Federal Policy Updates

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Better Health – NOW Praises Draft Medicare Payment Rule but Calls for Bolder Action

September 11, 2023

In comments submitted to the Centers for Medicare and Medicaid Services (CMS) on September 11th, the Primary Care Collaborative’s Better Health – NOW Campaign backed several provisions of Medicare’s proposed 2024 Part B Physician Fee Schedule rule, while urging still bolder action to address the unfolding crisis in primary care workforce and access.

The comments reflect broad consensus across PCC’s multistakeholder Better Health – NOW Campaign. The letter calls on CMS to:

  • Invest in whole-person primary care by implementing payment for inherently complex care (the G2211 code) as well as improved reimbursement for behavioral health services and vaccine administration.
  • Bolster primary care in ACOs by quickly implementing a PCC/NAACOS hybrid proposal which would offer upfront, population-based payment options to Medicare Shared Savings Program (MSSP) primary care practices.
  • Help primary care teams support whole-person health, by finalizing reimbursement for lifestyle change and community health integration as well as improvements to behavioral health integration services.

PCC’s Better Health – NOW Campaign applauds CMS for their efforts to support primary care teams in addressing behavioral health and complex care needs. However, we encourage CMS to respond swiftly to the primary care crisis by increasing investment and offering pathways for practices to transition from fee for service to population-based, prospective payment models.
 

Download and read the full comment letter here.

Pay for What Patients Want: Primary Care for the Whole Person 

August 9, 2023

 

If you or someone you love depends on Medicare, you know managing that person’s health isn’t easy. Even on a good day, you may find yourself navigating multiple chronic health needs while simultaneously addressing the mental, behavioral and cognitive health conditions.  

If that’s your situation, continuous, whole person primary care - where a trusted clinician actually listens to you, gets to know you and ensures your goals and needs don’t get lost in our complicated healthcare system – can be a game changer.  If there was any doubt of that, research over the years continues to show that improved continuity in primary care reduces mortality while constraining health care expenditures and hospitalizations.  

Unfortunately, the way Medicare pays for health care tends to reward tests and procedures…but starves this kind of personalized primary care of the support it needs.   (That’s one reason why we see so many ads for the hospital’s latest surgical wing on billboards, but finding a timely primary care appointment keeps getting harder.) 

In two Presidential administrations – Republican and Democratic – Medicare officials have proposed that Medicare actually cover and pay for this kind of continuous, inherently complex care. (Medicare even gave the service a billing code: G2211.) After one Congressionally-mandated delay, that long-needed policy is now proposed to go into effect on January 1st, 2024.  

But some on Capitol Hill, at the urging of the same specialty lobbies who win out under today’s payment system, may be tempted to roll back Medicare’s proposal yet again. 

When much of health care quickly shuffles people through the doors, covering and paying for complex care could drive more resources to your trusted source for primary care. That support, in turn, can help your primary care practice do a better job of delivering all that goes into high-quality, whole person care…helping them dedicate the time needed to fully understand your health needs and build the primary care teams needed to address those needs. 

Paying for continuous, complex care over time is important but not a panacea. PCC’s Better Health – NOW Campaign has called for bolder and broader changes to how and how much we pay for primary care. But investing more now in complex care for people on Medicare is a critical down payment. 

At a time when the U.S. health system is weathering a primary care workforce crisis, another delay in in the G2211 policy and the complex care it supports would be an unacceptable step backwards.  

In our comments on this year’s annual Part B Medicare payment rule, PCC expects to praise Medicare officials for standing strong against political pressure.  Now Members of Congress have to follow their example.  

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Statement of Primary Care Collaborative President and CEO and leader of the Better Health – Now Campaign Ann Greiner on the Medicare Part B Notice of Proposed Rulemaking

July 14, 2023

 

“Twenty-seven diverse organizations have urged CMS to leverage the Medicare Shared Savings Program (MSSP) to transform how and how much the United States invests in primary care. Yesterday’s Notice of Proposed Rulemaking (NPRM) acknowledged the clear value of this hybrid payment approach to the health of people with Medicare. Even as it continues to engage stakeholders, CMS should waste no time in turning this acknowledgment into bold, broad-scale change.

“Medicare Part B’s fee schedule sets the pattern for alternative payment models, state Medicaid programs and private payers.  It’s encouraging that CMS has included proposals to better support complex care management, caregivers, behavioral health, diabetes prevention and community health worker/peer supporter programs. For a senior or disabled person on Medicare, especially those facing inequities, these services can be key to whole-person care, provided that care is built on a strong primary care foundation.

