diabetes,
coronary heart disease (CHD), stroke, gallbladder disease,
osteoarthritis, sleep apnea and respiratory problems, and some types of
cancer (endometrial, breast, prostate, and colon), among others.
Approximately 75% \2\ of people with severe obesity have at least one
co-morbid condition, often type 2 diabetes, hypertension or sleep
apnea, which increases the risk of premature death.
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\1\ https://www.ncbi.nlm.nih.gov/books/NBK2003/.
\2\ https://jamanetwork.com/journals/jama/fullarticle/192030.
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Obesity results in increased use of health care services.
Adults with obesity in the United States compared with those with
normal weight experienced higher annual medical care costs by $2,505 or
100%, with costs increasing significantly with class of obesity, from
68.4% for class 1 to 233.6% for class 3. The effects of obesity raised
costs in every category of care: inpatient, outpatient, and
prescription drugs. Increases in medical expenditures due to obesity
were higher for adults covered by public health insurance programs
($2,868) than for those having private health insurance ($2,058). In
2016, the aggregate medical cost due to obesity among adults in the
United States was $260.6 billion.\3\
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\3\ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10394178/.
Successful care management of obesity can improve outcomes/reduce
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costs.
The benefits of care management in individuals with obesity have been
well documented. For example, a recent University of Southern
California Schaeffer Center study on the ``Benefits of Medicare
Coverage for Weight Loss Drugs''\4\ estimated the benefits of treating
Americans living with obesity and the cost-offsets that Medicare and
society could accrue if laws were changed to allow Medicare to cover
AOMs. The study found that coverage for new obesity treatments could
generate approximately $175 billion in cost offsets to Medicare in the
first 10 years alone. By 30 years, cost offsets to Medicare could
increase to $700 billion. The positive impacts extend beyond Medicare--
with society possibly reaping as much as $100 billion per year (or $1
trillion over 10 years) of social benefit in the form of reduced
healthcare spending and improvements in quality of life from reduced
disability and pain if all eligible Americans were treated.
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\4\ https://healthpolicy.usc.edu/research/benefits-of-medicare-
coverage-for-weight-loss-drugs/.
OCAN also remains concerned that coverage for services to prevent,
manage, and/or treat chronic conditions such as diabetes, prediabetes,
and obesity currently exists as a patchwork within CMS with persistent
gaps and limitations related to the receipt of same-day service,
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referrals, coverage levels, payment, and sites of service.
One prime example of these problems surrounds the 2011 National
Coverage Determination for Intensive Behavioral Therapy for Obesity
(210.12) (the ``2011 NCD'') to modify the limitations that this service
only be delivered by primary care providers (physicians, nurse
practitioners (NPs), physician associates (PAs)) in a primary care
setting. CMS should reconsider the 2011 NCD to allow other qualified
healthcare providers (i.e., registered dieticians, clinical
psychologists, specialty physicians and specialty NPs and PAs) to
independently provide and bill for this service upon referral from the
primary care provider without limitation to the primary care setting.
We appreciate the commitment made by the Biden Administration in its
National Strategy on Hunger, Nutrition and Health to ``expand Medicare
beneficiaries' access to . . . obesity counseling. We also appreciate
the interest expressed in the CY 2023 Medicare Physician Fee Schedule
to ``understand what existing services within current Medicare benefits
may represent high value, potentially underutilized services'' and the
request for information about ``obstacles to accessing these services
and how specific potential policy, payment or procedural changes could
reduce potential obstacles and facilitate better access to high value
health services.'' The original IBT for Obesity benefit resulted in
unintended administrative burdens and unnecessary expenses that could
be remedied through a reconsideration of the benefit's 2011 NCD.
Again, OCAN appreciates the opportunity to offer these recommendations
to the Committee regarding potential reforms to the Medicare Physician
Payment System to better address chronic disease care for Medicare
beneficiaries. Should you have any questions or need additional
information, please feel free to contact us.
Sincerely,
Christine Gallagher, MPAff
OCAN Co-Chair
Redstone Global Center for Prevention and Wellness
George Washington University
cqgallagher@gwu.edu
Catherine Ferguson
OCAN Co-Chair
Vice President, Federal Advocacy
American Diabetes Association
cferguson@diabetes.org
Anthony G. Comuzzie, Ph.D., FTOS
OCAN Co-Chair
Chief Executive Officer
The Obesity Society
tcomuzzie@obesity.org
______
Primary Care Collaborative and Better Health--NOW
1101 Connecticut Ave., Suite 1150
Washington, DC, 20036
The Primary Care Collaborative and our Better Health--NOW Campaign
partners thank the Senate Finance Committee for convening the hearing
and for this opportunity to submit a statement for the record. As it
examines the sweep of issues related to Medicare payment, we urge the
Finance Committee to put Medicare primary care at the center of its
work.
High-quality, whole-person primary care is an essential foundation for
any proactive strategy to address chronic physical and mental health
conditions and the increasingly unaffordable costs they generate. The
National Academies of Sciences, Engineering and Medicine's (NASEM) 2021
consensus report, Implementing High-
Quality Primary Care, found that ``primary care is the only health care
component where an increased supply is associated with better
population health and more equitable outcomes.''\1\
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\1\ The National Academies of Sciences, Engineering and Medicine.
