History of CMS primary care initiative

Many factors went into the development of the Centers for Medicare and Medicaid Services (CMS) Primary Cares Initiative, including a concern for patient healthcare outcomes, a need to reduce healthcare costs, and a focus on reducing hospitalizations. Based on the previous Comprehensive Primary Care (CPC) models, the new initiative includes five models developed by the Center for Medicare and Medicaid Innovation (CMMI) with input from physicians and organizations such as the American Academy of Family Physicians (AAFP) and the American Medical Association (AMA).

CPC models were launched in October 2012 as a “a four-year multi-payer initiative designed to strengthen primary care.” CPC was the foundation of a five-year initiative, Comprehensive Primary Care Plus (CPC+), “a national advanced primary care medical home model that aims to strengthen primary care through regionally-based multi-payer payment reform and care delivery transformation.” Each of these initiatives offered various levels of physician participation, based on different payment models. The original CPC initiative concluded in 2016.

CPC+ was launched in January 2017, integrating “lessons learned from CPC, including insights on practice readiness, the progression of care delivery redesign, actionable performance-based incentives, necessary health information technology, and claims data sharing with practices.” CPC+ included three payment elements: Care Management Fee (CMF); Performance-Based Incentive Payment; and Payment under the Medicare Physician Fee Schedule, with two track options.

The latest initiatives were developed by CMMI with input from stakeholders and a focus on the need to improve primary care outcomes that will reduce hospitalization rates for Medicare recipients. When announcing the CMS Primary Cares Initiative, CMS Administrator Seema Verma referenced the financial state of what is commonly known as Medicare Part A. Essentially, the Social Security Board of Trustees reported “that the Hospital Insurance (HI) Trust Fund portion—otherwise known as Medicare Part A—will be depleted in 2026, the same year projected in last year’s report. Revenues will be enough to pay 89% of HI costs.”

In regard to the CMS Primary Cares Initiative, U.S. Department of Health and Human Services (HHS) Secretary Alex Azar stated that “For years, policymakers have talked about building an American healthcare system that focuses on primary care, pays for value, and places the patient at the center. These new models represent the biggest step ever taken toward that vision.” He added, “these models will test out paying for health and outcomes rather than procedures on a much larger scale than ever before.”

Janie Feldsher
January 21, 2020


Gauging ACO success in 2019

The number of ACO contracts has decreased slightly, but the number of individuals covered by those ACOs has increased from 2018 to 2019. The Centers for Medicare & Medicaid Services (CMS) recently released data on Medicare Shared Savings Program (MSSP) Accountable Care Organizations (ACOs) for Performance Year 2019 that show some changes in provider participation as of July 1, 2019. Experts writing for Health Affairs analyzed the results of the report, gauging the level of ACO success during the reporting period.

MSSP “facilitates coordination among providers to improve the quality of care for Medicare fee-for-service beneficiaries while reducing the growth in health care costs. Eligible providers, hospitals, and suppliers may apply to participate in the Shared Savings Program by creating or participating in an Accountable Care Organization (ACO).” In addition, CMS has created a new ACO program, Pathways to Success, which may also have impacted the success of ACOs in 2019.

The Health Affairs analysts state that there has been an increase in the number of physician-led ACOs “and they have moved to downside risk at a slightly higher rate than ACOs with hospitals.” The total number of ACOs has decreased while the number of lives impacted has increased during the performance year. Of the 995 ACOs currently active, 425 (43 percent) are physician-led, compared to 274 hospital-led and 294 jointly led.

Previous estimates speculated that about half of ACOs would exit MSSP, the largest ACO program, with the rollout of the Pathways to Success program. However, in reality only a modest number left and 41 ACOs joined the program in July 2019. Higher dropout rates were noted for physician-led ACOs than for hospital-led and large ACOs.

Health Affairs also reports that “so far this year in 2019, there was a modest decrease in the proportion of downside risk contacts by small organizations, and conversely there was a modest increase in proportion of downside risk contacts by large organizations.” The analysts stated that “The acceleration of ACOs accepting downside risk beginning in 2019 could represent the MSSP policy changes taking effect and deterring smaller organizations from joining or staying based on mandatory downside risk.”