“Primary care is in crisis, and there is no time to waste. CMS should implement hybrid payment models within MSSP that offer flexibility needed to ensure adequate investment in primary care. PCC looks forward to a more detailed examination of the rule with our members - in light of the widening crisis in primary care workforce and access and the proposed rule’s overall impact on primary care payment.”

Ann Greiner, MCP
President & CEO of the Primary Care Collaborative
Leader of the Better Health – Now Campaign

 

 

For more information on the impact of the proposed rule on overall Medicare Part B payment, consult this CMS fact sheet which describes a 3.34% reduction in the Medicare conversion factor applied to fee schedule services.

For more information on the crisis in primary care workforce and access, see The Health of US Primary Care: A Baseline Scorecard Tracking Support for High-Quality Primary Care from the Milbank Memorial Fund and the Physician’s Foundation.

The above statement references a section of the NPRM, which states on page 672:

CMS has also continued to receive significant input from interested parties regarding opportunities to increase participation in ACO initiatives. One such option would be to identify ways that the Shared Savings Program can support ACOs’ efforts to strengthen primary care, such as by providing prospective payments for primary care that would reduce reliance on fee for-service payments and support innovations in care delivery that better meet beneficiary needs and increase access to primary care in underserved communities. Empirical data support the notion that primary care serves as the foundation of high-performing ACOs.

 

CMS Blog Post Touts New Portfolio-Wide Primary Care Strategy

June 13, 2023

On Friday evening, June 9th, the Centers for Medicare and Medicaid Services Innovation Center released a new primary care strategy envisioning multiple pathways to strengthen primary care financing, including a hybrid primary care payment option within MSSP. This is the approach that PCC, NAACOS and other stakeholders have championed. The new strategy follows the day after the announcement of the new Making Care Primary payment demonstration in eight states. (See PCC's statement on the new model HERE.) 

As detailed in the excerpt below, the new CMS strategy explicitly includes exploration of an MSSP-based hybrid primary care payment option. As primary care practices and their communities in all fifty states weather a workforce crisis, PCC is pressing CMS for a commitment to make a hybrid option as quickly as possible and on a nationwide basis. 

Taken together, last week’s developments and the Administration's efforts to strengthen Medicaid primary care  suggest important policy windows are opening–provided the primary care community can work together to make the most of them.  That is the focus at PCC and our Better Health – NOW Campaign. Reach out to our Director of Policy Larry Mcneely at lmcneely@thepcc.org to get further involved in this important work. 

 

Excerpt from CMS' Blog:

Future Pathways to Strengthen Primary Care Financing

“Evidence indicates that physician-led, primary-care-oriented ACOs generate more savings and have better outcomes compared to hospital-based ACOs.  To better support ACO-based primary care practices, the Innovation Center is exploring ACO-based primary care model tests that may focus on practices in the Shared Savings Program. Such a model could consider ways to provide increased investment through prospective payments that allow primary care clinicians the flexibility to deliver care to improve beneficiary quality, outcomes, experience, and health equity.” 

A New Approach to Paying for Primary Care in the Medicare Shared Savings Program

April 13, 2023

On April 23, 2023, PCC and the National Association of ACOs jointly published this blog, calling on CMS to rapidly implement a hybrid primary care payment option in the Medicare Shared Savings Program and detailing key principles and understandings related to the proposal.

Highlights:

  • Innovative payment models within accountable care organizations (ACOs) would strengthen primary care and advance CMS’ goal of having all traditional Medicare beneficiaries in a care relationship with accountability for quality and total cost of care by 2030.
  • There is broad multistakeholder support for a hybrid payment option within the Medicare Shared Savings Program (MSSP), including primary care clinicians, ACOs, consumer organizations, health plans and others.
  • CMS should implement a hybrid primary care payment model within MSSP that accommodates the differing needs and capabilities of various primary care practice types. 

By Ann Greiner, Aisha Pittman, Larry McNeely, Alyssa Neumann 

Continued underinvestment in primary care, increased administrative burden, and lingering effects of the COVID-19 pandemic have dramatically undermined access to primary care that’s essential for better health. There is growing consensus that payment reform is necessary to create a robust primary care system, changing both how and how much we pay. Evidence has shown that prospective payments offer primary care practices the flexibility to transform care delivery and provide comprehensive, team-based care. Specifically, the National Academies of Sciences, Engineering, and Medicine (NASEM) recommends shifting primary care payment toward hybrid models that include prospective population-based payment in addition to a per-visit payment. 

