Value-Based Care News

Why Primary Care Matters in Medicare Shared Savings Program

By Vera Gruessner

The Centers for Medicare & Medicaid Services (CMS) is moving forward with updating the rules and programs around accountable care organizations. The American Academy of Family Physicians  (AAFP) is urging for CMS to include key provisions related to family medicine when developing their new rulings for the accountable care organizations and the Medicare Shared Savings Program.

Robert L. Wergin, MD, Board Chair of the AAFP, wrote in a letter to CMS Acting Administrator Andy Slavitt ways to improve the program. The letter consisted of information discussing how to assign patient, share vital medical data, establish performance benchmarks, and report overall performance on an annual basis.

“CMS proposes to calculate an ACO’s rebased benchmark using historical expenditures for the beneficiaries assigned to the ACO in the three years prior to the start of its current agreement period,” he wrote in the letter.

“In addition, CMS proposes to adjust the ACO’s rebased historical benchmark to reflect risk-adjusted regional average expenditures, based on county FFS expenditures determined for the ACO’s regional service area. The AAFP supports this rebasing methodology, because we believe benchmarks should be established and rebased on a blend of historical and regional data to ensure physicians are showing improvement at any level. As the MSSP evolves, we implore CMS to test whether rebasing benchmarks more on regional average expenditures and less on historical expenditures would yield a fairer methodology for measuring performance.”

According to a news release from the American Academy of Family Physicians, the organization believes that sharing medical data more quickly and effectively with primary care physicians will allow more small and medium-sized medical centers to participate in accountable care organizations and the Medicare Shared Savings Program.

The way patients are assigned to an accountable care organization revolves around their choice in a primary care physician. Wergin states in the letter that more priority should be given to a doctor who has provided more services for a patient versus a physician that a patient has recently seen when assigning patients to accountable care organizations.

Additionally, the American Academy of Family Physicians requests that CMS create an appeals process for doctors who wish to decline serving a particular patient within an ACO depending upon the services needed to treat a certain beneficiary.

The letter also describes the importance of reimbursing primary care physicians depending upon the diversity of their patient population as well as efficiency of services especially when treating patients with multiple medical conditions.

Essentially, when greater priority is given to primary care and preventive health, more expensive treatments and surgeries can be avoided over the long-term. Primary care physicians play a vital role in diagnosing patients’ health concerns. For instance, 55 percent of visits to a primary care office due to diabetes has led to the diagnosis of a secondary condition.

Wergin also wrote in the letter that primary care visits tend to be much more complex than that of a specialist visit and, therefore, should be compensated with this in mind. AAFP also cited some concerns with the progress of accountable care organizations including the fact that reimbursement is made up to two years after a physician practice joins an ACO. Performance data is gathered or two years before a physician is reimbursed, which makes it difficult for doctors to reform their work practices.

A survey conducted in 2015 by the American Academy of Family Physicians and Humana shows that as many as 63 percent of doctors do not receive feedback in a timely enough manner to make any significant changes to their medical practice in order to receive much-needed revenue.

“In 2015, the AAFP and Humana conducted a survey of family physicians to understand their perceptions and attitudes on value-based payment (VBP),” Wergin wrote in the letter. “The survey showed practice sustainability was the factor family physicians felt was most important in evaluating the success of a VBP system (92 percent). Benchmarking is one of the primary factors for gauging an ACO’s success or failure and plays a critical role in sustainability.”

“If initial benchmarks are established in a way that provides an opportunity for organizations of different sizes and levels of sophistication to succeed, this will help maximize participation among providers. The AAFP applauds CMS’ efforts to continually reexamine its Medicare ACO policies and offer greater flexibility so that small- to medium-sized primary care practices will be more likely to participate and succeed. In that same spirit, the AAFP supports policies that expand the shared savings methodology so all practices could choose, if they desire, to enter two-sided risk arrangements.”

Within the Medicare Shared Savings Program, primary care doctors would be required to monitor a patient's medical costs when making referrals. However, this is a very complex request when considering the current health care delivery system. The problem revolves around the lack of cost transparency.

What happens is that doctors working through an ACO often receive cost information after a patient receives services and they tend to lack data comparing low-cost and high-cost specialists. In the survey, more than three out of four doctors stated they did not have enough data on service costs to appropriately refer patients to certain specialists.

While accountable care organizations are meant to improve care coordination throughout the health care delivery system, this could potentially decline to follow a doctor's recommendation or see a provider outside of the network their insurance covers.

CMS will need to consider all of these issues in order to make stronger reforms in the Medicare Shared Savings Program and in their revision of rules regarding accountable care organizations.

Image Credits: Humana and the American Academy of Family Physicians