Tuesday, November 25, 2025

Bipartisan Policy Center and Medicare: They Can't Stop Writing

I ran across five recent documents from the Bipartisan Policy Center on Medicare reform.  


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AI CORNER

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Chat GPT5/ Here’s a structured take on the three groups you asked for.

1. The 54-page white paper (N0): Strengthening Primary Care: Medicare Physician Payment and Related Reforms

Big frame.
The report reframes Medicare Part B reform explicitly as primary-care policy and not just fee-schedule engineering. It opens with the now-familiar BPC storyline: chronic disease is driving unsustainable Medicare spending; the U.S. underinvests in primary care (5–8% of spend vs ~13% in peer countries); and Part B is both the problem child and the lever for change. The chart on page 5, showing Part B rising from ~$231B (2011) to a projected $1.17T (2034), is doing a lot of rhetorical work here: Part B is presented as the largest and fastest-growing piece of Medicare, and therefore the natural focus for sustainability policy.

Diagnosis: three intertwined failures.

  1. Misaligned incentives that keep clinicians in FFS and out of APMs.

    • MACRA’s APM bonus is phasing out; the remaining differential in conversion-factor updates is too small to matter.

    • APMs demand upfront investments and operational changes that are especially hard for small and rural practices, and hybrid payment (APCM codes, partial capitation) is underdeveloped as a bridge.

    • Integration of primary care with specialty and behavioral health is a key ambition but underpowered in existing models.

  2. Structural undervaluation of primary-care work in the MPFS and lack of data.

    • CMS is depicted as overly dependent on RUC survey data and specialty-dominated recommendations; empirical data on time, intensity, and resource use are too thin.

    • There is no consistent federal definition or tracking of “primary-care spend” across programs, making target-setting and accountability almost impossible.

  3. Crippling administrative complexity, especially in APMs.

    • Measure clutter, unaligned quality metrics, and non-interoperable EHR requirements are framed as primary reasons clinicians stay in or drift back to plain FFS.

Solutions: what’s materially new in BPC’s thinking.

The report’s recommendations are not just “more ACOs” but a package that tries to rebalance FFS, APM incentives, and primary-care infrastructure:

  • Rebuild the APM incentive structure, not just extend it.
    The report calls for extending and restructuring the Advanced APM bonus, with an explicit shift toward prospective, per-beneficiary, risk-adjusted payments rather than all-or-nothing thresholds based on total Part B revenue.

  • Create a formal HHS advisory body on MPFS valuation.
    This is one of the clearest “new” institutional proposals. BPC wants a FACA-governed advisory body inside CMS to complement (and de-bias) the RUC by:

    • relying more heavily on empirical data (claims, EHRs, time-motion studies),

    • prioritizing primary-care and care-coordination services for review, and

    • systematizing identification of misvalued services.

  • Track and eventually set targets for primary-care spending.
    HHS would define “primary-care spending,” report it across federal programs, and use that to inform policy targets—essentially building the same infrastructure states like Rhode Island built for commercial plans, but at the federal level.

  • Align quality measurement and reduce reporting load.
    The report explicitly backs convergence of measures across Medicare, Medicaid, and private payers, using Medicare’s agenda-setting role to force simplification rather than adding yet another measure set for each model.

  • Support hybrid and prospective primary-care payments.
    It highlights new APCM codes as a step toward hybrid models but warns that if valuation and beneficiary cost-sharing aren’t addressed, they will be marginal rather than transformative.

Net effect: the 54-pager is BPC’s “integrated theory” document. It ties Medicare sustainability, primary care, APM design, and MPFS reform into a single policy program, with primary care explicitly cast as the system’s leverage point rather than just another stakeholder.

2. N1, N2, N3 in sequence: the three-brief policy staircase

The three briefs function as a stepwise argument: N1 = problem + history; N2 = barriers; N3 = actionable recommendations. Read together, they show BPC tightening from broad concern about MACRA’s underperformance to a concrete legislative/regulatory agenda.

N1 – The Need for Medicare Part B Physician Payment Reform (Issue Brief #1)

This brief sets up the macro problem and the political economy:

  • MACRA hasn’t delivered on its promise.
    It walks through the SGR era, the annual “doc fixes,” and MACRA’s intent to move clinicians into APMs via the QPP (MIPS vs Advanced APMs). Then it shows that FFS remains dominant, and MACRA’s formula continues to generate unsustainable cuts that require yearly congressional patches.

  • Part B spending is the pressure point.
    N1 reprises the chart showing Part B at ~49% of Medicare benefit outlays in 2023 and growing at ~9% annually through 2034. It emphasizes that this growth is not clearly associated with measurable gains in quality or outcomes, and that beneficiaries are bearing higher premiums and deductibles.

