APG Letter on Recommendations for Phase Four of National COVID-19 Stimulus Package

April 21, 2020

The Honorable Nancy Pelosi
Speaker of the House
U.S. House of Representatives
Washington, DC 20515

The Honorable Mitch McConnell
Majority Leader
United States Senate
Washington, DC 20510

The Honorable Kevin McCarthy
Republican Leader
U.S. House of Representatives
Washington, DC 20515

The Honorable Chuck Schumer
Democratic Leader
United States Senate
Washington, DC 20510

Re: Recommendations for Phase Four of National COVID-19 Stimulus Package

Dear Speaker Pelosi, Majority Leader McConnell, Republican Leader McCarthy, and Democratic Leader Schumer:

America’s Physicians Groups (APG) would like to thank you for your efforts to address the struggles that healthcare organizations have faced during the ongoing COVID-19 pandemic. Initiatives resulting from the Coronavirus Aid, Relief, and Economic Security Act (CARES) Act legislation such as the Paycheck Protection Program, the expansion of telehealth programs, and the Public Health and Social Services Emergency Fund (PHSSEF) have greatly assisted physician practices and hospitals in providing treatment for those patients in need, flattening the curve, and relieving the financial pressures they have faced while serving their communities.

But, as you know, the community public health need is still great. As you continue to explore new provisions for inclusion in a fourth phase of legislation to address the ongoing Coronavirus emergency, APG asks that your offices consider the following recommendations for providing substantial relief that would address the needs and ongoing challenges faced by physician groups and the patient populations they serve. Physician groups continue to make investments to best serve patients during this pandemic. Ensuring these providers have a stable stream of financial assistance is paramount to maintaining a strong and effective public health response. Alleviating near-term financial concerns about meeting payroll commitments or other financial risks will allow providers to concentrate fully on ending this pandemic.

About America’s Physician Groups
APG is a national professional association representing over 300 physician groups that employ or contract with approximately 195,000 physicians that provide care to nearly 45 million patients.  Our tagline, “Taking Responsibility for America’s Health,” represents our members’ vision to move from the antiquated fee-for-service (FFS) reimbursement system to a value-based system where physician groups are accountable for the cost and quality of care. Our preferred model of capitated, delegated, and coordinated care eliminates incentives for waste associated with FFS reimbursement.

APG member organizations are working diligently to rise to the challenge presented by the COVID-19 pandemic. We are focused on the transition of most patient visits to telehealth as a best practice in slowing the spread of the virus and keeping patients safe.

Summary of APG’s Recommendations

• Healthcare civil liability protections, including qualified immunity for physicians treating and testing all patients under COVID-19 conditions

• Stable payment for providers who contract under Medicare Advantage, as well as incentives for downside risk contracts in the program

• Enhanced Payment relief for primary care providers

• Accelerated and/or advanced payment of 2019 performance year shared savings, quality, or performance incentives for accountable care organizations

• Lowers the interest rate to 2 percent and extends the repayment period for advanced/accelerated payments from CMS to 2 years

• Pass legislation prohibiting business interruption insurance coverage policies from excluding the COVID-19 pandemic.

Civil Liability Protections. As our healthcare system experiences an unprecedented crisis, on the ground realities have forced physician groups to forge ahead amidst a shortage of staff and supplies, including personalized protective equipment (PPE), in order to treat a surge of patients needing care. As physicians face trying circumstances and are forced to make tough choices, it is important to protect physicians and physician groups from potential liabilities that could result from the current pandemic. As physicians work in good faith to care for patients during this public health emergency, it is important that they be shielded from analysis in hindsight regarding treatment and operational decisions made during dire and extraordinary circumstances. We request that Congress build on Section 3215 in the CARES act that provides protection from liability for volunteers and to extend it to all medical professionals during this public emergency.

