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Originally published in the November 1, 2022, issue of MGMA’s MGMA Regulatory Alert Reprinted with permission from MGMA
The Centers for Medicare & Medicaid Services (CMS) released the final 2023 Medicare Physician Fee Schedule (PFS) rule this afternoon, which in addition to major payment implications, includes changes to the Merit-based Incentive Payment System (MIPS) and alternative payment model (APM) participation options and requirements for 2023. The final rule:
Sets 2023 Medicare payment rates for physician services. For 2023, CMS finalized a conversion factor of $33.0607 and $20.6097 for Anesthesia (a decrease of -4.47% and -4.42%, respectively, over final 2022 rates);
Finalizes implementation of provisions of the Consolidated Appropriations Act, 2022 that extend the application of certain Medicare telehealth flexibilities for an additional 151 days after the end of the COVID-19 public health emergency (PHE), such as allowing telehealth services to be furnished to patients in their homes;
Extends flexibilities to permit split/shared E/M visits to be billed based on one of three components (history, exam, or medical decision making) or time until 2024;
Expands access to behavioral health by permitting marriage and family therapists, licensed professional counselors, and others to furnish behavioral health services under general supervision instead of direct;
Maintains the MIPS performance threshold at 75 points for the 2023 MIPS performance year/2025 payment year;
Adds five new MIPS Value Pathways related to nephrology, oncology, neurological conditions, and promoting wellness, for voluntary reporting beginning in 2023; and
Creates an advanced incentive payment pathway for certain low-revenue, new entrant accountable care organizations to bolster participation in the Medicare Shared Savings Program.
MGMA submitted detailed comments in response to the proposed rule in September. Be on the lookout for a more detailed analysis of the final changes to physician payment policies and the Quality Payment Program (QPP) in the coming weeks.
2021 Alliance sponsor feature article courtesy of Pearl Health
It’s no secret that the U.S. healthcare system could benefit from a healthy dose of creativity and innovation. Over the past several decades, healthcare costs have been rising at an unsustainable rate, while patient outcomes have been less than ideal. Efforts to create a more value-based healthcare system, which have featured an especially concerted effort over the last decade, have thus far not succeeded. In recognition of this reality, the Centers for Medicare/Medicaid Services (CMS) has recently introduced its Direct Contracting model. Specifically designed to encourage innovative healthcare ideas, Direct Contracting will hopefully lead us toward a more value-based healthcare system.
Many healthcare organizations and providers believe the Direct Contracting model has tremendous potential. While the model is currently being used only for Medicare beneficiaries, many hope that its central themes–provider capitation, quality measures with minimal administrative overhead for practices, and global risk sharing–may soon be adopted by private payers and providers furnishing care in the commercial sector. Such proliferation will depend on the model’s initial success in managing costs of the Medicare population and how well providers adapt. If the model works as planned, it will incentivize innovative healthcare strategies, leading to better outcomes and lower costs. With this in mind, it’s essential that healthcare professionals understand ways to innovate in this environment.
It is well known that many healthcare systems lack efficient operational workflows. This is especially true in coordinating care among different care settings in and out of various facilities. Therefore, innovative healthcare ideas are needed to streamline many of these more complex care activities. The Direct Contracting model accomplishes this by linking rewards to value-based outcomes. As a result, all stakeholders are motivated to develop more efficient and coordinated processes of care. Healthcare organizations can leverage the Direct Contracting model’s investment capital construct (i.e. the ‘enhanced cap’) to pursue better workflow efficiencies. Likewise, they can encourage the use of standardized workflows that are patient-centric in an effort to reduce care variations. Similar to Lean Six Sigma approaches, these efforts reduce waste while improving the capacity for predictable and reproducible results. This is an area of innovation needed for many healthcare systems today.
Innovative Healthcare Strategy #2 – Advance Digital Integrations
Advancing and streamlining digital integrations across the healthcare system may lead to more efficient healthcare delivery. Interoperability, the ability of different digital healthcare platforms to communicate, has been a barrier for efficient and effective healthcare. Healthcare systems can use the Direct Contracting model to encourage improved connectivity and interoperability by incentivizing such investment through outcomes alignment. This inherently reduces waste by limiting duplication services and increases access to information for better decision-making. Such connectivity can also improve the insight of analytics efforts, providing healthcare systems with better data to drive future changes. By investing in these types of activities, organizations can better thrive under the Direct Contracting model and reap the rewards.
Under CMS’s Direct Contracting model, Direct Contracting Entities (DCEs) have the ability to structure bespoke risk contracts with the providers that they engage. A DCE may choose different risk tracks, taking on 50% or 100% of the risk and shared savings benefits. While past ACO programs allowed for similar risk-sharing, DCEs are afforded greater freedom to create more targeted risk-based and capitated contracts with providers that incentivize them to develop innovative healthcare solutions. This is one of the major advantages of the Direct Contracting model that did not exist with prior CMS approaches to value-based healthcare.
Innovative Healthcare Strategy #4 – Engage and Involve Patients
The Direct Contracting model places the burden to develop innovative healthcare solutions on DCEs and member providers. Yet the involvement of patients is critical to the success of efforts to achieve performance improvement in value-based care. By empowering and incentivizing patients to engage in this manner, DCEs can make better, more informed choices about which strategies they will invest in and patients can contribute to self-care and self-monitoring. DCEs and providers should therefore invest resources in educating and training patients in these areas. In doing so, they are better able to utilize patient resources that reduce costs and lead to better results. These types of activities also broaden care coordination across additional care settings that include the patient’s home environments.
Embracing a Culture of Innovation in Healthcare
Each of the above strategies can help organizations and providers realize more innovative healthcare practices. The Direct Contracting model simply serves as a framework by which these efforts can be used. Over time, however, DCEs and providers alike can embrace a culture of value-based innovation to achieve healthcare goals.
The Centers for Medicare & Medicaid Services (CMS) announced new flexibilities to current and future Innovation Center alternative payment models (APMs) to address the public health emergency, as detailed in a new chart. The agency previously made changes to the Medicare Shared Savings Program, summarized in the MGMA COVID-19 Action Center, but did not address other APM policies until this announcement.
Adjustments include:
Extending the Next Generation accountable care organization (ACO) model through December 2021 and reducing 2020 downside risk.
Delaying the start of new Direct Contracting and Kidney Care Choices models until April 1, 2021, and creating a new application cycle for 2022. The new Primary Care First model will still begin Jan. 1, 2021, but the Serious Illness component is delayed until April 1.
Allowing participants in the Bundled Payments for Care Improvement (BPCI) model the option to eliminate upside and downside risk for 2020.
Additional changes to these and other models are further detailed in the chart.
MGMA advocated for CMS to extend the Next Gen ACO program as it was previously set to end this year and also called on the agency to make adjustments to APM policies in response to COVID-19. We are pleased to see that CMS heeded our advice and is in the process of evaluating individual model changes.
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