  • Political alignment.
    Bi-partisan concern is flagged explicitly: both parties accept that the current “yearly patch” dynamic is untenable, and both profess support for increasing APM participation and primary-care strength.

Functionally, N1 is BPC’s case memo to Congress: it validates the sense of crisis, documents MACRA’s structural flaws, and primes the reader to accept that something bigger than annual patches is now required.

N2 – Key Barriers to Clinicians’ Participation in Promising APMs (Issue Brief #2)

N2 dives into why APMs aren’t scaling, organizing barriers into three clusters.

  1. Misaligned incentives and a flawed bonus design.

    • Expiring Advanced APM bonus; dwindling differential in conversion-factor updates.

    • All-or-nothing thresholds (≥35% of Medicare patients or ≥50% of Part B revenue through an APM) that can punish clinicians who are part-way through the transition.

    • Bonus amounts keyed to total Part B revenue rather than the population actually in the APM—advantaging large, high-volume systems and doing little to reward marginal high-value care.

  2. Fee-schedule misvaluation and its drag on APMs.
    The brief explains how APMs sit on an MPFS “chassis,” so undervaluation of primary-care and care-coordination codes flows directly into ACO and other model economics. It highlights the lack of robust empirical data and CMS’s reliance on RUC survey data as core technical obstacles.

  3. Fragmented APM landscape + MSSP structural issues + admin burden.

    • Multiple overlapping models with shifting rules.

    • MSSP benchmarks that “ratchet down” when ACOs succeed, discouraging continued participation.

    • Risk adjustment that under-captures the complexity and cost of high-need patients.

    • Quality reporting and EHR interoperability burdens estimated in the billions annually, which are particularly punitive for primary care and small/rural practices.

N2 is where BPC’s analytic voice comes through most strongly; it’s essentially a barrier taxonomy and sets up the logic for each of N3’s recommendations.

N3 – Recommendations to Modernize Medicare Part B Physician Payment and Related Reforms (Issue Brief #3)

N3 is the action menu that flows directly from N2’s barrier map.

Highlights (in roughly the order presented):

  • Rebuild the Advanced APM bonus.
    Extend the bonus (no lower than the 1.88% level) with no gap, then convert it to a flat, risk-adjusted per-beneficiary payment and drop the problematic patient/payment thresholds.

  • Create a CMS/HHS advisory body on MPFS valuation.
    Focus on empirical data, transparency, and systematic reviews of misvalued services; explicitly complementary to CMS’s proposed efficiency adjustments and expanded data use in the 2025 PFS rule.

  • Simplify and rationalize APMs, especially ACOs.

    • Elevate the most promising primary-care-focused models, particularly those using prospective payments.

    • Establish a permanent higher-risk MSSP track for “graduated” ACOs.

    • Fix benchmarking and risk adjustment (including using EHR data) to avoid penalizing successful ACOs and better capture high-need patients’ costs.

  • Attack administrative burden directly.

    • Implement and enforce a national data-exchange framework (e.g., CMS Interoperability Framework) for APM participants by a target date (e.g., 2028).

    • Align quality metrics across payers to move toward a unified reporting system.

  • Strengthen primary-care infrastructure.

    • Consolidate and streamline federal HIT and EHR support grants, with explicit attention to small and rural primary-care practices.

As a sequence, N1→N2→N3 shows BPC’s full theory of change: you fix MACRA’s incentive structure, clean up APM design, and simultaneously re-platform MPFS and primary-care infrastructure. The long N0 report is then a deeper dive on one pillar—primary care—inside this larger framework.

3. The two comment letters (PFS and OPPS): “live-fire exercises” of the framework

The PFS and OPPS comment letters are essentially where BPC takes the intellectual architecture above and tests it against real regulatory text. They show BPC applying the same themes—site neutrality, empirical valuation, primary-care support, digital health, and rural equity—to specific code proposals.

(a) OPPS/ASC rule comment (CMS-1834-P, Sept 15, 2025)

Core themes.

  • Site neutrality & volume control.
    BPC explicitly supports CMS’s use of OPPS volume-control authority to extend the 2019 “unnecessary volume” policy to drug administration in excepted off-campus PBDs, with a carve-out for rural sole community hospitals. They link this to their earlier recommendation for broader site-neutral payments for services safely furnished in multiple ambulatory settings, with savings partially reinvested in rural and safety-net hospitals.

  • Alignment with their 2023 Sustaining and Improving Medicare report.
    The letter repeats the argument that payment differentials between MPFS and OPPS drive consolidation and billing shifts that inflate total program outlays and beneficiary cost-sharing—essentially importing the “FFS chassis + misaligned incentives” critique into OPPS.

