We Have the Tools to Increase High-Value, Underused Services in Medicare – and Improve Health Outcomes
By Casey Korba, Director of Policy
This blog is the third of a three-part series summarizing Aledade's comment letter to CMS on the 2023 proposed Physician Fee Schedule.
The Centers for Medicare & Medicaid Services is looking for ideas on how to increase certain high-value health care services that beneficiaries should be receiving but for a variety of reasons, are not. In the 2023 Medicare Proposed Physician Fee Schedule,, CMS issued a Request for Information to understand barriers and potential solutions Medicare beneficiaries face around high-value, underused services. These services include many preventive screenings, such as recommended cancer screenings, Annual Wellness Visits, which provide the primary care team the opportunity to make a personalized care plan for the year for individuals in Medicare, and Transitional Care Management services, which help Medicare patients transition from an inpatient stay to their home or another site of care.
While the health care system recognizes these services as high value, it can be harder to convince patients they need these services, for many reasons. Prevention is tough because many of us, when we are not having an acute episode or are not feeling sick, can find reasons not to schedule a doctor’s appointment. Lack of time, transportation, and financial concerns are common barriers to why people might not get these services.
Transitioning from a volume-driven to a value-based health care system requires a change in both how we pay for care and how we engage patients in the care delivery process. Based on our experience at Aledade in partnering with physician-led accountable care organizations, we included in our comment letter to CMS the following recommendations to increase these high value but underused services:
- Lower the cost: CMS should cover the cost-sharing for high-value services on behalf of low-income individuals receiving services within ACOs and other alternative payment models (APMs).
- Increase care delivery models that work: CMS should incentivize primary care providers to join physician-led ACOs, which have higher use of these services.
- Share the data: CMS should encourage health plans to share more actionable and timely data with health care professionals for better insights.
Waive cost-sharing for high-value services for low-income individuals.
Traditional Medicare has a one-size-fits-all approach that requires beneficiary cost-sharing for most services without regard to the value the service may provide to the beneficiary. While services graded A & B by the US Preventive Services Task Force and Annual Wellness Visits do not have cost-sharing, there are some other high-value underutilized services that do. Further, Community Health Centers cannot bill for two services, such as if they do an Annual Wellness Visit but also address depression or hypertension during the visit. This issue should be fixed to ensure CHCs get the credit for their work and make it as easy as possible for the patient to get the recommended services.
Research demonstrates that increases in patient cost-sharing leads to decreases in non-essential and essential care. Aledade has previously advocated for the Center for Medicare and Medicaid Innovation (CMMI) to test a value-based insurance design (VBID) model that would allow physicians to waive cost-sharing for high-risk Medicare beneficiaries attributed to ACOs in the Medicare Shared Savings Program when patients are receiving high-value, recommended primary care services. Rather than just focusing on aligning incentives for the physician and the health care system to reduce costs and improve quality, this model would also align beneficiary incentives. CMS could start by testing this approach for evaluation and management services received from a primary care physician participating in an ACO (or other APM), TCM services, and Advance Care Planning services. VBID for traditional Medicare has the potential to better serve patients, encourage high-value care, and incentivize physician practices to join MSSP.
Alternatively, we request that CMS issue guidance or FAQs that provide clarity for providers on what flexibilities ACO participants have to waive co-insurance for these high-value services. We believe any flexibility would help more beneficiaries who could benefit from these services to use them while reducing the administrative burden on the practice.
Incentivize primary care practices to join physician-led ACOs.
CMS has set a goal of getting 100% of Medicare beneficiaries into an accountable care arrangement by 2030. According to CMMI’s Strategic’s Objectives, “Accountable care reduces fragmentation in patient care and cost by giving providers the incentives and tools to deliver high-quality, coordinated, team-based care.” There is much data to support this:
- Aledade’s study of our 2016 ACO cohort showed that over a 4-year period, the cohort of ACOs is estimated to have prevented 10,917 hospitalizations, 19,338 emergency department visits, and 8859 skilled nursing facility visits, compared with the region. We believe these preventions are largely driven by improvements in care transitions and preventive care, such as Annual Wellness Visits, which the cohort of ACOs performed at 265% above the regional average in 2019.
- In spring 2022, the Assistant Secretary for Planning and Evaluation (ASPE) released a report that showed TCM was greatly underused by beneficiaries in traditional Medicare. The report showed of all beneficiaries with acute care discharges eligible, only 17.9% received TCM services. The report found that beneficiaries aligned to ACOs were more likely to receive TCM services (national rate of 24%). Aledade found that for 2021, nationally, Aledade bills 40% of eligible patients for TCM visits. It is not surprising that ACOs have a bigger uptake in these services since they are typically more incentivized to coordinate care and invest in technology and data analytics to make the outreach and workflows easier.
- For Annual Wellness Visits, another high-value service, research shows that less than 20% of all eligible Medicare patients receive this service, and only 23% of practices provided AWVs to at least a quarter of their eligible patients. At Aledade, our most recent data shows that 65% of eligible patients have received an AWV in the last year.
- Research shows that ACOs participating in MSSP who exited the program were associated with considerably lower rates of preventive service use compared to ACOs that stayed in the program. The researchers concluded that without the potential for shared savings, health care professional groups have little incentive to maintain the data systems, analytic support, and coordination capabilities needed to support patient engagement in these services.
- A recent study published in Health Affairs shows that ACO participation in the MSSP modestly reduced Medicare spending for patients with serious mental illness.
It’s clear that physician-led ACOs can increasingly provide beneficiaries more recommended preventive and primary care services. To ensure that more beneficiaries have access to the infrastructure and high-quality care delivery systems ACOs provide, CMS should incentivize primary care practices to join ACOs and other accountable models by making sure the benchmarking and other program features encourage practices in underserved areas to join ACOs and to retain practices currently in the ACO model.
Many of the high-value underused services CMS are concerned about require continual, coordinated patient outreach and engagement. Technology and data analytics can help make practices and operations more efficient. Still, services such as Annual Wellness Visits, TCM, and preventive services all require people trained to care for patients to devote time and energy to reaching out and counseling patients rather than the patient taking the initiative to call the office and schedule a visit.
Encouraging and incentivizing the ACO model is one strategy to reduce workforce barriers made worse by the pandemic. Many of the physicians we partner with have told us that there are so many ways that practicing in value-based care models, particularly with Shared Savings, helps them weather workforce challenges. They have the funds to invest in the workforce through better pay to recruit and retain staff and hire more care coordinators and staff such as social workers.
Encourage health plans to share more timely, actionable data with health care professionals for better insights.
The more timely and actionable data the physician practices we partner with have from the health plans, the more likely they can move to actionable insights to deliver patient care. The physicians, clinicians, and office staff we partner with are focused on improving the health of patients and lowering costs. A well-informed physician is a major asset for a health plan to meet the goals of improving quality and member satisfaction. Building trust and credibility between plans and practices means encouraging open channels of communication that help improve member and patient engagement and care management.
Aledade has successfully used geo-hotspotting data to reach underserved populations who were overdue for mammograms. ACOs and practices participating in Advanced APMs often have the infrastructure to use data to better identify, outreach, and successfully engage harder-to-reach patients, but they can’t do it as efficiently on their own. Health plan data is seldom real-time data, so any advanced analytics practices they want to do –building interfaces, mapping, or geo-hot-spotting– will not be based on the best available data. While we recognize this is a complex issue that can’t be solved overnight, encouraging better data sharing will help health care professionals improve their ability to identify when a patient is due or overdue for a recommended service and their ability to reach and engage that patient in care.