(2021, May). Implementing High-Quality Primary Care: Rebuilding the
Foundation of Health Care. Nationalacademies.org. https://
www.nationalacademies.org/our-work/implementing-high-quality-primary-
care.
Primary care payment reform can unlock powerful improvements in quality
and real cost savings, particularly in public programs that shape the
entire marketplace Within the Medicare Shared Savings Program, primary
care centric ACOs reduced preventable downstream costs compared to
other ACOs and produced twice the shared savings as other, hospital-
based ACOs.\2\ For certain practices, states and geographies, the CMS
Innovation Center has also introduced new or re-tooled promising
primary care models, including Making Care Primary, ACO Primary Care
Flex and ACO REACH.
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\2\ Improve Care in Medicare by Growing Primary Care in ACOS.
Primary Care Collaborative. (2024b, March). https://thepcc.org/
resource/improve-care-medicare-growing-primary-care-acos.
Despite these bright spots, our overall health care system's priorities
remain out of balance, devoting less than five (4.7) cents of each
dollar to primary care in 2021.\3\ Most primary care practices report
no participation in either shared savings or
population-based payment.\4\ In 2023, an estimated 1 in 4 (28.7%)
Americans lack a usual source of care \5\ and rural and underserved
communities, in particular, face widening gaps in access.\6\
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\3\ The health of US Primary Care: 2024 Scorecard Report--No One
Can See You Now. Milbank Memorial Fund. (2024b, February 29). https://
www.milbank.org/publications/the-health-of-us-primary-care-2024-
scorecard-report-no-one-can-see-you-now/.
\4\ Horstman, C., & Lewis, C. (2023, April 13). Engaging Primary
Care in Value-Based Payment: New Findings from the 2022 Commonwealth
Fund Survey of Primary Care Physicians. https://
www.commonwealthfund.org/blog/2023/engaging-primary-care-value-based-
payment-new-findings-2022-commonwealth-fund-survey.
\5\ The Health of US Primary Care: 2024 Scorecard Report--No One
Can See You Now. Milbank Memorial Fund. (2024b, February 29). https://
www.milbank.org/publications/the-health-of-us-primary-care-2024-
scorecard-report-no-one-can-see-you-now/.
\6\ Rural-Urban Disparities in Health Care in Medicare--CMS.
Centers for Medicare and Medicaid Services. (2023, November). https://
www.cms.gov/files/document/rural-urban-disparities-health-care-
medicare-national-report.pdf.
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Reorient Medicare Payment toward Primary Care and Prevention
Over time, policy choices guiding Medicare Part B's fee-based payment
structure have generated distortions that have systematically undercut
investment in primary care \7\ and contributed to growing health
disparities, based on geography, race and ethnicity.\8\ This persistent
under-resourcing of primary care is an obstacle to the health of
Medicare beneficiaries and the sustainability of the primary care
workforce. Moreover, because all Medicare APMs and most private APMs
are built upon the Medicare Physician Fee Schedule to one extent or
another, shortcomings in Medicare's support for primary care are
magnified throughout the nation's entire health care system.
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\7\ MedPAC (Medicare Payment Advisory Commission). 2006. Report to
the Congress: Medicare payment policy. Washington, DC: Medicare Payment
Advisory Commission.
\8\ McNeely, L., Douglas Megan, Westfall, N., Greiner, A.,
Gaglioti, A., & Mack, D. (2022). PRIMARY CARE: A Key Lever to Advance
Health Equity. The Primary Care Collaborative. https://thepcc.org/
sites/default/files/resources/PCCNCPC%20Health%20Equity%20Report.pdf.
To address the rising tide of chronic disease discussed in the April
11th hearing, policymakers must fix the underlying flaws in Medicare
Part B's payment policies. Below, we detail our initial recommendations
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to the Committee in this regard.
Enhance Transparency: As noted above, America's allocation of health
care dollars is deeply unbalanced, devoting just 4.7 cents for each
dollar spent to primary care. Congress should require HHS to follow the
lead of more than twenty states \9\ and report primary care spending as
a share of total spending. This requirement should apply to traditional
Medicare, Medicare Part C and across federal programs.
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\9\ See PCC's State Primary Care Investment HUB for information on
state based legislation measuring and reporting primary care spend,
available at https://thepcc.org/primary-care-investment/legislation.
Give Primary Care Practice a Choice: An Alternative to Fee-for-Service:
Better Health--NOW supports efforts to rapidly transition primary care
payment from a predominantly fee-for-service model to predominantly
population-based prospective payment (hybrid) models. These new models
must include up-front and ongoing investments, as well as guardrails to
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assure quality and access in rural and underserved communities.
