Physicians face barriers in the standard payment systems used by Medicare and other payers that prevent them from delivering all of the services their patients need and delivering services that will work best for individual patients.

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The AMA believes well-designed, patient-centered alternative payment models (APMs) can provide significant opportunities to improve the quality and outcomes of patients’ care in ways that also lower growth in health care spending.   

Many of the patients in an accountable care organization (ACO) have health problems that require diagnosis, treatment and/or care management services from a specialist. The way primary care physicians who participate in ACOs coordinate care with specialists and how specialists deliver services has a significant impact on ACOs’ ability to improve quality and control spending. Many specialists want to deliver care in different ways to improve patient outcomes and reduce spending but they cannot do so because of barriers in the payment systems currently used by Medicare and other payers.  

In most cases, there are no APMs or other value-based payments available to specialists that would overcome these barriers. ACOs have not had the ability to directly change the way specialists are paid, and because of this and other requirements, most ACOs have not been able to effectively engage specialists in achieving the ACO’s goals. As part of its strategy refresh, the Center for Medicare & Medicaid Innovation (CMMI) reached out to the AMA to help identify ways to better integrate specialist care into ACOs. 

The AMA has found that specialists want to increase the quality of care they deliver and reduce spending but they are often unable to do so because of the barriers in the current payment system. The AMA designed "Payments for Accountable Specialty Care" (PDF) to respond to CMMI and address the needs of both ACOs and specialists. It enables the ACOs to identify and develop formal relationships with specialists who have similar goals, and it allows the specialists to be paid in ways that enable them to deliver higher-value care. 

In 2021, the Veterans Health Administration (VHA) created the Supremacy Project which will establish National Standards of Practice (NSPs), irrespective of state scope of practice laws, for approximately 50 categories of health professionals. VHA recently published three draft NSPs in the Federal Register with a 60-day comment period. The three NSPs include: 

The AMA’s preliminary review of these NSPs indicates that the VHA is not proposing a change in practice so there will be no impact on the practice of these occupations once their NSPs are finalized. The AMA is likely to submit clarifying comments on the Ophthalmology Technician NSP due to specialty interest. Future NSPs released by VHA may impact the practice of those occupations specifically and pose licensure concerns more broadly that warrant more detailed comments. 

Last year, the AMA convened a specialty society workgroup to engage VHA on its effort to develop NSPs. As a result of meetings with the VHA and sign-on letters, the Biden administration agreed to allow for notice and a 60-day comment period and to significantly slow down its timeline for NSP implementation, including staggering the publication and comment periods for the various NSPs. The AMA will remain heavily engaged as this process moves forward.

The recording for the latest webinar in the AMA Advocacy Insights series, “Medicare payment principles —A vision for reform,” is now available. In this webinar, AMA Board of Trustees Chair Sandra Fryhofer, MD, is joined by Cynthia Brown, vice president, AMA Government Affairs, and Jason Marino, director, AMA Congressional Affairs.  

The Medicare physician payment system needs an overhaul to remedy financial instabilities impacting physician practices due to the pandemic, statutory payment cuts, lack of inflationary updates and significant administrative burdens. To define the goals of reform, the AMA and 120 state medical and national specialty societies created the “Characteristics of a Rational Medicare Physician Payment System.” 

Hear about what these principles call on Congress to do to improve the Medicare physician payment system in this webinar. The webinar digs deeper into some of the causes of the current systemic issues and charts a path forward. 

Questions were also answered during a live Q&A session at the end of the webinar.

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