Aug. 25, 2023: Medicare Payment Reform Advocacy Update

The AMA was encouraged to recently learn that the Center for Medicare & Medicaid Innovation (CMMI) wants to develop new episode payment models to better engage non-primary care specialist physicians in alternative payment models (APMs).

In response to its recent request for input on a number of questions pertaining to its development of these models, the AMA submitted a letter (PDF) strongly encouraging the Centers for Medicare & Medicaid Services (CMS) to keep any new episode APMs voluntary and to improve transparency and physician involvement in pursuing this policy. The AMA also recommended that CMMI use prospective payments in its model design instead of relying on retrospective calculations of shared savings.  

CMMI needs to ensure that new payment models:

• Place physicians at the center of decision making about care delivery
• Give physicians the resources and flexibility they need to deliver services that can achieve good outcomes for all types of patients while lowering overall spending for Medicare  
• Do not place physicians at risk for outcomes or costs they cannot control

The letter noted that, eight years after the passage of the Medicare Access and CHIP Reauthorization Act (MACRA) and over a decade after the creation of CMMI, most physicians still do not have opportunities to participate in APMs designed for the kinds of patients they treat. Many frontline physicians who have experienced barriers to value-based care in their practices have devoted years of work to develop patient-centered APMs that could offer meaningful benefits to patients and savings for the Medicare program, but none of these APMs have been implemented by CMMI. 

On August 14, CMS released the request for applications for its new Making Care Primary (MCP) Model, which includes new details about eligibility criteria, payment methodologies and other important information about the model. The voluntary model is intended to improve patient outcomes through enhanced care management and coordination with specialists and community-based services with a focus on whole-person centered care. It will run for 10.5 years and features three progressive risk tracks with multiple types of payments including clinical and social risk adjustment payments and specialty integration incentive payments.  

The model will operate in eight states including Colorado, North Carolina, New Jersey, New Mexico, Minnesota, Massachusetts, Washington and certain counties in New York, and it will operate in collaboration with state Medicaid agencies. Eligible applicants must have a majority of their physical locations in an eligible state, a minimum of 125 attributed Medicare beneficiaries, and at least 40% of their Medicare service revenue from primary care services. In addition, applicants are required to partner with at least one of three specialties—cardiology, orthopedics or pulmonology—but may establish relationships with multiple specialty care partners among a broader range of eligible specialties, which are listed in the request for application. Primary Care First, ACO Reach and Medicare Shared Savings Program (MSSP) participants will not be eligible to participate in MCP (though a limited six-month overlap will be allowed for current MSSP participants only). At this time, CMS does not have plans for future cohorts of the model. 

Applications will open on Sept. 4 and close on Nov. 30, 2023. The model will start in July 2024. Learn more about the model and sign up to receive updates. Applicants are also encouraged to submit non-binding letters of intent to signal their interest, though this is not required to apply. 

With the Congressional August recess in full swing, the AMA’s top federal priority this summer is reforming Medicare’s broken physician payment system. The August recess provides physician advocates unique opportunities to engage on this important issue with their members of Congress “back home” in the district. The AMA’s Fix Medicare Now site has seen 11,000+ contacts to Congress so far during the August recess in support of H.R. 2474, which would provide annual Medicare Economic Index updates.  

To make these interactions with your legislators as impactful as possible, the AMA has developed an online August recess resources site that is your one-stop-shop for toolkits and information on scheduling and preparing for in-district legislative meetings, hosting members of Congress at site visits, and best practices for interacting and conversing with them online. The site also contains issue one-pagers, a recording of a recent AMA grassroots webinar on August recess engagement and an easy to fill out feedback form once you have completed your in-district meetings and interactions.    

Everyone agrees that the Medicare physician payment system is broken—let’s do something about it.

The AMA’s Medicare Basics explainer series provides an in-depth look at important aspects of the Medicare physician payment system. Through straightforward explanations, policymakers and physician advocates can learn about key elements of the payment system and why they are in need of reform. Visit the new landing page to get the latest updates and find out more.  

Access PDF versions of the pages for your advocacy efforts: 

• Medicare physician payment adequacy: Budget neutrality 
• Merit-based Incentive Payment System (MIPS) 
• The Medicare Economic Index 
• Advancing value-based care with alternative payment models 
• Transitioning to value-based care: Clinical data registries 
• MIPS data problems 

• Aug. 25, 2023: National Advocacy Update
• Aug. 25, 2023: State Advocacy Update