Nov 8, 2022 - Health

Medicare eyes changes to pay for specialty care

Image of a coin connected to a stethoscope.

Shoshana Gordon/Axios

The Biden administration is getting serious about transforming Medicare payments for specialty care.

  • Some doctors will be required to participate in programs that pay fixed amounts for care connected to certain surgeries and procedures.

Why it matters: The Centers for Medicare and Medicaid Services says it has struggled to control health spending and boost the quality of care through steps like coordinating primary and specialty care.

Driving the news: The CMS Innovation Center, which tests new ways for Medicare and Medicaid to pay providers, released a strategy report for specialty care payment experiments on Monday.

Details: It revolves around integrating payments to specialists and primary care doctors.

  • Giving primary care providers insight into specialists' performance data could help boost referrals to high-performing specialists, CMS said.
  • The strategy also involves finding financial incentives for better coordination between primary care providers and specialists in caring for patients.

The center also wants to create a new mandatory payment model built around "bundled" payments for episodes of care, to incentivize providers to manage their spending.

  • Medicare scaled back bundled payment plans for bypass surgery, hip procedures and joint replacements in 2017 after providers complained about the mandatory nature of the programs. CMS has begun a mandatory model for end stage renal disease care since then.
  • The new model wouldn't begin for at least three years.

What's next: The Innovation Center also announced plans to publish a roadmap on aligning value-based payment efforts across different federal payers, and to continue making its payment experiments more equitable.

  • Improving data sharing and infrastructure in care models is on the center’s agenda, too.

Go deeper: An overhaul for Medicare’s pay transformation system

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