On November 2, 2016, the Centers for Medicare and Medicaid Services (CMS), released the 2017 Medicare Physician Fee Schedule (MPFS) final rule, which finalized a number of new policies designed to improve Medicare payment for services provided by primary care physicians to patients with multiple chronic conditions, behavioral health issues, and cognitive impairment conditions. The final rule also updates quality measures, audit, and reporting under the Medicare Shared Savings Program. It includes revisions to permit eligible professionals in Accountable Care Organizations (ACOs) to report quality separately from the ACO, incorporates updates to align with the Physician Quality Reporting System and the Quality Payment Program, and implements modifications to the assignment algorithm to align beneficiaries to an ACO when a beneficiary has designated an ACO professional as responsible for his/her overall care.
The final rule provides new requirements mandating the release of data associated with Medicare Advantage Organizations, in an effort to foster transparency and better educate beneficiaries making enrollment decisions. It also expands the Medicare Diabetes Prevention Program while adding several codes to the list of services eligible to be furnished via telehealth, including end-stage renal disease-related services for dialysis, advance care planning services, and critical care consultations. These provisions highlight CMS’s continued efforts to improve payment for primary care and care management.
Following the release of the final rule, the Commonwealth Fund published its 2016 International Health Policy Survey. Its results showed that Americans are in poorer health than citizens of other countries, have a harder time affording care, and have difficulty accessing primary care, which causes them to resort to more expensive emergency room care. The report did point out that since the Affordable Care Act was enacted, fewer people have reported cost as a barrier to accessing health care. We still, however, lag behind other countries.
With the buzz currently surrounding repealing and replacing the Affordable Care Act – just as 2017 enrollment in the Marketplace in underway – efforts continue across the country to address the socioeconomic determinants of health, such as access to affordable housing and food insecurity. Further, with the continued prevalence of diabetes, the Medicare Diabetes Prevention Program is being expanded. This program is a behavioral change intervention intended to prevent the onset of type 2 diabetes among Medicare beneficiaries who are diagnosed with pre-diabetes. The program will be covered as an additional preventive service with no cost-sharing under Medicare, and will entail services in community and health care settings furnished by coaches that are trained community health workers or health professionals.
While it remains to be seen what the new Administration will do – or undo – with regard to the Affordable Care Act, providers and payors continue to align efforts to reward providers for prevention and population health management efforts. As lessons are learned and data analyzed, progress is continuing and refinements are being made to programs and initiatives. We are left wondering, however, whether the efforts made over the past few years will be partially or completely unraveled, and whether any disruption in federal programs will actually hamper the work currently underway in the move away from fee-for-service reimbursement models. Certainly, data driven approaches to manage population health and improve healthcare delivery coupled with innovative solutions to improve access, increase quality, and lower healthcare spending can and should continue.