To that end, the Finance Committee should work with stakeholders toward
legislative solutions that make a well-constructed primary care hybrid
payment option broadly available. Under such an approach, payment would
be provided to practices upfront each month to deliver primary care for
patients with an ongoing relationship, coupled with FFS payment for
other services. The design and implementation of hybrid payment should:
invest in primary care capacity, support personalized, team-
based care and pay for services tailored to the needs of the patient
and the community;
reduce or simplify the burdensome documentation associated with
many FFS codes, which add to systemic costs and consume clinician time
that could be better spent with patients; and
allow for additional, higher payment tiers based on the scope of
services included in such payments, such as greater behavioral health
integration and ability to address health-related social needs.
Enhance Primary Care Affordability in Medicare: As part of any Medicare
payment reform legislation, Congress should remove financial barriers
patients face in accessing the comprehensive, whole-person primary care
necessary to manage their chronic conditions. We support
authorizing patient cost-sharing waivers for the services
provided prospectively as part of any hybrid primary care payment,
eliminating cost-sharing for Medicare's behavioral health
integration services (Section 102 of S. 923 the Better Mental Health
Care for Americans Act) and
removing cost-sharing requirements for Chronic Care Management
codes (HR 2829, the Chronic Care Management Improvement Act).
Accelerate Primary Care-Behavioral Health Integration: Research has
shown that evidence-based, primary care integration models, like the
Collaborative Care Model and Primary Care Behavioral Health, can
successfully improve outcomes while making better use of an
overstretched mental health workforce. In 2016, Medicare established
payment codes to support the delivery of the collaborative care model
and general behavioral health integration services. The Centers for
Medicare and Medicaid Services and Congress have taken steps in the
years since to further support integrated care. Unfortunately,
availability of evidence-based, integrated primary care has been badly
outpaced by patients' growing need for mental health and addiction
services.
To address the present crisis in behavioral health and strengthen the
health of Medicare beneficiaries and their communities, Better Health--
NOW supports S. 1378, the COMPLETE Care Act and S. 3157 the More
Behavioral Health Providers Act. We appreciate the inclusion of these
measures in the Better Mental Health Care, Lower Cost Drugs and
Extenders Act of 2023, and urge all members of the Committee to press
for enactment of these provisions this year. The More Behavioral Health
Providers Act extends and expands the Health Professional Shortage Area
program to help communities attract behavioral health clinicians needed
to support integrated primary care teams. The COMPLETE Care Act
provides for technical assistance and enhanced reimbursement for
integrated care services.
In light of the dual crises of mental health and addiction, we
encourage the Committee to consider additional steps. One approach
would be to remove expenditures on Collaborative Care Management (CoCM)
and General Behavioral Health Integration codes from the expenditures
compared against spending benchmarks in MSSP and other benchmark-based
payment models. Accountable payment has the potential to support
broader adoption of behavioral health-primary care integration. But
because expenditures associated with delivering the services can
increase spending over the short term, benchmark-based payment models
like MSSP have a built-in disincentive to the delivery of and billing
for integrated behavioral health. We encourage you to explore how to
address this issue.
(For more information, please see PCC/BHN responses to the Senate
Finance Committee's bipartisan mental health legislative work here and
here.)
Support Private Sector and State Payment Innovation
Primary care practices rarely serve only traditional Medicare enrollees
and rely on other payers to remain viable and sustain services for all
their patients, including Medicare beneficiaries. To succeed, Medicare
primary care payment innovations should align with payment innovations
by state Medicaid programs, as well as those advanced by private market
payers and purchasers. In tandem with its Medicare payment reform work,
the Finance Committee should pursue targeted policy steps this year
that support constructive state Medicaid and private market primary
care innovations, including the following.
Strengthen Primary Care in Rural and Underserved Communities,
Leveraging Medicaid and CHIP
Strengthening primary care for Medicaid and CHIP beneficiaries is an
essential complement to reforming Medicare payment. Medicaid and CHIP
cover more than 80 million Americans, including a disproportionate
percentage of rural people, low-income seniors, people with
disabilities, and people of color. Yet, Medicaid primary care payment
averages just 78% of Medicare's. Congressional leadership is necessary
to ensure practices and clinics serving these communities can sustain
primary care access. The following represent essential and immediate
steps:
Enact S. 2556 the Improving CARE for Youth Act, which eliminates
payment restrictions on primary care and behavioral health services
delivered on the same day for children in Medicaid/CHIP.
Work with the Health, Education, Labor and Pensions Committee to
provide longer-term funding for the Community Health Center Fund and
increase the yearly outlay for the Fund to help Federally Qualified
Health Centers reach more rural and underserved communities.
(For more information on strengthening primary care in Medicaid, see
PCC's report Access and Equity in Medicaid.)
Encourage Primary Care Access Innovations in the Private Market:
According to the Centers for Disease Control and Prevention (CDC), in
2017 nearly a quarter of individuals with employer sponsored insurance
were enrolled in high deductible plans without a health savings
account.\10\ Over 50 percent of individuals with an HSA live in zip
codes where the median income is below $75,000 annually.\11\ Yet HSA/
HDHPs are barred from covering many primary care services until a
patient meets their full deductible.
