Latest / Off the Chart: A Business of Medicine Podcast / S1 Ep201: Why ACOs still need Congress after the 2027 fee schedule, with Aisha Pittman of NAACOS

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S1 Ep201: Why ACOs still need Congress after the 2027 fee schedule, with Aisha Pittman of NAACOS · Off the Chart: A Business of Medicine Podcast

• Speaker 1 0:00 If you don't have adequate payment, you are then not going to move into or stay in a payment model like ACOs, where you have downside risk, and if you don't perform well, could potentially owe the government back money. So we really need to ensure that clinicians have adequate payment. You need that as a foundation before you move into value-based care. Speaker 2 0:38 Welcome to Off the Chart, a Visits a Medicine podcast featuring lively and informative conversations with healthcare experts, opinion leaders, and practicing physicians about the challenges facing doctors and medical practices. My name is Austin Luttrell, and the associate editor of Medical Economics. And I'd like to thank you for joining us today. CMS released the final 2027 Medicare physician fee schedule last week with deeper conversion factor cuts than the agency first proposed. So in today's episode, Medical Economics senior editor Richard Perriton sat down with Aisha Pittman, who leads the government affairs team for the National Association of ACOs, to sort through what that rule means for physicians in accountable care organizations. They get into new guardrails on how ACO benchmarks are set, why she wants Congress to step in on the payment cuts again for 2027, how ACOs can use new flexibility to waive patient cost sharing starting in April, and what the midterm election results could mean for long-term physician payment reform. And before we get started, a quick reminder: the next Medical Economics Practice Academy is coming up on Thursday, november 19. You'll find details on that in the show notes below. But with that said, Ayesha Pittman, thank you for joining us. Let's get into the episode. Speaker 3 1:45 I think a lot of our audience is probably familiar with NACOS, but just for those who may not be, can you introduce the organization? Speaker 1 1:52 Sure. So NACOS is the association focused on advancing accountable care, and so we represent the clinicians and providers who are participating in various accountable care arrangements. That includes the ACOs, so the Medicare Shared Savings Program and the CMMI ACO approaches. So reach and now moving into the lead ACO model. But then our members are also doing accountable care across all lines of business, so doing risk-based arrangements with other payers, so their Medicare Advantage and commercial Medicaid payers, as well as implementing other value-based care approaches like bundled payments. Speaker 3 2:35 The 2027 Medicare Physician Fee Schedule is a dense document. Overall, NACOS has said that it applauds CMS Medicare for the final policies. What is the single provision that matters the most to NACOS members, and why? Speaker 1 2:52 Yeah, we've been focused on advancing accountable care. So the ACO program, Medicare Shared Savings Program, is the permanent approach. We like many of the innovation center approaches, but they are temporary tests versus this permanent program that's in in statute and has been proven successful over time. It leads to reduced costs and better outcomes for patients. But there's a lot of opportunity to innovate it and make sure that it is a sustainable program long term. That we take some of the burden away for the clinicians and providers participating in the program, and that we bring innovation into the the program. So I would say that one of the major things that our members were happy to see that was finalized is guardrails on what is called the accountable care perspective trend. So this really this approach in putting guardrails on that trend factor ensures that ACO benchmarks are fair and accurate. It's a a policy that is intended to address challenges that we see with ACO participation, where once you've been in the program for a long time and you redo your contract, your benchmark is reset based on your prior performance and all of that great work you did to lower costs now almost penalizes you in in the perform in the new benchmark. And so the accountable care perspective trend aims to slowly increase ACO benchmarks over time, so that we have a sustainable approach. But the challenge that we saw is that in its first two years of implementation, it didn't actually increase benchmarks; it significantly decreased them because the trend was much lower than healthcare inflation, and so what the what they finalized was in putting guardrails that if the trend is significantly different than the healthcare healthcare inflation, it can only go minus one to plus 1.5% different from healthcare inflation. So they intentionally. Is that it'll grow the program over time without arbitrarily penalizing if the trend is inaccurate of what healthcare inflation would be. The Speaker 3 5:09 the emergence of that that trend on the ACO benchmarks, I've heard I've heard it kind of more and more this year, and it's become fascinating to me only