Federal Policy Updates

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April Senate Finance Committee Hearing Features Primary Care

April 22, 2024

Primary care played a starring role in a bipartisan April 11th Senate Finance Committee hearing, Bolstering Chronic Care through Medicare Physician Payment, led by Chairman Ron Wyden (D-OR) and Ranking Member MIke Crapo (R-ID).

With PCC members and team in attendance, Chairman Wyden responded directly to a recommendation from hearing witness Amol Navathe, MD, PhD that Congress create a path to scaling hybrid primary care payment, saying, “I like that idea very much.” Dr. Navathe is a physician and Professor at the Unversity of Pennsylvania.

Over the past year, PCC and its Better Health – NOW Campaign championed a hybrid payment option with CMS – now reflected in the new ACO PC Flex Model available next year to up 130 Medicare ACOs.  But Congress has a crucial role to play as well.

Earlier this spring, Better Health – NOW  argued  that “primary care is a primary solution to address chronic physical and mental health conditions and the increasingly unaffordable costs they generate,” in submitted testimony to the Senate Budget Committee. The Campaign will be submitting additional recommendations to the Senate Finance Committee later this week.

“The first place to start is to invest more in primary care.” argued Navathe.

PCC Applauds CMS/CMS Innovation Center for Taking Steps to Strengthen Primary Care in Medicare

March 19, 2024

Washington, D.C. (March 19, 2024) – The Primary Care Collaborative (PCC) applauds the Centers for Medicare and Medicaid Services (CMS) and the CMS Innovation Center for taking substantive steps to strengthen primary care to deliver better outcomes by announcing a hybrid payment model under the Medicare Shared Savings Program (MSSP).

The announcement comes less than a year after PCC’s Better Health – NOW mobilized more than two dozen stakeholder organizations in support of CMS and the Innovation Center implementing hybrid payment models (mix of prospective and fee for service) to encourage primary care participation in MSSP and develop primary care led accountable care organizations. NASEM’s 2021 report underscored the evidence related to hybrid payment.

“Primary care is the foundation of an equitable, effective health care system,” said Ann Greiner, President and CEO of the PCC. “Today, CMS and the CMS Innovation Center demonstrated they understand the urgent need to reinforce that foundation.

“We’re also encouraged to see that this model centers equity by promoting participation by rural health clinics and federally qualified health centers, puts guard rails in place to ensure payments reach primary care practices and benefits beneficiaries by giving clinicians a prospective payment that allows them to deliver more flexible, comprehensive care. We’re eager to learn more about this model and its potential to lower costs and improve beneficiary outcomes.”

Dr. Liz Fowler, Director of CMS Innovation Center, will provide additional details about the new model in a presentation and Q&A with PCC President and CEO Ann Greiner during a PCC webinar earlier today. The webinar also featured thoughts and reactions from leaders at the National Association of Community Health Centers, the American Academy of Family Physicians, the National Association of Accountable Care Organizations and the National Partnership for Women and Families.

Registration for the webinar is open here.

 

About the Primary Care Collaborative

Founded in 2007, PCC is a multistakeholder organization dedicated to advancing an effective and efficient health system built on a strong foundation of primary care. Representing a broad coalition that includes patient and consumer advocacy groups, health care clinics, professional societies, payers, leading corporations and other health care stakeholders, the PCC’s mission is to unify and engage diverse stakeholders in promoting policies and sharing best practices that support the growth of high-performing primary care to achieve the “Quintuple Aim”: better care, better health, lower costs, greater joy for clinicians and staff, and greater health equity.

PCC Sends Recommendations on Strengthening Primary Care for Rural & Underserved Communities to House Ways & Means Leaders

December 14, 2023

With a December 14 letter, the Primary Care Collaborative (PCC) is applauding House Ways and Means Committee leaders for their efforts to date to develop solutions for healthcare access in rural and underserved locales and offering its own recommendations to strengthen primary care for all communities.

Rep. Jason Smith (R-MO), Chairman of the House Committee on Ways and Means, has identified rural health as a priority for the Committee. Earlier this Fall, the Committee reached out to healthcare stakeholders with a request for information (RFI) on bold solutions to improve healthcare access issues for those in rural and underserved communities.

PCC’s recommendations to Chairman Smith and Ranking Member, Rep. Richard Neal (D-MA) include the following:

  • Invest in primary care by supporting CMS’ work to develop a hybrid payment option in the Medicare Shared Savings Program (MSSP), and pay adequately for inherently complex care (G2211 code)
  • Integrate mental health and addiction services by expanding Primary Care-Behavioral Health Integration (BHI), improving Medicare’s Health Professional Shortage Area Bonus program, removing barriers to BHI in Federally Qualified Health Centers and Rural Health Clinics, supporting telemental health and tele-prescribing services
  • Address misaligned Medicare policies that impact beneficiaries who are dually eligible for Medicare and Medicaid (duals) by establishing continuity of coverage protection for duals, expanding access to the Program of All-Inclusive Care for the Elderly (PACE), address the serious coverage and reimbursement barriers (“lesser-of payment policies”) for duals

While PCC applauds the Committee’s first steps to explore access for rural and underserved communities, we encourage them to take the bold action necessary to enact these improvements in the New Year.

Finding Things to Celebrate in Medicare's New Fee Schedule Rule

November 6, 2023

We are celebrating after #Medicare announced new changes to strengthen primary care and build care teams in the final 2024 physician fee schedule rule. In collaboration with PCC members, our advocacy made a difference!

As we review the final rule we see many of the shared priorities of the Better Health Now campaign are advanced in the final policies from Centers for Medicare & Medicaid Services. Yet current Medicare law forced the agency to couple this forward progress with negative across-the-board payment reductions.

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.

We continue to urge CMS to use all of its authorities to quickly shift primary care to hybrid population-based and fee-for-service payments in the Medicare Shared Savings Program (MSSP). To build robust primary care teams that can deliver whole-person care, we must move away from fee-for-service payment. 

In our comment letter on proposed rule, we urged Centers for Medicare & Medicaid Services 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.

We are pleased to see so many of the priorities we fought for---from support for family caregivers, to the inclusion of community health workers in primary care teams, to more support for a broad range of behavioral health services and clinicians, to more opportunities for primary care practices to demonstrate their impact in Medicare ACOs included in the final 2024 rule.

We thank the many collaborators who contributed to our comments and advocacy.

U.S. Representatives Introduce the COMPLETE Care Act to Support Behavioral Health Integration

September 26, 2023

On July 26th, with the full support of PCC and its Better Health – NOW Campaign, U.S. Representatives Michelle Steel (R-CA), Dan Kildee (D-MI), Lizzie Fletcher (D-TX), Gus Bilirakis (R-FL), August Pfluger (R-TX), and Susie Lee (D-NV) introduced H.R. 5819 the COMPLETE Care Act of 2023. A companion bill to the Senate’s S. 1378, this House legislation would improve the behavioral health care available to Medicare beneficiaries in primary care settings through:  

  • enhanced Medicare payment rates for collaborative care and general behavioral health integration services,  

  • support for quality measure reporting for behavioral health integration, and  

  • investment in technical assistance to broaden adoption of integrated care. 

Read PCC’s Letter of Support.

Read the bill sponsors’ press release. 

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.  

__________ 

 

 

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.

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