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ASTRO survey: Prior authorization delays care, add costs
Nine in 10 radiation oncologists report that prior authorization for treatment is either very challenging (42%) or moderately challenging (48%), according to data from a member survey released by the American Society for Radiation Oncology (ASTRO).
“In 2018, [prior authorization] became the most challenging issue facing radiation oncologists,” Paul Harari, MD, Jack Fowler Professor and chair of oncology at the University of Wisconsin, Madison, and chair of the ASTRO board of directors, said during a press briefing. “Prior authorization is creating multiple obstacles to cancer patient care.”
According to responses from 673 ASTRO members, 31% said seeking prior authorization has caused delays in treatment of 5 or more days, 32% said it causes delays of 4-5 days, and 30% said it causes delays of 1-3 days. Seven percent said the prior authorization requests are resolved within less than a day.
Prior authorization delays forced 32% of respondents to alter treatment plans in more than 10% of their cases, and another 31% said treatment plans were altered in 5%-10% of their cases. For 37% of the respondents, less than 5% of their treatment plans were altered because of delays in the prior authorization process.
Data on initial treatment denials show that few hold up on appeal.
“If there is evidence of large-scale inappropriate utilization or overutilization, then treatment denials should withstand scrutiny on appeal,” Vivek Kavadi, MD, a radiation oncologist with Texas Oncology and vice chair of ASTRO’s Payer Relations Subcommittee, said during the briefing. “However, that is not what we found. This raises serious questions on the justification for the denial in the first place.”
In the survey, 41% of respondents said 76%-100% of denials are overturned, 22% said 51%-75% are overturned, 17% said 26%-50% are overturned, 19% said 0-25% are overturned, and 2% said none of their appeals resulted in a prior authorization denial being overturned.
In addition, 44% of respondents said the peer-to-peer appeals processes are typically not handled by a radiation oncologist on the payer side.
“We very rarely have a case denied following peer-to-peer review or appeal,” Dr. Harari said. “However, the many hours spent by our physician providers and the delays in commencing treatment for these cancer patients can never be recovered.”
To handle the workload generated by the prior authorization process, 63% of those responding to the survey said they have hired staff specifically to handle prior authorization requests.
“In an era of value-based care, where is the value when we are increasing costs without adding clinical benefit?” Dr. Kavadi asked.
Dr. Harari called for legislation to simplify the prior authorization process and make it less burdensome, but individual proposals were not highlighted.
SOURCE: American Society for Radiation Oncology survey.
Nine in 10 radiation oncologists report that prior authorization for treatment is either very challenging (42%) or moderately challenging (48%), according to data from a member survey released by the American Society for Radiation Oncology (ASTRO).
“In 2018, [prior authorization] became the most challenging issue facing radiation oncologists,” Paul Harari, MD, Jack Fowler Professor and chair of oncology at the University of Wisconsin, Madison, and chair of the ASTRO board of directors, said during a press briefing. “Prior authorization is creating multiple obstacles to cancer patient care.”
According to responses from 673 ASTRO members, 31% said seeking prior authorization has caused delays in treatment of 5 or more days, 32% said it causes delays of 4-5 days, and 30% said it causes delays of 1-3 days. Seven percent said the prior authorization requests are resolved within less than a day.
Prior authorization delays forced 32% of respondents to alter treatment plans in more than 10% of their cases, and another 31% said treatment plans were altered in 5%-10% of their cases. For 37% of the respondents, less than 5% of their treatment plans were altered because of delays in the prior authorization process.
Data on initial treatment denials show that few hold up on appeal.
“If there is evidence of large-scale inappropriate utilization or overutilization, then treatment denials should withstand scrutiny on appeal,” Vivek Kavadi, MD, a radiation oncologist with Texas Oncology and vice chair of ASTRO’s Payer Relations Subcommittee, said during the briefing. “However, that is not what we found. This raises serious questions on the justification for the denial in the first place.”
In the survey, 41% of respondents said 76%-100% of denials are overturned, 22% said 51%-75% are overturned, 17% said 26%-50% are overturned, 19% said 0-25% are overturned, and 2% said none of their appeals resulted in a prior authorization denial being overturned.
In addition, 44% of respondents said the peer-to-peer appeals processes are typically not handled by a radiation oncologist on the payer side.
“We very rarely have a case denied following peer-to-peer review or appeal,” Dr. Harari said. “However, the many hours spent by our physician providers and the delays in commencing treatment for these cancer patients can never be recovered.”
To handle the workload generated by the prior authorization process, 63% of those responding to the survey said they have hired staff specifically to handle prior authorization requests.
“In an era of value-based care, where is the value when we are increasing costs without adding clinical benefit?” Dr. Kavadi asked.
Dr. Harari called for legislation to simplify the prior authorization process and make it less burdensome, but individual proposals were not highlighted.
SOURCE: American Society for Radiation Oncology survey.
Nine in 10 radiation oncologists report that prior authorization for treatment is either very challenging (42%) or moderately challenging (48%), according to data from a member survey released by the American Society for Radiation Oncology (ASTRO).
“In 2018, [prior authorization] became the most challenging issue facing radiation oncologists,” Paul Harari, MD, Jack Fowler Professor and chair of oncology at the University of Wisconsin, Madison, and chair of the ASTRO board of directors, said during a press briefing. “Prior authorization is creating multiple obstacles to cancer patient care.”
According to responses from 673 ASTRO members, 31% said seeking prior authorization has caused delays in treatment of 5 or more days, 32% said it causes delays of 4-5 days, and 30% said it causes delays of 1-3 days. Seven percent said the prior authorization requests are resolved within less than a day.
Prior authorization delays forced 32% of respondents to alter treatment plans in more than 10% of their cases, and another 31% said treatment plans were altered in 5%-10% of their cases. For 37% of the respondents, less than 5% of their treatment plans were altered because of delays in the prior authorization process.
Data on initial treatment denials show that few hold up on appeal.
“If there is evidence of large-scale inappropriate utilization or overutilization, then treatment denials should withstand scrutiny on appeal,” Vivek Kavadi, MD, a radiation oncologist with Texas Oncology and vice chair of ASTRO’s Payer Relations Subcommittee, said during the briefing. “However, that is not what we found. This raises serious questions on the justification for the denial in the first place.”
In the survey, 41% of respondents said 76%-100% of denials are overturned, 22% said 51%-75% are overturned, 17% said 26%-50% are overturned, 19% said 0-25% are overturned, and 2% said none of their appeals resulted in a prior authorization denial being overturned.
In addition, 44% of respondents said the peer-to-peer appeals processes are typically not handled by a radiation oncologist on the payer side.
“We very rarely have a case denied following peer-to-peer review or appeal,” Dr. Harari said. “However, the many hours spent by our physician providers and the delays in commencing treatment for these cancer patients can never be recovered.”
To handle the workload generated by the prior authorization process, 63% of those responding to the survey said they have hired staff specifically to handle prior authorization requests.
“In an era of value-based care, where is the value when we are increasing costs without adding clinical benefit?” Dr. Kavadi asked.
Dr. Harari called for legislation to simplify the prior authorization process and make it less burdensome, but individual proposals were not highlighted.
SOURCE: American Society for Radiation Oncology survey.
Medicare withdraws plans to exclude drugs from Part D protected classes
Proposals that would have allowed Medicare Part D prescription drug plan sponsors to exclude certain drugs in the six protected classes have been withdrawn by the Centers for Medicare & Medicaid Services.
In a final rule that targets drug pricing in Medicare Advantage and Part D – released online May 16 and scheduled for publication in the Federal Register on May 23 – CMS did not finalize a proposal that would have allowed a plan sponsor to exclude a drug in a protected class from a formulary, if the price of that drug increased faster than the rate of inflation.
“In considering whether to propose these exceptions, CMS took our other enrollee access protections into account, which have successfully protected beneficiary access to needed medications in the more than 12 years the Part D program has been operational,” the agency stated in the final rule.
Agency officials cited rules on formulary transparency, formulary requirements, reassignment formulary coverage notices, transition supplies and notices, and the expedited coverage determination and appeals process as policies that have protected beneficiary access.
Agency officials said that they believe the current enrollee access protections are “sufficient,” and they are not finalizing the pricing threshold exception.
The agency also chose not to finalize a plan’s ability to exclude a drug in a protected class if the drug represents a new formulation of an existing single-source product, regardless of whether the older formulation remains on the market.
Part D plan sponsors are required by law to cover “all or substantially all” drugs in six classes: antidepressants, antipsychotics, anticonvulsants, immunosuppressants for the treatment of transplant rejection, antiretrovirals, and antineoplastics.
CMS chose not to finalize this proposal because it was persuaded by comments noting that under the proposed policy, “in a scenario where our other formulary requirements did not require Part D sponsors to have the new formulation on their formulary, a Part D enrollee who is stable on the old formulation could be left without access to the new formulation,” the agency stated in the final rule. “Consequently, we decline to finalize this exception.”
The final rule codifies in regulation a plan’s ability to impose prior authorization and step therapy for beneficiaries initiating therapy in five of the six classes, as has been the policy since 2006 (antiretrovirals are excluded from prior authorization and step therapy).
CMS also finalized a policy implemented in 2019 that allows Medicare Advantage plans to implement step therapy for drugs administered in the physician office under Medicare Part B. Similar to step therapy in Medicare Part D, this applies only to beneficiaries newly starting on treatment and includes an appeals process similar to Part D.
Another proposal finalized is one that prohibits so-called “gag clauses” in Part D contracts, which prevent or penalize pharmacists from discussing lower-cost pharmaceutical options with customers.
CMS also will be requiring Part D plans to adopt tools no later than Jan. 1, 2021, that integrate with a prescriber’s electronic health record or e-prescribing software to inform providers when lower-cost pharmaceutical options are available under a patient’s drug benefit. Similarly, the Part D explanation of benefits statement, effective the same date, will be required to inform beneficiaries of drug price increases and lower-cost alternatives.
Proposals that would have allowed Medicare Part D prescription drug plan sponsors to exclude certain drugs in the six protected classes have been withdrawn by the Centers for Medicare & Medicaid Services.
In a final rule that targets drug pricing in Medicare Advantage and Part D – released online May 16 and scheduled for publication in the Federal Register on May 23 – CMS did not finalize a proposal that would have allowed a plan sponsor to exclude a drug in a protected class from a formulary, if the price of that drug increased faster than the rate of inflation.
“In considering whether to propose these exceptions, CMS took our other enrollee access protections into account, which have successfully protected beneficiary access to needed medications in the more than 12 years the Part D program has been operational,” the agency stated in the final rule.
Agency officials cited rules on formulary transparency, formulary requirements, reassignment formulary coverage notices, transition supplies and notices, and the expedited coverage determination and appeals process as policies that have protected beneficiary access.
Agency officials said that they believe the current enrollee access protections are “sufficient,” and they are not finalizing the pricing threshold exception.
The agency also chose not to finalize a plan’s ability to exclude a drug in a protected class if the drug represents a new formulation of an existing single-source product, regardless of whether the older formulation remains on the market.
Part D plan sponsors are required by law to cover “all or substantially all” drugs in six classes: antidepressants, antipsychotics, anticonvulsants, immunosuppressants for the treatment of transplant rejection, antiretrovirals, and antineoplastics.
CMS chose not to finalize this proposal because it was persuaded by comments noting that under the proposed policy, “in a scenario where our other formulary requirements did not require Part D sponsors to have the new formulation on their formulary, a Part D enrollee who is stable on the old formulation could be left without access to the new formulation,” the agency stated in the final rule. “Consequently, we decline to finalize this exception.”
The final rule codifies in regulation a plan’s ability to impose prior authorization and step therapy for beneficiaries initiating therapy in five of the six classes, as has been the policy since 2006 (antiretrovirals are excluded from prior authorization and step therapy).
CMS also finalized a policy implemented in 2019 that allows Medicare Advantage plans to implement step therapy for drugs administered in the physician office under Medicare Part B. Similar to step therapy in Medicare Part D, this applies only to beneficiaries newly starting on treatment and includes an appeals process similar to Part D.
Another proposal finalized is one that prohibits so-called “gag clauses” in Part D contracts, which prevent or penalize pharmacists from discussing lower-cost pharmaceutical options with customers.
CMS also will be requiring Part D plans to adopt tools no later than Jan. 1, 2021, that integrate with a prescriber’s electronic health record or e-prescribing software to inform providers when lower-cost pharmaceutical options are available under a patient’s drug benefit. Similarly, the Part D explanation of benefits statement, effective the same date, will be required to inform beneficiaries of drug price increases and lower-cost alternatives.
Proposals that would have allowed Medicare Part D prescription drug plan sponsors to exclude certain drugs in the six protected classes have been withdrawn by the Centers for Medicare & Medicaid Services.
In a final rule that targets drug pricing in Medicare Advantage and Part D – released online May 16 and scheduled for publication in the Federal Register on May 23 – CMS did not finalize a proposal that would have allowed a plan sponsor to exclude a drug in a protected class from a formulary, if the price of that drug increased faster than the rate of inflation.
“In considering whether to propose these exceptions, CMS took our other enrollee access protections into account, which have successfully protected beneficiary access to needed medications in the more than 12 years the Part D program has been operational,” the agency stated in the final rule.
Agency officials cited rules on formulary transparency, formulary requirements, reassignment formulary coverage notices, transition supplies and notices, and the expedited coverage determination and appeals process as policies that have protected beneficiary access.
Agency officials said that they believe the current enrollee access protections are “sufficient,” and they are not finalizing the pricing threshold exception.
