Doc Groups Ask Congress to Extend Payment Bonus for Alternative Payment Models

WASHINGTON — Congress must extend Medicare’s payment bonus to doctors participating in alternative payment models (APMs) to incentivize them to continue, doctors and health policy experts said Thursday at a Capitol Hill briefing.

“It’s not like you can go from fee-for-service today and then jump into an APM tomorrow,” said Kisha Davis, MD, MPH, vice president of health equity at Aledade, a company that helps medical groups set up accountable care organizations (ACOs), which are groups of doctors, hospitals, and other healthcare providers who come together to give coordinated high-quality care to their Medicare patients. “There is a level of investment in infrastructure that needs to take place, in understanding the data and hiring support staff.”

Davis was speaking at a briefing sponsored by America’s Physician Groups and the National Association of ACOs, all of whose members participate in alternative payment models. The two groups have spearheaded a letter signed by more than 800 organizations that urges Congress to extend the 5% incentive payment to advanced APM participants — a payment that is set to expire at the end of the year. The incentive helps pay for hiring additional staff and providing services that aren’t covered in fee-for-service visits.

“Really, our physicians have grown up in fee-for-service,” Davis said. “They’re baked in that, and so it takes more than just saying, ‘This is a moral imperative’ to help them make that investment,” and without additional funding to do it, “they just can’t make the switch and they will continue on this hamster wheel of fee-for-service and not really be able to get to that next level.”

“One of our priorities is to move away from just a fee-for-service model and to focus on quality care, especially in the primary care setting,” said Rep. Brad Wenstrup, DPM (R-Ohio). “You think about the cardiothoracic surgeons that split open your chest and go in and replace the arteries on your heart and save your life … Doctors should be rewarded for that. But what we don’t really do in our system is reward the doctor that prevented him from ever needing that surgery. And I think we need to focus more on those types of things.”

Wenstrup, a podiatrist and co-chair of the House Republican Doctors Caucus, is a co-sponsor of the Value in Health Care Act, which extends the incentive payments and “makes some common-sense changes to some of the program parameters for alternative payment models,” he explained. “It removes some of the barriers or red tape that maybe inhibits somebody from wanting to join in on these programs, and hopefully will encourage more participation.”

Wenstrup is also part of a bipartisan group of House members — including Reps. Ami Bera, MD (D-Calif.), Larry Bucshon, MD (R-Ind.), Kim Schrier, MD (D-Wash.), and Michael Burgess, MD (R-Texas) — who are seeking feedback by October 31 from providers, economists, and others on the best way to reform the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

“The experience of a pandemic has highlighted a need to re-evaluate our nation’s healthcare infrastructure, which cannot be done without considering its healthcare payment structure,” the House members wrote in a letter requesting feedback. “MACRA was intended to support a healthcare system with greater value to both patients and providers, but it has become evident that further reforms are necessary.”

APMs “take some effort to implement successfully,” said Mark McClellan, MD, PhD, founding director of the Duke-Margolis Center for Health Policy. “It takes real investments of money, time, engagement with care teams, with patients, to focus on what matters most to them, and do it successfully.”

The good news, however, is that Medicare’s biggest value-based payment program, known as the Medicare Shared Savings Program, is lowering costs and improving care, he added. And Medicare’s newest APM, known as ACO REACH, “is building on what we’ve learned in this case about finding ways to help reach beneficiaries who have been [traditionally] harder to reach,” such as those in underserved areas, said McClellan, who was administrator of the Centers for Medicare & Medicaid Services (CMS) under former President George W. Bush.

Not surprisingly, the APM concept has its critics, especially when it comes to the ACO REACH program. “CMS should take further action to protect beneficiaries by terminating the ACO REACH program,” wrote 31 Democratic House members in an August 31 letter to officials at CMS. ACO REACH “places beneficiaries into arrangements remarkably similar to Medicare Advantage without the enrollee’s knowledge or consent … Further, we are concerned with the misaligned financial incentives in the ACO REACH program, which may encourage denials of care and medically unnecessary and inappropriate utilization controls in order to increase profit margins from unspent monthly payments for medical care.”

Richard Shuman, MD, CEO of Baycare Health Partners in Springfield, Massachusetts, sees it differently. “I’m a primary care physician, and I have a population of people to take care of,” he said. “If I just think about people who are in front of me, I’m not really doing the job. Healthcare is one of those things where it’s very easy to just look at what’s in front of you, and the way reimbursement is now, the more I see, the better I do, so there is no incentive to think about the other 300 patients [I don’t see] … value-based care [via APMs] is that opportunity to be proactive as opposed to reactive.”

“Fee-for-service medicine is always reactive — it’s what shows up at your door,” he added. “Until we change that paradigm, we’re not going to give the type of care we want to provide … This 5% [incentive] makes such a difference in the way we can take care of the entire population, and changes the way we have resources to build the infrastructure to find out who those people are, to reach out to them, to provide them the resources to stay healthy.”