Should Medicare Pay Hinge on Seeing Medicaid, ACA Patients? CMS Asks

September 30, 2015

Updated November 11, 2015 — Editor's note: This story has been updated to include the revised deadline for comments, November 17, 2015.

The federal government is asking physicians whether their Medicare reimbursement should hinge in part on accepting new Medicaid patients or participating in provider networks of health plans offered through Affordable Care Act (ACA) exchanges.

The question comes as the Centers for Medicare & Medicaid Services (CMS) tries to flesh out the reimbursement system Congress enacted earlier this year to replace Medicare's sustainable growth rate formula for physician pay. Yesterday, CMS issued a formal request for information (RFI) asking physicians to weigh in on how exactly the new arrangement should work.

The law that abolished the sustainable growth rate — the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) — shifts reimbursement from volume to value without entirely eliminating fee-for-service. The centerpiece of MACRA is the Merit-Based Incentive Payment System (MIPS), which will consolidate the incentive program for meaningful use of an electronic health record (EHR) system, the Physician Quality Reporting System, and the value-based modifier program. Medicare will adjust fee-for-service payments to physicians up or down, depending on how they score on various measures of clinical quality, resource use (think cost control), meaningful use of EHR technology, and clinical practice improvement activities.

"A Very Interesting Policy Departure"

Similar to other laws, MACRA drafts a framework and leaves it to government regulators to fill in the details, such as, What are clinical practice improvement activities under MIPS that might fatten a Medicare payment? At the very least, the activities must fall into mandatory subcategories that include expanded practice access, population management, care coordination, and patient safety and practice assessment, according to MACRA. When CMS floated a draft of its 2016 Medicare fee schedule in July, it suggested activities that might fit into these subcategories, such as extended clinic hours for expanding practice access.

Yesterday's RFI proposes additional subcategories of clinical practice improvement activities that extend beyond the usual bounds of the Medicare program. One possible subcategory is called "promoting health equity and continuity." CMS said credit-earning activities under this umbrella could include:

  • serving Medicaid beneficiaries, including those also eligible for Medicare;

  • accepting new Medicaid beneficiaries;

  • participating in the provider network of an ACA health plan; and

  • maintaining wheelchairs and similar equipment for patients with disabilities.

Linking Medicare reimbursement to the care of non-Medicare patients, and underserved ones at that, strikes one veteran leader in organized medicine as "a very interesting policy departure."

"We're offering rewards for taking patients who have difficulty getting access and adequate care," said Jack Lewin, MD, president and chief executive officer of the Cardiovascular Research Foundation, in an interview with Medscape Medical News. "I think this is sound public policy. It will cause physicians to look differently at underserved populations. But the devil will be in the details."

Dr Lewin, formerly chief executive officer of the American College of Cardiology and the California Medical Association, said this proposal to sweeten Medicare pay addresses both Medicaid's struggle to recruit enough physicians and the existing economic disincentives to treat Medicare–Medicaid dual eligibles, "who need a lot of chronic care coordination and management to keep them out of the hospital."

CMS asked for comment on other possible subcategories of clinical practice improvement:

  • Social and Community Involvement: Referrals to social services or partnerships with community groups could count toward this subcategory.

  • Achieving Health Equity: Physicians could be rewarded "at a more favorable rate" for delivering high-quality care to underserved populations such as racial and ethnic minorities, "sexual and gender minorities," and rural inhabitants.

  • Emergency Preparedness and Response: Physicians could receive credit under this subcategory if they volunteered for humanitarian relief work.

  • Integration of Primary Care and Behavioral Care: An appropriate activity here might be cross-training clinicians to treat both medical and psychological problems.

CMS Mulls "Choosing Wisely" Guidelines as Cost-Control Standard

CMS sought feedback on other MIPS performance categories in addition to clinical practice improvement. Agency concerns about quality of care centered on how to submit performance data and ensure their accuracy.

The agency already has some experience measuring a physician's use of healthcare resources. Medicare's value-based payment modifier program, for example, looks at total per capita costs for all participating beneficiaries and breaks them out for those with specific conditions, such as diabetes. In its RFI, CMS asked whether it should consider other cost measures. The agency suggested possibly grading physicians on whether they avoided the kind of potentially harmful or overused services identified by the Choosing Wisely initiative, the brainchild of the American Board of Internal Medicine.

With regard to the EHR component of MIPS, CMS asked whether it should base a physician's score solely on "full achievement of meaningful use," or whether he or she should get credit for satisfying some of the program's requirements. Likewise, CMS wanted to know whether meaningful users who significantly exceed performance thresholds ought to receive extra credit.

Another section of MACRA needing regulatory specifics is the provision that allows individual clinicians and group practices of not more than 10 clinicians to join with others to form "virtual groups" so that MIPS can grade them collectively. This way, solo practices and small groups can pool their resources to satisfy MIPS requirements and still remain independent, according to the American Academy of Family Physicians.

The RFI from CMS seeks input on setting parameters for these virtual groups: How should their performance be assessed? Should there be a maximum or minimum size? Should there be geographic limits?

Alternative Payment Models Need Fine-tuning Too

MACRA calls for other forms of Medicare pay-for-performance that are more advanced than MIPS. These are the law's alternative payment models (APMs), which include patient-centered medical homes, accountable care organizations, and shared savings. Physicians who participate in them are exempt from MIPS. In addition to fee-for-service revenue, they will receive a 5% bonus each year from 2019 to 2024, provided they meet quality measures similar to those in MIPS and use certified EHR technology. In models other than medical homes, participants must assume significant, not nominal, financial risk for monetary losses.

The law's outline for APMs raises more questions that CMS would like answered: What is an appropriate level of financial risk? What should quality measures look like? And could medical homes established under state Medicaid programs qualify as APMs?

Although the deadline to comment on the agency's RFI was originally 30 days after it was published in the Federal Register on October 1, the deadline has been extended to November 17.

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