Tyler Comstock
December 9, 2019


Trump administration attempts to revise Stark Law for value-based care

The Stark Law, named after Rep. Pete Stark, a Democrat from California, was originally enacted in 1989 with the basic premise of not allowing physicians to refer Medicare or Medicaid patients to healthcare services from which the physician or a member of the physician’s family would profit financially. Over the years, additional regulations and exceptions were added to the Stark Law and it eventually became a vast collection of regulations and statutes.

The idea behind the original concept was to keep physicians from sending patients for unnecessary tests or healthcare services and driving up healthcare costs. In October 2019, given the current shift to value-based care and away from the fee-for-service model, the Centers for Medicare & Medicaid Services (CMS) proposed a new ruling that would “modernize and clarify the regulations that interpret the Medicare physician self-referral law,” or the Stark Law.

CMS published a Request for Information (RFI) in June 2018, soliciting input on addressing regulatory barriers to a value-based healthcare payment and delivery system under the Stark Law. The responses they received indicated that “regulations have not kept up with the evolution of a healthcare landscape that is focused more on value than volume.” Comments included requests for “additional guidance on fundamental requirements and other changes to help ease burden and make compliance more straightforward.”

As a result, CMS is now proposing a rule that would “create new, permanent exceptions to the Stark Law for value-based arrangements.” With today’s healthcare environment, industry stakeholders are now saying that “because the consequences of noncompliance with the Stark Law are so dire, physicians and other healthcare providers may be discouraged from entering into innovative arrangements that would improve quality outcomes, produce health system efficiencies, and lower costs (or slow their rate of growth).”

CMS states that revisions to the Stark Law that are based on the changing value-based healthcare environment “would unleash innovation by permitting physicians and other healthcare providers to design and enter into value-based arrangements without fear that legitimate activities to coordinate and improve the quality of care for patients and lower costs would violate the Stark Law.”

Tyler Comstock
November 1, 2019


Everything independent physicians need to know about today’s healthcare landscape

Healthcare is the main focus of presidential candidates, the media, and technology advocates. Today’s healthcare landscape can be complicated, with many elements for the independent physician to keep up with and to be in compliance with, depending on the provider’s situation. Those independent physicians who care for Medicare patients must know the latest updates from the Centers for Medicare & Medicaid Services (CMS).  Providers with younger patients need to understand the healthcare preferences of Millennials and Generation Zers. Rising healthcare costs impact all independent physicians.

Today’s healthcare landscape includes:

Campaigns for Medicare for All and other variations of one-payer healthcare plans. Presidential candidates are promoting their own versions of government-sponsored programs, ranging from an all-inclusive, expanded Medicare program, to public options that complement private insurance and the programs covered under the Affordable Care Act (ACA).

Technology advances. Telehealth and other virtual healthcare services are becoming more accepted and more commonly used as alternatives to the traditional office visit. Even CMS is “finalizing changes that would allow Medicare Advantage beneficiaries to access additional telehealth benefits, starting in plan year 2020.” In addition, the electronic health record (EHR) is advancing in capabilities, including interoperability, which is key to the physician’s ability to coordinate a patient’s care with other providers.

Adjusting to changing preferences. Speed, convenience, and available technology are the primary concerns for Millennials, particularly in regard to how they access healthcare. Independent physicians who offer the ability to communicate electronically, to access telehealth services, and to make appointments online or through an app will be more attractive to that busy age group.

Prescription drug prices are a topic of major concern. In a research study conducted by the Scripps Research Translational Institute, five years of pharmacy claims (from 2012 to 2017) were analyzed. The study included 49 brand-name drugs that had more than 100,000 total claims each. As reported by NBC News, “All but one of the drugs included in the study saw regular annual or biannual cost increases. The cost of 36 of the drugs increased over the six-year period by more than 50 percent, and the cost of 16 more than doubled. Overall, the median cost of the drugs included in the study increased 76 percent.”

Tyler Comstock
October 17, 2019


Everything you need to know about the new physician fee schedule

In July 2019, the Centers for Medicare & Medicaid Services (CMS) issued its Proposed Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2020. The new policies will take effect January 1, 2020. The proposed rule includes “proposals to update payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS).”