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\10\ Cohen, R.A., Zammitti, E.P. (2018). High-deductible Health
Plan Enrollment Among Adults Aged 18-64 With Employment-based Insurance
Coverage. 317. https://www.cdc.gov/nchs/products/databriefs/db317.htm.
\11\ Cohen, R.A., Zammitti, E.P. (2018). High-deductible Health
Plan Enrollment Among Adults Aged 18-64 With Employment-based Insurance
Coverage. 317. https://www.cdc.gov/nchs/products/databriefs/db317.htm.
To address this barrier to primary care, Congress should broaden the
preventive services safe harbor for High-Deductible Health Plans to
facilitate pre-deductible access to comprehensive, whole-person primary
---------------------------------------------------------------------------
care, inclusive of integrated behavioral health.
Better Health--NOW supports the following legislation, introduced in
the 118th Congress:
H.R. 7681, The Primary and Virtual Care Affordability Act, which
gives employers and health plan sponsors the flexibility to reduce or
waive cost-sharing for primary care and extends the existing, waiver
flexibility for telehealth services through 2026.
S. 655, The Chronic Disease Management Act, which allows high-
deductible health plans with HSAs to cover care for chronic conditions
before exhausting the deductible.
Within the U.S. health care system, primary care is the level of care
best positioned to beat back the endemic rates of chronic disease and
spiraling costs. The need for bold Congressional action to champion
primary care could not be more urgent.
We look forward to continuing to work with you to strengthen primary
care. Please contact PCC's Director of Policy, Larry McNeely
(lmcneely@thepcc.org) with any questions.
______
Society of General Internal Medicine
1500 King St., Suite 303
Alexandria, VA 22314
(202) 887-5150
https://www.sgim.org
The Society of General Internal Medicine (SGIM) thanks the Senate
Finance Committee (``the Committee'') for holding this hearing on how
to better reimburse physicians and the care teams who deliver chronic
care to Medicare beneficiaries and for providing this opportunity to
submit this statement for the record.
SGIM is a member-based medical association of more than 3,300 of the
world's leading academic general internal medicine physicians, who are
dedicated to delivering high-quality clinical care, improving access
for all populations, eliminating health care disparities, and enhancing
medical education. Our members are committed to ensuring patients have
equitable and affordable access to the highest quality of care
possible.
Primary care is the foundation of a strong health care system. Primary
care physicians, including general internal medicine physicians,
provide a broad range of clinical services and expertise, from
preventative healthcare to treatment of multiple chronic medical
conditions. In addition, primary care physicians also serve as the
coordinator of their patients' overall care. In this role, they not
only coordinate with other physicians, nurses, pharmacists, and social
workers within their practice but also specialists, mental health
professionals, and laboratories outside of them. They ensure that other
care team members understand the patient's medical history and comorbid
conditions and that the decisions being made are patient-centered. Our
members take pride in cultivating enduring, trust-based relationships
with patients that span decades. However, despite the robust evidence
that coordinated primary care improves health outcomes and equity,
incentives and infrastructure are not in place to allow primary care to
deliver on its promise.
This Committee must develop policies that will support the delivery of
patient-
centric care to Medicare beneficiaries and bolster the primary care
workforce. The shortages of general internal medicine and other primary
care physicians are well documented. The inadequate reimbursement for
primary care generally and care coordination specifically has only
perpetuated this shortage. SGIM members practice at the nation's
medical schools and academic medical centers where they serve as
educators and mentors. Therefore, we are ever mindful of the career
choices made by students and residents and the influence compensation
discrepancies between primary care and procedurally-oriented
specialties have on those choices.
Without meaningful change, more patients--regardless of where they
live--will experience challenges accessing comprehensive primary care.
Primary care practices have been operating on minimal or even negative
profit margins in recent years. The financial challenges as well as the
long hours and administrative burden associated with the practice of
primary care has brought the United States to the point that there is a
severe shortage of general internal medicine and other primary care
physicians. Without action, these shortages will only grow and become
more problematic as the Medicare population ages and their needs for
coordinated comprehensive care grow.
The overarching problems facing the Medicare Physician Fee Schedule
(MPFS) are making it difficult to enact reforms to support primary care
and chronic care delivery. As access to primary care services becomes
more challenging, cognitive and procedural specialties are also being
challenged by the downward pressure on Medicare physician payment,
which has stagnated over the past 2 decades without receiving necessary
increases or adjustments for inflation or to account for increased
costs of providing comprehensive care in stark contrast to other
Medicare fee schedules. According to an American Medical Association
analysis of Medicare Trustees data, Medicare physician payment has
declined by 30% percent when adjusted for inflation from 2001-2024.
