Value-Based Care News

Medical Groups Call for Value-Based Care Reforms to Reduce Burden

In response to CMS’ push to reduce administrative burden, AMGA and MGMA offered value-based care reforms, such as aligning quality measures and updating the Stark Law.

Value-based care reform and administrative burden

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By Jacqueline LaPointe

- Operating with one foot in fee-for-service and the other in value-based care has created significant administrative burdens for providers, so medical groups are now offering CMS value-based care reforms to simplify the model and move more providers away from volume.

In response to a request for information on how to reduce administrative burdens, AMGA (American Medical Group Association) and the Medical Group Management Association (MGMA) recently submitted formal comments to CMS. Within those comments, the associations called for value-based care reforms to alleviate provider burdens.

“Our members are treating patients through delivery models that hold them accountable for the cost and quality of the care they provide,” said AMGA President and CEO Jerry Penso, MD, MBA. “These models by design do not contain the same misaligned incentives seen in the fee-for-service environment, and Medicare’s rules and policies need to recognize and account for this difference.”

Specifically, the associations called for quality measure alignment, more consistent waivers and rules across value-based care programs, and Stark Law reform.

Align quality measures across models to simplify reporting

As it currently stands, quality reporting for value-based care models is burdensome and overly complex, adding to practice costs, AMGA highlighted in its comment letter to CMS.

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Quality reporting for physician practices in four common specialties cost over $15.4 billion annually, and the practices spent 785 hours per physician, on average, to report quality measures, AMGA reported citing a 2016 Health Affairs study. Additionally, an internal survey of AMGA members found that medical groups employ 17 IT professionals per 100 physicians to support quality reporting.

“These costs are much better spent on caring for patients, not maintaining an expensive IT infrastructure,” the association stressed.

Starting with Medicare, CMS should reduce the number of quality measures for providers participating in value-based care models and move to an outcomes-based system in which CMS can determine quality performance using claims data, AMGA advised.

“Policymakers should work to harmonize and scale down the amount of existing quality measures for all providers in value-based arrangements. Using a standard set of value measures will help reduce the variation in the measures that are reported and help eliminate unnecessary confusion and administrative burden,” the comment letter stated.

AMGA even offered CMS a set of quality measures endorsed by the association’s Board of Directors in 2018 that are a mix of 14 process and outcomes measures that “are clinically meaningful to both patients and providers and will lead to a more simplistic and cost-reducing quality measurement reporting system.” The measures include emergency department use per 1,000 patients, 30-day all-cause hospital readmissions, depression screening, and pediatric well-child visits.

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MGMA also advised CMS to reduce the number of quality measures Medicare used in the Merit-Based Incentive Payment System (MIPS), a fairly new pay-for-performance program for physicians billing under Medicare Part B.

“In 2019, group practices’ finite resources are spread across at least 16 measures, including a minimum of six quality measures, two cost measures, six promoting interoperability measures, and two improvement activities. CMS should structure MIPS to allow practices to prioritize effective and impactful improvements to patient care, rather than comply with sprawling reporting mandates,” the group stated in a comment letter emailed to journalists.

CMS recently proposed changes to quality reporting under MIPS, which would overhaul the current system and require eligible clinicians to report on foundational measures as well as specialty or disease-specific measures.

MGMA applauded CMS for the proposed overhaul, but the group still advised CMS to carefully choose new quality measures, such as cost measures.

Consistently apply waivers across non-risk and risk-based programs

While medical groups are looking to streamline quality reporting across value-based care programs, the providers are also demanding harmonization of rules and regulations across non-risk and risk-based models.

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AMGA commented that payment waivers, such as the 3-day skilled nursing facility (SNF) and telehealth coverage waivers used in certain Medicare accountable care organization (ACO) programs, should be available to providers in all levels of the program, even if the level does not include downside financial risk.

Restricting the use of such waivers based on the level of risk assumed “is counterproductive to the goals of the program and hinders the ability of providers to develop care delivery models,” the association stated.

Offering payment waivers has been key to value-based care success. For example, the ability to send patients to an SNF even if the inpatient stay was fewer than three consecutive days has helped Medicare ACOs improve care coordination and continuity, as well as discharge patients to the most appropriate care setting.

Non-risk based ACOs should be able to use this waiver to deliver coordinated care to patients, AMGA asserted.

Additionally, the shorter glide path to risk under Pathways to Success means ACOs have a limited timeframe in non-risk based tracks. Limiting waivers and other opportunities available to risk-based ACOs “creates a situation that requires providers to adjust how they deliver care with no benefit to patients,” the association argued.

Reform Stark Law to align with value-based care models

Congress created the Stark Law, or physician self-referral law, to prevent physicians from gaming the system under fee-for-service. However, new requirements under value-based care models require policymakers to modernize the law, MGMA asserted.

The association explained that efforts to reduce the burden of complying with the Stark Law under value-based care models have been “highly frustrating; with each successive CMS rulemaking under the Stark Law, the regulatory scheme has become more complex, to the point where it is now virtually unfathomable to all but the most specialized attorneys and compliance consultants.”

As a result, smaller group practices cannot afford the resources to ensure their providers comply with the healthcare fraud law under new models for practicing medicine, MGMA stressed.

Even HHS has acknowledged that the Stark Law creates administrative burden and “may serve as an impediment to robust, innovative programs that align providers by using financial incentives to achieve quality standards, generate cost savings, and reduce waste.”

MGMA advised CMS to modernize the Stark Law by creating a single, overarching compensation exception for providers participating in alternative payment models and innovative clinical and financial models.

The law should also support the group practice model, MGMA highlighted. The in-office ancillary services exception should remain in the law to ensure physicians in group practice can still provide coordinated care for patients, the association explained.

“We seek assurance from CMS that any reform will account for physician group practices of all sizes and specialties and offer protection to all medical groups that participate in or contribute to innovative payment arrangements as a component of a larger entity,” the comment letter stated.