because it seems counterintuitive to reduce rewards for performance. If that is practically what happens, Speaker 1 5:26 what the work ahead still is to figure out. So this this guardrail is positive. It's one step. We do really need to think about how do we make sustainable long term benchmarks. So next year we will be at 15 years of the Medicare Shared Savings Program, and for some of the the clinicians and and providers who have been doing this from the start, they have had benchmark updates every three to five years for for many years, and that effectively because of their strong performance, it's lowered their their benchmark approaches. The ACPT helps. There's some other policies in the rule that help as well. But how do we fix this long term? How do we make it more predictable and stable for folks who have been doing great work these past 15 years? Speaker 3 6:18 For 2027, of course, another element that has really gotten a lot of attention in our audience deals with the conversion factor, and the final conversion factor cuts are deeper than CMS had originally proposed earlier this year, as I understand it, 1.83% for qualifying APM clinicians and 2.31% for others. How do those cuts affect ACO participants, and what does being in an advanced alternative payment model soften them? Speaker 1 6:52 Yeah, so there's sort of two points here. First, then the overall cuts it creates challenges. If you don't have adequate payment, you are then not going to move into or stay in a payment model like ACOs, where you have downside risk, and if you don't perform well, could potentially owe the government back money. So we really need to ensure that clinicians have adequate payment. You need that as a foundation before you move into value-based care, and so we're hoping that Congress takes up this this issue and continues to work on fixing physician payment overall. So what we've seen over the past few years is Congress has mitigated this this cut. We're going to be asking Congress to do that again to remove this payment cut, but how what we all know is sort of the statutory current formula does not work, which is why we're seeing a payment cut year over year, and so we want to get to long-term physician payment approaches that are more sustainable, and that means paying physicians, including inflationary update into physician payment, so that there are not cuts. And so we saw work by Congress in the House with the House Republican and Doctors Caucus this year. It was a great first step into thinking about long-term payment reform. We want to keep working on that. We need the immediate fix so that we need Congress to immediately fix it for 27 to avoid the payment cut, but we need to continue the work on defining a long-term solution on the higher payment for clinicians in advance APMs. We know that these incentives work and give providers additional dollars to innovate in the care delivery transformation that you see that's a part of accountable care. So MACRA, when it passed in 2015, set two approaches: one having a one-time advance APM incentive payment, and then two bringing in this higher higher base clinician payment. So a higher conversion factor update for the clinicians who are in downside risk APMs. We're 2026. It's just the first year that this higher payment has been in place, and it compounds over time. And so, we know that incentive works. We also know that the one-time advance, the sort of one-time each year, advance APM incentives have worked. We've seen an increase in the number of clinicians participating in downside risk models. We've seen examples of where clinicians move to risk-bearing models faster than is required in the Medicare Shared Savings Program because of those incentives. We also see a lot of examples of how clinicians use those dollars to reinvest in patient care, bringing in care managers, creating 24-hour care lines, designing other things that they know that their patients want. What the beauty of that is, it goes directly to the clinicians who are doing the great work, so they can define how they're going to use those extra dollars to reinvest in care, and that reinvestment ultimately leads to better outcomes and lower. Costs. It's statutorily mandated. What we saw in the final rule is that CMS is implementing that statutory mandate. What we are really focused on and are hoping Congress continues to think about is how these incentives work long term. There's positive benefits of a one-time incentive payment or bonus each year because that sort of gives you a influx of dollars at once that you can use to design care versus doing it throughout your payment. Both both are are great and necessary, and we should think about how those things interact to ensure that long term the incentives remain. and And we need to incent both folks who have not previously participated in these type of models, but also the ones that have been in it for a long term, because you continue to make investments, you continue to pay for these these things that Medicare does not pay for that you are are giving your patients or designing care around, and so those need to to remain. And so we're hoping that as Congress thinks about this long term physician