4 changes to payment models physician groups want from CMS

Physician groups and value-based care proponents have written to CMS Administrator Seema Verma, MPH, asking for the agency to focus its efforts to promote the transition to value amongst independent physician practices.

Verma has cited concerns for smaller practices in many of her initiatives and agency’s regulations since taking the helm at CMS, such as exempting more clinicians from the Merit-based Incentive Payment System (MIPS) for 2018 and reducing process-focused quality measures. She’s also touched on concerns that CMS policies under the Obama administration encouraged the wave of consolidation in the healthcare industry, which the groups cited for advocating for their suggested changes to assist smaller practices.

“Physicians—especially independent physician practices—are the lynch pin of our nation’s health care system,” wrote Aledade, the Americian Academy of Family Physicians, CAPG, ChenMed, Iora Health, the Medical Group Management Association, and the Texas Medical Association. “They have repeatedly demonstrated their superior ability to generate positive results in value-based care arrangements, both in improved health outcomes and reduced costs. They are the most powerful tool we have to foster an affordable, accessible system that puts patients first.”

Here are their four recommendations for reforms from CMS:

1. Prioritize physician-led advanced alternative payment models (AAPMs)

More “advanced, higher-gain” models for two-sided risk should reflect the financial reality for independent practices, the group wrote, citing the Medicare Shared Savings Program Track 1+ as one example.

“New models should, over time, put physician practices at financial risk while offering greater reward for taking on risk,” the group wrote. “The risk must be proportional to the finances of independent physician practice and not so large as to favor consolidation of practices. In addition, models should provide more predictable and accurate benchmarks, as in Medicare Advantage, with regional benchmarks and risk adjustment.”

They added that CMS should consider creating a new version of the Next Generation ACO model for “full risk taking within traditional Medicare.”

2. Take action to combat consolidation

CMS should take stronger action to curb the consolidation trend in healthcare, the groups said, by reducing “regulatory incentives that undermine physician independence, create excessive consolidation, and thus drive up costs.” Specifically, they asked CMS to curb facility fees which can create higher rates for the same services based on setting, as well as take action on actions which larger health systems could use limit competition, like data blocking and physician non-compete clauses.

3. Create new demonstration on provider-run Medicare Advantage plans

More providers will become comfortable to take on downside risk, the groups wrote, and this expertise could be put to use to increase competition in Medicare Advantage markets. This could tested through a Center for Medicare and Medicaid Innovation (CMMI) project where providers interested in Medicare Advantage could simplify the administrative aspects of participation by “insourcing” claims processing and fraud detection to CMS.

4. Let patients share in the savings

Consumerism in healthcare is supported by the groups—despite evidence patients aren’t responding to the push to shop for services or better manage their costs—and they said CMS should go further by incentivizing that behavior. They suggested allowing primary care practices in a two-sided risk model to waive or reimburse patient cost-sharing on their recommendation, create behavioral incentive programs funded by the provider and allow share savings received from CMS with Medicare beneficiaries.