The agency also chose not to finalize a plan’s ability to exclude a drug in a protected class if the drug represents a new formulation of an existing single-source product, regardless of whether the older formulation remains on the market.
Part D plan sponsors are required by law to cover “all or substantially all” drugs in six classes: antidepressants, antipsychotics, anticonvulsants, immunosuppressants for the treatment of transplant rejection, antiretrovirals, and antineoplastics.
CMS chose not to finalize this proposal because it was persuaded by comments noting that under the proposed policy, “in a scenario where our other formulary requirements did not require Part D sponsors to have the new formulation on their formulary, a Part D enrollee who is stable on the old formulation could be left without access to the new formulation,” the agency stated in the final rule. “Consequently, we decline to finalize this exception.”
The final rule codifies in regulation a plan’s ability to impose prior authorization and step therapy for beneficiaries initiating therapy in five of the six classes, as has been the policy since 2006 (antiretrovirals are excluded from prior authorization and step therapy).
CMS also finalized a policy implemented in 2019 that allows Medicare Advantage plans to implement step therapy for drugs administered in the physician office under Medicare Part B. Similar to step therapy in Medicare Part D, this applies only to beneficiaries newly starting on treatment and includes an appeals process similar to Part D.
Another proposal finalized is one that prohibits so-called “gag clauses” in Part D contracts, which prevent or penalize pharmacists from discussing lower-cost pharmaceutical options with customers.
CMS also will be requiring Part D plans to adopt tools no later than Jan. 1, 2021, that integrate with a prescriber’s electronic health record or e-prescribing software to inform providers when lower-cost pharmaceutical options are available under a patient’s drug benefit. Similarly, the Part D explanation of benefits statement, effective the same date, will be required to inform beneficiaries of drug price increases and lower-cost alternatives.
Key clinical point: A proposal that would have allowed for drugs to be excluded from Medicare Part D protected classes was not finalized by the Centers for Medicare & Medicaid Services.
Major finding: Agency officials wrote that there are “sufficient” enrollee access protections in place, and they were not finalizing the proposal.
Study details: The proposal would have allowed a plan sponsor to exclude a drug in a protected class from a formulary, if the price of that drug increased faster than the rate of inflation.
Disclosures: CMS makes no disclosures in issuing the final rule.
Source: CMS final rule.
Medicaid coverage decreased in Arkansas following work requirements
WASHINGTON – Early analysis of the implementation of Medicaid work requirements suggests administrative burden on beneficiaries is leading to decreased coverage.
according to state reports.
A study of the early months after Arkansas put its work requirement into effect in June 2018 found those most affected were people already working but unaware of or unable to meet the administrative requirements to demonstrate they were working. These people lost coverage.
Researchers identified “lots of confusion,” Anna Goldman, MD, of Harvard University, Boston, told attendees at the annual meeting of the Society of General Internal Medicine 2019 conference. “People didn’t know if they should report, or if they thought they should, they didn’t know how.”
Additionally, there is no evidence that the implementation of the work rules caused an increase of employment within the Medicaid-eligible population in Arkansas within the first 6 months of the law going into effect.
Arkansas’s rules required individuals aged 30-49 years (applied during the first 6 months of the rollout) to work at least 80 hours a month in a job or doing something equivalent to a job, such as job skills training. Exemptions were available to those who were disabled, pregnant, or caregiving; had student status; or were receiving treatment for substance abuse. Individuals were required to report their work hours each month. Failure to do so for 3 months in a year would cause Medicaid benefits to be suspended for the balance of the year.
Dr. Goldman noted that phone surveys were done in four states (Arkansas, Kentucky, Louisiana, and Texas) of low-income adults earning up to 138% of the federal poverty limit. About 6,000 people were surveyed across the four states, with half coming from 2016 and the other from a survey in 2018. In both years, the surveys were conducted in November and December of survey years. She acknowledged a low response rate of 14%, but she said that weighting was used to minimize nonresponse bias.
With the introduction of the work requirements, researchers found a 13.2% decrease in Medicaid or marketplace insurance and a 7.1% increase in the uninsured rate. No change in employment rates were found.
She noted that the findings that employment didn’t change were not surprising “given that 95% of people were either exempt or working, according to our survey results.”
Dr. Goldman said the survey completed for this study was consistent with studies done in Arkansas that showed most people that would be covered by the work rule were either working or would be exempt from the work requirements laid forth by state regulation.
“Those studies had raised an initial concern that most of the coverage losses would be related to nonreporting and administrative issues as opposed to just removing people who were healthy and didn’t want to get a job,” she explained.
Dr. Goldman noted that this newer study found that of the people required to report their work activities to the state, half didn’t because they either had no Internet access or were confused and could not figure out how to use the reporting system, even though they met the work requirements necessary to keep their Medicaid coverage.
In general, about 52% of the Arkansas population surveyed had heard something about the work requirements, but of those in the age range targeted by the rules, only 22% thought they were subject to the work requirements. Of those informed by the state that they needed to report, only half said they were doing so, Dr. Goldman added.
The survey results were consistent with state reports on the number of people experiencing coverage loss after the rollout, she said.
“One important thing to take away is that information barriers and administrative hassles are key reasons why people are losing coverage. ... Therefore, anything that states can do to automatically exempt people using state data that they already have can possibly reduce unnecessary coverage losses,” Dr. Goldman concluded.
Arkansas’s Medicaid work requirements were blocked by a federal judge in March 2019. Appeals are ongoing.
The authors reported no disclosures.
WASHINGTON – Early analysis of the implementation of Medicaid work requirements suggests administrative burden on beneficiaries is leading to decreased coverage.
according to state reports.
A study of the early months after Arkansas put its work requirement into effect in June 2018 found those most affected were people already working but unaware of or unable to meet the administrative requirements to demonstrate they were working. These people lost coverage.
Researchers identified “lots of confusion,” Anna Goldman, MD, of Harvard University, Boston, told attendees at the annual meeting of the Society of General Internal Medicine 2019 conference. “People didn’t know if they should report, or if they thought they should, they didn’t know how.”
Additionally, there is no evidence that the implementation of the work rules caused an increase of employment within the Medicaid-eligible population in Arkansas within the first 6 months of the law going into effect.
Arkansas’s rules required individuals aged 30-49 years (applied during the first 6 months of the rollout) to work at least 80 hours a month in a job or doing something equivalent to a job, such as job skills training. Exemptions were available to those who were disabled, pregnant, or caregiving; had student status; or were receiving treatment for substance abuse. Individuals were required to report their work hours each month. Failure to do so for 3 months in a year would cause Medicaid benefits to be suspended for the balance of the year.
Dr. Goldman noted that phone surveys were done in four states (Arkansas, Kentucky, Louisiana, and Texas) of low-income adults earning up to 138% of the federal poverty limit. About 6,000 people were surveyed across the four states, with half coming from 2016 and the other from a survey in 2018. In both years, the surveys were conducted in November and December of survey years. She acknowledged a low response rate of 14%, but she said that weighting was used to minimize nonresponse bias.
With the introduction of the work requirements, researchers found a 13.2% decrease in Medicaid or marketplace insurance and a 7.1% increase in the uninsured rate. No change in employment rates were found.
She noted that the findings that employment didn’t change were not surprising “given that 95% of people were either exempt or working, according to our survey results.”
Dr. Goldman said the survey completed for this study was consistent with studies done in Arkansas that showed most people that would be covered by the work rule were either working or would be exempt from the work requirements laid forth by state regulation.
“Those studies had raised an initial concern that most of the coverage losses would be related to nonreporting and administrative issues as opposed to just removing people who were healthy and didn’t want to get a job,” she explained.
Dr. Goldman noted that this newer study found that of the people required to report their work activities to the state, half didn’t because they either had no Internet access or were confused and could not figure out how to use the reporting system, even though they met the work requirements necessary to keep their Medicaid coverage.
In general, about 52% of the Arkansas population surveyed had heard something about the work requirements, but of those in the age range targeted by the rules, only 22% thought they were subject to the work requirements. Of those informed by the state that they needed to report, only half said they were doing so, Dr. Goldman added.
The survey results were consistent with state reports on the number of people experiencing coverage loss after the rollout, she said.
“One important thing to take away is that information barriers and administrative hassles are key reasons why people are losing coverage. ... Therefore, anything that states can do to automatically exempt people using state data that they already have can possibly reduce unnecessary coverage losses,” Dr. Goldman concluded.
Arkansas’s Medicaid work requirements were blocked by a federal judge in March 2019. Appeals are ongoing.
The authors reported no disclosures.
WASHINGTON – Early analysis of the implementation of Medicaid work requirements suggests administrative burden on beneficiaries is leading to decreased coverage.
according to state reports.
A study of the early months after Arkansas put its work requirement into effect in June 2018 found those most affected were people already working but unaware of or unable to meet the administrative requirements to demonstrate they were working. These people lost coverage.
Researchers identified “lots of confusion,” Anna Goldman, MD, of Harvard University, Boston, told attendees at the annual meeting of the Society of General Internal Medicine 2019 conference. “People didn’t know if they should report, or if they thought they should, they didn’t know how.”
Additionally, there is no evidence that the implementation of the work rules caused an increase of employment within the Medicaid-eligible population in Arkansas within the first 6 months of the law going into effect.
Arkansas’s rules required individuals aged 30-49 years (applied during the first 6 months of the rollout) to work at least 80 hours a month in a job or doing something equivalent to a job, such as job skills training. Exemptions were available to those who were disabled, pregnant, or caregiving; had student status; or were receiving treatment for substance abuse. Individuals were required to report their work hours each month. Failure to do so for 3 months in a year would cause Medicaid benefits to be suspended for the balance of the year.
Dr. Goldman noted that phone surveys were done in four states (Arkansas, Kentucky, Louisiana, and Texas) of low-income adults earning up to 138% of the federal poverty limit. About 6,000 people were surveyed across the four states, with half coming from 2016 and the other from a survey in 2018. In both years, the surveys were conducted in November and December of survey years. She acknowledged a low response rate of 14%, but she said that weighting was used to minimize nonresponse bias.
With the introduction of the work requirements, researchers found a 13.2% decrease in Medicaid or marketplace insurance and a 7.1% increase in the uninsured rate. No change in employment rates were found.
She noted that the findings that employment didn’t change were not surprising “given that 95% of people were either exempt or working, according to our survey results.”
Dr. Goldman said the survey completed for this study was consistent with studies done in Arkansas that showed most people that would be covered by the work rule were either working or would be exempt from the work requirements laid forth by state regulation.
“Those studies had raised an initial concern that most of the coverage losses would be related to nonreporting and administrative issues as opposed to just removing people who were healthy and didn’t want to get a job,” she explained.
Dr. Goldman noted that this newer study found that of the people required to report their work activities to the state, half didn’t because they either had no Internet access or were confused and could not figure out how to use the reporting system, even though they met the work requirements necessary to keep their Medicaid coverage.
In general, about 52% of the Arkansas population surveyed had heard something about the work requirements, but of those in the age range targeted by the rules, only 22% thought they were subject to the work requirements. Of those informed by the state that they needed to report, only half said they were doing so, Dr. Goldman added.
The survey results were consistent with state reports on the number of people experiencing coverage loss after the rollout, she said.
“One important thing to take away is that information barriers and administrative hassles are key reasons why people are losing coverage. ... Therefore, anything that states can do to automatically exempt people using state data that they already have can possibly reduce unnecessary coverage losses,” Dr. Goldman concluded.
Arkansas’s Medicaid work requirements were blocked by a federal judge in March 2019. Appeals are ongoing.
The authors reported no disclosures.
REPORTING FROM SGIM 2019
Senators question whether health IT regulation can keep up with innovation
It has been more than 10 years since Congress passed the HITECH Act to jump start the adoption of electronic health records. And yet interoperability, the key to making their adoption meaningful, remains an elusive target.
Members of the Senate Health, Education, Labor, and Pensions Committee questioned whether attempts to regulate interoperability – and health IT in general – are doing more harm than good in terms of creating a truly interoperable environment.
A key concern raised during a May 7 hearing examining the implementation of the health IT provisions of the 21st Century Cures Act (H.R. 34), signed into law in December 2016, was that the slow speed of government regulatory action simply cannot keep pace with innovation.
“In 2016, my question to a panel like this was, ‘How the hell are you going to do this?’ I think what you’ve heard is different variations of that going around the room,” Sen. Richard Burr (R-N.C) said. “The difference is we’re in 2019 and this is a discussion that we started in 2013 about how do we get systems to talk to other systems.”
“Here is my problem,” he continued, noting that between 2013 and 2019, “technology has exploded. It runs at an unbelievable pace. And here we are trying to set standards and set architecture of software ... that 12 months from now is going to be obsolete because that’s how fast technology is changing.”
Sen. Burr added that the problem is that government can’t regulate fast enough. “Our problem is we can’t get rules through when the technology that we are applying it to is in existence. By the time we get a rule through, technology’s changed, and it may or may not apply.”
Donald Rucker, MD, national coordinator for health information technology at the Health & Human Services department, testified that the current app marketplace is “stable” and “the entire point of what we are doing jointly is to allow these apps in the market economy to incorporate patient’s medical data into that.”
Centers for Medicare & Medicaid Services Chief Medical Officer Kate Goodrich, MD, agreed.
“I would absolutely agree with Don that the timing is really right for this because of where the state of play is with the standards, and I think it’s a good time to take advantage of that and move the field forward,” she testified at the hearing.
The Office of the National Coordinator for Health IT recently issued a proposed rule related to interoperability. The CMS has issued a concurrent proposed rule, also related to interoperability.
Sen. Burr, however, was not moved by these assurances.
