MedPAC Considers Recommendations to Support, Reward Primary Care

The Medicare Payment Advisory Commission, or MedPAC, is considering sending Congress a number of recommendations that call for, among other things, an increase in Medicare payments for physicians who provide primary care services and implementation of a medical home pilot project to better coordinate and improve care for Medicare beneficiaries.

MedPAC members discussed the draft recommendations during a meeting here on March 5. The commission meets again in early April to further discuss the draft recommendations and to decide whether to include finalized versions of those recommendations in its report to Congress in June. Most of the commission members openly expressed support for the general intent of the draft recommendations.

The first draft recommendation pertaining to primary care says, in part, that Congress "should establish a budget-neutral payment adjustment for physician services built on the (Medicare) physician fee schedule." It further states that the payment increase would apply to clinicians identified by the HHS secretary as "furnishing primary care services." Under a second proposed recommendation, the HHS secretary would rely on HHS' rule-making authority to determine the criteria for identifying primary care clinicians eligible for the increased payment.

A third draft recommendation calls on Congress to initiate a Medicare medical home pilot project for practices that meet several "stringent criteria." Those criteria would require eligible practices to

Under the pilot project, Medicare would provide modest, per-beneficiary monthly payments to support the medical home infrastructure and activities, but the medical homes still would bill for Medicare Part B services. The project would not require beneficiaries to share the cost of medical home fees. It would, however, include a pay-for-performance, or P4P, component , although the details of that part of the project have not been finalized.

"Introducing a medical home program, I think, provides an opportunity to implement real P4P incentives for physicians," said Christina Boccuti, M.P.H., a senior MedPAC analyst who helped present the draft recommendations to commission members.

The medical home pilot initially would target beneficiaries who have at least two chronic conditions.

"We start with beneficiaries with multiple conditions because they are the population most in need of improved care coordination," explained Boccuti. "As the number of medical conditions increases, encounters with different health care professionals and different health care settings also increase -- as does Medicare spending."

One of the goals of medical home programs is to "enhance the viability and the role of primary care practices while increasing access to primary care for beneficiaries," Boccuti said.

"Medicare should also engage in a public education campaign to inform beneficiaries about the health and cost-effectiveness benefits of primary care, as well as the medical home program," Boccuti said.

The draft proposals spurred discussion among meeting participants about the value of primary care. Glenn Hackbarth, J.D., chair of MedPAC, pointed out that the draft proposals to increase physician payment and establish a medical home pilot project are not "mutually exclusive" -- that they do, in fact, complement each other.

In some ways, he noted, the draft proposals represent an attempt to improve on the recommendations put forth by the AMA/Specialty Society Relative Value Scale Update Committee, or RUC, which consistently undervalue primary care. That undervaluation has resulted in an inequitable payment system for primary care services compared with other services.

"We want to reward a category of services, not because they have been incorrectly calculated by the RUC, but because of their value to the health care system and its patients," said Hackbarth.

Primary care services, Hackbarth said, are "critical to a well-functioning, efficient, high-performing health care system."

Thomas Dean, M.D., of Wessington, S.D., the only family physician on MedPAC, said that one of the values of primary care is "care coordination," but care coordination does not translate readily into the CPT codes used to determine payment for Medicare services. In many instances, he noted, care coordination does not require a meeting between patients and their physicians, yet the current Medicare system allows physicians to be paid only for face-to-face consultations.