ACOs offer opportunity to test payment shifts
The accountable care model is built on a foundation of comprehensive, coordinated, team-based primary care and stands to benefit from improvements that strengthen that foundation. As the largest and only permanent ACO program, serving nearly 11 million traditional Medicare beneficiaries, the MSSP is well-positioned to drive primary care payment innovation. Given CMS’ existing authority to implement partial capitation within the MSSP and test new ways of payment through the CMS Innovation Center, the model offers the opportunity to rapidly implement hybrid payments for primary care. 

Leading voices from the primary care and accountable care communities agree. On March 22, 27 diverse organizations, representing primary care clinicians, ACOs, medical groups, consumer advocates, mental health, and health care payers sent a letter to CMS leadership calling on the agency to establish a new hybrid primary care payment option in the MSSP this year. Additionally, the letter outlines six principles to guide the approach:

  • Equity considerations must be embedded in the hybrid payment option.
  • There will be added value for the Medicare beneficiary.
  • The option must result in increased investment in primary care.
  • The option must be fully voluntary.
  • The option must be available rapidly and in all geographies.
  • Implementing this option will create additional value for Medicare. 

Two payment approaches to recognize varying practice needs and capabilities
The Primary Care Collaborative (PCC) and National Association of ACOs (NAACOS) brought together ACOs and primary care stakeholders to discuss implementation of a hybrid payment option within the MSSP. These discussions uncovered three additional shared understandings that can and should inform CMS’ work. First, one size cannot fit all. In any given community, the primary care needs can differ; ACOs and primary care practices may have varying capabilities for managing population-based payments. Second, additional support may be needed to promote new entrants to join MSSP and ensure success for rural, independent, and safety net practices. Finally, increased investment in primary care is a must. While achieving this won’t necessarily be easy under CMS’ current requirements for models, delaying reconciliation or recouping the increased primary care payments through future shared savings can support increased investment in primary care. These strategies recognize the longer-term ROI of advanced primary care and the time it takes for new ACOs to generate shared savings. 

To meet practices where they are and encourage broad participation, we propose CMS offer two payment approaches within the hybrid primary care payment option. 

Approach 1: CMS pays prospective and per-visit payments directly to the primary care practices, with a portion paid to the ACO. Participating practices and ACOs would select from a range of options based on practice capabilities and the services included in capitated payments. The payment portion withheld for the ACO could be used to fund infrastructure, data analytics, care coordination services, and performance incentives for delivering high-value care. The options selected would be mutually agreed upon by the ACO and the participating practices. This approach will likely be most suitable for ACOs that lack the infrastructure and experience to administer payments. 

Approach 2: CMS makes payments directly to the ACO, which administers the capitated payments to participating primary care practices. This approach is similar to the methodology being tested in the ACO Realizing Equity, Access, and Community Health (REACH) Model and is likely most suitable for ACOs with the experience and infrastructure to pay practices. Similar to the first approach, the downstream payment arrangements would be mutually agreed upon by the ACO and its participating primary care practices, with details outlined in the Participation Agreements. In addition to sub-capitation, payments from the ACO may include a bonus pool or other incentives to reward the delivery of high-value care. 

Guided by the principles described above, a hybrid primary care payment option in MSSP can help Medicare, primary care practices, and ACOs deliver better health. We encourage CMS to rapidly implement these approaches. CMS should send a clear signal of agency action on the proposal this year.

27 Organizations, led by PCC and NAACOS, Urge CMS to Create Primary Care Hybrid Payment Option in MSSP

March 23, 2023

For Media Inquiries: Edward Walrod, Senior Communications Manager, PCC, ewalrod@thepcc.org

In a March 22nd letter, 27 diverse organizations that support primary care  including the Primary Care Collaborative (PCC) and the National Association of ACOs (NAACOs), called on the Centers for Medicare and Medicaid Services (CMS) to establish a new hybrid primary care payment option in the Medicare Shared Savings Program (MSSP).  Building on the recommendations of PCC's Better Health-NOW campaign, this new approach would offer practices a combination of prospective and fee for service payments to bring better health outcomes, greater equity, and lower costs to patients and providers.

The United States is systematically underinvesting in primary care, leading to erosion of the primary care workforce and a greater number of U.S. residents without a usual source of care, according to recent findings. In the letter, PCC, NAACOs and other signatories urge CMS to implement the hybrid payment model in MSSP this year – arguing that it is  critical that we change how and how much primary care is paid to give patients the better health they deserve.

 

The PCC joins the Smarter HealthCare Coalition in Supporting the Reintroduction of the Chronic Disease Management Act (S. 655)

March 8, 2023

On March 6, 2023, the Smarter HealthCare Coalition, of which PCC is a member, sent a letter to Senate leadership expressing support for the reintroduction of the Chronic Disease Management Act (S. 655). The Coalition represents a broad-based, diverse group of health care stakeholders, including consumer groups, employers, health plans, life science companies, provider organizations, and academic centers.

