Physician groups remain split over CMS proposal to allow direct Medicare billing

A stethoscope on a computer keyboard
It will be up to CMS to decide whether to proceed with a new DPC model. (Getty/anyaberkut)

Physicians are split on a Centers for Medicare & Medicaid Services proposal to allow doctors to bill Medicare patients directly.

At issue is a CMS proposal to allow so-called direct provider contracting (DPC) between payers and primary care or multispecialty group practices within the Medicare fee-for-service program, Medicare Advantage and Medicaid. Numerous healthcare groups submitted comments to CMS by Friday’s deadline as the agency sought feedback before testing the new billing model.

The idea is controversial. The Medical Group Management Association (MGMA) and America’s Physician Groups (APG) urged CMS to move forward with the new model as a way to advance value-based care. On the flip side, the American Medical Group Association (AMGA) urged CMS to focus its efforts on improving existing programs rather than move forward with a new DPC model.

According to CMS, the government would directly contract with physician group practices, which would agree to be accountable for the cost and quality of care of a defined beneficiary population under a DPC model. Beneficiaries would voluntarily enroll in a practice and would receive enhanced access to physician services.

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The MGMA urged CMS to move ahead. “The proposed DPC model has potential to increase opportunities for physician group practices to participate in Advanced [alternative payment models],” said Anders Gilberg, senior vice president of government affairs. “Through this model, it’s clear that CMS is working towards recognizing innovative care delivery and payment reforms in the marketplace and encouraging physician-led, value-based transformation.”

RELATED: Future CMS innovation center initiatives could include outcomes-based drug pricing, telehealth

In its letter (PDF) to CMS, the group noted key points CMS’ Innovation Center needs to consider when developing the model, including reducing paperwork burden, enhancing access to data, establishing a family of DPC models with attainable performance metrics and offering upfront investment support to physician group practices. “If these issue areas are not carefully considered, the DPC model could drive further consolidation among healthcare providers while forcing independent practices out of business—actions which restrict patient access to care,” Gilberg said.

APG, a professional association for accountable physician groups, promoted what it called its “Third Option” and argued in its letter that the DPC model will advance the value movement.

RELATED: 3 reasons to let go of fee-for-service payment models

“This model will truly put physicians and patients in the driver’s seat in terms of taking responsibility for improving health,” said Don Crane, the group’s president and CEO.

The AMGA, however, said in its letter (PDF) that CMS should strengthen the existing Medicare Shared Savings Program (MSSP) and accountable care organizations (ACOs) rather than moving forward with a new DPC model. 

“While it is encouraging that CMS is interested in developing new models that are based on primary care, patients, providers and the Medicare program would be better served by building on the considerable investments already made in the ACO program,” said Jerry Penso, M.D., the group’s president and chief executive officer.

Consumer advocates, including AARP, also opposed the plan at the time CMS announced the proposal. AARP said private contracting would allow doctors to pick and choose the patients or services for which they will bill Medicare.

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