payment reform, that they also think about how we design long term incentives to keep folks in and bring others in. But we're also asking Congress that with the 2027 fix of the physician payment. That they also extend the existing advance APM incentives an additional year as well. Speaker 3 11:28 One of the things that I get the impression of is that when medical practices commit to working with accountable care, this is not something that necessarily transforms in a month's time or six months time, it takes. It sounds like it takes longer. Am I understanding that correctly? Speaker 1 11:45 That is correct. What we know, and and now that we are 15 years into MSSP and have tested a number of innovation center approaches, it takes about three to five years to really see the change because it's everything from when you first start getting getting additional data, looking at that data and understanding your patient population, and thinking about to your point there of sort of like emergent needs, long term chronic needs, what ACOs bread and butter is sort of looking at their population and segmenting and thinking what they do for each of those segments and how they address them, and then you design care delivery around that, and you enhance care delivery with other types of services that you have, whether that's care management approaches or whether that's what we're seeing emerging now is more and more clinicians and providers and ACOs leveraging some of that tech-enabled and AI enabled care; those things all cost upfront dollars. And so, what often happens is you come into the ACO, you do you make improvements that you can in house without additional investment. And then, once you start to get to shared savings, that's when you're able to make those additional investments. This is why we like those incentives because it gives you these additional investments sometimes a little bit sooner than what you might see with waiting for achieving share of savings. We also want to see CMS do other things to address those cash flow things. So our members are really looking forward to more like capitation or hybrid payment approaches, where you move away from the RVUs into providing upfront payments. Primary care capitation is a great example of one that we have tested in the ACO Reach program, and it will be incorporated into the lead model, where you move away from your regular RVU-based billing, and you are paid a primary care capitation amount, and that gives you upfront funds to make some of those investments and redesign care proactively rather than waiting for your shared savings or waiting to get your advanced APM incentive. This is why I was saying there's some benefit of the higher payment as well because that comes to you as soon as you bill as well. So we need a blend of incentives and approaches, recognizing that it does take a lot of investment to make this work. And if we can speed practices and providers being able to make those investments, we might be able to shorten that three to five year timeline to maybe only a year or two of seeing real outcomes. Speaker 3 14:27 Nacos praised the advance investment payments enhancements, but asks for more innovation on cash flow to practices. Maybe to continue along those lines, what would a good fix look like? Speaker 1 14:41 Yeah, one of the things that we just want to see, and we are hoping CMS can do this quickly, is to implement a primary care capitation or hybrid payment approach similar to what we have seen in ACO reach and seen in the lead model. We know this works if we go back to the. Comprehensive primary care model, which was discontinued because it didn't save money. But what we saw is those practices that were in CBC Plus and in an ACO had had stronger shared savings than if they were not in both programs. And so that does speak to the benefits of shifting the cash flow up front so that you can make those investments upfront, and so we think because there is a tested and tried approach in the innovation center models, let's bring that into the permanent program immediately. And I am encouraged that CMS did have an RFI about it in the proposed rule. They never address the RFIs in the final rule, but we're hoping that that is something that they are working on for next year's cycle of rulemaking. Physicians Practice 15:52 Hey there, Keith Reynolds here, and welcome to the P2 Management Minute. In just 60 seconds, we deliver proven real-world tactics you can plug into your practice today. Whether that means speeding up check-in, lifting staff morale, or nudging patient satisfaction north, no theory, no fluff, just the kind of guidance that fits between appointments and moves the needle before lunch. But the best ideas don't all come from our newsroom; they come from you. Got a clever workflow hack, an employee engagement win, or a lesson learned the hard way? I want to feature it. Shoot me an email at kreynolds@mjhlifesciences.com with your topic, a quick outline, or even a smartphone clip. We'll handle the rest and get your insights in front of your peers nationwide. Let's make every minute count together. Thanks for watching, and I'll see you in the next P2 Management Minute. Speaker 3 16:44 There