LUGPA Policy Brief: The Preserving Patient Access to Accountable Care Act

Feb. 2025 

Introduction

Lowering healthcare costs and improving patient access to care are paramount goals for LUGPA, particularly through payment reforms in Medicare. A significant driver of healthcare costs historically has been the traditional fee-for-service reimbursement model, which incentivizes volume over value. This model often results in unnecessary tests and procedures, driving up costs without necessarily improving patient outcomes.

Overview of the Preserving Patient Access to Accountable Care Act

Introduced by Congressman Darin LaHood (IL-16) and cosponsored by Representatives Neal Dunn (FL-02), Suzan DelBene (WA-01), and Kim Schrier (WA-08), the Preserving Patient Access to Accountable Care Act (H.R. 786) aims to extend incentive payments for qualifying participants (QPs) in advanced alternative payment models (APMs) through payment year 2027. This bipartisan legislation freezes the qualifying thresholds increase, promoting stability and encouraging provider participation in innovative care models.

Value-Based Care and Alternative Payment Models (APMs)

Value-based care (VBC) shifts focus from volume to quality and efficiency, aligning provider incentives with patient outcomes. Alternative Payment Models like Accountable Care Organizations (ACOs), bundled payments, and patient-centered medical homes (PCMHs) are pivotal in achieving these goals:

• Accountable Care Organizations (ACOs): Networks of providers incentivized to deliver coordinated, high-quality care while sharing in savings.
• Bundled Payments: Single payments for an entire episode of care, encouraging cost-effective treatments across providers.
• Patient-Centered Medical Homes (PCMHs): Centralized, coordinated care models that enhance patient-provider relationships and improve care management.

LUGPA’s Advocacy for Alternative Payment Models

LUGPA advocates for specialty-focused APMs that align incentives with clinical best practices. Despite challenges, such as PTAC’s reluctance to recommend certain models, LUGPA stresses the economic benefits and improved care outcomes these models can offer. There is a strong call for CMS to expand evaluation and adoption of these models to enhance healthcare delivery. CMS has actively encouraged providers and healthcare organizations to submit new value-based care Alternative Payment Models (APM) to the agency that could introduce innovations into Medicare and improve patient care while reducing costs. LUGPA strongly supports the development of a specialty-focused value-based care model and, in 2017, was among the first to submit an APM application to the Physician-Focused Payment Model Technical Advisory Committee (PTAC), entitled “Initial Therapy of Newly Diagnosed Patients with Organ-Confined Prostate Cancer.”

LUGPA’s proposed APM was an “episode-based payment that aligns incentives with clinical best practices and guidelines for physicians to recommend active surveillance (AS) in clinically appropriate patients with low-risk localized prostate cancer, allowing these patients to avoid unnecessary interventions.” The APM incentivized patient-physician shared decision-making by compensating physicians for the management time required to responsibly continue these patients on AS. Practices using this model would be eligible for a performance-based payment if they met certain quality thresholds and for enhancing performance year utilization of AS relative to a historical period. 

Despite comments from PTAC recognizing the appropriateness of the model, its economic benefit to the system, and its positive effects in combatting racial disparities in access to care, PTAC ultimately declined to recommend this to CMS. Since the proposal, LUGPA has voiced concerns that CMS has yet to approve many of the proposed APM brought to them by groups like LUGPA and that CMS should move to embrace more of these value-based models and allow them to be evaluated for their effectiveness.

Recommendations to Congress

LUGPA presents key recommendations to Congress to support the transition to value-based care and ensure independent providers can participate meaningfully in APMs:

1. Reforming Payment Updates: Eliminate pending cuts to the Medicare Physician Fee Schedule (MPFS), repeal sequester cuts, and adopt reliable payment methodologies reflecting actual costs.
2. Promoting Physician-Focused Payment Models (PFPMs): Reform PTAC to include independent physician input, require CMS testing of approved PFPMs, and encourage CMMI to adopt PFPMs independently.
3. Reforming MIPS: Replace the current MIPS system with one rewarding quality and value, eliminate winner/loser systems, and expand specialty-specific quality measures.
4. Advancing Site-Neutral Payments: Move Medicare towards true site-neutral payments for physician-administered drugs and outpatient surgical procedures.
5. Codifying Reforms: Codify recent administrative reforms to Stark and Anti-Kickback laws to facilitate innovative, integrated value-based care models.

The Preserving Patient Access to Accountable Care Act represents a critical step towards achieving LUGPA’s goals of reducing healthcare costs and improving patient access through innovative payment reforms. LUGPA urges Congress to support this legislation and continue advancing policies that promote value-based care and sustainability in healthcare delivery.