Congress enacted the Medicare Access and CHIP Reauthorization Act
(MACRA) to enable Medicare to pay for high-quality care rather than the
volume of services provided. However, this experiment failed. MACRA
only authorized 0.5% updates to the conversion factor through 2019. For
the last several years, the lack of positive updates and the MPFS'
budget neutrality requirements have resulted in cuts to Medicare
reimbursement, which Congress has mitigated. While SGIM appreciates
Congressional actions to minimize these cuts, the downward pressure on
Medicare reimbursement continues and is exacerbated by the MPFS' budget
neutrality requirements, which have not been updated since 1992. The
budget neutrality threshold, which remains $20 million, pits
specialties against one another. As long as some specialties experience
losses when new codes are added to the MPFS or positive updates are
recommended for certain services, Congress and the Centers for Medicare
& Medicaid Services (CMS) will not be able to transform the MPFS to
support the delivery of high-quality coordinated primary and chronic
care. Therefore, SGIM urges this Committee to make two structural
reforms to the MPFS to support more equitable reimbursement: (1) an
annual inflationary update to the conversion factor, and (2) an
increase in the budget neutrality threshold to $53 million from $20
million with the provision of inflationary updates every 5 years
thereafter. These two changes will help reverse the downward pressure
on Medicare physician payment. Making all physicians' reimbursement
more sustainable will allow the Committee to make additional changes to
support the delivery of high quality primary and chronic care.
The significantly lower payment rates for primary care compared to
those for procedural specialties discourage medical students from
choosing primary care specialties, as they are attracted to higher-
paying specialties particularly considering their growing amounts of
medical school debt. As a result, many Americans do not have a primary
care physician with whom they can schedule timely visits and receive
longitudinal, comprehensive care; instead, they receive care from
urgent care clinics and overcrowded emergency rooms. Even those with
established primary care physicians have difficulty accessing the
appropriate level of care, as primary care physicians are forced to see
a higher volume of patients for shorter appointments. This leads to a
viscous cycle of either less comprehensive care, or physicians being
forced to work after-hours doing uncompensated but critical care
coordination, leading to fatigue, burnout and erosion of the primary
care workforce. Further, the persistent shortage of primary care
physicians nationwide, particularly in rural communities, exacerbates
existing disparities among vulnerable populations that are already
facing significant healthcare challenges.
CMS has taken steps in recent years to support primary care by creating
new services, like those for chronic care management, and revising and
revaluing evaluation and management (E/M) services. However, the lack
of positive conversion factor increases and budget neutrality
adjustments has eroded the value of these reimbursement increases for
primary care. SGIM urges Congress to work with us to develop a set of
reforms to support primary care and bring stability to the Medicare
physician payment system. Specifically, Congress must improve
reimbursement for the E/M services that are central to the
comprehensive care of patients delivered by primary care physicians.
Better reimbursement for these E/M services would also help to support
the comprehensive care that many specialists deliver to patients with
complex conditions such as diabetes mellitus, congestive heart failure,
and kidney failure. Despite recent efforts to redefine and revalue E/M
services, further improvements should be made to support patient-
centered care, particularly for Medicare beneficiaries who have one or
more chronic conditions.
SGIM believes that establishing a technical advisory committee (TAC) to
define and value E/M and other non-procedural work is critical to
appropriately reimbursing for primary care services and supporting the
delivery of high-quality comprehensive care as outlined in Senator
Sheldon Whitehouse's primary care discussion draft. This has been a
longstanding priority of our professional society. SGIM believes that
Congress should codify CMS' responsibility to ensure that the MPFS is
accurate, reliable, and publicly accountable. A TAC could assess the
existing processes for service code development and valuation and
propose solutions that are sustainable and evidence based.
The TAC can begin making meaningful improvements to reimbursement for
primary care now and ensure that the valuations of physician services
provide reliable building blocks, which can be used in developing
innovative alternative payment models like a hybrid payment system for
primary care. Specifically, the TAC can determine how to base payments
on the relative intensity of cognitive work by establishing a reliable
process for defining services and assigning values. The existing
mechanisms for valuing cognitive work are not evidence based and have
helped perpetuate a system that has not prioritized primary care, while
the volume and value of technical and procedural services has grown.
SGIM believes that a TAC is critical to support primary care but
recognizes that the existing mechanisms to value MPFS services may be
better suited to be applied to procedures. This TAC does not have to
replace the existing mechanisms for valuing all MPFS services.
As the population ages, Medicare must lead the way in supporting
primary care and other cognitive based care (e.g., addiction treatment
and behavioral health). A TAC will incorporate evidence-based data into
the valuation process of E/M service codes and be best equipped to
ensure that these services are evaluated at more regular intervals. We
believe that a regular, independent assessment of available data and
data-driven policy recommendations will stabilize what has evolved to
become an irregular process, which has been a major contributor to the
declining primary care workforce. Even as hybrid and other alternative
payment models expand, the importance of proper valuation of E/M
services and the critical role of a TAC will remain. Alternative
payment models continue to be based on the underlying MPFS, and any
payment model must have a strong primary care system as the foundation.
Appropriate valuation of primary care will remain critical to ensure
resources are appropriately distributed to enable high quality,
comprehensive, patient-centered care.
Again, thank you for the opportunity to submit this statement for the
record. SGIM looks forward to working with the Committee and the
bipartisan working group on physician payment to meaningfully reform
the MPFS.
______
Society of Gynecologic Oncology
1440 W Taylor St., Suite 4299
Chicago, IL 60607
P: (312) 235-4060
https://www.sgo.org
The Society of Gynecologic Oncology (SGO) applauds the Senate Finance
Committee for holding the recent hearing, Bolstering Chronic Care
through Medicare Physician Payment. This is an important step in
protecting Medicare beneficiaries' access to high-quality care.