are a lot of physicians who say we spend just too much time on paperwork. Does the 2027 Medicare physician fee schedule address administrative burdens? Speaker 1 16:54 It does in some small ways, and we're encouraged that CMS is continuing to seek feedback on how we can reduce burden. So, once one example in the ACO, the MSSP space was around beneficiary notifications. There were some cumbersome requirements that really just made it burdensome for the ACO to notify patients that they are in an ACO statutory requirement. We think it's good to let patients know that you're in this care model because they align through their primary care relationship. It's not something that they actively opt into, and so we want to let them know. But the requirements had some stringent timelines that just didn't make sense. It's also disconnected from care. One of the we always hear from our members is like we send out these notifications and we get 1000s of calls from patients being like, "What is this?" And really, trying to say is your doctor participates in this program that's going to help them to deliver better care and bring more and give and support you in a different and better way. But the the notifications create confusion, and so what we saw was some some modifications to that. wasn't everything that we would like to see, but those modifications are going to save real dollars and and labor on the ACO's part and how they push that out. And specifically, they change the number and and timing of the modifications. That little bit goes a long way just from staff time and resources. But it's another area that we want to continue to work with CMS line. Not just how we notify beneficiaries, but how do we make ACOs a known choice for beneficiaries? Beneficiaries are really thinking about: Am I do I stay in traditional Medicare or do I go to MA? They don't know that when you're in traditional Medicare, you could be part of an ACO that has all of these great assets to it, enhanced care management that your your doc is supported in a way differently. That's not something that's known to beneficiaries. Even if you look at like the Medicare and you handbook, it's only like a couple of pages devoted to an ACO. We think there's a lot more work that we can do to help ACOs be a known choice for for beneficiaries, and sort of calling out some of those similarities and differences to Medicare Advantage. There's some things that beneficiaries like an MA has that you also can get through an ACO, but that's just not known to the beneficiary. So we see that sort of as as a next place. If we're going to meet CMS's intent that all beneficiaries are in accountable care, whether that's an ACO or MA, we need to do a lot more to educate patients on what ACOs mean and its benefits. I think another place on burden reduction is around quality reporting. So quality is tied to payment in the ACO model and in any value-based care model, and so CMS is wanting to move away from our prior mechanisms for reporting quality to electronic clinical quality measures or digital quality measures. This presents a lot of challenges. So I think every. Everyone's well aware of many of the interoperability challenges. You've seen one instance of an EMR. You've seen one instance of an EMR. And so, while it's simpler for like an individual facility or individual practice to report electronic clinical quality measures, it's difficult for an ACO because they're trying to ingest the the EMR data from hundreds of practices, sometimes who are all on various EMRs, and so because we have not achieved the interoperability that we would like to see, that just increases creates incredible burden. ACOs are spending hundreds of 1000s of dollars on trying to move to electronic clinical quality measures, and so we have been encouraging CMS to rethink this pathway. And what we saw them do in the finalized rule was retain some of the other reporting options, so giving ACOs more options in how they report, so it can best meet their needs. We saw them retain those reporting options so that it can best meet the ACOs need, but then they also made a a commitment to the transition to digital quality measures and using the FHIR standard to report. And so they've said that they want to get there by 2030. Speaker 1 21:12 We're looking to work with the administration to ensure that when 2030 comes, we've thought through all of the nuances and we've pilot tested with ACOs to make sure that the policy reflects reality. We're really wary of ACOs investing a lot of dollars in quality reporting, and it just not not working. And so we want to make sure that quality reporting reflects what ACOs are doing to close quality gaps anyway, and that it's not an additional investment just for the sake of reporting. So we saw some some some steps towards that relieving that burden in this rule, and it's another place where there's some more work to be done Speaker 3 21:56 for 2027. As I understand it, CMS is creating the modifier modifiers b1 and b2. How are those modifiers going to change the math for joining or staying in an accountable care organization? Speaker 1 22:11 It's another thing that we are pleased to see because, as I was talking