3 Reforms Aim to Reduce Administrative Burden of Value-Based Care

As the industry transitions from the fee-for-service model to value-based care, many providers are finding themselves struggling to straddle the divide. The shift away from volume has created many new administrative burdens that are handicapping providers’ ability to focus on patient care.

In an effort to alleviate these significant provider burdens, CMS recently sent out a request for information to various organizations-including the American Medical Group Association (AMGA) and Medical Group Management Association (MGMA)-on how they can better streamline the process.

AMGA proposed several reforms, saying in a statement that “[We have] recommended that [CMS] reform a number of regulations and policies to ensure they support providers’ ability to deliver care in value-based model … [including] detailed policy recommendations designed to reduce Medicare programs’ regulatory complexity so our member providers are better able to focus on providing the best possible patient care.”

The recommendations from the AMGA and MGMA include:

1. Synchronize rules and regulations across programs.

Differing rules and regulations across risk-based and non-risk models create extra complications for providers. Within the Medicare Shared Savings Program (MSSP) the rules currently governing the accountable care organizations (ACOs) shift based on the ACO’s accepted amount of financial risk. Waivers are restricted based on this level of risk.

However, the AMGA believes this is counterproductive and should change, and that even non-risk based ACOs should be allowed to deliver coordinated care using the appropriate waivers. The organization stated in their comment letter that “providers that participate in these value-based arrangements should enjoy a consistent regulatory framework and have access to the tools that support their ability to deliver the highest quality care to their patients. The only meaningful difference among the levels of the MSSP’s glide path should be the level of financial risk an ACO faces as it progresses.”

AMGA also commented that the regulations developed in the fee-for-service model don’t account for the investment that providers must make to transition to value-based care and population health models. “Limiting waivers and beneficiary incentive opportunities to a subset of ACOs creates a situation to adjust how they deliver care with no benefit to patients,” the letter concludes.

2. Simplify quality measurement reporting.

An overly-complex system for quality reporting in value-based care models is a huge burden for providers, requiring excessive amounts of time and manpower, as well as complex IT infrastructures-which leads to increased costs. 

AMGA suggested CMS scale down the amount of quality measures for value-based care providers. “Using a standard set of value measures will help reduce the variation in the measures that are reported and help eliminate unnecessary confusion and administrative burdens,” AMGA wrote in their comment letter to CMS. AMGA suggested that CMS use a set of 14 process and outcomes quality measures approved in 2018 by the association’s Board of Directors.

Related:Three Reasons Why Value-based Care Works

“Given the immense provider burden with very little added value, the Medicare program should reduce the number of quality measures for all value-based providers and more to a more outcomes-based system supported by claims data,” the comment letter added.

MGMA agreed and further advised that CMS evaluated a reduction in quality measures used in the Medicare Merit-Based Incentive Payment System (MIPS). MGMA stated in their comment letter that MIPS, a relatively new pay-for-performance modes for providers billing under Medicare Part B, should be structured “to allow practices to prioritize effective and impactful improvements to patient care, rather than comply with sprawling reporting mandates.”

3. Enact Stark Law reform.

The Stark Law (or “self-referral law”) was enacted to prevent healthcare fraud, and prohibits physicians from referring patients needing certain services paid for by Medicare to other providers or entities with which they have a financial relationship. (The federal government defines “financial relationship” as any direct or indirect ownership or investment by the referring physician or their immediate family members.)

However, this law was designed under the fee-for-service model. MGMA asserts that the law needs to be adapted due to the new requirements of value-based care models, stating “with each successive CMS rulemaking under the Stark Law, the regulatory scheme has become more complex, to the point where it is now virtually unfathomable to all but the most specialized attorneys and compliance consultants.”

This administrative burden means that smaller organizations may struggle to ensure their providers comply with the self-referral law, as they aren’t able to afford the resources to evaluate compliance. This, asserts MGMA, is a huge impediment.

CMS reform should “account for physician group practices of all sizes and specialties and offer protection to all medical groups that participate in or contribute to innovative payment arrangements as a component of a larger entity,” the organization states. A modernized version of the law, MGMA says, should include an overarching compensation exception for the providers taking part in alternative payment model systems, while also taking into account the group practice model and allowing for the coordination of care.

“Considerable work must be accomplished to overcome the numerous technical, legal and logistical barriers,” the MGMA comment letter concludes. “CMS has taken on the formidable task of reshaping public policy in an effort to create a healthcare environment that leads to improved patient care and more efficient delivery of care. We look forward to continuing to work with CMS and other federal agencies to facilitate practice transition.”

Laura Dorr is a freelance writer based outside of Cleveland, Ohio. She has served as a writer and editor for a variety of publications and websites across the medical, dental, sports, education, and nonprofit industries.