Among the changes and updates proposed in the 2020 Physician Fee Schedule (PFS) are several adjustments in codes and payment rates:

CY 2020 PFS Rate setting and Conversion Factor

Relative Value Units (RVUs) are applied to each service for physician work, practice expense, and malpractice. They become payments rate after a conversion factor is applied. Those payment rates include an overall payment update specified by statute. The proposed CY 2020 PFS conversion factor is $36.09, a slight increase above the CY 2019 PFS conversion factor of $36.04.

Medicare Telehealth Services

The following codes are proposed for the list of telehealth services: HCPCS codes GYYY1, GYYY2, and GYYY3, which describe a bundled episode of care for treatment of opioid use disorders.

Payment for Evaluation and Management (E/M) Services

The proposed PFS consolidates the Medicare-specific add-on code for office/outpatient E/M visits for primary care and non-procedural specialty care that was finalized in the CY 2019 PFS final rule for implementation in CY 2021 into a single code describing the work associated with visits that are part of ongoing, comprehensive primary care and/or visits that are part of ongoing care related to a patient’s single, serious, or complex chronic condition.

Care Management Services

A number of the Chronic Care Management (CCM) services codes are proposed to be replaced with Medicare-specific codes to allow clinicians to bill incrementally to reflect additional time and resources required in certain cases and better distinguish complexity of illness as measured by time. Physicians involved in CCM provide care coordination and management services to beneficiaries with multiple chronic conditions over a calendar month service period.

Medicare Shared Savings Program (MSSP)

As part of the PFS proposed rule, CMS is soliciting comment on how to potentially align the Medicare Shared Savings Program (MSSP) quality performance scoring methodology more closely with the Merit-based Incentive Payment System (MIPS) quality performance scoring methodology, recognizing that accountable care organizations (ACOs) and their participating providers and suppliers dedicate resources to performing well on quality metrics. The goal is to align quality metrics across programs that will reduce burden and will allow ACOs to more effectively target their resources toward improving care.

Tyler Comstock
September 20, 2019


How is MIPS changing in 2020

The Centers for Medicare & Medicaid Services (CMS) announced changes to the Merit-based Incentive Payment System (MIPS) on July 29, 2019, that are intended to streamline the Quality Payment Program (QPP). CMS is focused on reducing administrative burden for healthcare providers with its new pay-for-performance program called the MIPS Value Pathways (MVP). In the same announcement, CMS included updates to the Medicare Physician Fee Schedule (PFS) effective January 1, 2020.

One of the goals of the updated policies is to help physicians who care for chronically ill patients. CMS Administrator Seema Verma states that “Today one in five Medicare beneficiaries have multiple chronic diseases.” The proposed rule for 2020 “would increase payments to practitioners for time spent on care management after a patient leaves the hospital ensuring proper follow-up and continuity of care for patients.” In addition, CMS is proposing, for the first time, “to pay for care management services for patients with a single, high-risk chronic condition such as diabetes or high blood pressure.” Under the new rule, physicians would also be paid for “additional time spent on care management activities for patients suffering from multiple chronic conditions.”

The new MVP program would begin in the 2021 performance period, moving MIPS “from its current state, which requires clinicians to report on many measures across the multiple performance categories, such as Quality, Cost, Promoting Interoperability and Improvement Activities, to a system in which clinicians will report much less. Under MVPs, clinicians would report on a smaller set of measures that are specialty-specific, outcome-based, and more closely aligned to Alternative Payment Models (APMs) – new approaches to paying for care through Medicare that incentivize quality and value.”

CMS’s proposed rule includes:

  • CY 2020 PFS rate setting and conversion factor
  • Medicare telehealth services
  • Payment for evaluation and management services
  • Physician supervision requirements for physician assistants
  • Review and verification of medical record documentation
  • Care management services
  • Comment solicitation on opportunities for bundled payments
  • Medicare coverage for opioid use disorder treatment services furnished by opioid treatment programs
  • Bundled payments for substance use disorders
  • Therapy services
  • Ambulance services
  • Ground ambulance data collection system
  • Open Payments Program
  • Medicare Shared Savings Program
  • Stark advisory opinion process

The public is invited to comment on the CY 2020 Physician Fee Schedule proposed rule and the CY 2020 Quality Payment Program proposed rule. Comments must be received within the 60-day comment period, which closes on September 27, 2019. When commenting refer to file code: CMS-1715-P.