“I am probably no less convinced that we are going to get to the finish line today than I was in 2016, though the tools that we have are much better,” he said, telling an anecdote about how providers and insurers took the initiative to improve the outcomes of diabetes patients without any prompting from legislative or regulatory action.
“It seems to me that that’s the most appropriate first place to go, is to create an incentive for the providers,” he said. “It is to their financial benefit to do that.”
Sen. Mitt Romney (R-Utah) also expressed doubt as to whether the goal of interoperability was achievable.
“I wonder exactly whether it is conceivable for us to achieve standards that will allow systems to talk to each other from one hospital system, for instance, to another provider, or whether that’s frankly a bridge too far at this stage,” he said.
Dr. Rucker acknowledged that there is “plenty of room for skepticism,” but he said that the goals of interoperability in health care are achieved broadly across most sectors in the economy today, and it’s about customizing what already works in the marketplace to the needs of the health care environment.
Dr. Goodrich agreed, noting that, in her time as a practicing physician, she has seen advances in the amount of data that can be transfered electronically.
“There is reason for optimism,” she said. “So, yes, plenty of room for skepticism, but also more optimism than probably any of us would have had a couple of years ago.”
It has been more than 10 years since Congress passed the HITECH Act to jump start the adoption of electronic health records. And yet interoperability, the key to making their adoption meaningful, remains an elusive target.
Members of the Senate Health, Education, Labor, and Pensions Committee questioned whether attempts to regulate interoperability – and health IT in general – are doing more harm than good in terms of creating a truly interoperable environment.
A key concern raised during a May 7 hearing examining the implementation of the health IT provisions of the 21st Century Cures Act (H.R. 34), signed into law in December 2016, was that the slow speed of government regulatory action simply cannot keep pace with innovation.
“In 2016, my question to a panel like this was, ‘How the hell are you going to do this?’ I think what you’ve heard is different variations of that going around the room,” Sen. Richard Burr (R-N.C) said. “The difference is we’re in 2019 and this is a discussion that we started in 2013 about how do we get systems to talk to other systems.”
“Here is my problem,” he continued, noting that between 2013 and 2019, “technology has exploded. It runs at an unbelievable pace. And here we are trying to set standards and set architecture of software ... that 12 months from now is going to be obsolete because that’s how fast technology is changing.”
Sen. Burr added that the problem is that government can’t regulate fast enough. “Our problem is we can’t get rules through when the technology that we are applying it to is in existence. By the time we get a rule through, technology’s changed, and it may or may not apply.”
Donald Rucker, MD, national coordinator for health information technology at the Health & Human Services department, testified that the current app marketplace is “stable” and “the entire point of what we are doing jointly is to allow these apps in the market economy to incorporate patient’s medical data into that.”
Centers for Medicare & Medicaid Services Chief Medical Officer Kate Goodrich, MD, agreed.
“I would absolutely agree with Don that the timing is really right for this because of where the state of play is with the standards, and I think it’s a good time to take advantage of that and move the field forward,” she testified at the hearing.
The Office of the National Coordinator for Health IT recently issued a proposed rule related to interoperability. The CMS has issued a concurrent proposed rule, also related to interoperability.
Sen. Burr, however, was not moved by these assurances.
“I am probably no less convinced that we are going to get to the finish line today than I was in 2016, though the tools that we have are much better,” he said, telling an anecdote about how providers and insurers took the initiative to improve the outcomes of diabetes patients without any prompting from legislative or regulatory action.
“It seems to me that that’s the most appropriate first place to go, is to create an incentive for the providers,” he said. “It is to their financial benefit to do that.”
Sen. Mitt Romney (R-Utah) also expressed doubt as to whether the goal of interoperability was achievable.
“I wonder exactly whether it is conceivable for us to achieve standards that will allow systems to talk to each other from one hospital system, for instance, to another provider, or whether that’s frankly a bridge too far at this stage,” he said.
Dr. Rucker acknowledged that there is “plenty of room for skepticism,” but he said that the goals of interoperability in health care are achieved broadly across most sectors in the economy today, and it’s about customizing what already works in the marketplace to the needs of the health care environment.
Dr. Goodrich agreed, noting that, in her time as a practicing physician, she has seen advances in the amount of data that can be transfered electronically.
“There is reason for optimism,” she said. “So, yes, plenty of room for skepticism, but also more optimism than probably any of us would have had a couple of years ago.”
It has been more than 10 years since Congress passed the HITECH Act to jump start the adoption of electronic health records. And yet interoperability, the key to making their adoption meaningful, remains an elusive target.
Members of the Senate Health, Education, Labor, and Pensions Committee questioned whether attempts to regulate interoperability – and health IT in general – are doing more harm than good in terms of creating a truly interoperable environment.
A key concern raised during a May 7 hearing examining the implementation of the health IT provisions of the 21st Century Cures Act (H.R. 34), signed into law in December 2016, was that the slow speed of government regulatory action simply cannot keep pace with innovation.
“In 2016, my question to a panel like this was, ‘How the hell are you going to do this?’ I think what you’ve heard is different variations of that going around the room,” Sen. Richard Burr (R-N.C) said. “The difference is we’re in 2019 and this is a discussion that we started in 2013 about how do we get systems to talk to other systems.”
“Here is my problem,” he continued, noting that between 2013 and 2019, “technology has exploded. It runs at an unbelievable pace. And here we are trying to set standards and set architecture of software ... that 12 months from now is going to be obsolete because that’s how fast technology is changing.”
Sen. Burr added that the problem is that government can’t regulate fast enough. “Our problem is we can’t get rules through when the technology that we are applying it to is in existence. By the time we get a rule through, technology’s changed, and it may or may not apply.”
Donald Rucker, MD, national coordinator for health information technology at the Health & Human Services department, testified that the current app marketplace is “stable” and “the entire point of what we are doing jointly is to allow these apps in the market economy to incorporate patient’s medical data into that.”
Centers for Medicare & Medicaid Services Chief Medical Officer Kate Goodrich, MD, agreed.
“I would absolutely agree with Don that the timing is really right for this because of where the state of play is with the standards, and I think it’s a good time to take advantage of that and move the field forward,” she testified at the hearing.
The Office of the National Coordinator for Health IT recently issued a proposed rule related to interoperability. The CMS has issued a concurrent proposed rule, also related to interoperability.
Sen. Burr, however, was not moved by these assurances.
“I am probably no less convinced that we are going to get to the finish line today than I was in 2016, though the tools that we have are much better,” he said, telling an anecdote about how providers and insurers took the initiative to improve the outcomes of diabetes patients without any prompting from legislative or regulatory action.
“It seems to me that that’s the most appropriate first place to go, is to create an incentive for the providers,” he said. “It is to their financial benefit to do that.”
Sen. Mitt Romney (R-Utah) also expressed doubt as to whether the goal of interoperability was achievable.
“I wonder exactly whether it is conceivable for us to achieve standards that will allow systems to talk to each other from one hospital system, for instance, to another provider, or whether that’s frankly a bridge too far at this stage,” he said.
Dr. Rucker acknowledged that there is “plenty of room for skepticism,” but he said that the goals of interoperability in health care are achieved broadly across most sectors in the economy today, and it’s about customizing what already works in the marketplace to the needs of the health care environment.
Dr. Goodrich agreed, noting that, in her time as a practicing physician, she has seen advances in the amount of data that can be transfered electronically.
“There is reason for optimism,” she said. “So, yes, plenty of room for skepticism, but also more optimism than probably any of us would have had a couple of years ago.”
REPORTING FROM A SENATE HELP COMMITTEE HEARING
CBO predicts more Medicare spending with drug rebate proposal
Medicare spending on pharmaceuticals is projected to increase if the Centers for Medicare & Medicaid Services finalizes changes to drug rebates in the Medicare program.
The Congressional Budget Office is estimating that Medicare spending would increase by $170 billion from 2020-2029 if the rebate rule goes into effect, according to a report released May 2.
The proposed rule, issued Jan. 31, would make it illegal for drug manufacturers to pay rebates to health plans and pharmacy benefit managers in return for better formulary placement. Instead of rebates, manufacturers could offer discounts directly to beneficiaries by lowering list prices or making a payment to the pharmacy for the full amount of the negotiated discount – a chargeback. Under the proposal, a beneficiary’s cost sharing would be based on the lower list price or the price after the chargeback.
The CBO’s projected spending increases are based on the assumption that manufacturers will withhold 15% of current-law rebates, as well as increases in federal subsidies for premiums, changes in annual thresholds to beneficiary cost sharing, and the cost of implementing the chargeback system.
The agency expects premiums to rise, as many plans currently use the rebates they receive from drug companies to lower premiums across the board.
However, some beneficiaries “would pay lower prices on their prescription drugs, and for some beneficiaries, those reductions would be greater than their premium increases,” the CBO stated in its report. For beneficiaries who use few drugs or who use drugs that have no significant rebates, “the premium increase would outweigh the price reduction.”
Another reason federal spending would increase under this proposal is an expected increase in utilization that would come with the lowering of prices.
“In CBO’s estimate, the additional Part D utilization stemming from implementing the proposed rule would increase federal spending for beneficiaries who are not enrolled in the low-income subsidy program over the 2020-2029 period by a total of about 2% or $10 billion,” the report noted.
But the increase in utilization would have a net positive effect on Medicare spending for this population, as more beneficiaries followed their drug regimens resulting in lower spending for physician and hospital services under Medicare Part A and Part B by an estimated $20 billion over the same period, according to the CBO.
“On net, those effects are projected to reduce Medicare spending by $10 billion over the 2020-2029 period,” according to the report.
Medicare spending on pharmaceuticals is projected to increase if the Centers for Medicare & Medicaid Services finalizes changes to drug rebates in the Medicare program.
The Congressional Budget Office is estimating that Medicare spending would increase by $170 billion from 2020-2029 if the rebate rule goes into effect, according to a report released May 2.
The proposed rule, issued Jan. 31, would make it illegal for drug manufacturers to pay rebates to health plans and pharmacy benefit managers in return for better formulary placement. Instead of rebates, manufacturers could offer discounts directly to beneficiaries by lowering list prices or making a payment to the pharmacy for the full amount of the negotiated discount – a chargeback. Under the proposal, a beneficiary’s cost sharing would be based on the lower list price or the price after the chargeback.
The CBO’s projected spending increases are based on the assumption that manufacturers will withhold 15% of current-law rebates, as well as increases in federal subsidies for premiums, changes in annual thresholds to beneficiary cost sharing, and the cost of implementing the chargeback system.
The agency expects premiums to rise, as many plans currently use the rebates they receive from drug companies to lower premiums across the board.
However, some beneficiaries “would pay lower prices on their prescription drugs, and for some beneficiaries, those reductions would be greater than their premium increases,” the CBO stated in its report. For beneficiaries who use few drugs or who use drugs that have no significant rebates, “the premium increase would outweigh the price reduction.”
Another reason federal spending would increase under this proposal is an expected increase in utilization that would come with the lowering of prices.
“In CBO’s estimate, the additional Part D utilization stemming from implementing the proposed rule would increase federal spending for beneficiaries who are not enrolled in the low-income subsidy program over the 2020-2029 period by a total of about 2% or $10 billion,” the report noted.
But the increase in utilization would have a net positive effect on Medicare spending for this population, as more beneficiaries followed their drug regimens resulting in lower spending for physician and hospital services under Medicare Part A and Part B by an estimated $20 billion over the same period, according to the CBO.
“On net, those effects are projected to reduce Medicare spending by $10 billion over the 2020-2029 period,” according to the report.
Medicare spending on pharmaceuticals is projected to increase if the Centers for Medicare & Medicaid Services finalizes changes to drug rebates in the Medicare program.
The Congressional Budget Office is estimating that Medicare spending would increase by $170 billion from 2020-2029 if the rebate rule goes into effect, according to a report released May 2.
The proposed rule, issued Jan. 31, would make it illegal for drug manufacturers to pay rebates to health plans and pharmacy benefit managers in return for better formulary placement. Instead of rebates, manufacturers could offer discounts directly to beneficiaries by lowering list prices or making a payment to the pharmacy for the full amount of the negotiated discount – a chargeback. Under the proposal, a beneficiary’s cost sharing would be based on the lower list price or the price after the chargeback.
The CBO’s projected spending increases are based on the assumption that manufacturers will withhold 15% of current-law rebates, as well as increases in federal subsidies for premiums, changes in annual thresholds to beneficiary cost sharing, and the cost of implementing the chargeback system.
The agency expects premiums to rise, as many plans currently use the rebates they receive from drug companies to lower premiums across the board.
However, some beneficiaries “would pay lower prices on their prescription drugs, and for some beneficiaries, those reductions would be greater than their premium increases,” the CBO stated in its report. For beneficiaries who use few drugs or who use drugs that have no significant rebates, “the premium increase would outweigh the price reduction.”
Another reason federal spending would increase under this proposal is an expected increase in utilization that would come with the lowering of prices.
“In CBO’s estimate, the additional Part D utilization stemming from implementing the proposed rule would increase federal spending for beneficiaries who are not enrolled in the low-income subsidy program over the 2020-2029 period by a total of about 2% or $10 billion,” the report noted.
But the increase in utilization would have a net positive effect on Medicare spending for this population, as more beneficiaries followed their drug regimens resulting in lower spending for physician and hospital services under Medicare Part A and Part B by an estimated $20 billion over the same period, according to the CBO.
“On net, those effects are projected to reduce Medicare spending by $10 billion over the 2020-2029 period,” according to the report.