Access to high-value health care services is an area of focus for the Smarter Health Coalition including work to ensure that the millions of Americans in High-Deductible Health Plans with Health Savings Accounts have access to services and medications to manage chronic conditions on a pre-deductible basis.

The bill would ensure high-deductible health plans (HDHPs) that are used with health savings accounts (HSAs) can cover care related to chronic disease management prior to a beneficiary reaching their plan deductible. The bill would also help address the impacts of chronic diseases by allowing patients that are enrolled in HDHPs greater flexibility in accessing the care they need.

Amidst a Tough Season for Primary Care, There Could Be Better Weather Ahead

February 1, 2023

This winter has been hard for primary care practices - and for the health of their patients. 

 A confluence of flu, RSV, and resurgent COVID challenged a primary care platform already weathering nearly three years of COVID and mental health challenges.  

Unfortunately, primary care’s situation today is no accident of nature; decades of policy choices have left many practices, particularly those in underserved communities, in fee-based reimbursement systems that do not adequately recognize their contributions. No matter the community we live in, this systematic underinvestment in primary care undermines our shared goal of better health. Congress’ year-end omnibus legislation, with its Medicare fee cut and phase-down of value-based care incentives, added insult to injury.  These retrenchments were balanced in part by helpful telehealth, mental health, children, and maternal health provisions. 

Yet in this New Year, there are signs of optimism with at least some policymakers having heard PCC's message: this nation’s health depends on changing how and how much we invest in primary care: 

  1. Education and Training: With the first 200 additional medical residency slots funded by Medicare since 1996, the Department of Health and Human Services allocated nearly three out of four to primary care including obstetrics/gynecology as well as psychiatry. This follows $13 million in HRSA nursing workforce investments last year. 
  1. Medicaid: The Center for Medicaid and CHIP Services will now provide federal matching dollars if state Medicaid programs reimburse for interprofessional consultation and initiatives to address unmet, health-related social needs – important steps to serving complex Medicaid populations in the primary care setting 
  1. MedPAC: Congress’ designated advisors for Medicare payment voted to recommend a new bonus for safety net practices: 15% for primary care compared to 5% for other specialties 
  1. State Capitols: Just a few days into 2023’s state legislative sessions, PCC’s brand-new State Primary Care Investment Hub already shows Massachusetts, Minnesota, Nevada, and Oklahoma legislators introducing bills to measure and/or strengthen primary care investment – joining 19 states that have already taken steps to do so. 

Could these rays of winter sunshine portend a broader break in the weather for federal primary care policy?  We await with anticipation the expected HHS Action Plan to Strengthen Primary Health Care and this year’s Medicare and Medicaid rulemaking to show that policymakers are taking significant steps to strengthen the primary care platform as a key lever to improve the health of the nation. In the meantime, PCC’s Better Health – NOW Campaign will keep insisting federal policymakers chart a bolder course in primary care – one that delivers better health for all our families and communities. If your organization is not yet involved, contact Larry McNeely at lmcneely@thepcc.org. 

Medicaid Moves to Ease Impacts of Post-Emergency Disenrollments

February 1, 2023

The COVID-19 pandemic resulted in numerous federal policies and temporary flexibilities, some of which directly impacted Medicaid eligibility and enrollment. According to the Kaiser Family Foundation, Medicaid and CHIP program enrollment grew by nearly 29 percent, between February 2020 and September 2022. As of September 2022, over 90 million people were enrolled in Medicaid and CHIP. 

The enrollment growth is largely due to states’ implementation of continuous enrollment and receiving a temporary bump in Federal Medical Assistance Percentage (FMAP) support in response to the COVID-19 pandemic.  

As we emerge from the declared public health emergency, The Centers for Medicare and Medicaid Services (CMS) issued an update to states to help them maintain continuity of coverage as they navigate the looming expiration of COVID-19 flexibilities and policies. For example, states will have 12 months at the end of the declared emergency to resume regular enrollment and verification operations.  

PCC Convenes Member Working Group to Chart Course on Medicaid Policy

February 1, 2023

Next month, with support from the California Health Care Foundation, PCC is convening a small group of  external experts and advocates drawn from PCC Executive Membership – charged with identifying effective Medicaid strategies that improve primary care utilization and outcomes.  The working group’s formation follows a new level of PCC engagement on Medicaid and CHIP issues in 2022. (See HERE and HERE) 

Informed by an environmental scan of levers for change at the federal and state levels and the deliberations of this working group, PCC plans to release an issue brief and identify policy options for consideration by PCC’s Better Health – NOW campaign.  Stay tuned for more later this year. 

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