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Washington Highlights

MedPAC Discusses Primary Care, Quality

April 4, 2014—The Medicare Payment Advisory Commission (MedPAC) convened April 3 for its final meeting until Sept. 11-12. On the agenda was a discussion on ways Medicare can support team-based primary care for beneficiaries, extending and replacing the primary care bonus payment, and potential ways to measure quality across Medicare populations. No recommendations were made on any topics.

Commissioners are interested in learning how Medicare can more adequately support the development of teams to provide primary care for beneficiaries. To support their work, MedPAC staff examined other models of team-based care and interviewed 10 self-identified team-based practices. Models examined by staff were clinics of the Veterans Health Administration (VHA), federal qualified health centers (FQHCs) and nurse-managed health clinics. Of the self-identified practices, five were physician-led teams and five were nurse-led.

From these interviews, staff discovered that teams vary considerably in how they organize, structure, and staff their practice. One commonality found across all sites was that it requires significant resources to adopt a team-based model. A major regulatory impediment to team-based models of care proposed by MedPAC staff and echoed by commissioners is the face-to-face requirement for payment in traditional Medicare fee-for-service (FFS).

The commission supports efforts to promote the development of team-based care. They view care teams as a way to increase access to primary care services and to do so in a manner that is more efficient and of higher quality. They will continue to examine this issue in the future with a particular emphasis on identifying policies that may prevent the development of care teams as well as ways to incentivize their development.

Next, commissioners continued their March discussion on extending the primary care bonus payment in the form of a per-beneficiary payment [see Washington Highlights, March 7]. The commission’s discussion focused around three main areas: payment amount, beneficiary attribution, and implementation of practice requirements.

The commission feels an appropriate starting point for the payment amount would be $2.60 per beneficiary per month which is the same amount providers would be reimbursed if the total amount of bonus payments paid out in 2012 ($664 million) would have been paid on a per-beneficiary-per-month basis.

In terms of attributing beneficiaries to providers for the purpose of payment, commissioners felt a prospective system would be preferred compared to a retrospective system. There was discussion on whether a blended form of attribution could emerge in which prospective payment is provided with a retrospective reconciliation of payment.  To pay for the per-beneficiary payment, commissioners support first looking within the fee schedule to identify overpriced services. They view this option as the most feasible.

In terms of practice requirements to receive the payment, the commission felt imposing additional burdens on providers would be counterproductive. They recognize that any additional requirements bring additional costs to practices. A chapter on this topic will appear in the June 2014 report to congress. The commission intends to continue this discussion and make recommendations in the fall.

Lastly, MedPAC continued its discussion from the March 2014 meeting on measuring quality of care across Medicare programs [see Washington Highlights, March 7]. Commissioners reiterated their concerns with the current provider-level measures, which they argued overly rely on process of care quality measures and fail to coordinate across care settings.

They discussed using a limited set of outcome and overuse measures to assess Medicare populations across FFS, accountable care organizations (ACOs), and Medicare Advantage (MA) plans for a specific geographic area. There were disagreements as to whether this type of measurement should be used solely for reporting purposes, or whether payment adjustments should also be incorporated under this model.


Evan Collins, MHA
Specialist, Clinical Operations and Policy
Telephone: 202-828-0552

Scott Wetzel, M.P.P.
Lead, Quality Reporting
Telephone: 202-828-0495


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Washington Highlights, a weekly electronic newsletter, features brief updates on the latest legislative and regulatory activities affecting medical schools and teaching hospitals.

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Jason Kleinman
Sr. Legislative Analyst, Govt. Relations
Telephone: 202-903-0806