Tyler Comstock
August 26, 2019


Medicare for All: An overview for independent practices

When Medicare was created in 1965, it was intended to eventually cover all Americans as a universal healthcare plan, not to remain as an insurance program exclusively for the elderly. In 1972, minor changes were made to Medicare eligibility, including as recipients those with disabilities and with end-stage renal disease. The idea of a national health insurance plan was also re-introduced in the early 1970s but was defeated each time it was proposed. Republican Senator Jacob Javits proposed expanding Medicare to cover all Americans in 1970 and was the first one credited to have coined the phrase “Medicare for all.”

From 2003 to 2017, Democratic Representative John Conyers introduced and reintroduced his Expanded and Improved Medicare for All Act. In 2006, Democratic Senator Ted Kennedy introduced a Medicare for All Act, which proposed the idea that was the original intent of the Social Security Administration staffers who set up Medicare, to gradually expand Medicare to include all citizens and legal residents.

In recent years, “Medicare for all” has re-emerged in political campaigns. Today, the concept refers to a single-payer type of health insurance that would virtually eliminate private health insurance or exist alongside private insurance, depending on the proposal.

Various versions of the universal healthcare concept are being proposed. Essentially the idea of “Medicare for all” includes the basic healthcare benefits of the current Medicare system such as provider visits, certain outpatient services, and hospitalization. Some proposals expand that coverage to include dental, vision, hearing, and long-term care services with no premiums, deductibles, or co-pays. Other proposals include a “public option” that would not eliminate private insurance but would be considered a “government insurance plan” offered as an option to those seeking health insurance.

“Medicare for all” is sometimes referred to as “single payer” or “universal” healthcare. Single-payer means that there would only be one payer for the cost of the universal health coverage and that would be the federal government. Taxes would probably increase to cover part of the costs, but how much and who would be taxed are also issues up for debate.

Medicare coverage for all Americans would ensure that everyone in the country has healthcare coverage, a concept that has been embraced by every wealthy, developed nation except the US. With rising healthcare costs, including the costs of health insurance, one in ten Americans is uninsured today and many of those with insurance are challenged financially by their medical bills.

Tyler Comstock
August 14, 2019


2019 Medicare Advantage and Part D Prescription Drug Program updates

Enrollment in Medicare Advantage plans is up and premiums are down, according to data released by the Centers for Medicare & Medicaid Services (CMS). Medicare Advantage plans cover what is sometimes referred to as Medicare Part C. Advantage plans are administered by private companies and require the patient to pay an additional premium for services covered by the plan. Medicare then pays those companies a fixed amount for the patient’s care.

CMS projects that there will be record enrollment in Medicare Advantage plans in 2019, estimating that 36.7% of Medicare beneficiaries will enroll in an Advantage plan this year. CMS also states that “Medicare Advantage premiums, on average, have steadily declined since 2015 from the actual average premium of $32.91. For 2019, CMS estimates the Medicare Advantage average monthly premium will decline by $1.81 to $28.00 from 2018.”

Approximately 99 percent of Medicare beneficiaries will have access to a Medicare Advantage plan as well as a prescription drug plan in 2019. Prescription drugs are covered under Medicare Part D, which is generally included in most Advantage plans. Additional benefits, such as vision, hearing, dental, and/or health and wellness programs, may also be included in Medicare Advantage plans.

CMS also states that “Due to new flexibilities available for the first time in 2019, nearly 270 Medicare Advantage plans will be providing an estimated 1.5 million enrollees new types of supplemental benefits, including:

  • Expanded health-related supplemental benefits, such as adult day care services, and in-home and caregiver support services; and
  • Reduced cost sharing and additional benefits for enrollees with certain conditions, such diabetes and congestive heart failure due to the agency’s reinterpretation of uniformity requirements.

Premiums for prescription drug plans are also declining, with the basic premium projected to decline for the second year in a row. The average monthly premium for a basic Medicare prescription drug plan is projected to decrease in 2019 by 3.2%, to an estimated $32.50 per month.

