Summary
Highlights
CMS (Centers for Medicare and Medicaid Services) has released a 1,592-page proposal that could significantly alter Medicare benefits. This rule is open for public comment until September 14th. The speaker emphasizes the importance of understanding these changes as they can affect doctor payments, care coordination, and out-of-pocket costs. Some aspects are proposed, while others, like new eligibility restrictions affecting 32,000 people, are already law. Viewers are encouraged to visit regulations.gov to submit comments.
The proposal includes some positive changes, such as extending telehealth services until 2027, which benefits rural clinics and community health centers. It also delays in-person visit requirements for mental health telehealth and allows rural clinics to bill separately for diabetes education and nutrition therapy. New options for group medical appointments are introduced, enabling up to 10 patients with similar chronic conditions to meet, fostering peer learning and support, though privacy concerns are noted.
A major concern is the structural change to original Medicare through the expansion of Accountable Care Organizations (ACOs). Unlike Medicare Advantage, ACOs are part of original Medicare, coordinating care and endeavoring to keep costs in check. The incentive structure allows ACOs to keep a share of savings if they stay under budget, but they may face penalties if costs are too high. While ideal ACOs can improve care by preventing duplicate tests and managing chronic conditions, there's a risk that cost-cutting measures could lead to reduced care, delayed appointments, or difficulty accessing expensive treatments. The speaker questions how CMS will ensure medically necessary care isn't deemed wasteful.
CMS explicitly aims to increase the number of healthcare providers and beneficiaries in ACO relationships, with a target of moving more original Medicare beneficiaries into these models. They also intend to involve specialists, who are currently viewed as not sufficiently tied to ACO financial goals. The speaker expresses concern that financial incentives for specialists could pressure them to make cost-driven decisions rather than solely focusing on patient health. New rules proposed for 2028 would make it easier to assign new Medicare enrollees, those returning from Medicare Advantage, and individuals with enrollment gaps into ACOs after just one month of Part A and B coverage.
The proposal also suggests reducing transparency by pushing back the initial notification deadline for ACO assignment and eliminating follow-up notices. While this could be a cost-cutting measure, it raises concerns about patient awareness. On a more positive note, the new rules could allow ACOs to reduce or eliminate the Part B deductible and co-insurance for certain services and patients, though this would not be automatic and wouldn't apply to durable medical equipment, orthotics, or prescription drugs. Individuals already on Medicaid or Medicare savings plans would not receive additional benefits.
The proposal includes changes that might inconvenience patients, such as cutting payments for doctors who perform both a visit and a procedure on the same day. Physicians worry this could lead to separate appointments, increasing patient time and inconvenience. Additionally, starting February 1st, 2027, Medicare eligibility will be limited to four specific immigration status groups, potentially causing approximately 32,000 individuals to lose coverage. The current proposal outlines the notice and appeals procedures for these changes.
CMS is also seeking feedback on future considerations, including redesigning primary care payment. This could involve a set monthly payment per patient instead of per-visit payments, and tying Medicare payments to patient health results rather than just services delivered. The speaker raises concerns about how this outcome-based pay would affect patients with chronic conditions or disabilities. There are also considerations for limiting repeat medical testing, potentially denying or reducing payments for duplicative tests or imposing frequency limits on lab work and imaging. The speaker expresses strong opinions against limiting medically necessary repeat testing, fearing potential negative health impacts.
The speaker concludes by reiterating that while CMS press releases emphasize coordination and streamlining, cost control is a significant part of this plan. The concern is that cost-cutting could extend beyond waste reduction and potentially impact medically necessary care for patients with expensive conditions. Viewers are strongly urged to utilize the public comment period, which closes on September 14th, by visiting regulations.gov or mailing comments. They are also encouraged to contact Chapter for any Medicare-related questions.