MedPAC's June 2019 Report to the Congress

Medicare and the Health Care Delivery System

MedPAC, or the Medicare Payment Advisory Commission, is an independent congressional agency established by the Balanced Budget Act of 1997 to advise the U.S. Congress on issues affecting the Medicare program. The Commission's 17 members bring diverse expertise in the financing and delivery of health care services. MedPAC meets publicly to discuss policy issues and formulate its recommendations to the Congress. In the course of these meetings, Commissioners consider the results of staff research, presentations by policy experts, and comments from interested parties.

In March 2019, MedPAC hosted a meeting with a session on Medicare's Role in the Supply of Primary Care Physicians (Ariel Winter, MPP). This began with a report of the current state of primary care accessibility for Medicare beneficiaries, and the pipeline of future primary care physicians with the current state of federal scholarship and loan programs for physicians.  This was followed by a presentation of design ideas for a future program specifically targeted at encouraging physicians to provide primary care to Medicare beneficiaries. The Commission determined that more research was needed before concrete decisions could be made. Next steps included going into the field to talk to the students and professors at the programs that effectively foster primary care uptake, provide community hospital teaching, and focus on the social determinants of health before deciding on program design.
In MedPAC’s June 2019 report to the Congress, Chapter 5 focused on the topic of “Issues in Medicare Beneficiaries’ Access to Primary Care,” in which they addressed this issue further. Based on the research of current programs, the Commission determined that the best course of action may be to establish a Medicare-specific scholarship or loan repayment program that would give medical students an incentive to choose geriatrics. This is because geriatricians are the most knowledgeable in managing the unique health and treatment needs of elderly individuals and there has been a decline in geriatric medicine residents over the past five years. 
The two key recommendations they made regarding access to primary care for Medicare beneficiaries were to require advanced practice registered nurses (APNs) and physician assistants (PAs) to bill the Medicare program directly, eliminating “incident to” billing for services they provide; and that the Secretary of the Department of Health and Human Services (HHS) should refine Medicare’s specialty designations for advanced practice registered nurses and physician assistants. 
The reasoning for the first recommendation is that billing “incident to” means the program lacks information about who is treating beneficiaries and Medicare is overpaying for services rendered by APRNs and PAs. It is estimated that eliminating “incident to” billing would reduce Medicare spending by $50 million to $250 million in the first year and by $1 billion to $5 billion over five years compared with the current law. While some practices that employ NPs, PAs, and Clinical Nurse Specialists (CNSs) could experience reduced revenue, the recommendation is not expected to adversely affect beneficiaries’ access to care. 
The second recommendation is made because NPs and PAs are increasingly practicing in specialty fields, but Medicare often considers all NPs, PAs, and CNSs to be primary care providers. In order to be able to effectively and efficiently identify and support clinicians furnishing primary care, they should at a minimum, distinguish between NPs, PAs, and CNSs that are practicing in primary care versus a specialty field. This will allow policymakers to have a better understanding of beneficiaries’ access to primary care services.


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