  • Rural Emergency Hospital quality measurement & SDOH.
    BPC backs CMS’s proposal to offer an eCQM access/timeliness measure as an alternative to the median ED arrival-to-departure measure, framing this as consistent with their earlier rural-health work. They also urge CMS to retain SDOH-1 and SDOH-2 measures, while acknowledging burden and urging ongoing stakeholder engagement—a nice example of their “pro-SDOH but administratively sober” posture.

  • Hospital price transparency.
    The letter supports CMS’s push for meaningful, accurate pricing data and explicitly invokes BPC’s prior 2020 transparency work on uniform data collection.

In short, the OPPS letter deploys the site-neutrality and rural-reinvestment planks of the broader agenda and ties OPPS policy back to Part B alignment and SDOH measurement.

(b) PFS rule comment (CMS-1832-P, Sept 12, 2025)

This letter is more tightly connected to the physician-payment and primary-care work, and you can almost read it as the “short regulatory version” of N0 + N1–3.

Key positions:

  • Practice expense RVUs and valuation methodology.
    BPC strongly supports CMS’s efforts to update PE methodology, use a wider range of empirical data, and better capture cost differences across settings. This is explicitly linked to their June 2025 recommendation for an HHS advisory body inside CMS to make the valuation process more empirical and transparent.

  • Telehealth services list.
    They endorse the proposal to permanently maintain all previously approved telehealth codes, including those added during the PHE, and to shift the review standard toward “can it be safely furnished by interactive telecommunications?” with strong program-integrity oversight. That aligns with their generic telehealth view: stable benefit design + clinical-appropriateness test + guardrails.

  • Direct supervision via two-way audio/video and “incident-to.”
    BPC takes a notably skeptical line on incident-to billing:

    • It argues incident-to makes quality and fraud oversight harder,

    • recommends prohibiting incident-to billing for any practitioner who can bill directly, and

    • at minimum urges targeted monitoring for telehealth incident-to claims, referencing pending Hill legislation on telehealth oversight.
      That is a relatively strong position and consistent with their emphasis on clear accountability and data specificity.

  • Efficiency adjustment and misvalued services.
    BPC supports CMS’s proposed efficiency adjustment to non time-based codes and again ties this to their call for an advisory body and more empirical studies for valuation. They explicitly encourage CMS to use automatic adjustments and systematic methods to identify and correct misvalued, high-growth codes.

  • Remote physiological and therapeutic monitoring (RPM/RTM).
    They back new codes that allow less rigid data-collection days and time blocks, arguing that clinically effective remote monitoring often requires only short bursts of data and largely asynchronous analysis. They then press for:

    • patient-selection and re-assessment requirements,

    • EHR integration and response-time expectations,

    • removal of geographic payment dampers for rural providers, and

    • richer claims data elements (device types, data type, ordering clinician) to support evidence generation and program integrity.

Across both letters, the through-line is clear: site neutrality + primary-care support + empirical valuation + digital innovation with guardrails. The comment letters show BPC in “reg-ops mode,” continuously reinforcing the intellectual scaffolding from N0 and the issue briefs, but translating it into very specific stances on CMS proposals.

Compare the big white paper 54pp with the triplet of smaller ones.

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How the 54-page white paper differs from — and relates to — the N1/N2/N3 triplet

1. Scope and Purpose

  • 54-page report (N0):
    A comprehensive, integrated blueprint for modernizing Medicare physician payment through the lens of strengthening primary care. It addresses the entire ecosystem: MPFS valuation, primary-care underinvestment, APM structure, quality measurement, administrative burden, rural issues, and system-wide sustainability.

  • Triplet (N1/N2/N3):
    A modular, staged argument focused specifically on MACRA, APMs, and Part B reform mechanics.

    • N1: Why Medicare physician payment reform is needed.

    • N2: The specific barriers preventing APM adoption.

    • N3: Targeted, actionable recommendations to fix those barriers.

2. Intellectual Center of Gravity

  • 54-page report:
    Primary care is the central organizing principle. Everything else—APMs, valuation, interoperability, metrics—is framed as either supporting or inhibiting robust primary care.

  • Triplet:
    MACRA and the APM architecture are the center.  Primary care appears often, but as one part of the mechanics of Part B reform, not the conceptual anchor.

3. Policy Breadth

  • 54-page:
    Broad, system-level. Includes:

    • National primary-care spending targets

    • Federal advisory body on RVUs

    • Hybrid payments, APCM codes

    • APM redesign

    • Quality-measurement simplification

    • Interoperability and admin-burden reduction
      It functions as “the full blueprint.”

  • Triplet:
    Narrower and more tactical. Each paper takes one slice:

    • Problem definition →

    • Barrier taxonomy →

    • Recommended fixes

  • Together they form a policy staircase rather than a full system redesign.