Senators hear what’s wrong with APMs, MIPS
Few advanced alternative payment models plus the sunsetting bonus for participation couple to keep physician interest in value-based payment low, physician groups told the Senate Finance Committee.
“One important goal of MACRA [Medicare Access and CHIP Reauthorization Act] was to provide busy physicians with a path to transition into new, innovated payment models,” Barbara McAneny, MD, president of the American Medical Association testified during a May 8 hearing to review the first 2 years of Medicare’s Quality Payment Program (QPP).
MACRA – the law that created QPP – provided a 5% bonus to physicians and other professionals who participate in the first 6 years of the program; the payment was designed to help cover expenses needed to transition to value-based care.
“Unfortunately, during the first 3 years of the program, too few APM [advanced alternative payment model] options were available for physicians, and now only 3 years remain, which is not enough time for physicians to transition to an APM,” Dr. McAneny said, calling on Congress to extend the APM incentive for an additional 6 years.
John Cullen, MD, president of the American Academy of Family Physicians, also called on legislators to extend the APM bonus for at least 3-5 years.
He also advocated for changes to QPP’s Merit-based Incentive Program (MIPS), calling for the exceptional performance bonus to reward year-over-year improvement versus simply scoring high on MIPS criteria in a given year.
MIPS “has created a burdensome and extremely complex program that has increased practice costs and is contributing to physician burnout, Dr. Cullen testified. “Understanding the requirements and scoring for each MIPS performance category and reporting the required data to CMS is a complex task and detracts from physicians’ ability to focus on patients.”
Dr. McAneny put the costs and rewards of MIPS into perspective for lawmakers.
She testified that, in 2017, her small practice was a participant in MIPS and was able to achieve the highest MIPS score of 100. That score qualified the practice for an exceptional performance bonus, which ended up being a 1.88% bonus to Medicare payments.
“After the adjustment that occurred after that, it lowered that increase to where the entire change that I got was $34,000,” she said. “When I added up how much I had to pay my EMR [electronic medical record] to submit that data, when I added up everything that I had to do in terms of paying staff overtime to make sure the data was accurate, I lost $100,000 to score that perfect score. So we need to modify that. That’s, I think, a great example of why the lower-volume practices need to be kept out of this process so they can continue to use their resources on patient care.”
Scott Hines, MD, member of the AMGA board of directors testified differently, arguing that less exclusion from participation is needed, because with around half of eligible physicians not required to participate, the pool for exceptional performance bonuses is significantly smaller than what would be the maximum available of up to 9% in 2023 as the years in the program advanced.
Between the low-volume exclusion and the budget neutrality of the program, there is little incentive to participate, he noted.
Few advanced alternative payment models plus the sunsetting bonus for participation couple to keep physician interest in value-based payment low, physician groups told the Senate Finance Committee.
“One important goal of MACRA [Medicare Access and CHIP Reauthorization Act] was to provide busy physicians with a path to transition into new, innovated payment models,” Barbara McAneny, MD, president of the American Medical Association testified during a May 8 hearing to review the first 2 years of Medicare’s Quality Payment Program (QPP).
MACRA – the law that created QPP – provided a 5% bonus to physicians and other professionals who participate in the first 6 years of the program; the payment was designed to help cover expenses needed to transition to value-based care.
“Unfortunately, during the first 3 years of the program, too few APM [advanced alternative payment model] options were available for physicians, and now only 3 years remain, which is not enough time for physicians to transition to an APM,” Dr. McAneny said, calling on Congress to extend the APM incentive for an additional 6 years.
John Cullen, MD, president of the American Academy of Family Physicians, also called on legislators to extend the APM bonus for at least 3-5 years.
He also advocated for changes to QPP’s Merit-based Incentive Program (MIPS), calling for the exceptional performance bonus to reward year-over-year improvement versus simply scoring high on MIPS criteria in a given year.
MIPS “has created a burdensome and extremely complex program that has increased practice costs and is contributing to physician burnout, Dr. Cullen testified. “Understanding the requirements and scoring for each MIPS performance category and reporting the required data to CMS is a complex task and detracts from physicians’ ability to focus on patients.”
Dr. McAneny put the costs and rewards of MIPS into perspective for lawmakers.
She testified that, in 2017, her small practice was a participant in MIPS and was able to achieve the highest MIPS score of 100. That score qualified the practice for an exceptional performance bonus, which ended up being a 1.88% bonus to Medicare payments.
“After the adjustment that occurred after that, it lowered that increase to where the entire change that I got was $34,000,” she said. “When I added up how much I had to pay my EMR [electronic medical record] to submit that data, when I added up everything that I had to do in terms of paying staff overtime to make sure the data was accurate, I lost $100,000 to score that perfect score. So we need to modify that. That’s, I think, a great example of why the lower-volume practices need to be kept out of this process so they can continue to use their resources on patient care.”
Scott Hines, MD, member of the AMGA board of directors testified differently, arguing that less exclusion from participation is needed, because with around half of eligible physicians not required to participate, the pool for exceptional performance bonuses is significantly smaller than what would be the maximum available of up to 9% in 2023 as the years in the program advanced.
Between the low-volume exclusion and the budget neutrality of the program, there is little incentive to participate, he noted.
Few advanced alternative payment models plus the sunsetting bonus for participation couple to keep physician interest in value-based payment low, physician groups told the Senate Finance Committee.
“One important goal of MACRA [Medicare Access and CHIP Reauthorization Act] was to provide busy physicians with a path to transition into new, innovated payment models,” Barbara McAneny, MD, president of the American Medical Association testified during a May 8 hearing to review the first 2 years of Medicare’s Quality Payment Program (QPP).
MACRA – the law that created QPP – provided a 5% bonus to physicians and other professionals who participate in the first 6 years of the program; the payment was designed to help cover expenses needed to transition to value-based care.
“Unfortunately, during the first 3 years of the program, too few APM [advanced alternative payment model] options were available for physicians, and now only 3 years remain, which is not enough time for physicians to transition to an APM,” Dr. McAneny said, calling on Congress to extend the APM incentive for an additional 6 years.
John Cullen, MD, president of the American Academy of Family Physicians, also called on legislators to extend the APM bonus for at least 3-5 years.
He also advocated for changes to QPP’s Merit-based Incentive Program (MIPS), calling for the exceptional performance bonus to reward year-over-year improvement versus simply scoring high on MIPS criteria in a given year.
MIPS “has created a burdensome and extremely complex program that has increased practice costs and is contributing to physician burnout, Dr. Cullen testified. “Understanding the requirements and scoring for each MIPS performance category and reporting the required data to CMS is a complex task and detracts from physicians’ ability to focus on patients.”
Dr. McAneny put the costs and rewards of MIPS into perspective for lawmakers.
She testified that, in 2017, her small practice was a participant in MIPS and was able to achieve the highest MIPS score of 100. That score qualified the practice for an exceptional performance bonus, which ended up being a 1.88% bonus to Medicare payments.
“After the adjustment that occurred after that, it lowered that increase to where the entire change that I got was $34,000,” she said. “When I added up how much I had to pay my EMR [electronic medical record] to submit that data, when I added up everything that I had to do in terms of paying staff overtime to make sure the data was accurate, I lost $100,000 to score that perfect score. So we need to modify that. That’s, I think, a great example of why the lower-volume practices need to be kept out of this process so they can continue to use their resources on patient care.”
Scott Hines, MD, member of the AMGA board of directors testified differently, arguing that less exclusion from participation is needed, because with around half of eligible physicians not required to participate, the pool for exceptional performance bonuses is significantly smaller than what would be the maximum available of up to 9% in 2023 as the years in the program advanced.
Between the low-volume exclusion and the budget neutrality of the program, there is little incentive to participate, he noted.
REPORTING FROM A SENATE FINANCE COMMITTEE HEARING
HHS finalizes controversial conscience regulation
Health care professionals may not be compelled to provide medical care, including abortion services or even referrals, if they object on religious or moral grounds under a federal regulation finalized May 2.
The regulation also requires health care entities that receive federal funding to alert their employees to their federal conscience rights.
This final rule “replaces a 2011 rule that has proven inadequate, and ensures that HHS implements the full set of tools appropriate for enforcing the conscience protections passed by Congress,” HHS officials said in a statement. “These federal laws protect providers, individuals, and other health care entities from having to provide, participate in, pay for, provide coverage of, or refer for, services such as abortion, sterilization, or assisted suicide. It also includes conscience protections with respect to advance directives.”
The regulation was first proposed in January 2018, shortly after the formation of the Conscience and Religious Freedom Division within the HHS Office of Civil Rights (OCR).
Application of the regulation extends beyond the clinic and hospital. The regulation notes that, on a case-by-case basis, those providing emergency services such as EMTs or even ambulance drivers could be protected should they choose to exercise their conscience and not provide services based on their religious beliefs.
“With this final rule, the Department seeks to educate protected entities and covered entities as to their legal rights and obligations; to encourage individuals and organizations with religious beliefs or moral convictions to enter, or remain in, the health care industry; and to prevent others from being dissuaded from filing complaints due to prior OCR complaint resolutions or sub-regulatory guidance that no reflect the views of the Department,” according to the regulation.
HHS officials denied accusations that the regulation puts the needs of providers over those of patients.
By “protecting a diversity of beliefs among health care providers, these protections ensure that options are available to patients who desire, and would feel most comfortable with, a provider whose religious beliefs or moral convictions match their own. Even where a patient and provider do not share the same religious beliefs or moral convictions, it is not necessarily the case that patients would want providers to be forced to violate their religious beliefs or moral convictions,” according to the regulation.
However, the American Civil Liberties Union and others see the new regulation as license to discriminate.
“Once again, this administration shows itself to be determined to use religious liberty to harm communities it deems less worthy of equal treatment under the law,” Louise Melling, ACLU deputy legal director, said in a statement. “This rule threatens to prevent people from accessing critical medical care and may endanger people’s lives. Religious liberty is a fundamental right, but it does not include the right to discriminate or harm others. Denying patients health care is not religious liberty. Discriminating against patients based on their gender or gender expression is not religious liberty. Medical standards, not religious beliefs, should guide medical care.”
The regulation does not yet have a scheduled publication date in the Federal Register, nor has it been posted as a preview document on the publication’s website. It will become effective 60 days after publication.
Health care professionals may not be compelled to provide medical care, including abortion services or even referrals, if they object on religious or moral grounds under a federal regulation finalized May 2.
The regulation also requires health care entities that receive federal funding to alert their employees to their federal conscience rights.
This final rule “replaces a 2011 rule that has proven inadequate, and ensures that HHS implements the full set of tools appropriate for enforcing the conscience protections passed by Congress,” HHS officials said in a statement. “These federal laws protect providers, individuals, and other health care entities from having to provide, participate in, pay for, provide coverage of, or refer for, services such as abortion, sterilization, or assisted suicide. It also includes conscience protections with respect to advance directives.”
The regulation was first proposed in January 2018, shortly after the formation of the Conscience and Religious Freedom Division within the HHS Office of Civil Rights (OCR).
Application of the regulation extends beyond the clinic and hospital. The regulation notes that, on a case-by-case basis, those providing emergency services such as EMTs or even ambulance drivers could be protected should they choose to exercise their conscience and not provide services based on their religious beliefs.
“With this final rule, the Department seeks to educate protected entities and covered entities as to their legal rights and obligations; to encourage individuals and organizations with religious beliefs or moral convictions to enter, or remain in, the health care industry; and to prevent others from being dissuaded from filing complaints due to prior OCR complaint resolutions or sub-regulatory guidance that no reflect the views of the Department,” according to the regulation.
HHS officials denied accusations that the regulation puts the needs of providers over those of patients.
By “protecting a diversity of beliefs among health care providers, these protections ensure that options are available to patients who desire, and would feel most comfortable with, a provider whose religious beliefs or moral convictions match their own. Even where a patient and provider do not share the same religious beliefs or moral convictions, it is not necessarily the case that patients would want providers to be forced to violate their religious beliefs or moral convictions,” according to the regulation.
However, the American Civil Liberties Union and others see the new regulation as license to discriminate.
“Once again, this administration shows itself to be determined to use religious liberty to harm communities it deems less worthy of equal treatment under the law,” Louise Melling, ACLU deputy legal director, said in a statement. “This rule threatens to prevent people from accessing critical medical care and may endanger people’s lives. Religious liberty is a fundamental right, but it does not include the right to discriminate or harm others. Denying patients health care is not religious liberty. Discriminating against patients based on their gender or gender expression is not religious liberty. Medical standards, not religious beliefs, should guide medical care.”
The regulation does not yet have a scheduled publication date in the Federal Register, nor has it been posted as a preview document on the publication’s website. It will become effective 60 days after publication.
Health care professionals may not be compelled to provide medical care, including abortion services or even referrals, if they object on religious or moral grounds under a federal regulation finalized May 2.
The regulation also requires health care entities that receive federal funding to alert their employees to their federal conscience rights.
This final rule “replaces a 2011 rule that has proven inadequate, and ensures that HHS implements the full set of tools appropriate for enforcing the conscience protections passed by Congress,” HHS officials said in a statement. “These federal laws protect providers, individuals, and other health care entities from having to provide, participate in, pay for, provide coverage of, or refer for, services such as abortion, sterilization, or assisted suicide. It also includes conscience protections with respect to advance directives.”
The regulation was first proposed in January 2018, shortly after the formation of the Conscience and Religious Freedom Division within the HHS Office of Civil Rights (OCR).
Application of the regulation extends beyond the clinic and hospital. The regulation notes that, on a case-by-case basis, those providing emergency services such as EMTs or even ambulance drivers could be protected should they choose to exercise their conscience and not provide services based on their religious beliefs.