about, like first, I appreciate that CMS in in its rulemaking recognize that practices in accountable care are making significant investments in how they deal with complex care patients, and so part that evaluation of paying the practices in an ACO more is in recognition of all of the good work and that I've sort of alluded to and given examples of. So we appreciate that recognition. I think it also creates another incentive, and so we have the congressionally mandated incentives. This puts in place an an incentive that wasn't required to be mandated by Congress that demonstrates to clinicians and providers that this is the model of care that we are moving towards, and if you're doing this model of care, we're going to make the investments in that, and so we were pleased to see that they retain that higher payment for for the complexity code for clinicians that are in ACOs. The ACOs, Speaker 3 23:14 as I understand it, can reduce or eliminate Part B cost sharing starting in April next year. How do you expect that the organizations are going to use that flexibility, and are there going to be additional operational or compliance issues that members will have to deal with? Speaker 1 23:32 Yeah, this is this is a great example of the how we want to modernize the ACOs, and some of that is embracing innovation. So we've had Part B cost sharing waiver ability in the ACO reach model, and it's something that a lot of ACOs did adopt. What it it really helps with if we think about something like a complex complex care management or transitions of care management like CCM TCM, those all have a patient cost sharing option, and it's sometimes hard to justify. Sometimes patients are reluctant to do a round of CCM because there is a cost sharing obligation. And so, what this allows the ACO to say is, "We think this is the best care for you. Well, we're going to take away, and we're going to pay the cost sharing piece. Chronic care management and transition care management are the two places that we saw a lot of adoption and reach. But there are others as well. It helps you design essentially patient incentives as well, and the incentive of not having the cost share is is significant and can impact patient behavior. And so, I gave two examples that are pretty prolific that we see. There's others, and I think what we see from ACOs is that they look at their patient population and think about the things that they want their patients to do and decide if it's an area that's great for cost sharing. So we were happy to see that, and we're looking to learn more. So once you are able to remove the cost sharing for the patient, what does that mean in outcomes long term? We have some early signals from from Reach in the areas of chronic condition management, but what else could be possible if we address the affordability issue for patients, and so this is sort of one way that we can test and and learn more. So we're really happy to to see that. I think it's important to note that in waiving the cost sharing, Medic Medicare is still paid. It is that the ACO has decided to absorb that for the for the patient. So it's not a reduction to overall Medicare payment. It is ACOs choosing to leverage the additional the investment that they're getting from the incentives or their shared savings in removing the cost sharing requirement for patients. Speaker 3 25:56 Kind of looking ahead in the crystal ball, so to speak, Medicare has already announced the sunsetting of MIPS and the evolution to the new MVP, what questions do members have? What are people talking about? So Speaker 1 26:07 I will say, for many of our members, it is less of an issue because when you're in ACO, you're not subject to MIPS in the same way. So you're fully exempt if you are a meeting that QP status and a risk-bearing ACO, or if you're an upside ACO, they leverage the shared savings program quality approaches to determine your MIPS payment. So it has less of an impact to ACOs. But I will say, our members are are large groups where maybe some of their clinicians are still transitioning to to being in an ACO, and so there is some impact there. There is concern about is this solving the issue? As I talked about, where we are looking to Congress to think about some long term solutions in the physician payment space, it's the inflationary update. It's ensuring that we have strong incentives to adopt and remain in alternative payment models. But then it's also thinking about how we assess quality for those who are outside of those APMs. And so I know that piece is something that we're still working to to get right because there is a little bit of thought of are the measures meaningful? Are they simple and easy to report? Is it introducing burden? Is it really telling us outcomes about patient care? There's debate over that, and there's more work to do. I think MVPs attempts to solve some of those things, but still doesn't get it fully right. And I think it is going to take some congressional changes to statute to get it fully right. Speaker 3 27:44 As we speak right now, it's november 5. The 2020 2027 final rule was announced yesterday, and of course, the day before that was election day, with results that show there's going