Dive Brief:
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A new Robert Wood Johnson Foundation (RWJF) report analyzed how CMS has expanded billing codes and demonstrations focused on supporting primary care.
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The report said primary care providers (PCPs) involved in CMS demonstrations are getting higher monthly payments. The shift has meant more up-front payments rather than end-of-year bonuses.
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Those providers are also being held accountable for a wide range of outcomes, but often “not expected to independently influence the total cost of all care received by Medicare beneficiaries,” according to the RWJF report.
Dive Insight:
The RWJF and the Urban Institute have been monitoring and tracking compensation and demonstration projects since 2011 to learn how payment reforms are impacting the healthcare industry.
The compensation gap between PCPs and specialists is well documented, but the report said the CMS has worked to bridge that gap. That was evident way back with the Physician Fee Schedule in 1992, but the report said the compensation gap remains.
Bridging the PCP/specialist payment gap is one way also to help resolve potential doctor shortages. The Federation of State Medical Boards recently reported that the number of actively licensed physicians at the end of 2016 increased 12% since 2010. The U.S. physician-to-population ratio increased in that time from 277 physicians per 100,000 people to 295 per 100,000. Despite those gains, that’s not expected to keep up as the country ages.
California is one state concerned about potential shortages. A recent report from the Healthforce Center at University of California, San Francisco (UCSF) predicted that California won’t have enough primary care physicians by 2030. To make up for the gap, the researchers suggested nearly half of the state’s full-time equivalent primary care clinicians will be nurse practitioners and physician assistants by 2030.
The PCP payment focus, especially the transition from fee-for-service to value-based payments, has led to CMS compensating PCPs to perform activities during their workday that are often not part of compensation. Demonstration payment models give financial incentives, such as flat monthly fees, for activities that are not part of the fee schedule, such as calling patients. The CMS has also added billing codes to help PCP payments. Those reimbursements compensate for non-face-to-face services and “low-cost activities," including emailing patients.
The RWJF report said CMS is trying to accomplish two things with its new billing codes and demonstrations:
- Incentivize specific activities that the agency knows it wants clinicians to engage in.
- Test whether it can achieve favorable outcomes by paying for promising new delivery reforms.
“Only time will tell what payment amount will be sufficient to convince practitioners to deliver these services and what effect these services will have on patients’ quality of care," the RWJF report states.
In the 2018 Medicare Physician Fee Schedule, CMS said it is working incrementally to “identify gaps in appropriate coding and payment for care.”
“CMS’ new primary care billing codes and primary care demonstrations suggest a willingness to pay increasingly large amounts to primary care practitioners for managing the care of patients with chronic conditions,” according to the report.
RWJF said its research shows CMS has shifted some compensation into flat monthly payments “that give clinicians more flexibility in the type and location of activities they engage in while maintaining a role for fee-for-service payment for other services.” This blended payment approach will let CMS “finely tune the financial incentives it directs to practitioners.”
CMS is changing course on demonstrations. Moving away from the Obama administration’s approach to mandatory bundled payment programs, the Trump administration recently canceled mandatory demonstrations with the promise of soon unveiling new voluntary payment demonstrations that minimize physician burdens. The new payment models will likely involve tracking quality, outcomes and costs, but physicians and hospitals will likely get to choose whether to move to value-based payments rather than being required.