Health Care 2020: Be Sure to Check the Engine Room

As we enter the election year, the more things change, the more likely they will stay the same when it comes to health care issues. 

The big three — “Medicare for All,” surprise billing and drug prices — will continue to dominate the headlines coming out of Washington. But down inside health care’s engine room, both Congress and the Trump administration also have been grappling with issues that, while less visible, are significant for both patients and health care providers.

Consider the issue of health care data. The promise of better, connected data to improve both patient outcomes and population health is often discussed, but the promise remains as elusive on the front lines of health today as it did a decade ago. 

This is because across America, two separate streams of data track most patients: data based on their insurance claims, maintained by insurance companies; and the data within electronic health records, maintained by providers. Each data stream is valuable in its own right, but used together, they can be even more powerful.  

For example, without claims data, if a patient goes outside his or her usual health system for care, the primary physicians may not even know that another physician has ordered tests or that the patient went to the emergency room across town. This is because many insurers, including Medicare, provide health systems limited or no access to their claims data.

“Payer claims data is helpful to analyze our population from a broader perspective, especially for preventative exams and tests,” says Christina Taylor, M.D., the chief quality officer of the Iowa Clinic.  Lacking complete data, medical groups such as the Iowa Clinic can’t precisely flag which patients they need to contact regarding these recommended services. 

The Lower Health Care Costs Cost Act, S.1895, approved by the Senate Health, Education, Labor and Pensions Committee last summer, would fix the issue by granting providers access to commercial claims data. While some insurers want to hold this data close, others see the benefit for their members. This is one issue flying under the radar that could have a major impact on health care delivery by assuring that physicians have all the data they need to provide the best care, and one that AMGA will continue to push in 2020. 

A second issue with major implications for patients and their providers is chronic care management. More than 35 million Medicare beneficiaries suffer from multiple chronic conditions and are eligible for chronic care management services, such as medication reconciliation or preventative health counseling. But only 684,000 beneficiaries — less than 2 percent — make use of CCM services, mostly because of Medicare’s coinsurance requirement. 

The Chronic Care Management Improvement Act, H.R. 3436, would waive Medicare’s cost-sharing requirements for patients who need help managing their chronic conditions. The House Ways and Means Committee has approved the bill. 

A third legislative issue involving improving care and reducing cost in the Medicare program could make a significant difference in whether health systems and others continue to establish accountable care organizations to serve Medicare beneficiaries. ACOs are groups of health care providers that take responsibility for the total cost and quality of care for their patients, and in exchange, they can receive a portion of the savings they achieve. 

ACOs have proven to be a promising mechanism for delivering higher-quality, lower-cost care, but the way that the Centers for Medicare and Medicaid Services currently determines whether ACOs have achieved savings discourages ACOs from participating in the program. This is because CMS calculates performance based on the results of all beneficiaries in a region, including their own ACO. 

In effect, groups end up competing against themselves, and the better they do, the harder it becomes to demonstrate additional savings. H.R. 5212, the Accountable Care in Rural America Act, would fix this issue by removing an ACO’s own population from CMS’ regional adjustment calculation. 

Finally, it is worth noting that sometimes what doesn’t happen can be as important as what does. This was the case when CMS in 2019 sought to simplify the way it pays physicians for office visits by patients who need typical evaluation and management services. 

Under the existing rule, physicians were paid according to the five level of services, each progressively more intense. CMS wanted to consolidate levels two through four into one payment. This would have caused a massive disruption for physicians and patients because of the need to change care delivery models and practice patterns. 

The changes may have created an incentive to increase the number of visits or refer more complex patients to specialists or to a different setting. The changes also would have potentially undermined care coordination efforts. Based on feedback from AMGA and other stakeholders, CMS reversed course in its 2020 rulemaking cycle and will continue to pay a separate rate for each level.

The big three issues will continue to drive the health care policy conversation in 2020, but if you want to understand the nuts and bolts of it, don’t forget to check the engine room.


Jerry Penso, M.D., MBA, is president and CEO of AMGA.

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