Arnold Ventures submitted a formal comment in response to the Centers for Medicare & Medicaid Services (CMS)’s annual Medicare Physician Fee Schedule Proposed Rule, which plays a critical role in shaping our health care system.
Each year, the Medicare Physician Fee Schedule (MPFS) determines how clinicians are paid for services provided to the 33 million Americans with traditional Medicare and the relative difference in reimbursement levels across primary and specialty care, which in turn can influence how private insurers pay clinicians. It also impacts the Medicare Shared Savings Program (MSSP), a promising alternative payment approach that encourages primary care clinicians, specialists and hospitals serving Medicare beneficiaries to come together to work as accountable care organizations (ACOs). ACOs give providers greater flexibility to deliver patient care while holding them accountable for the quality and total cost of care.
Below is a high-level overview of AV’s comments and suggestions to support a health care system oriented around higher quality, less costly care that meets the individual needs of patients.
Arnold Ventures supports offering successful ACOs the option to receive prepaid shared savings in the form of quarterly, prospective payments rather than as an annual, lump sum payment several months after the end of the performance year. This quarterly approach allows ACOs to better plan for and invest in resources that can support the delivery of high quality, person-centered care. However, AV encourages CMS to drop the proposal’s requirement that participating ACOs use 50 percent of these funds on direct beneficiary services. Instead, AV believes that ACOs are well-positioned to determine the appropriate use of these funds on their own, based on the specific needs of their clinicians and the populations they serve, and should retain the same flexibility ACOs currently have to allocate shared savings as they see fit.
CMS also proposes creating a health equity benchmark adjustment (HEBA) for the MSSP that provides ACOs serving a higher proportion of beneficiaries from historically underserved communities a direct increase to their spending benchmark used to determine savings. While AV applauds CMS’ goal to advance equity and ensure rural and vulnerable populations receive the care they deserve, the proposed design of the HEBA presents a problematic tradeoff between health equity adjustments and other existing upward adjustments to an ACO’s benchmark for prior savings and regional efficiency, conflating risk adjustment with the goals of benchmarking policy. AV recommends alternative designs to achieve health equity goals, such as the policies used in models like ACO REACH, where the HEBA is applied to all eligible ACOs separately from other benchmark adjustments.
AV applauds the proposed changes to the fee schedule to improve payment accuracy. In particular, AV supports CMS’ interest in improving the accuracy of 90-day global surgery codes that are used to reimburse providers for all services associated with a surgical procedure. As clinicians today deliver considerably less follow-up services than they did decades prior when the rule was introduced, surgeons may often receive payment for care they did not provide. CMS’ proposal would help ensure more accurate and appropriate payment moving forward. Beyond this proposal, AV encourages the administration take additional steps to further improve accuracy of global surgery codes and address misvaluation in the fee schedule more broadly
Lastly, AV supports the introduction of new advanced primary care management codes to compensate providers with greater accuracy for the time and intensity associated with comprehensive, advanced and flexible primary care, which is far too often undervalued. However, while this change is a potential improvement to the status quo, relying on additional fee schedule codes is not likely to be a long-term solution for primary care. AV encourages CMS to continue exploring more transformative and holistic policy reforms to primary care payment, including implementing hybrid capitated payment.
Read our full letter here.
