MedPAC urges MA data, primary care reforms

By | June 18, 2019

Dive Brief:

  • In its annual report to Congress, the Medicare Payment Advisory Committee issued three recommendations impacting Medicare Advantage plans, ER spending and primary care.
  • The commissioners recommended Congress allow advanced practice registered nurses and physician assistants to bill Medicare directly, to shed light on current treatment and help ease primary care access issues.
  • Concerned about the accuracy of Medicare Advantage encounter data, commissioners want MA plans to meet certain thresholds for submitting complete and accurate information. Commissioners are also pushing for national guidelines on coding for ER visits.

Dive Insight:

MedPAC commissioners are concerned about the quality of data CMS receives from the numerous health insurance plans that sell Medicare Advantage coverage to a growing number of seniors throughout the country.

Commissioners want MA plans to submit more complete and accurate information that could ultimately improve oversight and better inform future policymaking.

“Detailed encounter data are the best vehicle for learning about how, and how much, care is provided to the one-third of Medicare beneficiaries who receive their benefit through an MA plan,” the 2019 MedPAC report states.

Commissioners also zeroed in on curbing spending among Medicare’s fee-for-service population.

An increase in ER visits has led to an uptick in spending, according to the report. In 2017, $ 4.1 billion was spent on providing emergency room care to Medicare in fee-for-service. Just five years prior that figure was $ 2.4 billion.

The commissioners noted that a sizable portion of the growth (20% to 25%) in ED spending is tied to visits being coded at higher levels. The higher the level of coding, the higher the payment, which is why the commissioners are recommending establishing national guidelines for how to code emergency room visits.

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In years prior, CMS has encouraged hospitals to develop their own coding guidelines, and the levels of coding have gradually shifted over time.

“From 2005 to 2017, the share of ED visits coded as Level 1 or Level 2 decreased from 28.0 percent to 7.5 percent, and the share coded as Level 5 increased from 11.2 percent to 30.0 percent,” the report notes.

As concerns about the supply of primary care physicians persist, MedPAC points out that the supply of nurses and physician assistants has “increased rapidly” and is expected to continue. The commissioners are also recommending allowing certain nurses and physician assistants to bill Medicare directly.

Yet Medicare has little data to know the depth and breadth of the services nurses and PAs provide Medicare beneficiaries due to the way the current billing system is set up. Fixing this issue could later aid in identifying how best to allocate resources toward primary care services.

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