On Friday, Dec. 23, just before Congress adjourned for the year, the House of Representatives passed the omnibus spending bill that the Senate had passed the day before, on Thursday, Dec. 22, thus sending the bill to President Joe Biden for his signature. As the bill was wending its way through both houses of Congress, the leaders of nationwide healthcare professional associations weighed in on its healthcare policy provisions, as we reported on Dec. 21.
On Dec. 22, Healthcare Innovation Editor-in-Chief Mark Hagland spoke with Jamie Miller, senior director of government relations at the Alexandria, Va.-based AMGA (American Medical Group Association), which represents most of the largest multispecialty medical groups in the U.S., and whose member groups represent more than 175,000 physicians in practice. Hagland spoke with Miller regarding his perspectives on the legislation about to be passed through Congress, and what it means for the next two years in overall federal healthcare policy. Below are excerpts from that interview.
What is your overall impression of the omnibus spending bill?
We’ve been working tirelessly to raise awareness about a lot of issues, payment cuts to physicians based on the conversion factor, sequestration, pay-as-you-go, telehealth, etc. We’re thankful that Congress attempted to address these issues, and they did, to some extent. We were hearing that Congress might not have done anything; so the fact that they did do something, is an accomplishment. That said, we obviously would have liked more relief regarding the conversion factor and other elements. But the fact that Congress in this very complicated end-of-year package, addressed things, was helpful.
Initially, the conversion cut was set at 4.5 percent, but instead, they ultimately went to a 2.5 percent cut, eliminating 2 percent from what had been 4.5 percent. We were hearing that a lot of folks in Congress were trying to do 2.5 percent. We worked with Representatives Susan Wild (D-Pa.) and Mariannette Miller-Meeks (R-Ia.) on the issue.
[A Dec. 14 press release noted that “Yesterday, U.S. Representatives Susan Wild (PA-07) and Mariannette Miller-Meeks, M.D. (IA-02), led a bipartisan letter to President Biden, Leader Schumer, Minority Leader McConnell, Speaker Pelosi, and Minority Leader McCarthy urging swift action to prevent the looming Medicare cuts. Reps. Wild and Miller-Meeks were joined by 113 colleagues urging action to prevent Medicare reimbursement cuts that would force medical groups and integrated systems of care to ‘eliminate services, furlough staff, implement hiring freezes, and delay population health initiatives.’ ‘We are opposed to paying for preventing these cuts with additional provider cuts,’ the lawmakers continued. ‘The combination of skyrocketing expenses, significant staffing shortages and looming cuts to Medicare payments will only make a bad situation far worse – especially for seniors in rural and underserved areas who continue to face health care access issues. Physicians, in particular, do not receive inflationary updates in the Medicare program and, as a result, we urge Congressional intervention to prevent the entirety of these cuts. Anything short of this is still a cut that hurts providers and the patients that they treat.’ Further, ‘As hospitals across Iowa continue to face unprecedented financial challenges because of rising costs, workforce needs and diminished Medicare and Medicaid reimbursements, an additional cut to Medicare through the PAYGO sequester would be catastrophic to hospitals and threaten to restrict Iowans access to care,’ said Iowa Hospital Association President and CEO Chris Mitchell. ‘We thank Representative Miller-Meeks for her steadfast support on this issue and her efforts to prevent these cuts.’”]
Their action helped. Also, the Republican physician caucus sent a letter to leadership, and that sent a clear signal to the negotiators that something needed to happen. Congress had a limited amount of resources to help with the conversion factor bump. They also gave us a bridge for next year with a 1.25-percent bump in 2024. So that’s helpful.
To AMGA, this sends a clear signal. Policymakers on both sides understand that this year-to-year fix is not sustainable either for government or for providers. Ways and Means and Energy and Commerce are working on this. There’s talk about a major MACRA [Medicare Access and CHIP Reauthorization Act of 2015] reform. A MACRA RFI [request for information] came out this fall, and we sent out a detailed set of suggestions.
