WASHINGTON -- No change is needed for the current update planned for Medicare physician payments in calendar year 2021, members of the Medicare Payment Advisory Commission (MedPAC) agreed Thursday. But commissioners also emphasized the need for collecting more data on the costs of running a physician practice.
"I support the recommendation [to collect additional data], but I hope we'll take the work up next year," said commission member Karen DeSalvo, MD, MPH, chief health officer at Google.
"We really need to get a better handle on physician expenses from 2020 and beyond, including for health IT" and the costs of running a practice team. For physicians looking to change the way they're paid by Medicare, "it's expensive to hire consultants to help you move to alternative payment models," she added.
Paul Ginsburg, PhD, director of the USC-Brookings Schaeffer Initiative for Health Policy, had a similar thought. "The information we have on physician practice expenditures compared to what we could know is a big gulf," because the last Centers for Medicare & Medicaid Services (CMS) survey was based on data from 2007 and 2008, he said. "I think we should take it on ourselves to encourage CMS, because the appearance that we can't afford a survey more than once every 10 or 15 years seems not to be a good way to manage policy."
Under current Medicare policy, no payment increase is planned for 2021, but clinicians who participate in the Merit-based Incentive Payment System (MIPS) program will receive updates of +/- 7%, and some may be eligible for an "exceptional" performance bonus, said Rachel Burton, MPP, a senior analyst at MedPAC. Doctors who participate in advanced alternative payment models (AAPMs) are eligible for a 5% incentive payment depending on their performance.
One reason no payment changes were recommended is that beneficiaries' access to care remains good. Most beneficiaries had no problems obtaining an appointment with a physician when they needed one, or finding a new physician who takes Medicare, said Burton. And the number of clinicians billing Medicare fee-for-service grew at a faster rate than the number of beneficiaries from 2013 to 2018, she added.
A total of 99.6% of providers' fee-for-service claims were paid "on assignment," meaning that the providers accepted the approved Medicare rate as full payment; that rate includes a 20% patient copay in addition to the 80% that Medicare itself pays. In addition, about 1 million providers -- the vast majority of those who treat Medicare patients -- received additional payments through the MIPS program or from the AAPM bonus program, Burton said. Following the recommendation to stick with current law for 2021 shouldn't affect beneficiaries' access to care or doctors' willingness to furnish care, according to MedPAC staff.
Larry Casalino, MD, PhD, professor of healthcare policy and research at Weill Cornell Medical College in New York City, said that if nearly everyone is getting payment bonuses, "it must mean the bonuses are quite small." Burton agreed, noting that the bonus amount went only as high as 1.7%.
MedPAC chairman Francis Crosson, MD, of Palo Alto, California, said the high bonus rate was not really a big surprise. "Just to be clear, it was the projection of this commission based on staff work that what is currently playing out was going to play out," he said. "That's one of the reasons we suggested that the MIPS program needs to be replaced with something else." Their suggestion has not been taken up by CMS, so for now, the commission voted 16-0, with one commissioner absent, in favor of the recommendation to keep to the current update.
The commissioners also discussed Medicare payments for kidney disease treatment; currently Medicare uses a bundled payment system for care of patients with end-stage renal disease (ESRD). The commission voted to recommend that payments under the system for treating ESRD in 2021 be updated consistent with current law.
However, the commissioners were very concerned that Medicare take into consideration any new drugs that might come along for ESRD patients; Medicare should quickly update its payment bundle to accommodate new drugs, especially if they save costs overall, and not wait until the scheduled time for an update.
"Say there's another tPA [tissue plasminogen activator] that comes along," said commissioner Kathy Buto, a health policy consultant in Arlington, Virginia. "You'd want another manufacturer to feel that's going to be recognized sooner" than whenever the next bundle update is scheduled, she said.