Keep Bonuses Coming for New Medicare Models, Senators Told

Extending them for another 3 years isn't enough, physcian associations tell a Senate committee.

This article was first published on Wednesday, May 8, 2019 in MedPage Today.

By Joyce Frieden, News Editor, MedPage Today

WASHINGTON -- Extending the 5% payment bonus for participating in one of Medicare's new advanced alternative payment models (APMs) would help encourage their adoption, witnesses told the Senate Finance Committee Wednesday, although they had different ideas on how long it should be extended.

"We urge Congress to extend the APM incentive for an additional 6 years," said Barbara McAneny, MD, president of the American Medical Association.

"We recommend the bonuses be extended for an additional 3-5 years," said John Cullen, MD, president of the American Academy of Family Physicians.

"A good first step would be to make MACRA's advanced APM bonus permanent," said Matthew Fiedler, PhD, fellow at the USC-Brookings Schaeffer Initiative for Health Policy.

Witnesses had plenty of other suggestions for lawmakers on ways to improve the Medicare Access and CHIP Reauthorization Act of 2015, which overhauled the way physicians were paid under the Medicare program.

Under MACRA, physicians have two choices: one is to participate in MACRA's Merit-Based Incentive Payment System program, in which they must report a certain amount of quality data from 2017 in order to avoid a cut in their Medicare reimbursement. Their other options is to participate in an advanced APM, such as an accountable care organization.

"The AMA is recommending that Congress replace the scheduled physician payment freeze beginning in 2020 with positive annual updates for physicians," said McAneny. "The recent Medicare Trustees report found scheduled physician payments are not expected to keep pace with physician practice costs."

"As a result, trustees say, access for Medicare patients will be a significant issue in the future. Positive payment updates are needed to provide physicians a margin to maintain their practice as well as transition to more efficient models of care delivery," she said.

"The AMA also urges Congress to continue to make technical changes to MACRA to simplify the program and make it more clinically significant," McAneny said. "The AMA continues to hear from physicians that the measures they're required to report are taking time away from patient care."

McAneny also urged the senators to modernize the Stark self-referral and federal anti-kickback laws, which she said were preventing physician practices from working together to offer services to patients.

For example, the laws prevent physicians from getting together to offer patients transportation to appointments, help with food insecurity, or other assistance with social determinants of health.

The AAFP's Cullen focused on administrative burdens.

"The AAFP is concerned that the complexity and cost of administrative functions are creating practice environments that are more focused on administrative tasks than patient care," he said. "We are concerned that MIPS has created a burdensome and extremely complex program that has increased practice costs and is contributing to physician burnout."

"Many of my colleagues are frustrated and angry ... the AAFP believes more must be done to [improve] patient care within MIPS by reducing administrative burdens."

Fiedler had a more radical solution.

"MIPS's approach of adjusting payments based on clinician or practice performance is ill-suited to create strong, coherent incentives to improve the quality and efficiency of patient care," he said. "The fact that clinicians can choose quality measures they report under MIPS also prevents MIPS from facilitating meaningful quality comparisons across providers."

 MIPS is also creating significant administrative costs, he added, noting that Medicare estimated that providers will spend $482 million reporting to MIPS in 2019.

"We agree with MedPAC [Medicare Payment Advisory Commission] and a number of other experts that the best path forward is to eliminate MIPS," he said. "Even a reformed MIPS would likely struggle to create effective incentives to improve care."

Scott Hines, MD, director of the American Medical Group Association, suggested that lawmakers "need to synchronize rules across federal ACO programs ... Currently, the rules change across the degree of risk you're taking."

The senators seemed to hear what the witnesses were telling them.

"MACRA is not without its challenges but it's certainly an improvement over the SGR [sustainable growth rate formula for physician reimbursement]," said Sen. Pat Roberts (R-Kan.). However, he added, "I have several concerns about how the law affects small and rural practices ... We have set up to pay them based on requirements that are often simply too burdensome for these practices ... Much more work needs to be done to make meaningful improvements for these providers and their patients."

Sen. Mark Warner (D-Va.) urged a bigger focus on improving interoperability of electronic health records. "We should have seen this train coming," he said. "We so overpromised [EHRs] ... On a broader [scale], we are going to move toward a more data-centric system" which needs to include data security and standards.

Frank Opelka, MD, medical director for quality and health policy at the American College of Surgeons, praised the work of the Physician-Focused Payment Model Technical Advisory Committee, which is helping to develop new APMs.

"PTAC is going through the work in conceptual modeling and that's fantastic," he said. "But then it fails when it gets to the Innovation Center [at the Centers for Medicare & Medicaid Services] ... It goes inside the government and gets lost."

The hearing started out on a somber note, with Sen. Ron Wyden (D-Ore.) announcing the passing of New York Times health policy reporter Robert Pear, who covered health policy in Washington for several decades.

"The legendary New York Times health reporter Robert Pear passed away yesterday, and he was a gold standard of healthcare reporting," said Wyden, whose voice broke during his statement.

"He was described as 'the most important reporter in Washington, D.C. that nobody had ever heard of,'" Wyden said. "For all of us on this committee, this is a really sad moment because a really good guy who cared passionately about people, and passionately about improving healthcare, and always [was] trying to appeal to the better angels, passed away yesterday way too young; he was 69."