4. Relationship Between the Two Sets

  • The 54-page report is the umbrella, giving BPC’s complete argument for primary-care-centric Medicare reform.

  • The three briefs are the technical spine of that argument: a concise MACRA/APM package that can be handed to Congress.

  • Much of the 54-page analysis absorbs and extends the triplet’s insights, embedding them in a broader narrative linking primary care, MPFS valuation, and long-term Medicare sustainability.

5. Use Case for Readers

  • 54-page: For senior policymakers who want the whole theory and the cross-cutting rationale.

  • Triplet: For Hill staff, budget analysts, and CMS policy teams who need quick, structured modules they can plug into legislation or rulemaking discussions.

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Do they say much about "diagnostic tests" or the specialty of Pathology?
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Short answer:
No — across all four documents (the long 54-page white paper and the N1/N2/N3 triplet), diagnostic testing and the specialty of pathology are almost entirely absent.
When they appear at all, it is brief, indirect, and framed only in relation to primary care, APMs, or valuation mechanics, not as a domain of its own.

Below is the concise landscape:

1. In the 54-page report (N0): almost no discussion of diagnostics or pathology

The long primary-care-oriented report focuses overwhelmingly on:

  • undervaluation of cognitive/primary-care services,

  • APM incentive structure,

  • quality measures,

  • interoperability,

  • site-of-service dynamics, and

  • rural primary care.

Diagnostic testing is nearly invisible.
It is mentioned only in passing when discussing:

  • practice expense data or equipment inputs in RVUs (as examples of CMS data sources),

  • the need for data-sharing between primary care and specialists,

  • general “tests” as part of patient management.

There is no direct commentary on:

  • the role of lab diagnostics in APMs,

  • reforming coding/payment of clinical laboratory services,

  • the specialty of pathology,

  • clinical lab economics,

  • laboratory contribution to primary care value.

Even when discussing undervaluation, the focus is on evaluation and management, not pathology or diagnostic services.

2. In N1/N2/N3 (the triplet): silence on diagnostics and pathology

The triplet makes no substantive reference to lab diagnostics, laboratory workflow, or the pathology profession.

Their analytic frame is:

  • MACRA history

  • the failure of APM uptake

  • the barriers to risk-bearing

  • the flaws of the MPFS physician-work valuation system

  • the need for empirical time/intensity data

  • quality-measure alignment

  • rural and small-practice participation

  • care-management and primary-care financing

When diagnostic testing is mentioned at all, it is only in generic phrases like:

  • “tests ordered by clinicians”

  • “services delivered under the fee schedule”

  • “misvalued services” (meaning E/M and procedural codes, not labs)

Pathologists and laboratorians never appear.
There is no discussion of:

  • pathology specialty payment,

  • diagnostic coding policies,

  • clinical-laboratory contribution to APM models,

  • pathology reporting burdens,

  • molecular diagnostics or precision medicine.

3. Comment letters (PFS & OPPS): still very little on diagnostics

Even here—where diagnostic policy might naturally arise—BPC does not engage with laboratory issues.

In the PFS comment letter:

  • They support CMS updating practice-expense RVUs, but only in the context of physician office practice costs.

  • They endorse telehealth expansions, supervision rules, RPM/RTM coding, and efficiency adjustments—none of which involve lab diagnostics.

  • No discussion of Part B laboratory services, molecular diagnostics, or CLFS.

In the OPPS/ASC letter:

  • They discuss drug administration, site neutrality, and price transparency—but not lab tests.

  • No mention of hospital outpatient lab payments, packaged lab services, or OPPS-specific molecular test rules.

In short: laboratory testing is entirely orthogonal to the policy agenda they are advancing.

Why this absence is notable

BPC’s entire project is built around:

  • sustaining Medicare,

  • strengthening primary care,

  • making APMs workable,

  • rationalizing MPFS valuation,

  • reducing administrative burden,

  • improving rural equity.

They frame the crisis and its solutions almost entirely through the lens of clinicians who deliver longitudinal, face-to-face care.
Pathology and laboratory medicine—which sit outside that direct patient-facing E/M world—are not part of the narrative.

In fact, BPC’s framework implicitly accepts the CMS view that:

health-system sustainability hinges on primary care and APM incentives,
not on the organization or valuation of diagnostic testing.

Bottom line for policy watchers

Across the entire set of documents:

  • Diagnostics and pathology = almost completely absent.

  • Primary care = the anchor point of the entire reform logic.

  • APM and MPFS valuation = the dominant technical concerns.

If you want, I can also give you:

  • (1) a quick analysis of why BPC leaves diagnostics out (structural, political, and narrative reasons),

  • (2) what this means for pathology’s role in upcoming congressional conversations,

  • (3) how diagnostic-policy issues could piggyback on BPC’s larger framework.