WASHINGTON — Influential federal advisers today debated approaches for increasing Medicare’s financial support for primary care, seeking to attract future medical students into the field ahead of an expected serious staffing shortfall.
The Medicare Payment Advisory Commission (MedPAC) is preparing an overview of current challenges in primary care payment as part of its June annual report to Congress. MedPAC Chairman Francis J. Crosson, MD, said he would like to soon sharpen the panel’s views into a set of formal recommendations on primary care payment for lawmakers and the Centers for Medicare and Medicaid Services (CMS) to consider.
“We could find a situation in a few years where a significant number of Medicare beneficiaries who want to see a physician for primary care services are unable to do that,” Dr Crosson said at the Friday MedPAC meeting.
While MedPAC staff presented scenarios for boosting primary care pay by reducing Medicare’s reimbursement for other services, panelist Kathy Buto pitched the idea of direct assistance with school debt for physicians committed to this field.
Several of her fellow MedPAC members supported this suggestion from Buto, who earlier worked at the Health Care Financing Administration, which is now CMS. Many primary care doctors work for larger medical organizations, and thus might not directly benefit from additional Medicare payments, several MedPAC members said. It also might appeal to students considering which field of medicine to pursue.
“The idea of the loan repayment probably has the quickest impact and it’s something that would be more immediate” than other approaches considered, said MedPAC member Warner Thomas, president and chief executive officer of the Ochsner Health System in New Orleans, Louisiana.
Staff Suggestions
At the meeting, MedPAC staff put forward a suggestion of increasing payment rates for ambulatory evaluation and management and psychiatric services by 10% for all clinicians. This would increase spending for these services by $2.7 billion, which could be offset by a payment cut of 4.5% for other physician services, MedPAC staff said.
The increased payments would be targeted to office and home visits as well as calls made on patients in long-term-care settings. Psychiatric services in line for the boost would include diagnostic evaluation and psychotherapy, MedPAC staff said.
Another MedPAC suggestion was a 10% add-on payment for eligible services billed by primary care clinicians who derive at least 60% of their payments from eligible services. MedPAC staff put the price tag on this approach at $1 billion for about 220,000 eligible physicians. To absorb that cost, payment rates for other physician services would be cut by 1.7%, MedPAC staff said.
MedPAC staff also highlighted $500 million now slated to pay the Merit-based Incentive Payment System (MIPS) bonus as a potential source of funds for increasing primary care pay.
MedPAC will make a formal recommendation in March to Congress that it scrap MIPS and replace it with a new voluntary system for pegging Medicare pay to judgements about quality of care. The American Medical Association disagrees with this MedPAC proposal, urging instead that CMS address the physician group’s concerns about MIPS.
Constant Nudging
MedPAC has been prodding Congress and lawmakers for years to use Medicare’s payment policies to bolster the field of primary care. With annual spending of more than $600 billion, the federal health plan for senior citizens and for people with disabilities has great clout in medicine.
MedPAC in 2008 urged the creation of a budget-neutral bonus for primary care. This approach made its way into the Affordable Care Act, with Congress creating the Primary Care Incentive Payment program. Congress allowed this 10% bonus payment to expire at the end of 2015, despite MedPAC’s continued endorsement of the approach.
Primary care physicians are widely seen as losing out to specialists in CMS’ longtime struggles to set proper prices for services.
On Friday, MedPAC analysts Ariel Winter and Kevin Hayes reviewed the difficulties in adjusting the Medicare fee schedule to properly reflect time spent on patient care. Time needed for many procedures declines over time as physicians gain experience with them and technology advances. But evaluation and management services remain labor intensive, the MedPAC staff said.
Reduced time for procedures should result in lower Medicare reimbursement for procedures, raising pay for evaluation and management, MedPAC staffers said. But this “two-step sequence” often fails to happen, resulting in “passive devaluation” of evaluation and management services, they said.
“We’re all trying to grapple with recognizing that primary care is undercompensated and underpaid,” MedPAC member Buto observed.
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