The SGO is the premier medical specialty society for health care
professionals trained in the comprehensive management of gynecologic
cancers. Our more than 2,800 members include physicians, advanced
practice providers, nurses and patient advocates who collaborate with
the Foundation for Women's Cancer to increase public awareness of
gynecologic cancers and improve the care of those diagnosed with
gynecologic cancers. Our primary mission focuses on supporting
research, disseminating knowledge, raising the standards of practice in
the prevention and treatment of gynecologic malignancies, and
collaborating with other organizations dedicated to gynecologic cancers
and related fields, all with the ultimate vision of eradicating
gynecologic cancers.
Gynecologic oncologists play a multifaceted role in providing care for
women with gynecologic cancer. Gynecologic oncologists are involved in
the diagnosis of gynecologic cancer, developing personalized treatment
plans for patients, performing complex surgeries, overseeing the
administration of chemotherapy, and monitoring patients to detect
recurrence or complications. Unfortunately, Medicare reimbursement has
not kept pace with the costs of delivering this complex care.
The entire physician community continues to face unpredictable Medicare
reimbursement rates and rising inflation--a perfect storm of financial
instability that threatens SGO members' ability to care for patients.
Therefore, SGO recommends that Congress work with physicians to
implement long-term, systemic reforms that bring stability to the
Medicare physician payment system ending this cycle of annual payment
reductions and preserving beneficiary access to medical services.
Specifically, we urge you to consider supporting the following
legislative solutions:
Annual Inflationary Adjustments: The Medicare Physician Fee
Schedule (MPFS) does not receive necessary increases or adjustments for
inflation, in contrast to other Medicare fee schedules. Not only does
the MPFS not receive annual inflationary increases, the last statutory
increase to the MPFS conversion factor of 0.5% was applied in 2019. SGO
supports an annual inflationary adjustment, equal to the Medicare
Economic Index (MEI) or some other inflationary factor. An annual
inflation-based update to the MPFS will help practices cover the
growing cost of clinical staff, rent, medical supplies and equipment,
malpractice insurance, and other necessary expenses. Moreover, it will
help to protect the supply of our nation's physicians and preserve
patient access to care, particularly in areas where there may be a
shortage of specialized providers, like gynecologic oncologists.
Budget Neutrality: Current Medicare statute requires changes to
the MPFS be implemented in a budget neutral manner, which means that
policies that increase or decrease Medicare spending by more than $20
million require that upward or downward adjustments be made by that
excess amount to all physician services. This threshold has not changed
since 1992. SGO recommends that Congress consider raising the budget
neutrality threshold from $20 million to $53 million to accommodate
changes in Medicare spending, allowing for more flexibility in
adjusting physician payments. Congress should also provide for an
increase every 5 years equal to the cumulative increase in MEI to
ensure that physician payments keep pace with inflation and the cost of
delivering care.
Updates to Practice Expense: Medicare bases its payment rates
under the MPFS in part on estimates of the resources used in furnishing
each service to a typical Medicare patient. For each service, there is
a valuation for practice expense (PE), which is composed of the direct
and indirect practice resources involved in furnishing medical
services. SGO recommends that the Secretary of Health and Human
Services, no less than every 5 years, update prices and rates for
direct cost inputs for PE relative value units which includes clinical
wage rates, prices of medical supplies, and prices of equipment. PE
data should be updated on a regular basis to account for the inevitable
changes in technology, practice patterns, clinical labor rates, and
other factors that influence these inputs. Updating the data more
regularly will provide greater stability within the payment system.
Moreover, SGO appreciates the Committee's interest in making
improvements to the Centers for Medicare and Medicaid Services (CMS)
Quality Payment Program (QPP), including simplifying the Merit-based
Incentive Payment System (MIPS) and identifying strategies to bolster
widespread adoption of alternative payment models (APMs).
The purpose of value-based care programs is to drive down health care
costs and improve patient outcomes, but those goals cannot be achieved
without robust physician participation in these models. Unfortunately,
there are challenges for physicians, such as financial risk and
administrative burden. In an environment of stagnant Medicare
reimbursement, physicians are even more averse to the financial risk
posed by these programs. Additionally, physician practices vary by
size, specialty, and location; therefore, it is important that APMs are
developed in a way that is feasible and makes sense for different
practices and patient populations. There are significant financial
investments required to develop and implement an APM putting this
option out of reach for many specialties or health systems. Congress
should ensure that CMS is provided with the necessary resources to
support measure and APM development allowing them to partner with
interested stakeholders. It is critical that specialty physicians, like
SGO members, are involved in designing APMs to ensure that alternative
ways of delivering services are relevant to specialty practice, not
overly burdensome, and support the needs of our patients.
