APG’s Susan Dentzer: We’ve Got to Inspire PCPs Forward Into Value-Based Care

May 17, 2024
APG’s Susan Dentzer on the ins and outs of a new bill focused on primary care physicians and care management

The press release published jointly by the offices of the two senators began thus: “As part of their ongoing work to address primary care challenges and reform physician payment models, U.S. Senators Sheldon Whitehouse (D-RI) and Bill Cassidy, M.D. (R-LA) released a Request for Information (RFI) to accompany the introduction of the senators’ bipartisan Pay PCPs Act, legislation to better support and improve pay for high-quality primary care providers.” And it quoted the two senators as stating that “Primary care is a critical part of the health care equation.  Overwhelming evidence shows that primary care both improves health outcomes for patients and drives down health costs.  There are many issues to address in primary care, and we look forward to receiving feedback on our legislation through the RFI to make a meaningful difference to health care success.”

Per that, “The Pay PCPs Act would task the Centers for Medicare & Medicaid Services (CMS) with establishing hybrid payments to reward primary care providers who provide the best care to their patients — care that reduces patients’ emergency visits, hospitalizations, excess specialist services, and other big cost drivers — and reward patients with better health outcomes.  The bill would provide Medicare beneficiaries with reduced cost-sharing for certain primary care activities and services, and would also create a new technical advisory committee to help CMS more accurately determine Fee Schedule rates.”

As we noted, the leaders of APG expressed strong support for the legislation. And in that regard, Healthcare Innovation Editor-in-Chief interviewed APG’s Susan Dentzer following the announcement of the introduction of the legislation, to get her perspectives on the legislation, and also on the broader issues around empowering physicians to plunge more fully into value-based contracting. Below are excerpts from that interview.

What’s your perspective on this newly introduced legislation?

As of right now, we only have the barebones of the legislation so far, but we think it’s a good proposal. The Medicare Physician Fee Schedule is a monstrosity, and it has disadvantaged primary care providers for a long time, and continues to do so. And if one envisions a world in which more primary care providers are able to appropriately deliver care in the 21st century, underpaying them, as we have been doing, is wrong, and we can see the impacts: the number of Americans who say that they have a regular PCP continues to drop, and we’re moving into a crisis. And the Medicare Physician Fee Schedule influences private payers’ payment patterns as well, and compounds the problem. So not only will we not have enough primary care physicians to provider care going further into the 21st century; and if we really want to push the system into value-based models, we’re shooting ourselves in the collective foot. The ability to take on risk and be accountable for cost and quality, will just not happen if we continue to starve primary care.

So Senators Whitehouse and Cassidy have a good proposal. Does it go as far as the nation needs to go? No. Is it a good first step to take the Physician Fee Schedule and modify it? Yes. At the moment, we don’t know the cost; it has to get a CBO estimate, which could knock it out of the ring. But even establishing the cost, per that, they’ve put out a request for information and request for stakeholders to weigh in on the legislation’s key features. The most obvious is that if you’re going to hand a certain group of providers, prospective payments, you have to decide who will qualify, and who’s got the Medicare beneficiaries coming to them. And so we have the same problem as in the MSSP and other models. The challenge is that the prospective payment will be a per member per month amount, but in this case, they’re still be working in FFS. So you have to tie a patient to a doctor; and that’s just one of a long list of questions that they’ve asked for stakeholder comment on.

How do we get more and more physicians to flip over into value-based care delivery, per incentives?

Yes, there is tension, and this proposal—they need the same kinds of infrastructure support they would need in VBC. Right now, they need to produce volume to stay afloat financially. And we know that practice-cost inflation is now running nearly 4 percent a year, and yet once again this year, we’re cutting physician payment in absolute terms and in relation to overall inflation, even more. So right now, if you’re a FFS physician, you’re on a hamster wheel, seeing as many patients as possible. And what this bill essentially says, is that we’ll take have of your payment and give it to you prospectively, and we’ll take you off the hamster wheel for half of your practice so that you can focus away from volume and add to your in-office workforce. Maybe you can hire an advanced practice nurse to take off some of the load; maybe hire a pharmacy consultant to deal with medication issues. All of that is really good and really positive. Does it in and of itself get you into value-based care? No. Does it give you some of the things you need? Yes. So this gives a pathway for primary care practices to survive; and that is a prerequisite for going into value-based care. But there’s still a long way to go between this very valuable proposal, and VBC.

Can meaningful legislation like this be passed in this presidential and congressional election year?

I do think it’s possible. And also, Congress can do all sorts of things to mitigate the cost in the short run. There are a lot of questions they’ve got to decide fairly quickly, and some of the questions are serious. They have to decide whether they’ll take half of FFS payment and if they turn it into a prospective payment, they have to determine how big that payment will be. And how practices will use this hybrid payment, that’s not yet known. So realistically, if they passed something like this, this year, they would be instructing CMS to create this model and get it up and running a few years down the road, because it would take probably a couple of years to answer all these questions and get the model up and running. So do I think it’s possible they could enact it this year? Yes. But they would be handing off a lot of the details to CMS, and kicking the can of implementation down the road a couple of years, maybe more. Then again, the cost estimates could knock this out, though it’s not a given that this would cost more, because they’re going to take half of the FFS payment to work with; we don’t know yet how that will work out.

And there is one component of this legislation that would cost money. Several years ago, Congress determined that if you voluntarily designate a provider to do care management and care coordination, when that legislation as adopted, Medicare adopted a copayment. But Medicare beneficiaries are turning down that option because of their copayment. This bill reconfigures that, so that if a Medicare beneficiary designates a primary care provider who’s their primary source of care, they can get their coinsurance cut by half. That should incentivize Medicare beneficiaries to participate. But doing so will cost money. And that piece, we know will cost money. And then, depending on how else the rest of it is structured, it could cost more. But it doesn’t inherently have to cost more if they use existing spending as the baseline.

 

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