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MGMA 2021 policy outlook: What group practices need to know

Insight Article - December 15, 2020

Medicare Payment Policies

Federal Insurance Markets

MGMA Government Affairs
Editor's note: This piece has been updated since its initial publication in the January issue of MGMA Connection magazine to account for the outcome of the Georgia U.S. Senate runoff elections.

MGMA’s 2021 policy outlook provides group practice leaders with key insights on top issues to watch as we enter a new year. The new year also brings a new Congress and new Administration, which could shift the tone on critical healthcare issues. As these changes develop, MGMA stands ready to keep medical group practices informed about key updates that will affect their businesses and patient care. At the same time, we embrace the opportunity to advance our advocacy priorities in Washington, D.C., and improve the healthcare landscape on behalf of the medical group practice community.

Forecast for health issues clears after Georgia runoff elections: Clear skies for Democratic health agenda ahead

After securing two additional seats in the Georgia runoff elections, Democrats have secured control of the Senate, given Vice President-elect Kamala Harris’s ability to cast the tie-breaking vote within an evenly split chamber. Now that Democrats control both chambers of Congress and won the presidential election, the ability to successfully carry out their healthcare priorities, such as building upon the Affordable Care Act (ACA), seems within reach.

In addition to the healthcare agenda that will be championed by this new “blue wave,” there are a handful of bipartisan, bicameral healthcare priorities that we expect to see movement on, such as drug pricing, telehealth coverage and aspects of COVID-19 relief. Given the country’s ongoing struggle to control the COVID-19 pandemic and the “blue wave,” we expect to see healthcare issues take center stage in both Congress and the Administration this year.

Healthcare coverage takes center stage as Supreme Court shines spotlight on ACA

Health coverage will be top of mind for many in 2021. Economic downturn and increased unemployment may result in churn among the insured population, as patients shift from employer-based plans toward Exchange plans or forgo coverage altogether. Despite President-elect Biden’s intentions to expand coverage through ambitious reforms (such as creating a public option alongside the ACA marketplace and lowering the Medicare age), these policies will face an uphill climb in Congress.

At the same time, the fate of the ACA remains in the hands of the Supreme Court, which is expected to release a decision in late spring or summer after hearing arguments in November in California v. Texas, a case challenging the constitutionality of the law. While statements made at the hearing inferred the justices seem unlikely to overturn the law, one possible outcome is the ACA could be struck down in its entirety. A more likely outcome is that the Court will uphold major provisions of the law, preventing massive disruption in coverage for patients and the group practices that treat them. Stay up to date on key developments by bookmarking MGMA’s page tracking ACA updates: mgma.com/aca.

Telehealth expansion: The cat is out of the bag

Since the beginning of the COVID-19 pandemic, telehealth usage has soared. These higher utilization rates can be attributed to increased flexibilities stemming from congressional and regulatory action, but most of these flexibilities hinge upon the COVID-19 public health emergency (PHE) remaining in effect.

The benefits of virtual care have caught the attention of lawmakers, and bipartisan efforts are underway to permanently repeal statutory restrictions that historically served as roadblocks to increased utilization pre-COVID-19. With a new Administration and Congress in 2021, we expect to see certain telehealth flexibilities expanded, if not permanently, for at least a set period following the PHE. To quote a senior Department of Health & Human Services (HHS) official on the subject, “The cat is out of the bag.” Although this may be true, the outstanding questions of cost and quality of care linked to telehealth expansion will serve as roadblocks to making these waivers permanent. MGMA developed resources analyzing telehealth waivers and flexibilities to assist group practices with implementation: mgma.com/covid#tele.

COVID-19 response pivots from reactive to proactive as vaccines emerge

With multiple COVID-19 vaccines on the horizon, medical groups will undoubtedly play a critical role in preventing the spread of the coronavirus through the vaccination of patients. While hospitals and other critical care settings drew attention in the early days of the pandemic in treating the most severe cases of the disease, the distribution of a vaccine will put renewed focus on our nation’s community health providers in office and outpatient settings. However, providers who plan to administer the vaccine must plan to address several operational obstacles in their COVID-19 vaccination program:
  • Early COVID-19 vaccines will need to be kept at specific, colder-than-normal temperatures, so practices must ensure that vaccines are handled and stored properly.
  • Initial data on the vaccines indicate that two doses will be necessary for effectiveness, so practices will have to build patient follow-up into their vaccination workflows.
  • Each state has its own vaccine distribution plan, so providers planning to administer the vaccine should contact their state and local health departments to understand distribution protocols.
  • Providers will likely need to report vaccine administration data to state health departments, so providers will need to make sure their EHR or an alternate reporting system is in place to report these data.

Value-based care can mean risky business (but also reward) in 2021

Policymakers and the broader healthcare industry have focused on moving healthcare to a system that pays for quality, patient outcomes and efficiency for years. Despite a slow and bumpy transition, attention to alternative payment models (APMs) and replacing fee-for-service with value-based payments will continue in 2021.

