Understanding Current Providers, Health Plans, and the Government

Nathan Bays, JD, managing director of Cain Brothers & Company, LLC, discussed the current policy environment and regulatory landscape during a session called, “Tightening the Beltway: Providers, Health Plans, the Government, and Making Sense of it all” at the Health Care Quality Congress.

According to Mr Bays, health care is “caught in the political crosshairs.” He explained that although the parties—Republican and Democratic—generally agree on a handful of health care topics, there is a longer list of topics that they also generally disagree on. According to Mr Bays, the parties generally disagree on:

• Single payer;
• How to lower prescription prices;
• Opioids;
• Medicaid work requirements;
• Contraception;
• Health care consolidation; and,
• Tax exempt status.
• However, Mr Bays said that the parties usually agree on:
• Move to value-based health care;
• Surprise medical billing; and,
• Palliative care.  

According to Mr Bays’ takeaway points on the current policy environment, he predicted that the majority of health care policy direction is likely to come from the White House through 2020.

Mr Bays then shifted the session and focused on the regulatory landscape.  He outlined moving to value-based care, telehealth and documentation changes, and burden reduction and regulatory flexibility.

Value-based care remains a priority, Mr Bays explained. He said the value increasingly means taking on requisite risk. He said that the administration is seeking comprehensive and scalable approaches to address this.

Mr Bays then addressed Merit-based Incentive Payment System (MIPS) participation for 2019. He said that additional types of MIPS eligible clinicians will be added in 2019, which minimally bolster MIPS participation. The additional clinicians include physical therapists, occupational therapists, clinical social workers, and clinical psychologists. However, he noted that MIPS exemptions remain problematic and CMS will start allowing clinician to opt-in and participate. He said that organizations must exceed 200 Medicare Part B patients, or $90,000 in Part B billing, or provide more than 200 covered professional services. According to Mr Bays, CMS expects roughly 42,000 clinicians to be eligible to opt-in.

Shifting to cost, Mr Bays said Medicare will increasingly hold providers accountable for the cost of episodes of care. He expects the weight to increase from 15% to 30% in the next 3 years. Additionally, he expects a focus on high-cost, high-volume procedures, and he said specialists will need to be engaged from the outset to improve performance.

He also discussed episode-based scoring for costs as it presents new challenges. Mr Bay said that the new challenges can be attributed to a mix of taxpayer identifing number (TIN)-based and national provider identifier (NPI)-based attribution as well as peer benchmarks and performance variation.

Mr Bay then explained the overall impact of MIPS in payment year 2021. He said he believes there will be an estimated 650,000 eligible clinicians who will participate and 482,000 will be excluded or choose not to participate. Further, he said the impact of negative, positive and exceptional performance adjustments will be +2%. Additionally, roughly 594,132 eligible clinicians, or 96%, will be considered within the exceptional performance threshold at 80 points and will account for positive or neutral payment adjustment.

Mr Bays also discussed advanced alternative payment models (APM). He said that the “advanced APM track is more financially lucrative under [Medicare Access and CHIP Reauthorization Act (MACRA], but cost savings for Medicare remain elusive.” Further, he explained that CMS has not approved many new advanced APMs and this threatens the sustainability of the APM track of MACRA and limits provider uptake.

Mr Bays then dove into Medicare telehealth services, explaining that this subset of telehealth services is covered under the Physician Fee Schedule (FFS), and HHS secretary, Alex Azar, has the power to add and remove services from the list. He also noted that the Medicare telehealth services are substantially regulated. Under the Bipartisan Budget Act of 2018, he explained, these services modified and removed geographic limitations for tele-stroke and tele-dialysis patients, while allowing home dialysis and end-stage renal disease (ESRD) services to be provided in the home. The 2019 PFS proposed rule created new telehealth services under the PFS that are classified as Physician Services.

The last topic Mr Bays addressed was regulatory burden and flexibility. In order to address physician burden, he said, there needs to be a reduction of documentation requirements for visits of higher complexity in office or outpatient settings. Additionally, there has to be a limit on re-documentation of information that is already within a patient record. Further, for E/M (evaluation & management) codes, there needs to be a streamlining payment. Overall, Mr Bays says reducing physician burden remains an administrative priority.

Mr Bays concluded that there is interest in better leveraging technology for Medicare patients, and finally although the path is uncertain, the move to value continues.

—Julie Gould