December 2, 2020
By Travis Broome
The comment period for Medicare’s 2017 proposed physician fee schedule closes this evening and as usual we take this opportunity to share on full comments on the proposed updates to the way Medicare pays for physician services.
Dear Administrator Slavitt:
Aledade partners with 205 primary care physician practices, FQHCs and RHCs in value-based health care. Organized into sixteen accountable care organizations across 18 states these primary care physicians are accountable for over 190,000 Medicare beneficiaries. More than half of our primary care providers are in practices with fewer than ten clinicians. We are committed to outcome based approaches to determine the value of health care. We are committed to using technology, data, practice transformation expertise and most importantly the relationship between a person and their primary care physician to improve the value of health care.
As fee-for-service continues and will continue to underpin health care financing for the near term, we support CMS’s continued efforts to refine fee for service. Specifically:
- The expansion of the chronic care management code is a necessary refinement of care management to match the needs of the Medicare beneficiaries who need it the most.
- The integration of mental health care management is long overdue and with the history of confusion that exists in Medicare coverage of mental health we encourage CMS to not only adopt the measures, but to spend considerable effort in making the requirements clear and availability of the service wide spread
On improving the Medicare Shared Savings Program
- We have long advocated for an option for Medicare beneficiaries to choose their primary care physician and are fully supportive of CMS’s proposal. The level of beneficiary engagement this option brings to the MSSP cannot be measured simply in changes in attribution.
- The proposed changes to quality measures mostly strike a good balance between the impact of the measure, the evidence behind it and the feasibility of accurately reporting the measure
Below is a full explanation of those positions. Thank you very much for your consideration as we move together through this exciting time in healthcare. Please feel free to follow up with me or Travis Broome (travis@aledade.com) if you or your staff have questions or would like to explore these positions further.
Medicare Shared Savings Program
Incorporating Beneficiary Preference into ACO Assignment
We strongly support voluntary beneficiary choice of their primary care physician in all tracks of the MSSP. Currently, CMS only acknowledges primary care physicians when beneficiaries vote with their feet by walking through the practice’s door. However, there are many times where for a particular year that may not be an accurate reflection of the beneficiary’s wishes and normal care pattern. Simple and common examples, such as dealing with an acute illness or condition requiring specialized evaluation and management services, extended time away from primary residence, low health care utilizers where a single service plays a big role in determining the plurality of primary care services, or primary care physician (PCP) switching for a patient when they enter a skilled nursing facility (SNF), etc all could lead to inaccurate attribution. Beneficiaries should be able to also vote with their voice and declare that despite the data from a single, peculiar year, “this physician, this nurse practitioner, this physician assistant is whom I have a special relationship with, this is who I want to coordinate my care.” Thus we promote patient engagement and make known an active patient and physician relationship.
However, the benefits of giving beneficiaries this choice cannot simply be measured in improvements in ACO attribution. Empowering beneficiaries by creating a method for them to record their choice strengthens the physician-patient relationship, can serve as a driver for beneficiaries to access www.mymedicare.gov and the wealth of information stored there and generally increase engagement. This makes the implementation nearly as important as the decision to give beneficiaries the choice.
We appreciate the difficulty of implementing a system to accommodate this choice. Both for the difficulties in implementation and the difficulties in beneficiary education we recommend a single method for recording beneficiary, the beneficiary portal www.mymedicare.gov. As stated previously, we believe the benefits extend beyond improvements in attribution accuracy. Many of those benefits are dependent on increased beneficiary engagement shown by the beneficiary and/or their authorized family/friends interacting directly with Medicare not just filling out a form.
We do not support all of the various contingencies laid out in proposed rule. The manual process developed as a test within the Pioneer model was a significant administrative burden for ACOs, and the language provided by CMS for the outreach letter was highly confusing and often at odds with how beneficiaries think about their medical providers. The combination of these barriers resulted in low participation by ACOs. The process should be automated from the beginning even if that results in a delay in implementation.
Furthermore, the variations by track could lead to confusion among ACOs and difficulty to track beneficiary choice’s effect on attribution. We recommend simply that the most current choice of primary care physician at the end of the performance year be the driving choice. Therefore, a patient could switch out of a Track 3 ACO into a Track 1 ACO or switch out of a Track 3 ACO into no ACO at all. This does raise a concern for prospective assignment Track 3 ACOs and whether they would attempt to use beneficiary choice to move expensive beneficiaries out of the ACO to generate savings. While the corresponding decrease in risk scoring should prevent most unearned savings, we agree that CMS should track this carefully for signs of abuse, but should not complicate the process at the beginning in anticipation of a pattern that may not emerge.
Quality Measurement
Aledade, Inc. participates in the Health Care Transformation Taskforce and supports the principles laid out by the Taskforce for quality measurement.
- Quality measurement should focus on outcomes;
- Quality measurement should be consensus-based;
- Quality measurement should allow for the rapid accommodation of changes in evidence-based medicine;
- Quality measurement should cross over different payers and programs and every program should prioritize alignment with other programs; and
- Quality measurement should materially impact the financial performance of value driven health care models.
