On October 3-4, 2019, the Medicare Payment and Access Commission (MedPAC) held their second public meeting of the current term. Topics discussed include restructuring the Medicare Part D benefit, population-based outcome measures, and the methods used to assess the adequacy of Medicare payments.

MedPAC Explores Restructuring the Part D Benefit

The meeting began with the session on restructuring Medicare Part D. The commission has worked on Part D issues in the past and plan to use this term to build on previous recommendations. With a restructure, the commission hopes to expand access and use market-based approaches to allow for choice and create financial incentives for plan sponsors to manage benefit spending. Staff suggested in their presentation a Part D benefit design of a $415 deductible and 25% coinsurance with 75% plan liability after the deductible leading up to an out-of-pocket (OOP) threshold. MedPAC is also considering the following elements in their Part D restructure:

• Eliminating the coverage-gap discount
• Using the same benefit design for enrollees with and without the low-income subsidy (LIS)
• Redesigning the catastrophic benefit to include a new manufacturer discount, a cap on beneficiary out-of-pocket spending, higher plan liability, and lower Medicare reinsurance.

Overall, the Commissioners were very interested in this work and like the direction staff was heading in their presentation. Commissioners were supportive of making changes to existing reinsurance in Part D and said that a simplified benefit structure would be welcomed by beneficiaries. Some commissioners noted that they wanted to make sure manufacturers had some “skin in the game” and others suggested the MedPAC explore the role of biosimilars and look for ways to help support the biosimilars market. As this Part D work in is in the early stages, no recommendations were presented or voted on, but the Commission does intend to continue exploring this topic and will likely offer recommendations at some point during this term.

Commission Voices Concern Over Future Access to Primary Care Providers

In last year’s term, MedPAC asked for data pertaining to the amount of practicing Primary Care Physicians (PCPs) as a way to ensure that Medicare beneficiaries have appropriate access to services. The commission also requested information on primary care services provided by: hospitalists, internists, family practice providers, physician’s assistants (PAs), and advance practice registered nurses (APRNs). In analyzing data from 2013 to 2017, MedPAC staff found a moderate 3.0% decrease in visits to PCPs, but a significant 13.1% increase in visits to APRNs and PAs. There was also a minimal 0.3% increase to specialists (including hospitalists) providing primary care services.

Although the commission largely agreed that the small decrease of practicing PCPs does not indicate barriers to access of care, the commission is concerned that the overall declining number in PCPs could create access issues in future years. The commission requested additional information about the evolving scope of practice for APRNs and NPs and the work in the primary care space, as their visits from Medicare beneficiaries increased significantly.

PAC PPS Recommendation Could Finally Arrive This Term

The commission previously determined that payments to post-acute settings are extremely high; these include Skilled Nursing Facilities (SNFs), Long Term Acute Care Facilities (LTACs), Inpatient Rehabilitation Facilities (IRFs), and Home Health Agencies (HHA). This led to MedPAC exploring development of a unified post-acute care prospective payment system (PAC PPS) to lower overall spending for PAC services. MedPAC has been working on design and structure of a PAC PPS for the past few terms and at the meeting, the Commission indicated formal recommendations could be coming term.

Overall, commissioners were concerned that services across all PAC settings were very similar, which negates having the designation of several settings of PAC care; as such, the commission requested more information on how services and intensity of care differed across all PAC settings. There was disagreement, however, over whether the three-day rule currently in place for SNFs should remain. MedPAC staff stated that they would also like to provide more research on differences in PAC stays across geographic areas as well as PAC reimbursement data for dual-eligibles. The Commissioners stated their interest in PAC reimbursement remaining a focus of this term’s work.