SGO believes value-based care delivery is critical in maximizing
quality and cost effectiveness. Therefore, we are pleased that CMS
continues to develop and test new models suitable for a wide range of
practices of different sizes and specialties. Today, specialty
physicians, like gynecologic oncologists, will find few physician-
focused models available to them. We recognize that CMS intends to
sunset traditional MIPS and move to MIPS Value Pathways (MVPs), and the
agency is continuing to roll out new pathways each year. However,
specialties like gynecologic oncology do not yet have MVP options to
participate. Besides simplifying the MIPS program, the SGO strongly
believes that all providers should have measures and MVPs that reflect
the patient care they provide. Therefore, we encourage CMS to work with
stakeholders like SGO to support and incentivize the development of
specialty and subspecialty specific measures to make participation more
meaningful for providers, Medicare beneficiaries, and the agency.
The administrative requirements and reporting processes associated with
CMS' quality programs can feel burdensome for providers. This comes at
a time when providers are also experiencing burdensome prior
authorization requirements in the Medicare Advantage (MA) program.
Improving the program, which covers nearly half of all Medicare
beneficiaries, is imperative to ensuring that seniors receive the
highest quality of care. Prior authorization processes require
practices to realign staff or hire additional staff for the sole
purpose of doing this work. This comes at a time when there are
staffing shortages throughout the health care system and funneling
resources from direct patient care to prior authorization duties is not
in the best use of limited resources, while taking away time and energy
from direct patient care. Additionally, SGO members are concerned that
this process leads to delays in patient care, which is particularly
concerning when a patient has cancer and time is of the essence,
leading to negative health outcomes. One study found that 25 percent of
gynecologic oncology patients experienced prior authorization during
their cancer care with patients experiencing over a 2-week delay in
care when prior authorization occurred.\1\ Reform is needed to reduce
the burden of prior authorization in gynecologic oncology and SGO
encourages you to review the prior authorization policies within the MA
program to protect patient access to timely care.
---------------------------------------------------------------------------
\1\ Smith AJB, Mulugeta-Gordon L, Pena D, Kanter GP, Bekelman JE,
Haggerty AE, Ko EM. Prior authorization in gynecologic oncology: An
analysis of clinical impact. Gynecol Oncol. 2022 Dec;167(3):519-522.
doi: 10.1016/j.ygyno.2022.10.002. Epub 2022 Oct 14. PMID: 36244827.
Thank you for your leadership and interest in developing policy to
stabilize the Medicare physician payment system to support providers
and provide certainty for beneficiaries dependent on the program for
their health care. We look forward to working with you to achieve these
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goals.
______
UsAgainstAlzheimer's
5614 Connecticut Ave., NW, #288
Washington, DC 20015-2604
https://www.usagainstalzheimers.org/
UsAgainstAlzheimer's (UsA2) thanks the Finance Committee for holding
this hearing on the vitally important topic ``Bolstering Chronic Care
through Medicare Physician Payment'' and appreciates the opportunity to
submit this Statement for the Record.
UsA2 was founded in 2010 to disrupt and diversify the movement to end
Alzheimer's. Through urgent and inclusive mobilization, UsA2 has worked
to dramatically increase funding for Alzheimer's and dementia research.
Our work to stop Alzheimer's now centers on prevention, early detection
and diagnosis, and access to treatments for all regardless of gender,
race, or ethnicity.
Alzheimer's Is a Chronic Disease
Alzheimer's disease and related dementia (ADRD) is a chronic condition
whose death toll is outpacing other chronic conditions such as heart
disease, stroke, and cancer. ADRD is included on the Centers for
Medicare & Medicaid Services' (CMS) list of chronic conditions
identified in its advisory on chronic care management codes
(MLN909188--Chronic Care Management,\1\ page 6):
---------------------------------------------------------------------------
\1\ https://www.cms.gov/outreach-and-education/medicare-learning-
network-mln/mlnproducts/downloads/chroniccaremanagement.pdf.
Alzheimer's disease and related dementia Arthritis (osteoarthritis
and rheumatoid) Asthma Atrial fibrillation Autism spectrum
disorders Cancer
Cardiovascular disease Chronic Obstructive Pulmonary Disease
(COPD)
Depression Diabetes Hypertension Infectious diseases like HIV and
AIDS.
The Risk and Prevalence of ADRD Can Be Reduced
ADRD not only requires significant management, it is also
interconnected to other chronic conditions and shares similar risk
factors that if addressed could significantly reduce its prevalence by
40% or more.
Over the last decade, a growing and now undeniable body of evidence
suggests that a significant percentage of dementia cases are, in fact,
preventable or delayable, with the same strategies that can reduce the
risk of other chronic diseases including cardiovascular disease,
obesity, type 2 diabetes, chronic kidney disease, depression, and
certain forms of cancer. These strategies include physical activity,
proper nutrition, and sleep, and addressing other specific conditions
that increase the risk of cognitive impairment including hypertension,
hearing loss, and traumatic brain injury.
Because the science is now clear, the Department of Health and Human
Services (HHS) in 2022 updated the National Alzheimer's Plan to Address
Alzheimer's Disease to add a sixth goal: ``Accelerate Action to Promote
Healthy Aging and Reduce Risk Factors for Alzheimer's Disease and
Related Dementias.''