CMS is encouraging health plan providers to offer more choices in their Medicare Advantage plans, with policies for Medicare health and drug plans for 2019 that provide “new tools to improve quality of care.”

Tyler Comstock
July 23, 2019


Comprehensive Primary Care Plus (CPC+): what are the updates for 2019?

The Centers for Medicare and Medicaid Services (CMS) recently launched an Innovation Center that “supports the development and testing of innovative health care payment and service delivery models.” One of those innovations is Comprehensive Primary Care Plus (CPC+), a national advanced primary care medical home model. The CMS Innovation Center has published a number of updates and changes to the 2019 CPC+ program in its report, “CPC+ Payment and Attribution Methodologies for Program Year 2019.”

According to the Innovation Center, CPC+ includes two primary care practice tracks with incrementally advanced care delivery requirements and payment options to meet the diverse needs of primary care practices in the United States. CPC+ is a five-year model that began in January 2017 for 2017 Starters and will begin in January 2018 for 2018 Starters.

In addition to the information provided in the Innovation Center’s publication, a new track initiative that will reduce the reporting requirements for quality care is expected in 2019 as well. The new initiative should relieve independent physicians of many of the current reporting burdens they face in delivering value-based healthcare.

In 2019, CMS is providing the Care Management Fee (CMF) to CPC+ practices to support them in the expectation that CPC+ practices provide “wrap-around” primary care services. CMF is a non-visit-based fee that will be paid to practices in both tracks quarterly. The amount of the CMF is determined by (1) the number of beneficiaries attributed to a given practice per month, (2) the case mix of the attributed beneficiary population, and (3) the CPC+ track to which the practice belongs.

In its report on 2019 payment and attribution methodologies, the Innovation Center specifies that practice performance is measured against absolute performance thresholds. The minimum and maximum thresholds are determined from a reference population external to CPC+ participation. In turn, a practice’s own performance relative to these thresholds determines the incentive amount the practice retains. In addition, minimum and maximum performance goals are established using absolute thresholds that are the same for all practices. The performance goals are the same for both tracks and for all Starters.

CMS states that “In Program Year 2019, the minimum threshold is set to the 30th percentile of performance in the reference population for clinical quality and patient experience of care, and to the 50th percentile of performance in the reference population for utilization. Practices are not eligible to retain any of the PBIP (Performance-Based Incentive Payment) for the relevant measure if their performance score on an individual measure falls below this minimum threshold. This requirement ensures that practices are not rewarded for poor performance and encourages practices to place the highest priority on measures with very low scores to bring them above the minimum threshold.”

Damien Neuman
July 8, 2019


Why Elation Health supports CMS’ proposal to send discharge or ADT feeds from hospitals for improved interoperability

On June 3rd, Elation Health joined 33 other organizations to submit a letter in support of a CMS proposal which would require hospitals participating in Medicare or Medicaid to send event notifications – also known as admission/discharge/transfer or ADT feeds – to other health care facilities or community providers.

Why is this important? If adopted, hospitals would be required to tell independent practices when a patient is admitted. This allows primary care physicians to know that their patients have been admitted to the hospital, which can drive critical follow-up and longer-term preventative activities to reduce readmissions.

Currently, many hospitals choose not to share ADT feed alerts for competitive reasons, even though they have the ability to share this information. As the organizations in the letter stress, “these notifications are critical to improving patient safety through better care transitions and are key to enabling value-based care at scale.” By having access to ADT feeds, independent physicians can spend less time trying to understand pertinent details around admissions, discharges, transfers, and encounters for their patients to ensure optimal follow-up care.

Elation Health strongly supports any initiative that attempts to streamline data sharing, especially when it is in the interest of patient care. A number of studies have demonstrated how valuable this kind of data exchange could be for readmission rates and other areas of patient care.

As the only EHR platform that signed onto this letter, we are eager to continue advocating for improved interoperability standards. At the same time, we’ve invested in features like our Collaborative Health Record to put the patient’s story in the center of their care experiences, whether that includes visits to physicians in-network or out of network.

Click here to learn more about our commitment to improving interoperability.

Tyler Comstock
June 21, 2019