Transitioning to a new payment model may be difficult for group practices amidst revenue shortfalls and increased expenses due to the COVID-19 pandemic. Preparing for risk-based payments or APMs can involve significant upfront investments in tools such as data analytics, care coordination teams and new technologies. However, the prospect of upfront per-beneficiary per-month payments or shared savings could offer stability for group practices relying on volume-based reimbursement: In April 2020, practices reported a 60% decrease in volume due to COVID-19, according to an MGMA poll.1 This begs the question, could the risk of value-based payment be worth the reward?

One thing current APM participants must consider is how the pandemic will impact key metrics associated with model performance, such as benchmarks, risk adjustment, quality evaluation and cost of care. Deferred care may lead to higher acuity, more costly conditions. The Centers for Medicare & Medicaid Services (CMS) has instituted policies to help protect APMs against financial losses during the PHE, but group practices should carefully consider how disruption due to COVID-19 could impact model performance.

While the Trump Administration prioritized performance on cost savings and promoted models with substantial financial risk, the Biden Administration may favor increasing participation, even if that doesn’t immediately translate to cost savings in the near term. For group practices, this hopefully means more opportunities for Medicare APM participation in 2021 and beyond.

Patients go shopping

The Trump and Biden Administrations share a common desire to position patients as informed healthcare consumers. This is most evident in two areas of administrative rulemaking: the push to reduce drug costs and the creation of new price transparency rules for hospitals and health plans. For the latter policy, hospitals are required to post standard charges prominently and publicly. Further regulations would require an increased commitment from payers to collaborate with providers to achieve greater cost transparency for beneficiaries. As the Biden Administration takes the reins, cost-savvy patients, who increasingly prioritize convenience and ease of entry to care, will undoubtedly continue to drive policymakers to further consumer-focused changes. Medical groups must consider the implications of increasing transparency and consumerism moving into the new year.

New HIT environment presents opportunities, challenges

There is widespread consensus, emphasized by the COVID-19 pandemic, that a move to seamless data exchange and interoperable access to health information will improve healthcare delivery and support group practices in the transition to value-based care models. However, meeting the government’s myriad of current and future regulatory requirements may prove daunting. In 2021, two new rules go into effect to advance the government’s agenda. The requirement for hospitals to automatically transmit admission, discharge and transfer (ADT) alerts will help practices identify at-risk patients for follow-up care and could reduce readmission rates. At the same time, complying with the information blocking mandate with its complex exceptions and onerous reporting demands could prove challenging for practices.

We also expect to see new initiatives to automate administrative transactions in 2021. To reduce reliance on faxes, mail and portal uploads, several major payers announced plans to support electronic claim attachments. Further, work continues on the new Fast Healthcare Interoperability Resources (FHIR) standards, which show great promise to streamline prior authorization and clinical documentation submission requirements and other revenue cycle processes. Finally, efforts are underway to have end users report their experiences with EHR functionality, usability, patient safety and security. This “consumer report” approach should improve the practice software selection process.

The year of living dangerously: 2021 and cyberattacks

Cyberattacks on patient data, coupled with government enforcement of privacy and security regulations, could present challenges for group practices in 2021 and beyond. The sophistication and volume of cyberattacks is increasing exponentially, and practices must be more vigilant than ever to protect themselves. Cybercriminals have many resources and are highly knowledgeable about the vulnerabilities of provider technology. Smaller practices are not immune to cyberattacks, and they often are the target of cybercriminals due to the lack of high-quality security measures typical of organizations with more resources. Practices must assume a cyberattack is imminent, be proactive, implement preventative measures, and establish effective data backup and contingency plans.

As the government continues to emphasize the need for patients to have control over their health information, it has ramped up enforcement of the HIPAA privacy and security rules. In 2021, we expect continued vigorous enforcement of the patient right to access regulations, including their right to view, amend and receive a copy of their health information in the format they request. Practices can review their rights and responsibilities and leverage cybersecurity resources in the MGMA HIPAA resource center: mgma.com/hipaa.

The road to recovery: Building healthcare system resilience comes at a cost

Increased attention on building healthcare system resilience amid the COVID-19 pandemic poses a challenge for policymakers and industry stakeholders focused on reining in healthcare spending. Building resilience is costly: Establishing financial relief programs, spending on public health, expanding telehealth reimbursement and economic recovery measures all entail significant investments. While Washington is unlikely to double down on efforts to control spending during the most acute stages of the pandemic, budget hawks may begin calls to curb or evaluate unprecedented government spending once infection rates stabilize. When that happens, the healthcare system may see an uptick in government audits and congressional inquiries into how financial relief programs were administered.

At a minimum, group practices that received funds from these financial relief programs, such as the Provider Relief Fund and Paycheck Protection Program, should be closely tracking their use of funds to comply with relevant reporting and loan forgiveness requirements (Available from mgma.com/fed-covid-aid). Such practices should also be prepared to produce records in the event of a government inquiry down the road. Compliance with evolving guidance is a challenging undertaking and will inevitably require the attention of dedicated resources at the practice level.

Note:

  1. MGMA. “COVID-19 Financial Impact on Medical Practices.” April 13, 2020. Available from: mgma.com/covid-fin-impacts.

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MGMA Government Affairs
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