“With this final rule, the Department seeks to educate protected entities and covered entities as to their legal rights and obligations; to encourage individuals and organizations with religious beliefs or moral convictions to enter, or remain in, the health care industry; and to prevent others from being dissuaded from filing complaints due to prior OCR complaint resolutions or sub-regulatory guidance that no reflect the views of the Department,” according to the regulation.
HHS officials denied accusations that the regulation puts the needs of providers over those of patients.
By “protecting a diversity of beliefs among health care providers, these protections ensure that options are available to patients who desire, and would feel most comfortable with, a provider whose religious beliefs or moral convictions match their own. Even where a patient and provider do not share the same religious beliefs or moral convictions, it is not necessarily the case that patients would want providers to be forced to violate their religious beliefs or moral convictions,” according to the regulation.
However, the American Civil Liberties Union and others see the new regulation as license to discriminate.
“Once again, this administration shows itself to be determined to use religious liberty to harm communities it deems less worthy of equal treatment under the law,” Louise Melling, ACLU deputy legal director, said in a statement. “This rule threatens to prevent people from accessing critical medical care and may endanger people’s lives. Religious liberty is a fundamental right, but it does not include the right to discriminate or harm others. Denying patients health care is not religious liberty. Discriminating against patients based on their gender or gender expression is not religious liberty. Medical standards, not religious beliefs, should guide medical care.”
The regulation does not yet have a scheduled publication date in the Federal Register, nor has it been posted as a preview document on the publication’s website. It will become effective 60 days after publication.
CMS pushing primary care with two new payment models
“We’re launching CMS Primary Cares, an initiative of two new payment models that will enroll a quarter or more of traditional Medicare beneficiaries and a quarter of providers in arrangements that pay for keeping patients healthy, rather than ordering procedures,” Alex Azar, secretary of Health and Human Services, said April 22 during a press conference.
“Today’s announcement creates innovation in primary care that has the potential to entirely transform our fee-for-service system – which is about 65% of the Medicare program – into one that drives value,” Seema Verma, administrator of the Centers for Medicare & Medicaid Services, said during the press conference.
The voluntary models are an array of “new payment options that are all designed to reward [physicians] for keeping people healthy, improving quality of life and delivering positive health outcomes,” Ms. Verma said. “These models are intended to allow clinicians to focus on patient care, not billing, and to do what they’ve been trained to do.”
One option, the Primary Care First model, is aimed at small and solo primary care practices.
The model will “provide participating practices with a predictable payment stream, including a partial cap and some fee-for-service spend,” Ms. Verma said, adding that payments will be adjusted for performance in reducing hospitalizations.
Under Primary Care First, practices will receive a flat payment per beneficiary, allowing clinicians to focus more on care than on revenue cycle management, according to CMS. Practices will be able to receive bonuses of up to 50% or penalties of up to 10%, based on performance, as an incentive to reduce costs and improve quality. Performance will be assessed and paid quarterly. Specifics on the per-beneficiary payment were not released.
Participation in Primary Care First is limited to primary care professionals certified in internal medicine, general medicine, geriatric medicine, family medicine, and hospice and palliative medicine. Practices must provide services to at least 125 Medicare beneficiaries and primary care services must account for at least 70% of billing revenue. Practices also must have experience in value-based payments.
There also will be an option for enhanced payment for caring for patients with chronic illnesses.
“When a patient stays healthy and out of the hospital, these practices will get paid a bonus,” Secretary Azar said. “But if the patient ends up sicker than expected, these practices will bear responsibility for the extra spending up to a certain share of their practices’ revenue.”
More information about participating in the Primary Care First model will be available later in the spring of 2019, with the model launching in 2020.
A second option, the Direct Contracting model is “more ambitious and aimed at larger practices,” Mr. Azar said – those that serve at least 5,000 Medicare beneficiaries.
“Just like in Primary Care First, when patients have a better experience and stay healthier, these practices will make more money,” he continued. “But if patients end up sicker, Direct Contracting Practices will bear the risk for the extra health spending, not just at their own practice, but throughout the system.”
Options under the Direct Contracting model are designed for organizations ready to take on full financial risk that have experience managing large populations with accountable care organizations or working with Medicare Advantage plans, Ms. Verma explained.
The Direct Contracting model will start with two options. The Professional population-based payment (PBP) model offers a lower risk-sharing arrangement (50% savings/losses), while the Global PBP offers a 100% savings/losses risk-sharing arrangement.
CMS also is requesting information on a third payment model, the Geographic PBP model, which would have a similar risk-sharing arrangement as the Global PBP, but participants would assume responsibility for the total cost of care for all Medicare fee-for-service beneficiaries in a defined region.
This model also will launch in 2020.
The new Medicare primary care options were commended by quarters not always supportive of the current government.
Andy Slavitt, CMS administrator under President Obama, voiced his support for the new models.
“There are several watershed moments in the history of the Medicare program, like the coverage of prescription drugs and the shift to paying for better care,” he tweeted April 22. This announcement is “another one as it eases the connection of Medicare beneficiaries to a primary care physician and gives doctors the freedom, rewards, and tools to keep people healthy.”
He continued: “With this great starting point, even as CMS listens to input, physicians and patient groups should be considering who this helps move ... to a healthier country with a more sustainable system.”
The American Medical Association also voiced its support.
“Providing adequate financial support for high-quality primary care must be an essential element of any strategy to improve the quality and affordability of our country’s health care system, Gerald E. Harmon, MD, immediate past chair of the AMA Board of Trustees, said in a statement. “Many primary care physicians have been struggling to deliver the care their patients need and to financially sustain their practices under current Medicare payments. The new primary care payment models announced today will provide practices with more resources and more flexibility to deliver the highest-quality care to their patients.”
The American College of Physicians also noted their support of the new models.
“ACP is optimistic that the new models will emphasize the important role primary care plays in value-based care delivery, that models are voluntary and have a range of risk options, and that practices should use population health management data to reap potential benefits,” Robert McLean, MD, ACP president, said in a statement.
The success and viability of these models will depend on the extent that they are supported by payers in addition to Medicare and Medicaid, are adequately adjusted for differences in the risk and health status of patients seen by each practice, are provided predictable and adequate payments to support and sustain practices (especially smaller independent ones), are appropriately scaled for the financial risk expected of a practice, are provided meaningful and timely data to support improvement, and are truly able to reduce administrative tasks and costs, among other things.”
We are pretty excited about Primary Care First, for what it symbolizes.
The academy has long suggested that fee for service is not congruent with the core elements of advanced primary care, and our internal policies have asked for payments for primary care patients to be realigned in a way that would facilitate or drive this type of care.
There are a lot of details that we need to understand, but I think this model represents a really significant step towards prospective population-based payments. This model enables primary care physicians to continue to provide continuous and comprehensive care to their patients. It is a big step away from fee for service and we think that’s good for primary care.
I think primary care when it functions at its best really relies upon three elements; continuity and comprehensiveness are probably the two most important elements, and the third is coordination. These three elements are associated with better outcomes and lower cost in several studies. The idea that a patient would have a longitudinal (continuous) relationship with a primary care physician who provides comprehensive services is a desired policy objective.
This model, by implementing prospective, per patient payments, allows practices to focus on longitudinal patient-centered care versus episodes of care that drive revenue. The fee for service, in contrast, offers a payment by service, so it creates individual episodes of care. For the last decade we have questioned whether fee for service can really drive the key elements of primary care of the patient.
There’s always a place for fee for service, but as a foundation, I think the prospective nature of payments is a really important element of what the CMS did. Since physicians would receive payments in advance for providing comprehensive care, they won’t have to generate services to manage their revenue cycle.
I think the Direct Contracting payment model is interesting in that it requires a practice to have a minimum of 5,000 beneficiaries and involves the practice taking on risk for a large population of people. There are a lot more questions on the direct contracting side, but I think, philosophically, we could see why it would be a successful payment model.
From a 30,000 foot perspective, the Primary Care First program should allow any physician practice, regardless of size, to participate. It’s conceivable even for a solo practice to participate in this model.
Our main concern about this model is its geographic restrictions, and we would like to see more states added to this program quickly.
R. Shawn Martin is president of advocacy, practice advancement and policy of the American Academy of Family Physicians. He made these comments in an interview.
We are pretty excited about Primary Care First, for what it symbolizes.
The academy has long suggested that fee for service is not congruent with the core elements of advanced primary care, and our internal policies have asked for payments for primary care patients to be realigned in a way that would facilitate or drive this type of care.
There are a lot of details that we need to understand, but I think this model represents a really significant step towards prospective population-based payments. This model enables primary care physicians to continue to provide continuous and comprehensive care to their patients. It is a big step away from fee for service and we think that’s good for primary care.
I think primary care when it functions at its best really relies upon three elements; continuity and comprehensiveness are probably the two most important elements, and the third is coordination. These three elements are associated with better outcomes and lower cost in several studies. The idea that a patient would have a longitudinal (continuous) relationship with a primary care physician who provides comprehensive services is a desired policy objective.
This model, by implementing prospective, per patient payments, allows practices to focus on longitudinal patient-centered care versus episodes of care that drive revenue. The fee for service, in contrast, offers a payment by service, so it creates individual episodes of care. For the last decade we have questioned whether fee for service can really drive the key elements of primary care of the patient.
There’s always a place for fee for service, but as a foundation, I think the prospective nature of payments is a really important element of what the CMS did. Since physicians would receive payments in advance for providing comprehensive care, they won’t have to generate services to manage their revenue cycle.
I think the Direct Contracting payment model is interesting in that it requires a practice to have a minimum of 5,000 beneficiaries and involves the practice taking on risk for a large population of people. There are a lot more questions on the direct contracting side, but I think, philosophically, we could see why it would be a successful payment model.
From a 30,000 foot perspective, the Primary Care First program should allow any physician practice, regardless of size, to participate. It’s conceivable even for a solo practice to participate in this model.
Our main concern about this model is its geographic restrictions, and we would like to see more states added to this program quickly.
R. Shawn Martin is president of advocacy, practice advancement and policy of the American Academy of Family Physicians. He made these comments in an interview.
We are pretty excited about Primary Care First, for what it symbolizes.
The academy has long suggested that fee for service is not congruent with the core elements of advanced primary care, and our internal policies have asked for payments for primary care patients to be realigned in a way that would facilitate or drive this type of care.
There are a lot of details that we need to understand, but I think this model represents a really significant step towards prospective population-based payments. This model enables primary care physicians to continue to provide continuous and comprehensive care to their patients. It is a big step away from fee for service and we think that’s good for primary care.
I think primary care when it functions at its best really relies upon three elements; continuity and comprehensiveness are probably the two most important elements, and the third is coordination. These three elements are associated with better outcomes and lower cost in several studies. The idea that a patient would have a longitudinal (continuous) relationship with a primary care physician who provides comprehensive services is a desired policy objective.
This model, by implementing prospective, per patient payments, allows practices to focus on longitudinal patient-centered care versus episodes of care that drive revenue. The fee for service, in contrast, offers a payment by service, so it creates individual episodes of care. For the last decade we have questioned whether fee for service can really drive the key elements of primary care of the patient.
There’s always a place for fee for service, but as a foundation, I think the prospective nature of payments is a really important element of what the CMS did. Since physicians would receive payments in advance for providing comprehensive care, they won’t have to generate services to manage their revenue cycle.
I think the Direct Contracting payment model is interesting in that it requires a practice to have a minimum of 5,000 beneficiaries and involves the practice taking on risk for a large population of people. There are a lot more questions on the direct contracting side, but I think, philosophically, we could see why it would be a successful payment model.
From a 30,000 foot perspective, the Primary Care First program should allow any physician practice, regardless of size, to participate. It’s conceivable even for a solo practice to participate in this model.
Our main concern about this model is its geographic restrictions, and we would like to see more states added to this program quickly.
R. Shawn Martin is president of advocacy, practice advancement and policy of the American Academy of Family Physicians. He made these comments in an interview.
“We’re launching CMS Primary Cares, an initiative of two new payment models that will enroll a quarter or more of traditional Medicare beneficiaries and a quarter of providers in arrangements that pay for keeping patients healthy, rather than ordering procedures,” Alex Azar, secretary of Health and Human Services, said April 22 during a press conference.
“Today’s announcement creates innovation in primary care that has the potential to entirely transform our fee-for-service system – which is about 65% of the Medicare program – into one that drives value,” Seema Verma, administrator of the Centers for Medicare & Medicaid Services, said during the press conference.
The voluntary models are an array of “new payment options that are all designed to reward [physicians] for keeping people healthy, improving quality of life and delivering positive health outcomes,” Ms. Verma said. “These models are intended to allow clinicians to focus on patient care, not billing, and to do what they’ve been trained to do.”
One option, the Primary Care First model, is aimed at small and solo primary care practices.
The model will “provide participating practices with a predictable payment stream, including a partial cap and some fee-for-service spend,” Ms. Verma said, adding that payments will be adjusted for performance in reducing hospitalizations.
Under Primary Care First, practices will receive a flat payment per beneficiary, allowing clinicians to focus more on care than on revenue cycle management, according to CMS. Practices will be able to receive bonuses of up to 50% or penalties of up to 10%, based on performance, as an incentive to reduce costs and improve quality. Performance will be assessed and paid quarterly. Specifics on the per-beneficiary payment were not released.
Participation in Primary Care First is limited to primary care professionals certified in internal medicine, general medicine, geriatric medicine, family medicine, and hospice and palliative medicine. Practices must provide services to at least 125 Medicare beneficiaries and primary care services must account for at least 70% of billing revenue. Practices also must have experience in value-based payments.