[Here is an excerpt from an Oct. 31 letter that AMGA leaders sent to congressional leaders: “The Centers for Medicare & Medicaid Services’ (CMS) regulatory implementation of MACRA to transition Medicare to a value-based payment system was met with many challenges. AMGA is deeply concerned that CMS’s regulations do not honor the legislation's original intent. Since the passage of MACRA in 2015, physicians and groups have dedicated significant amounts of time and resources to implement its requirements. However, they have not received the financial incentives Congress authorized in MACRA. MACRA introduced two pathways to clinicians through the Quality Payment Program (QPP): the Merit-based Incentive Payment System (MIPS) and the Alternative Payment Model (APM) program. AMGA has concerns with both options. APMs have failed to attract the critical mass of physicians and medical groups necessary to ensure the success of the program due to unobtainable requirements. Further, CMS is continually changing these requirements year to year and as providers advance within a particular model. There is great instability within the programs and an ever-moving target that appears to be unachievable, as demonstrated in annual rulemaking and inconsistent subregulatory guidance. MIPS has failed to reward providers for superior performance because of its insignificant payment updates, which produced a nominal investment return. AMGA members make significant investments to provide care in value-based models. These systemic improvements require investments not only in technology but all require the investments in care managements, leadership, and analytics. Congress must address the inconsistent thresholds of Advanced APMs and provide incentives in MIPS so that more providers can transition to value as envisioned under MACRA. MACRA included incentive payments for participation in certain eligible APMs. The legislation included a 5% payment for Qualifying APM Participants (QPs) for payment years 2019 through 2024 (2018 through 2022 performance periods). Beginning in CY 2026, there will be two different Medicare physician fee schedule (PFS) conversion factors (CF): one for QPs and a lower one for non-QPs. The 5% incentive payment was intended to foster a value-based payment system in health care and reward physicians who provide high-quality care while taking on a certain level of financial risk. Congress must extend the 5% APM bonus to participating physicians to further incentivize high-quality care, as the QP free-schedule incentive is trivialized by the anticipated Physician Fee Schedule cuts.”]
So there is talk of major MACRA reform?
Yes. And I would say in the coming years, there will hopefully be MACRA reform or Medicare Part B reform in general. We’ll send you our response to RFI. We’re trying to promote value for the beneficiary, for the provider, to make sure that these Medicare beneficiaries have the best local care and have ready access. And there are some more weedy things about data and patient engagement, etc.
You were pleased with the continuation of APM incentives?
Yes, that is one of our major priorities. And that received a lot of bipartisan support. And the APM program saves the government money and facilitates the provision of better care to patients. But the extension of the APM incentives does cost money. The omnibus appropriations act extends the APM bonus for an additional year at 3.5 percent.
The fact that Congress has approved the APM incentives, has sent a signal to AMGA members that the government is invested in value. A very in-the-weeds thing is that, in order to qualify for an APM bonus, you need to reach a threshold in terms of percentage of patients in APMs. It was supposed to be 75 percent by now, but we were able to get that done to 50 percent. This omnibus bill keeps the threshold at 50 percent, and then it could go up to 75 percent. So for the 2023 performance year, it will be 50 percent.
What are your thoughts on the telehealth provisions?
Section 4113 of the bill removes the geographic and originating site-of-service restrictions until December 31, 2024. And then another thing is that it also delays the in-person requirements for Medicare telehealth for two years. It also continues to recognize audio-only, which is really important. But what it doesn’t do and never did was to recognize pay parity among telehealth, audio-only, and in-person; that’s in CMS’s province.
Do you have any thoughts on the hospital-at-home provisions?
We have a lot of members involved in hospital-at-home; we endorsed a House bill and a Senate bill—H.R. 7053 and S. 3792, so we’re on the record for endorsing this bill, and a lot of our members are doing innovative work of providing acute-level services at home. That was a two-year extension, is included in the omnibus, which included an extension of HAH until December 31, 2024. Section 4140. And we support that. We’ve adopted and have helped draft bills on that; a lot of our members are very interested in that.
What does the next couple of years look like in terms of healthcare policy development in Congress?
Congress no longer wants to make temporary fixes to physician payment. It’s clear that Republicans nd Democrats alike want more permanent reform. If you remember in 2015, Congress had addressed the SGR issue every year with a patch, and agreed to comprehensive Medicare reform through MACRA. And we are at the point again where Congress wants to reform Medicare payment more comprehensively.
There’s concern that because of some of the political developments taking place, that not much will be accomplished in Congress in the next two years. Do you have any thoughts about that?
I hope that good things will happen. You read sensational news, but at the end of the day, healthcare is very personal, and members of Congress are affected by the healthcare system, and are going to want to fix things. I’ve had extremely conservative members of Congress work with us on issues because they affected family members. And in Senate Finance and HELP [Health, Education, Labor and Pensions], things work well. I don’t know how things will work on the House floor. But there is appetite for Medicare reform. Members see that their constituents have to drive two hours to see a doctor. And I know during the debate on the ACA, things got pretty political. But everybody likes Medicare Advantage. And I’m optimistic; at least in the healthcare committees that I lobby, they’re helpful to address things. And the committee staffers negotiate more.