to be potentially significant changes here coming up in Congress in the next two years at least. Regarding those changes that are coming in Washington, can can you talk a little bit about how that might affect healthcare policy, the Medicare physician fee schedule, and payment to physicians? A Speaker 1 28:10 lot of these issues have had strong bipartisan support, particularly in the accountable care space. Everyone has the same goal of we need to get all patients and beneficiaries into accountable care relationships, how we achieve that goal is just where there's some variation between parties, and so I think we are in a place of continuing the good the the work that has been done and and building on it. So what we are looking for Congress to do it is to address physician payment cuts both in the short term and the and coming up with long term approaches, ensuring that we keep strong incentives to be in and remain in accountable care arrangements. Those have had bipartisan support. We saw the first attempt at a bipartisan approach with the Patients First Act introduced by the House Republican and Dr. Skuccis this year, and so while there is a shift in in Congress, we think these priorities remain. I think it also what we saw both parties really campaign on this election cycle was affordability and healthcare is a part of it. And one of the things that we know is when patients are in accountable care, because they're avoiding unnecessary care, we can address affordability for it. It also lowers the cost of care overall, and so it's it's still connected to their ultimate priorities. And we're still looking for Congress to do both the short term and long-term fixes to keep this movement going. Speaker 3 29:46 Again, given the the size and scope of the rule, what did I not ask about that you would like our audience to know? Speaker 1 29:52 I think there are some positive things where we heard concerns from our members where CMS is delaying the policy. So promote. Patient monitoring is a great example where CMS really listened to stakeholders' concern. Their original proposal was to say that remote patient monitoring can only be done by the clinician. But what we know from our members is that they're working with vendors to do this. They don't have the in-house capacity to do it themselves. We understand where some of CMS's concern was coming from, with is there overuse of remote patient monitoring? And we we in our comment said we need a little bit more time to get this right to address the concerns that you're thinking about, but then also ensure that we maintain access for patients and that we're not putting undue burden on providers by requiring them to conduct services that they don't have capacity for, so instead of implementing that policy for 2027, they delayed it through 20 to 2029, and that just gives us time to get the policy right. So we're really happy that they listened to stakeholder concerns, and I think it ties into the broader just focus and thinking about tech-enabled care and how we pay for it. Our members are doing a lot of tech-enabled care that they are using their shared savings dollars to make those those investments. We need to think about how we pay for that as part of base physician payment. And so, the remote monitoring is one example of that, and then Sanomized access model is another example where we're testing and trying to get the policy right. So that was one thing where they did make it on the remote patient monitoring, where they made a change that was really reflective of what our members and much of the fighter and clinician community was raising. Speaker 2 31:51 Once again, that was a conversation between Medical Economics senior editor Richard Payerton and Ayesha Pittman, senior vice president of government affairs, the National Association of ACOs. And if you want practical help with the pressures on your practice right now, join us for the next Medical Economics Practice Academy: Beneath the Surface: Efficiency, Revenue, and Burnout. It's a free virtual event on Thursday, november 19, from one to 4pm. Eastern, with sessions on AI scribes, hidden revenue gaps, and burnout. You'll find more information and the registration link for that one in the show notes below. But with that said, my name is Austin Luttrell, and on behalf of the whole Medical Economics and Physicians Practice teams, I'd like to thank you for listening to the show and ask that you subscribe so you don't miss the next episode. As always, be sure to check back on Monday and Thursday mornings for the latest conversations with experts sharing strategies, stories, and solutions for your practice. You can find us by searching Off the Chart wherever you get your podcasts. Also, if you'd like the best stories that Medical Economics and Physicians Practice published, delivered straight to your email six days of the week. Subscribe to our newsletters at medicaleconomics.com and physicianspractice.com. Off the chart, a visits in medicine podcast is executive produced by Chris Mazzolini and Keith Reynolds, and produced by Austin Latrell. Medical Economics and Physicians Practice are both members of the MJH Life Sciences family. Thank Unknown Speaker 32:59 you.