The MSSP generally follows these principles. We urge CMS to accelerate its efforts to replace process with outcomes measures for the MSSP program.
We support:
- The addition of ACO-37 and ACO-38, two outcome measures that report on inpatient hospital admissions of patient with clinical conditions that could potentially be prevented with high-quality outpatient care.
- The change to ACO-12 (NQF #0097) for medication reconciliation. This measure emphasizes a robust medication reconciliation at the time it is needed most – care coordination with post-acute care providers – and aligns with Core Measures Collaborative recommendation.
We do not support the inclusion of ACO-44 (NQF #0052) Use of Imaging Studies for Low Back Pain in the Medicare Shared Savings Program. The measure specifies patients aged 18-50, which represents a small population of the Medicare program. We ran analysis showing that only 0.11% (98 out of 92,075) attributed MSSP beneficiaries would be in the denominator. This is across eight ACOs with three ACOs having 5 or less patients in the denominator. In addition, this is proposed as a claims-based measure which does not allow an opportunity to include information from the chart. We do not believe that the administration of this measure in the MSSP adds sufficient value to the ACO program to justify its inclusion.
We support the proposed retirement and/or replacement of the four CMS web interface measures:
- ACO-39 Documentation of Current Medications in the Medical Record – Replaced by ACO-12 (NQF #0097)
- ACO-21 Preventive Care and Screening: Screening for High Blood Pressure and Follow-up Documented – Evidence base
- ACO-31 Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)
- ACO-33 Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy—for patients with CAD and Diabetes or Left Ventricular Systolic Dysfunction (LVEF <40%)
We support the proposal to eliminate ACO-9 and ACO-10, which both measure condition-specific admissions, and replace them with all cause admission measures for heart failure and chronic conditions. These will be easier for ACOs to track and trend internally for performance improvement purposes.
We fully support the Taskforce’s comments regarding TIN level participation, alignment and quality assurance.
Behavioral Health
One critical driver of medical costs is unmet behavioral health needs (mental health and substance use disorder issues). The most established model for addressing this challenge is the collaborative care model (CoCM) for integrating behavioral health and primary care. (https://icer-review.org/wp-content/uploads/sites/2/2015/01/BHI_Final_Report_0602151.pdf)
We wholeheartedly support the new proposed regulations aimed at encouraging broader implementation of the CoCM for integrating mental health and primary care. However, we have concerns regarding the requirement that the “behavioral health care manager would be on-site at the location where the treating physician or other qualified health care professional furnishes services to the beneficiary.”
As you are aware, 55% of U.S. counties have no psychologist or mental health-trained social worker https://store.samhsa.gov/shin/content/PEP13-RTC-BHWORK/PEP13-RTC-BHWORK.pdf). Because of this, the proposed CMS regulations will likely be of great benefits to areas of the country meeting two conditions:
- A trained mental health workforce is available locally for employment to provide on-site treatment.
- The volume provided at the primary care provider’s office is large enough to support the employment of an on-site behavioral health specialist.
Both of these conditions are unlikely to be met in small, rural medical practices, and it is in these areas where access to behavioral health services is most lacking. Being able to integrate primary care and behavioral health services is an excellent proposed solution to these access issues. In order to help achieve this benefit throughout the country, we propose that the requirement for an on-site behavioral health manager be removed and that it be permissible to provide behavioral health care management via an off-site care manger using telephonic or video technology.
Should CMS not agree with this proposal, we would ask that you consider, at a minimum, to waive the requirement for on-site care management in areas that have been designated by HHS to be Health Professional Shortage Areas in Mental Health. Under this proposed change, we recommend that it be permissible specifically in these areas to provide behavioral health care management via an off-site care manger using telephonic or video technology. This would be similar to the current CMS waiver system for Rural Health Centers.
Chronic Care Management
More than any administrative burden, the biggest barrier to implementing CCM is the current one size fits all CPT 99490 valuation and payment. This one size fits all payment creates inverse financial incentive to provide the service for those who qualify, but need it the least and to stay away from those who are going to require intensive care management work. We applaud CMS on recognizing this need and proposing a high complexity code and additional time add-on to the CCM service. Both of these codes address deficiencies in using just the one code and should be finalized.
While we appreciate the lack of uptake in the first year of CCM we continue to urge careful monitoring of the utilization of CCM and the benefit it generates. Nationwide, substantial capital investment has been made in utilizing the CCM code and that investment will continue to increase utilization over time. CMS should carefully monitor utilization and benefit and be prepared to limit the higher payment codes. Specifically, we had suggested last year that the high risk beneficiaries who are in the top 20% of HCC risk scores for the country.
We understand the difficulty many physicians have had utilizing health information technology (HIT) in providing chronic care management and the physicians we work with have experienced this as well. Therefore, we support CMS’s proposal to back off the requirements of HIT in the provision of chronic care management services. We would recommend that CMS make it clear in the final rule that if this proposal is finalized that the goal is to eventually reinstate the requirements as HIT continues to improve in the area of chronic care management.