There also will be an option for enhanced payment for caring for patients with chronic illnesses.
“When a patient stays healthy and out of the hospital, these practices will get paid a bonus,” Secretary Azar said. “But if the patient ends up sicker than expected, these practices will bear responsibility for the extra spending up to a certain share of their practices’ revenue.”
More information about participating in the Primary Care First model will be available later in the spring of 2019, with the model launching in 2020.
A second option, the Direct Contracting model is “more ambitious and aimed at larger practices,” Mr. Azar said – those that serve at least 5,000 Medicare beneficiaries.
“Just like in Primary Care First, when patients have a better experience and stay healthier, these practices will make more money,” he continued. “But if patients end up sicker, Direct Contracting Practices will bear the risk for the extra health spending, not just at their own practice, but throughout the system.”
Options under the Direct Contracting model are designed for organizations ready to take on full financial risk that have experience managing large populations with accountable care organizations or working with Medicare Advantage plans, Ms. Verma explained.
The Direct Contracting model will start with two options. The Professional population-based payment (PBP) model offers a lower risk-sharing arrangement (50% savings/losses), while the Global PBP offers a 100% savings/losses risk-sharing arrangement.
CMS also is requesting information on a third payment model, the Geographic PBP model, which would have a similar risk-sharing arrangement as the Global PBP, but participants would assume responsibility for the total cost of care for all Medicare fee-for-service beneficiaries in a defined region.
This model also will launch in 2020.
The new Medicare primary care options were commended by quarters not always supportive of the current government.
Andy Slavitt, CMS administrator under President Obama, voiced his support for the new models.
“There are several watershed moments in the history of the Medicare program, like the coverage of prescription drugs and the shift to paying for better care,” he tweeted April 22. This announcement is “another one as it eases the connection of Medicare beneficiaries to a primary care physician and gives doctors the freedom, rewards, and tools to keep people healthy.”
He continued: “With this great starting point, even as CMS listens to input, physicians and patient groups should be considering who this helps move ... to a healthier country with a more sustainable system.”
The American Medical Association also voiced its support.
“Providing adequate financial support for high-quality primary care must be an essential element of any strategy to improve the quality and affordability of our country’s health care system, Gerald E. Harmon, MD, immediate past chair of the AMA Board of Trustees, said in a statement. “Many primary care physicians have been struggling to deliver the care their patients need and to financially sustain their practices under current Medicare payments. The new primary care payment models announced today will provide practices with more resources and more flexibility to deliver the highest-quality care to their patients.”
The American College of Physicians also noted their support of the new models.
“ACP is optimistic that the new models will emphasize the important role primary care plays in value-based care delivery, that models are voluntary and have a range of risk options, and that practices should use population health management data to reap potential benefits,” Robert McLean, MD, ACP president, said in a statement.
The success and viability of these models will depend on the extent that they are supported by payers in addition to Medicare and Medicaid, are adequately adjusted for differences in the risk and health status of patients seen by each practice, are provided predictable and adequate payments to support and sustain practices (especially smaller independent ones), are appropriately scaled for the financial risk expected of a practice, are provided meaningful and timely data to support improvement, and are truly able to reduce administrative tasks and costs, among other things.”
“We’re launching CMS Primary Cares, an initiative of two new payment models that will enroll a quarter or more of traditional Medicare beneficiaries and a quarter of providers in arrangements that pay for keeping patients healthy, rather than ordering procedures,” Alex Azar, secretary of Health and Human Services, said April 22 during a press conference.
“Today’s announcement creates innovation in primary care that has the potential to entirely transform our fee-for-service system – which is about 65% of the Medicare program – into one that drives value,” Seema Verma, administrator of the Centers for Medicare & Medicaid Services, said during the press conference.
The voluntary models are an array of “new payment options that are all designed to reward [physicians] for keeping people healthy, improving quality of life and delivering positive health outcomes,” Ms. Verma said. “These models are intended to allow clinicians to focus on patient care, not billing, and to do what they’ve been trained to do.”
One option, the Primary Care First model, is aimed at small and solo primary care practices.
The model will “provide participating practices with a predictable payment stream, including a partial cap and some fee-for-service spend,” Ms. Verma said, adding that payments will be adjusted for performance in reducing hospitalizations.
Under Primary Care First, practices will receive a flat payment per beneficiary, allowing clinicians to focus more on care than on revenue cycle management, according to CMS. Practices will be able to receive bonuses of up to 50% or penalties of up to 10%, based on performance, as an incentive to reduce costs and improve quality. Performance will be assessed and paid quarterly. Specifics on the per-beneficiary payment were not released.
Participation in Primary Care First is limited to primary care professionals certified in internal medicine, general medicine, geriatric medicine, family medicine, and hospice and palliative medicine. Practices must provide services to at least 125 Medicare beneficiaries and primary care services must account for at least 70% of billing revenue. Practices also must have experience in value-based payments.
There also will be an option for enhanced payment for caring for patients with chronic illnesses.
“When a patient stays healthy and out of the hospital, these practices will get paid a bonus,” Secretary Azar said. “But if the patient ends up sicker than expected, these practices will bear responsibility for the extra spending up to a certain share of their practices’ revenue.”
More information about participating in the Primary Care First model will be available later in the spring of 2019, with the model launching in 2020.
A second option, the Direct Contracting model is “more ambitious and aimed at larger practices,” Mr. Azar said – those that serve at least 5,000 Medicare beneficiaries.
“Just like in Primary Care First, when patients have a better experience and stay healthier, these practices will make more money,” he continued. “But if patients end up sicker, Direct Contracting Practices will bear the risk for the extra health spending, not just at their own practice, but throughout the system.”
Options under the Direct Contracting model are designed for organizations ready to take on full financial risk that have experience managing large populations with accountable care organizations or working with Medicare Advantage plans, Ms. Verma explained.
The Direct Contracting model will start with two options. The Professional population-based payment (PBP) model offers a lower risk-sharing arrangement (50% savings/losses), while the Global PBP offers a 100% savings/losses risk-sharing arrangement.
CMS also is requesting information on a third payment model, the Geographic PBP model, which would have a similar risk-sharing arrangement as the Global PBP, but participants would assume responsibility for the total cost of care for all Medicare fee-for-service beneficiaries in a defined region.
This model also will launch in 2020.
The new Medicare primary care options were commended by quarters not always supportive of the current government.
Andy Slavitt, CMS administrator under President Obama, voiced his support for the new models.
“There are several watershed moments in the history of the Medicare program, like the coverage of prescription drugs and the shift to paying for better care,” he tweeted April 22. This announcement is “another one as it eases the connection of Medicare beneficiaries to a primary care physician and gives doctors the freedom, rewards, and tools to keep people healthy.”
He continued: “With this great starting point, even as CMS listens to input, physicians and patient groups should be considering who this helps move ... to a healthier country with a more sustainable system.”
The American Medical Association also voiced its support.
“Providing adequate financial support for high-quality primary care must be an essential element of any strategy to improve the quality and affordability of our country’s health care system, Gerald E. Harmon, MD, immediate past chair of the AMA Board of Trustees, said in a statement. “Many primary care physicians have been struggling to deliver the care their patients need and to financially sustain their practices under current Medicare payments. The new primary care payment models announced today will provide practices with more resources and more flexibility to deliver the highest-quality care to their patients.”
The American College of Physicians also noted their support of the new models.
“ACP is optimistic that the new models will emphasize the important role primary care plays in value-based care delivery, that models are voluntary and have a range of risk options, and that practices should use population health management data to reap potential benefits,” Robert McLean, MD, ACP president, said in a statement.
The success and viability of these models will depend on the extent that they are supported by payers in addition to Medicare and Medicaid, are adequately adjusted for differences in the risk and health status of patients seen by each practice, are provided predictable and adequate payments to support and sustain practices (especially smaller independent ones), are appropriately scaled for the financial risk expected of a practice, are provided meaningful and timely data to support improvement, and are truly able to reduce administrative tasks and costs, among other things.”
Medicare-for-All gets first legislative hearing
Medicare-for-All – the health care proposal that could play a key role in the 2020 presidential elections – got its first airing on Capitol Hill April 30 as the House Rules Committee discussed H.R. 1384.
The Medicare for All Act of 2019, introduced Feb. 27 by Rep. Pramila Jayapal (D-Wash.) and Rep. Debbie Dingell (D-Mich.), would provide universal coverage at the time of birth in the United States or upon the establishment of residency. The bill would make it unlawful for a private health insurer to sell coverage that duplicates the benefits of the Medicare-for-All system, and would prohibit employers from providing health insurance coverage that is provided by the Medicare-for-All system. At press time, the bill currently had 108 cosponsors, all Democrats.
Given the challenges the bill will face getting through the Democrat-controlled House – and the likelihood that the Republican-controlled Senate won’t even touch it – one Rules Committee member questioned why the hearing was being held.
Rep. Debbie Lesko (D-Ariz.) acknowledged that there are problems with health care and called for bipartisanship, noting problems of this magnitude need both sides of the aisle working together, but said she does not think H.R. 1384 has any chance of passage.
“Most, if not all, Republicans in the House are probably going to vote against it if it gets up for a vote and certainly the Senate is not going to hear it,” Rep. Lesko said. “I don’t know why we are doing this.”
Witnesses called by the committee offered differing takes on whether Medicare-for-All is feasible in the United States.
“A Medicare-for-All system of the type envisioned in the Jayapal bill is a huge step from our current system, which relies largely on private insurers,” according to Dean Baker, PhD, senior economist at the Center for Economic and Policy Research. “The list of transition problems that would arise is too long to address here. However, I would argue that it is essential that any move to such a system be done piecemeal since a quick changeover would virtually guarantee confusion and quite possibly lead to some people going without care.”
Indeed, many ideas contained in a number of different Medicare-for-All proposals could be implemented “without a major reorganization of the health care system,” according to Sara Collins, PhD, vice president of health care coverage and access at The Commonwealth Fund. “For example, paying providers in commercial plans at prices closer to those in Medicare or allowing the secretary of Health and Human Services to negotiate prescription drug prices have potential to slow health care cost growth and would not require an immediate shift to a single-payer system.
“On the other hand,” she continued, “moving piecemeal also involves trade-offs including the possibility, based on the experience of the [Affordable Care Act], that additional steps may take some time to achieve.”
Grace-Marie Turner, president of the Galen Institute, noted that many people, regardless of whether their coverage is public or private or not at all, have frustrations with the current health care delivery system.
“But it is hard to see how consumers would be more empowered when dealing with a single government payer,” she said. “In a country that values diversity, will one program with one list of benefits and set of rules work for everyone?”
If physician payment under Medicare-for-All were closer to what Medicare currently pays, “physicians would see 30% cuts. These payment reductions would gradually grow over time,” Ms. Turner testified.
Despite discussion of pay cuts, doctors invited to testify spoke in favor of a single-payer system.
“All I want is to practice medicine in a world where I no longer have to watch a patient walk out of the ER without medical care that could save their life because they are worried about going bankrupt,” said Farzon Nahvi, MD, an emergency physician at New York University Medical Center who serves on the board of directors for the New York Metro chapter of Physicians for a National Health Program. “From my perspective on the ground, the solution has to involve approaching medical care in just the same way we approach educating our children, maintaining our roads, and supporting our troops. This means treating health care like any other public good and creating a universal health care system like Medicare-for-All so that when they’re at their most vulnerable, my patients never have to make any consideration except to simply do what they need to do in order to get better.”
Doris Browne, MD, immediate past president of the National Medical Association agreed, calling for the adoption of “a system of universal coverage that minimizes administrative medical costs. It does not matter what label is used. Such an undertaking must include preventive care, screening, early detection, and treatment. The coverage would allow patients the ability to chose their provider, primary care or specialist. Care should be the same no matter where you live, rural or urban, California or Mississippi, and not be restricted based on language, age, gender, or race/ethnicity.”
Rep. Jim McGovern (D-Mass.), chairman of the Rules Committee, wrapped up the hearing noting that, even with some dissenting viewpoints, “what we have shown today, I believe, is that Medicare-for-All is possible; that we can build on the principles of the Affordable Care Act to make even bolder reforms. Reforms that would give doctors like Dr. Browne and Dr. Nahvi the ability to treat patients and give them the best care every time without letting cost dictate medical decisions. ... If you walk away with nothing else today, know that we have the ability to do that. Medicare-for-All is possible. It is reasonable. It can move forward and I think it should.”
Medicare-for-All – the health care proposal that could play a key role in the 2020 presidential elections – got its first airing on Capitol Hill April 30 as the House Rules Committee discussed H.R. 1384.
The Medicare for All Act of 2019, introduced Feb. 27 by Rep. Pramila Jayapal (D-Wash.) and Rep. Debbie Dingell (D-Mich.), would provide universal coverage at the time of birth in the United States or upon the establishment of residency. The bill would make it unlawful for a private health insurer to sell coverage that duplicates the benefits of the Medicare-for-All system, and would prohibit employers from providing health insurance coverage that is provided by the Medicare-for-All system. At press time, the bill currently had 108 cosponsors, all Democrats.
Given the challenges the bill will face getting through the Democrat-controlled House – and the likelihood that the Republican-controlled Senate won’t even touch it – one Rules Committee member questioned why the hearing was being held.
Rep. Debbie Lesko (D-Ariz.) acknowledged that there are problems with health care and called for bipartisanship, noting problems of this magnitude need both sides of the aisle working together, but said she does not think H.R. 1384 has any chance of passage.
“Most, if not all, Republicans in the House are probably going to vote against it if it gets up for a vote and certainly the Senate is not going to hear it,” Rep. Lesko said. “I don’t know why we are doing this.”
