The Medicare Payment Advisory Commission (MedPAC) met March 7-8 to discuss Medicare’s role in the supply of primary care physicians, the growth of spending for emergency department (ED) services, and clinician payment.
Primary Care Physicians:
MedPAC staff revisited its discussion of Medicare’s role in increasing the supply of primary care physicians. The presentation focused on traits of existing loan forgiveness programs and discussed the design of a potential program aimed at recruiting primary care physicians servicing Medicare beneficiaries. Staff cited the AAMC’s Medical School Graduation Questionnaire data on factors that influence physicians’ specialty choice, indicating debt is not a major influence on specialty choice.
In its discussion on program design, staff suggested that the program could be funded using savings if the Merit-based Incentive Payment System program were eliminated (a separate MedPAC discussion that would save $3 billion over six years). However, multiple commissioners expressed concern that the current debt relief programs need to be maximized before creating a new program. Several other commissioners suggested that additional graduate medical education funding for certain specialties (e.g., geriatrics and palliative care) was a more efficient and reliable method to increase primary care physicians.
Commissioners requested that staff continue to explore this topic, which includes site visits to primary care-focused medical schools, with the goal of including this chapter in the June 2019 Report to Congress.
Emergency Department Spending:
MedPAC staff presented on the growth of Medicare fee-for-service spending on ED services. The presentation highlighted that roughly 2% of all nonurgent ED care could have been appropriately treated in a lower-cost urgent care center, resulting in $2 billion in additional Medicare payments. In response, staff presented a number of policy options to encourage more appropriate use of EDs, including beneficiary education campaigns and requiring nurse help lines to assist with beneficiary decision making.
Moreover, commission staff said that ED visit coding has shifted, without clear explanation, to higher average complexity over the last decade. Commissioners requested additional information on the efficacy of nurse help lines and had mixed support for beneficiary education campaigns. However, commissioners supported a separate policy to implement a set of national guidelines for ED coding. The chairman’s draft recommendation on implementing national guidelines will be voted on at MedPAC’s April meeting.
Commission staff presented an update on the statutorily required Medicare clinician payment mandated report. The Medicare Access and CHIP Reauthorization Act (MACRA) requires MedPAC to consider the effect of statutory updates on a variety of factors. Building on previous reports on payment adequacy indicators, staff focused on fee schedule volume and spending in the context of site-of-service changes, noting the general systemwide shift in services being provided in hospital outpatient departments (HOPDs) versus physician offices.
Staff reported that volume and spending is sensitive to these shifts, with the total RVUs reported in physician offices being higher than in HOPDs, but total Medicare spending being higher in HOPDs than physician offices. Staff also noted that if site-of-service remained constant, the measure of volume growth in the Medicare program would be far higher.
Overall, staff reported generally stable trends of payment adequacy indicators. During the discussion, commissioners expressed appreciation for the report and explanation of the differences in volume and spending in settings. This material will be finalized as a chapter in the June 2019 Report.