As the deadline nears for continuing the Medicare primary care bonus program established as part of the Patient Protection and Affordable Care Act (ACA), members of the Medicare Payment Advisory Commission (MedPAC) continue to move toward maintaining the increased payment -- albeit in a different form.
MedPAC first recommended a primary care bonus in 2008 with the goal of directing more resources to primary care and rebalancing the fee schedule, and the Primary Care Incentive Program (PCIP) was created two years later. However, the current PCIP bonus of 10 percent for primary care services provided by eligible professionals will expire at the end of 2015. At their meeting last week, commissioners discussed whether to recommend continuing the payment in the same format or revising how it would be paid.
The total value of the Medicare bonus payment was $664 million in 2012, and 170,000 physicians received the payment. Among physicians who received the bonus, the average amount paid was $3,400 per year. Physicians who treated more Medicare patients received as much as $9,300 per year.
The proposed payment model is being called a per-beneficiary payment for primary care. Using the same budgeted amount, participating physicians would receive about $31 for each patient per year. The figure was calculated by dividing the $664 million by 21.3 million patients, which is the number who received primary care services under the program in 2012.
The commission is expected to draft a recommendation and vote on it in January.
During the meeting, MedPAC Chair Glenn Hackbarth, J.D., acknowledged that the bonus may be small but noted that it does provide a modest boost for primary care, which the commission believes is historically undervalued by Medicare.
"I think it's safe to say that none of us who have been involved in this have any illusions that, A, this is the perfect way to construct the payment and it's going to be targeted perfectly or, B, that it's going to make all the difference for primary care practices," said Hackbarth. However, he added, "even if this isn't a huge amount of money, it is important to continue it."
As currently envisioned, the pathway for paying the bonus would be to fund the payment through a reduction in fees of 1.4 percent for all non-evaluation and management services such as procedures, imaging and tests that are not currently eligible for the primary care bonus. Only a small group of specialties, including family medicine and general internal medicine, among others, would be eligible to receive the payment.
During the discussion, Commissioner Alice Coombs, M.D., questioned whether this requirement was too restrictive. She pointed to a colleague who is a rheumatologist and whose patient panel includes about 17 percent of patients who receive primary care services from that subspecialist. She asked why a specialist who serves as the primary care physician for many patients not be eligible to receive the bonus.
Under the scenario given above, a rheumatologist or surgeon would not qualify for the bonus payment even if that physician was considered to be a patient's primary care physician.
MedPAC staff analyst Kevin Hayes, Ph.D., responded that the intent of the commission was to address the compensation imbalance between primary care physicians and subspecialists with the financial tools that are available.
Ultimately, commission members were in agreement about the need to address this long-standing imbalance, but some commission members questioned whether an increased payment will affect any kind of long-term change.
"How does this enhance the delivery of primary care?" asked Commissioner William Hall, M.D. "What if I'm a cardiologist and I do some of these services? It doesn't promote a career in primary care.
"Part of what we're responding to here is that the bonus is expiring," noted Commissioner Scott Armstrong, M.B.A. "What's the real primary care problem that we're trying to solve? This is a good step, but it's not sufficient to solve our broader goal."
"It's a step, but it's a baby step," agreed Commissioner Craig Samitt, M.D., M.B.A. "We want to pay primary care more and pay differently, but this is not enough to move to a value-driven model." The ultimate solution, he said, is to make the transition to a per-member, per-month payment that would replace the relative value unit payment model traditionally used by Medicare.
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