Witnesses called by the committee offered differing takes on whether Medicare-for-All is feasible in the United States.
“A Medicare-for-All system of the type envisioned in the Jayapal bill is a huge step from our current system, which relies largely on private insurers,” according to Dean Baker, PhD, senior economist at the Center for Economic and Policy Research. “The list of transition problems that would arise is too long to address here. However, I would argue that it is essential that any move to such a system be done piecemeal since a quick changeover would virtually guarantee confusion and quite possibly lead to some people going without care.”
Indeed, many ideas contained in a number of different Medicare-for-All proposals could be implemented “without a major reorganization of the health care system,” according to Sara Collins, PhD, vice president of health care coverage and access at The Commonwealth Fund. “For example, paying providers in commercial plans at prices closer to those in Medicare or allowing the secretary of Health and Human Services to negotiate prescription drug prices have potential to slow health care cost growth and would not require an immediate shift to a single-payer system.
“On the other hand,” she continued, “moving piecemeal also involves trade-offs including the possibility, based on the experience of the [Affordable Care Act], that additional steps may take some time to achieve.”
Grace-Marie Turner, president of the Galen Institute, noted that many people, regardless of whether their coverage is public or private or not at all, have frustrations with the current health care delivery system.
“But it is hard to see how consumers would be more empowered when dealing with a single government payer,” she said. “In a country that values diversity, will one program with one list of benefits and set of rules work for everyone?”
If physician payment under Medicare-for-All were closer to what Medicare currently pays, “physicians would see 30% cuts. These payment reductions would gradually grow over time,” Ms. Turner testified.
Despite discussion of pay cuts, doctors invited to testify spoke in favor of a single-payer system.
“All I want is to practice medicine in a world where I no longer have to watch a patient walk out of the ER without medical care that could save their life because they are worried about going bankrupt,” said Farzon Nahvi, MD, an emergency physician at New York University Medical Center who serves on the board of directors for the New York Metro chapter of Physicians for a National Health Program. “From my perspective on the ground, the solution has to involve approaching medical care in just the same way we approach educating our children, maintaining our roads, and supporting our troops. This means treating health care like any other public good and creating a universal health care system like Medicare-for-All so that when they’re at their most vulnerable, my patients never have to make any consideration except to simply do what they need to do in order to get better.”
Doris Browne, MD, immediate past president of the National Medical Association agreed, calling for the adoption of “a system of universal coverage that minimizes administrative medical costs. It does not matter what label is used. Such an undertaking must include preventive care, screening, early detection, and treatment. The coverage would allow patients the ability to chose their provider, primary care or specialist. Care should be the same no matter where you live, rural or urban, California or Mississippi, and not be restricted based on language, age, gender, or race/ethnicity.”
Rep. Jim McGovern (D-Mass.), chairman of the Rules Committee, wrapped up the hearing noting that, even with some dissenting viewpoints, “what we have shown today, I believe, is that Medicare-for-All is possible; that we can build on the principles of the Affordable Care Act to make even bolder reforms. Reforms that would give doctors like Dr. Browne and Dr. Nahvi the ability to treat patients and give them the best care every time without letting cost dictate medical decisions. ... If you walk away with nothing else today, know that we have the ability to do that. Medicare-for-All is possible. It is reasonable. It can move forward and I think it should.”
Medicare-for-All – the health care proposal that could play a key role in the 2020 presidential elections – got its first airing on Capitol Hill April 30 as the House Rules Committee discussed H.R. 1384.
The Medicare for All Act of 2019, introduced Feb. 27 by Rep. Pramila Jayapal (D-Wash.) and Rep. Debbie Dingell (D-Mich.), would provide universal coverage at the time of birth in the United States or upon the establishment of residency. The bill would make it unlawful for a private health insurer to sell coverage that duplicates the benefits of the Medicare-for-All system, and would prohibit employers from providing health insurance coverage that is provided by the Medicare-for-All system. At press time, the bill currently had 108 cosponsors, all Democrats.
Given the challenges the bill will face getting through the Democrat-controlled House – and the likelihood that the Republican-controlled Senate won’t even touch it – one Rules Committee member questioned why the hearing was being held.
Rep. Debbie Lesko (D-Ariz.) acknowledged that there are problems with health care and called for bipartisanship, noting problems of this magnitude need both sides of the aisle working together, but said she does not think H.R. 1384 has any chance of passage.
“Most, if not all, Republicans in the House are probably going to vote against it if it gets up for a vote and certainly the Senate is not going to hear it,” Rep. Lesko said. “I don’t know why we are doing this.”
Witnesses called by the committee offered differing takes on whether Medicare-for-All is feasible in the United States.
“A Medicare-for-All system of the type envisioned in the Jayapal bill is a huge step from our current system, which relies largely on private insurers,” according to Dean Baker, PhD, senior economist at the Center for Economic and Policy Research. “The list of transition problems that would arise is too long to address here. However, I would argue that it is essential that any move to such a system be done piecemeal since a quick changeover would virtually guarantee confusion and quite possibly lead to some people going without care.”
Indeed, many ideas contained in a number of different Medicare-for-All proposals could be implemented “without a major reorganization of the health care system,” according to Sara Collins, PhD, vice president of health care coverage and access at The Commonwealth Fund. “For example, paying providers in commercial plans at prices closer to those in Medicare or allowing the secretary of Health and Human Services to negotiate prescription drug prices have potential to slow health care cost growth and would not require an immediate shift to a single-payer system.
“On the other hand,” she continued, “moving piecemeal also involves trade-offs including the possibility, based on the experience of the [Affordable Care Act], that additional steps may take some time to achieve.”
Grace-Marie Turner, president of the Galen Institute, noted that many people, regardless of whether their coverage is public or private or not at all, have frustrations with the current health care delivery system.
“But it is hard to see how consumers would be more empowered when dealing with a single government payer,” she said. “In a country that values diversity, will one program with one list of benefits and set of rules work for everyone?”
If physician payment under Medicare-for-All were closer to what Medicare currently pays, “physicians would see 30% cuts. These payment reductions would gradually grow over time,” Ms. Turner testified.
Despite discussion of pay cuts, doctors invited to testify spoke in favor of a single-payer system.
“All I want is to practice medicine in a world where I no longer have to watch a patient walk out of the ER without medical care that could save their life because they are worried about going bankrupt,” said Farzon Nahvi, MD, an emergency physician at New York University Medical Center who serves on the board of directors for the New York Metro chapter of Physicians for a National Health Program. “From my perspective on the ground, the solution has to involve approaching medical care in just the same way we approach educating our children, maintaining our roads, and supporting our troops. This means treating health care like any other public good and creating a universal health care system like Medicare-for-All so that when they’re at their most vulnerable, my patients never have to make any consideration except to simply do what they need to do in order to get better.”
Doris Browne, MD, immediate past president of the National Medical Association agreed, calling for the adoption of “a system of universal coverage that minimizes administrative medical costs. It does not matter what label is used. Such an undertaking must include preventive care, screening, early detection, and treatment. The coverage would allow patients the ability to chose their provider, primary care or specialist. Care should be the same no matter where you live, rural or urban, California or Mississippi, and not be restricted based on language, age, gender, or race/ethnicity.”
Rep. Jim McGovern (D-Mass.), chairman of the Rules Committee, wrapped up the hearing noting that, even with some dissenting viewpoints, “what we have shown today, I believe, is that Medicare-for-All is possible; that we can build on the principles of the Affordable Care Act to make even bolder reforms. Reforms that would give doctors like Dr. Browne and Dr. Nahvi the ability to treat patients and give them the best care every time without letting cost dictate medical decisions. ... If you walk away with nothing else today, know that we have the ability to do that. Medicare-for-All is possible. It is reasonable. It can move forward and I think it should.”
REPORTING FROM THE HOUSE RULES COMMITTEE
CMS pushing primary care with two new payment models
“We’re launching CMS Primary Cares, an initiative of two new payment models that will enroll a quarter or more of traditional Medicare beneficiaries and a quarter of providers in arrangements that pay for keeping patients healthy, rather than ordering procedures,” Alex Azar, secretary of Health and Human Services, said April 22 during a press conference.
“Today’s announcement creates innovation in primary care that has the potential to entirely transform our fee-for-service system – which is about 65% of the Medicare program – into one that drives value,” Seema Verma, administrator of the Centers for Medicare & Medicaid Services, said during the press conference.
The voluntary models are an array of “new payment options that are all designed to reward [physicians] for keeping people healthy, improving quality of life and delivering positive health outcomes,” Ms. Verma said. “These models are intended to allow clinicians to focus on patient care, not billing, and to do what they’ve been trained to do.”
One option, the Primary Care First model, is aimed at small and solo primary care practices.
The model will “provide participating practices with a predictable payment stream, including a partial cap and some fee-for-service spend,” Ms. Verma said, adding that payments will be adjusted for performance in reducing hospitalizations.
Under Primary Care First, practices will receive a flat payment per beneficiary, allowing clinicians to focus more on care than on revenue cycle management, according to CMS. Practices will be able to receive bonuses of up to 50% or penalties of up to 10%, based on performance, as an incentive to reduce costs and improve quality. Performance will be assessed and paid quarterly. Specifics on the per-beneficiary payment were not released.
Participation in Primary Care First is limited to primary care professionals certified in internal medicine, general medicine, geriatric medicine, family medicine, and hospice and palliative medicine. Practices must provide services to at least 125 Medicare beneficiaries and primary care services must account for at least 70% of billing revenue. Practices also must have experience in value-based payments.
There also will be an option for enhanced payment for caring for patients with chronic illnesses.
“When a patient stays healthy and out of the hospital, these practices will get paid a bonus,” Secretary Azar said. “But if the patient ends up sicker than expected, these practices will bear responsibility for the extra spending up to a certain share of their practices’ revenue.”
More information about participating in the Primary Care First model will be available later in the spring of 2019, with the model launching in 2020.
A second option, the Direct Contracting model is “more ambitious and aimed at larger practices,” Mr. Azar said – those that serve at least 5,000 Medicare beneficiaries.
“Just like in Primary Care First, when patients have a better experience and stay healthier, these practices will make more money,” he continued. “But if patients end up sicker, Direct Contracting Practices will bear the risk for the extra health spending, not just at their own practice, but throughout the system.”
Options under the Direct Contracting model are designed for organizations ready to take on full financial risk that have experience managing large populations with accountable care organizations or working with Medicare Advantage plans, Ms. Verma explained.
The Direct Contracting model will start with two options. The Professional population-based payment (PBP) model offers a lower risk-sharing arrangement (50% savings/losses), while the Global PBP offers a 100% savings/losses risk-sharing arrangement.
CMS also is requesting information on a third payment model, the Geographic PBP model, which would have a similar risk-sharing arrangement as the Global PBP, but participants would assume responsibility for the total cost of care for all Medicare fee-for-service beneficiaries in a defined region.
This model also will launch in 2020.
The new Medicare primary care options were commended by quarters not always supportive of the current government.
Andy Slavitt, CMS administrator under President Obama, voiced his support for the new models.
“There are several watershed moments in the history of the Medicare program, like the coverage of prescription drugs and the shift to paying for better care,” he tweeted April 22. This announcement is “another one as it eases the connection of Medicare beneficiaries to a primary care physician and gives doctors the freedom, rewards, and tools to keep people healthy.”
He continued: “With this great starting point, even as CMS listens to input, physicians and patient groups should be considering who this helps move ... to a healthier country with a more sustainable system.”
The American Medical Association also voiced its support.
“Providing adequate financial support for high-quality primary care must be an essential element of any strategy to improve the quality and affordability of our country’s health care system, Gerald E. Harmon, MD, immediate past chair of the AMA Board of Trustees, said in a statement. “Many primary care physicians have been struggling to deliver the care their patients need and to financially sustain their practices under current Medicare payments. The new primary care payment models announced today will provide practices with more resources and more flexibility to deliver the highest-quality care to their patients.”
The American College of Physicians also noted their support of the new models.
“ACP is optimistic that the new models will emphasize the important role primary care plays in value-based care delivery, that models are voluntary and have a range of risk options, and that practices should use population health management data to reap potential benefits, Robert McLean, MD, ACP president, said in a statement. “ACP is supportive of the fact that the new models aim to reduce administrative burdens – potentially allowing physicians to spend more time with their patients.
“The success and viability of these models will depend on the extent that they are supported by payers in addition to Medicare and Medicaid, are adequately adjusted for differences in the risk and health status of patients seen by each practice, are provided predictable and adequate payments to support and sustain practices (especially smaller independent ones), are appropriately scaled for the financial risk expected of a practice, are provided meaningful and timely data to support improvement, and are truly able to reduce administrative tasks and costs, among other things,” he noted.
As a primary care physician, these new payment models proposed by the Centers for Medicare and Medicaid Services sound like a dream come true. Professional organizations and advocacy groups seem to unanimously agree this is a step in the right direction. Meanwhile, there are a few caveats for primary care docs wondering how much champagne to pop: These models apply to Medicare and some Medicaid contracts. As with any payment reform, the hope is that, if successful, these precedents set by CMS will be adopted by other payers throughout the market and extend to other patients’ plans. It is unclear how this care will be integrated into practices that serve patients with a large payer mix, though it seems to be a natural progression of the Comprehensive Primary Care Plus (CPC+) model practices.
The plans are currently available only in select regions of the United States and in practices that already have the capacity to perform some less traditional care delivery models, which may include home visits, coordination of hospital discharges, telehealth, and group visits.