Achieving this goal means adopting strategies designed to combat
chronic disease and promote a healthy aging agenda including
interventions to encourage greater physical activity, a healthy diet,
cognitive stimulation, hearing loss treatment, social engagement, and
sleep hygiene. The evidence shows that the earlier people begin these
activities the better opportunity they have to reduce their risk of
ADRD. It is critical that Medicare reimbursement provides adequate
payment for the services and supports provided by physicians to prevent
and manage chronic conditions.
Even a 5-year delay in the onset of Alzheimer's disease would reduce
the population with the disease by 41% in 2050, which could reduce
annual costs by $640 billion.\2\ The Risk Reduction Subcommittee of the
National Alzheimer Project Act Advisory Council set a goal of reducing
dementia risk factors \3\ by 15% by 2030. A 15% proportional reduction
in risk factor prevalence would be associated with approximately
427,000 fewer prevalent dementia cases \4\ in the U.S. population.
---------------------------------------------------------------------------
\2\ https://www.degruyter.com/document/doi/10.1515/fhep-2014-0013/
html.
\3\ https://aspe.hhs.gov/sites/default/files/documents/
18454de4f0f9ef42dacef6ef167b1933/napa-2021-public-member-
recommendations.pdf.
\4\ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9260480/
#::text=A%2015%25%20propor
tional%20decrease%20in%20each%20risk%20factor%20would%20reduce,CI%2C%203
.7%25%2
D10.9%25).
---------------------------------------------------------------------------
Early and Accurate Detection Is Essential
One of the most important policies the Finance Committee can advance in
the area of prevention and risk reduction is early and accurate
detection of Mild Cognitive Impairment (MCI), so patients and their
medical team have as much time as possible to implement strategies to
slow the progression of the disease.
The bicameral, bipartisan Concentrating on High-Value Alzheimer's Needs
to Get to an End (CHANGE) Act (S. 2379/H.R. 4752) makes a point to
strengthen dementia detection. The act directs CMS to require
professionals providing the Medicare Annual Wellness Visit (AWV; 42
U.S.C. Sec. 1395x [hhh]) and the Initial Preventive Physical
Examination (also known as Welcome to Medicare Benefit, WMV; 42 U.S.C.
Sec. 1395x[ww][1]) to use cognitive impairment detection tools
identified by the National Institute on Aging (NIA).
CMS currently encourages, but does not require, providers to use a
brief validated structured cognitive assessment tool. Consequently,
many providers use ``direct observation,'' rather than a validated
tool, to assess patients' cognitive health. Direct observation is the
least useful and least appropriate tool, all too often contributing to
under-diagnosis, delayed diagnosis, misdiagnosis, and non-disclosure of
diagnosis. Recent studies showed that among patients aged 70 years or
older, seen in primary care settings, cognitive impairment goes
unrecognized in more than 50% of cases.\5\ Underutilization of
validated assessment tools delays detection and diagnosis, resulting in
decreased opportunities for people to implement important lifestyle
modifications, access timely treatment options, and participate in
clinical research. Use of these tools will allow clinicians to better
detect MCI and other early symptoms of Alzheimer's disease and related
forms of dementia.
---------------------------------------------------------------------------
\5\ https://www.nia.nih.gov/health/health-care-professionals-
information/assessing-cognitive-impairment-older-patients.
When people receive a timely and accurate diagnosis, they have improved
opportunities to make informed and productive lifestyle, medical,
financial, legal, and spiritual choices to strengthen both their own
quality of life and that of their family caregivers. The CHANGE Act
would help providers detect Alzheimer's sooner, which is increasingly
important in light of new Food and Drug Administration (FDA)-
approved and Medicare-covered therapies for use in early-stage
Alzheimer's disease. It is also critically timed, as Medicare prepares
---------------------------------------------------------------------------
to launch its nationwide comprehensive dementia care model.
CMS could adopt this this pragmatic policy administratively, and the
bill sponsors have long encouraged CMS to act. We are aware of CMS
concerns about overburdening primary care doctors. In response, the
bill sponsors significantly narrowed the bill, clarifying that
clinicians can use any one of the NIA-identified tools, including brief
assessments.\6\ Three of these tools can be filled out by the patient
and caregivers before the visit, which means doctors would not bear
added burdens. This small change puts patients concerns first.
---------------------------------------------------------------------------
\6\ https://alz-journals.onlinelibrary.wiley.com/doi/full/10.1002/
alz.13051.
We urge the Committee to include the CHANGE Act in any package of
policies designed to advance ``Bolstering Chronic Care through Medicare
---------------------------------------------------------------------------
Physician Payment.''
In conclusion, as the Committee considers policies designed to
``Bolster Chronic Care,'' ADRD should be included on the list of
conditions it considers, alongside cardiovascular disease, type 2
diabetes, hypertension, and other conditions that have more
traditionally been seen as chronic conditions. For too long,
Alzheimer's and Related Dementia has gone unaddressed, and we know now
there is much we can do to reduce the risk, detect it early, manage the
disease, and soon (we hope) effectively cure it.
[all]