The measurement of value-based care will likely rely on checkboxes like hemoglobin A1c targets and prescription of statins for secondary prevention of heart disease - measures we already know may be disproportionately more difficult to achieve in the presence of unfavorable “Social Determinants of Health.” The plans account for this by allowing for additional benefit payments for practices caring for “Seriously Ill Patients” or those with “Complex Chronic” conditions. However, it looks like these patients need to be proactively identified when the plans are contracted, and it is unclear who is responsible for determining these designations and how.
Lastly, and most significantly, like the CPC+ models and other similar direct-payment models of care, the practices must agree to carry most - or all - of the financial risk of these patients. Plain and simple, for some, the cost may still be too high.
Sarah G. Candler, MD, MPH, FACP is a primary care physician in Houston.
As a primary care physician, these new payment models proposed by the Centers for Medicare and Medicaid Services sound like a dream come true. Professional organizations and advocacy groups seem to unanimously agree this is a step in the right direction. Meanwhile, there are a few caveats for primary care docs wondering how much champagne to pop: These models apply to Medicare and some Medicaid contracts. As with any payment reform, the hope is that, if successful, these precedents set by CMS will be adopted by other payers throughout the market and extend to other patients’ plans. It is unclear how this care will be integrated into practices that serve patients with a large payer mix, though it seems to be a natural progression of the Comprehensive Primary Care Plus (CPC+) model practices.
The plans are currently available only in select regions of the United States and in practices that already have the capacity to perform some less traditional care delivery models, which may include home visits, coordination of hospital discharges, telehealth, and group visits.
The measurement of value-based care will likely rely on checkboxes like hemoglobin A1c targets and prescription of statins for secondary prevention of heart disease - measures we already know may be disproportionately more difficult to achieve in the presence of unfavorable “Social Determinants of Health.” The plans account for this by allowing for additional benefit payments for practices caring for “Seriously Ill Patients” or those with “Complex Chronic” conditions. However, it looks like these patients need to be proactively identified when the plans are contracted, and it is unclear who is responsible for determining these designations and how.
Lastly, and most significantly, like the CPC+ models and other similar direct-payment models of care, the practices must agree to carry most - or all - of the financial risk of these patients. Plain and simple, for some, the cost may still be too high.
Sarah G. Candler, MD, MPH, FACP is a primary care physician in Houston.
As a primary care physician, these new payment models proposed by the Centers for Medicare and Medicaid Services sound like a dream come true. Professional organizations and advocacy groups seem to unanimously agree this is a step in the right direction. Meanwhile, there are a few caveats for primary care docs wondering how much champagne to pop: These models apply to Medicare and some Medicaid contracts. As with any payment reform, the hope is that, if successful, these precedents set by CMS will be adopted by other payers throughout the market and extend to other patients’ plans. It is unclear how this care will be integrated into practices that serve patients with a large payer mix, though it seems to be a natural progression of the Comprehensive Primary Care Plus (CPC+) model practices.
The plans are currently available only in select regions of the United States and in practices that already have the capacity to perform some less traditional care delivery models, which may include home visits, coordination of hospital discharges, telehealth, and group visits.
The measurement of value-based care will likely rely on checkboxes like hemoglobin A1c targets and prescription of statins for secondary prevention of heart disease - measures we already know may be disproportionately more difficult to achieve in the presence of unfavorable “Social Determinants of Health.” The plans account for this by allowing for additional benefit payments for practices caring for “Seriously Ill Patients” or those with “Complex Chronic” conditions. However, it looks like these patients need to be proactively identified when the plans are contracted, and it is unclear who is responsible for determining these designations and how.
Lastly, and most significantly, like the CPC+ models and other similar direct-payment models of care, the practices must agree to carry most - or all - of the financial risk of these patients. Plain and simple, for some, the cost may still be too high.
Sarah G. Candler, MD, MPH, FACP is a primary care physician in Houston.
“We’re launching CMS Primary Cares, an initiative of two new payment models that will enroll a quarter or more of traditional Medicare beneficiaries and a quarter of providers in arrangements that pay for keeping patients healthy, rather than ordering procedures,” Alex Azar, secretary of Health and Human Services, said April 22 during a press conference.
“Today’s announcement creates innovation in primary care that has the potential to entirely transform our fee-for-service system – which is about 65% of the Medicare program – into one that drives value,” Seema Verma, administrator of the Centers for Medicare & Medicaid Services, said during the press conference.
The voluntary models are an array of “new payment options that are all designed to reward [physicians] for keeping people healthy, improving quality of life and delivering positive health outcomes,” Ms. Verma said. “These models are intended to allow clinicians to focus on patient care, not billing, and to do what they’ve been trained to do.”
One option, the Primary Care First model, is aimed at small and solo primary care practices.
The model will “provide participating practices with a predictable payment stream, including a partial cap and some fee-for-service spend,” Ms. Verma said, adding that payments will be adjusted for performance in reducing hospitalizations.
Under Primary Care First, practices will receive a flat payment per beneficiary, allowing clinicians to focus more on care than on revenue cycle management, according to CMS. Practices will be able to receive bonuses of up to 50% or penalties of up to 10%, based on performance, as an incentive to reduce costs and improve quality. Performance will be assessed and paid quarterly. Specifics on the per-beneficiary payment were not released.
Participation in Primary Care First is limited to primary care professionals certified in internal medicine, general medicine, geriatric medicine, family medicine, and hospice and palliative medicine. Practices must provide services to at least 125 Medicare beneficiaries and primary care services must account for at least 70% of billing revenue. Practices also must have experience in value-based payments.
There also will be an option for enhanced payment for caring for patients with chronic illnesses.
“When a patient stays healthy and out of the hospital, these practices will get paid a bonus,” Secretary Azar said. “But if the patient ends up sicker than expected, these practices will bear responsibility for the extra spending up to a certain share of their practices’ revenue.”
More information about participating in the Primary Care First model will be available later in the spring of 2019, with the model launching in 2020.
A second option, the Direct Contracting model is “more ambitious and aimed at larger practices,” Mr. Azar said – those that serve at least 5,000 Medicare beneficiaries.
“Just like in Primary Care First, when patients have a better experience and stay healthier, these practices will make more money,” he continued. “But if patients end up sicker, Direct Contracting Practices will bear the risk for the extra health spending, not just at their own practice, but throughout the system.”
Options under the Direct Contracting model are designed for organizations ready to take on full financial risk that have experience managing large populations with accountable care organizations or working with Medicare Advantage plans, Ms. Verma explained.
The Direct Contracting model will start with two options. The Professional population-based payment (PBP) model offers a lower risk-sharing arrangement (50% savings/losses), while the Global PBP offers a 100% savings/losses risk-sharing arrangement.
CMS also is requesting information on a third payment model, the Geographic PBP model, which would have a similar risk-sharing arrangement as the Global PBP, but participants would assume responsibility for the total cost of care for all Medicare fee-for-service beneficiaries in a defined region.
This model also will launch in 2020.
The new Medicare primary care options were commended by quarters not always supportive of the current government.
Andy Slavitt, CMS administrator under President Obama, voiced his support for the new models.
“There are several watershed moments in the history of the Medicare program, like the coverage of prescription drugs and the shift to paying for better care,” he tweeted April 22. This announcement is “another one as it eases the connection of Medicare beneficiaries to a primary care physician and gives doctors the freedom, rewards, and tools to keep people healthy.”
He continued: “With this great starting point, even as CMS listens to input, physicians and patient groups should be considering who this helps move ... to a healthier country with a more sustainable system.”
The American Medical Association also voiced its support.
“Providing adequate financial support for high-quality primary care must be an essential element of any strategy to improve the quality and affordability of our country’s health care system, Gerald E. Harmon, MD, immediate past chair of the AMA Board of Trustees, said in a statement. “Many primary care physicians have been struggling to deliver the care their patients need and to financially sustain their practices under current Medicare payments. The new primary care payment models announced today will provide practices with more resources and more flexibility to deliver the highest-quality care to their patients.”
The American College of Physicians also noted their support of the new models.
“ACP is optimistic that the new models will emphasize the important role primary care plays in value-based care delivery, that models are voluntary and have a range of risk options, and that practices should use population health management data to reap potential benefits, Robert McLean, MD, ACP president, said in a statement. “ACP is supportive of the fact that the new models aim to reduce administrative burdens – potentially allowing physicians to spend more time with their patients.
“The success and viability of these models will depend on the extent that they are supported by payers in addition to Medicare and Medicaid, are adequately adjusted for differences in the risk and health status of patients seen by each practice, are provided predictable and adequate payments to support and sustain practices (especially smaller independent ones), are appropriately scaled for the financial risk expected of a practice, are provided meaningful and timely data to support improvement, and are truly able to reduce administrative tasks and costs, among other things,” he noted.
“We’re launching CMS Primary Cares, an initiative of two new payment models that will enroll a quarter or more of traditional Medicare beneficiaries and a quarter of providers in arrangements that pay for keeping patients healthy, rather than ordering procedures,” Alex Azar, secretary of Health and Human Services, said April 22 during a press conference.
“Today’s announcement creates innovation in primary care that has the potential to entirely transform our fee-for-service system – which is about 65% of the Medicare program – into one that drives value,” Seema Verma, administrator of the Centers for Medicare & Medicaid Services, said during the press conference.
The voluntary models are an array of “new payment options that are all designed to reward [physicians] for keeping people healthy, improving quality of life and delivering positive health outcomes,” Ms. Verma said. “These models are intended to allow clinicians to focus on patient care, not billing, and to do what they’ve been trained to do.”
One option, the Primary Care First model, is aimed at small and solo primary care practices.
The model will “provide participating practices with a predictable payment stream, including a partial cap and some fee-for-service spend,” Ms. Verma said, adding that payments will be adjusted for performance in reducing hospitalizations.
Under Primary Care First, practices will receive a flat payment per beneficiary, allowing clinicians to focus more on care than on revenue cycle management, according to CMS. Practices will be able to receive bonuses of up to 50% or penalties of up to 10%, based on performance, as an incentive to reduce costs and improve quality. Performance will be assessed and paid quarterly. Specifics on the per-beneficiary payment were not released.
Participation in Primary Care First is limited to primary care professionals certified in internal medicine, general medicine, geriatric medicine, family medicine, and hospice and palliative medicine. Practices must provide services to at least 125 Medicare beneficiaries and primary care services must account for at least 70% of billing revenue. Practices also must have experience in value-based payments.
There also will be an option for enhanced payment for caring for patients with chronic illnesses.
“When a patient stays healthy and out of the hospital, these practices will get paid a bonus,” Secretary Azar said. “But if the patient ends up sicker than expected, these practices will bear responsibility for the extra spending up to a certain share of their practices’ revenue.”
More information about participating in the Primary Care First model will be available later in the spring of 2019, with the model launching in 2020.
A second option, the Direct Contracting model is “more ambitious and aimed at larger practices,” Mr. Azar said – those that serve at least 5,000 Medicare beneficiaries.
“Just like in Primary Care First, when patients have a better experience and stay healthier, these practices will make more money,” he continued. “But if patients end up sicker, Direct Contracting Practices will bear the risk for the extra health spending, not just at their own practice, but throughout the system.”
Options under the Direct Contracting model are designed for organizations ready to take on full financial risk that have experience managing large populations with accountable care organizations or working with Medicare Advantage plans, Ms. Verma explained.
The Direct Contracting model will start with two options. The Professional population-based payment (PBP) model offers a lower risk-sharing arrangement (50% savings/losses), while the Global PBP offers a 100% savings/losses risk-sharing arrangement.
CMS also is requesting information on a third payment model, the Geographic PBP model, which would have a similar risk-sharing arrangement as the Global PBP, but participants would assume responsibility for the total cost of care for all Medicare fee-for-service beneficiaries in a defined region.
This model also will launch in 2020.
The new Medicare primary care options were commended by quarters not always supportive of the current government.
Andy Slavitt, CMS administrator under President Obama, voiced his support for the new models.
“There are several watershed moments in the history of the Medicare program, like the coverage of prescription drugs and the shift to paying for better care,” he tweeted April 22. This announcement is “another one as it eases the connection of Medicare beneficiaries to a primary care physician and gives doctors the freedom, rewards, and tools to keep people healthy.”
He continued: “With this great starting point, even as CMS listens to input, physicians and patient groups should be considering who this helps move ... to a healthier country with a more sustainable system.”
The American Medical Association also voiced its support.
“Providing adequate financial support for high-quality primary care must be an essential element of any strategy to improve the quality and affordability of our country’s health care system, Gerald E. Harmon, MD, immediate past chair of the AMA Board of Trustees, said in a statement. “Many primary care physicians have been struggling to deliver the care their patients need and to financially sustain their practices under current Medicare payments. The new primary care payment models announced today will provide practices with more resources and more flexibility to deliver the highest-quality care to their patients.”
The American College of Physicians also noted their support of the new models.
“ACP is optimistic that the new models will emphasize the important role primary care plays in value-based care delivery, that models are voluntary and have a range of risk options, and that practices should use population health management data to reap potential benefits, Robert McLean, MD, ACP president, said in a statement. “ACP is supportive of the fact that the new models aim to reduce administrative burdens – potentially allowing physicians to spend more time with their patients.
“The success and viability of these models will depend on the extent that they are supported by payers in addition to Medicare and Medicaid, are adequately adjusted for differences in the risk and health status of patients seen by each practice, are provided predictable and adequate payments to support and sustain practices (especially smaller independent ones), are appropriately scaled for the financial risk expected of a practice, are provided meaningful and timely data to support improvement, and are truly able to reduce administrative tasks and costs, among other things,” he noted.