Stable Payment for Providers Who Contract under Medicare Advantage. It is important to continue supporting efforts in all programs within the Medicare program to move the provision of health care from volume to value. Medicare Advantage (MA) and its physician groups are the cornerstone of that transformation from volume to value and are leading the way on innovations such as the provision of telehealth services. However, as MA physicians experience large-scale reductions in fee-for-service (FFS) payments from Medicare and other public and private payers, ensuring fair and equitable payment for physicians who contract under Medicare Advantage is essential. It should be remembered that delegated physician groups are often the at-risk entity still must pay claims on their patients. Shoring up payment and extending much-needed relief for these providers could be achieved in a variety of ways, such as through an $80-100 per member per month (PMPM) payment over a three-month period based on plan enrollment. Other options could include an increased risk factor under MA tied to the percentage increase the hospitals are receiving for Medicare or a change in the payment formula for the program. As the financial toll on providers continues to mount, providing a reliable stream of MA income during this emergency will help greatly in managing this pandemic now, and ensuring the viability of MA in the future.

Adequate Payment Relief for Primary Care Physicians. Primary Care physicians are the cornerstone of value-based care and are in critical need during the COVID-19 pandemic. Unfortunately, they are the most affected specialty by the ongoing pandemic and must receive adequate funding needed to continue serving patients in need. Primary care physicians have lost substantial revenue as elective visits have dropped considerably and they work diligently on the frontlines in response to the ongoing crisis. As Congress works to provide financial relief to physicians through initiatives like the Public Health and Social Services Emergency Fund, primary care physicians and others who may have been overlooked in the first dissemination of funds such as providers under contract with Medicare Advantage Organizations must be accounted for as Congress seeks to extend its support. APG recommends that enhanced payment relief for primary care providers be developed to avoid widespread closure of these practices which are the backbone of the Nation’s delivery system.

Extended Repayment of Accelerated/Advanced Payment with Lower Interest Rate. The decision to expand the Medicare Accelerated Payment Program to include physician group practices and additional hospitals has assisted greatly in mitigating growing financial difficulties as physician groups drastically restructure their practices in the wake of significant decreases in revenue and services. As Congress, federal agencies, and stakeholders all navigate this expanded program, we ask that you consider lowering the interest rate of repayment to percent and extending the amount of time that entities have in order to repay their advances/accelerations to 2 years. The Federal Reserve recently set its interest rate to a number reflecting our new financial realities in the wake of the coronavirus and Congress should consider doing the same for the sector of the economy most affected by the pandemic. As organizations work diligently to provide care to growing numbers of patients nationwide amidst everchanging conditions, the very assistance extended to them should not represent one more financial burden thrust upon them in the wake of public emergency. A lower interest rate and extension of the amount of time required to begin repayment to 2 years would alleviate much of the pressure, both financial and administrative, currently faced by healthcare providers nationwide.

Accelerated Payment of 2019 Performance Year Incentives. Finally, as physician groups continue to work toward shifting the healthcare system from emphasizing volume to recognizing and rewarding value, we ask that Congress consider providing advanced payment for the 2019 performance year for accountable care organizations (ACO), or at least accelerating the process under which they receive payment. Like all providers, ACOs are adjusting their methods of care and infrastructure on the fly during this public health emergency, pooling resources and sharing patients. While this is a good thing in the short-term, it does have financial implications that must be remedied through Congressional action to provide an infusion of financial support. Providing accelerated or advanced payment of shared savings, payments for quality, and performance incentives will provide ACOs with stability during this trying time. It is imperative that in addressing the current COVID-19 pandemic, the progress that has been made in transforming the healthcare delivery system does not regress back toward an emphasis on FFS care.

Mandate insurance coverage for business interruption. Prior to the Ebola crisis in 2014, most general business interruption insurance policies included coverage for financial losses that occurred due to viruses. Following the crisis, many insurers amended their business interruption policies to exclude coverage related to Viruses. As the current pandemic results in devastating financial interruption for businesses in multiple industries, a need has arisen for Congress to provide financial protection for practices in order to prevent mass closures and inadequate access to health care. We ask that Congress pass legislation prohibiting business interruption insurance coverage policies from excluding the COVID-19 pandemic.

The COVID-19 pandemic has forced all of us to confront the existing gaps in our health care system which we must now evaluate and look to improve. Moving forward, we must do more to account for quality of care, increase the amount of risk taken on by providers and organizations, and try to increase the number of patients receiving coverage in the most responsible and feasible way possible. The positive movement to transform our system of care over the past month, e.g. expanding the use and reach of telemedicine to those in rural communities and underserved populations, must not be lost once we come out on the other side of the crisis. Ensuring the creation of strong incentives for the delivery system to improve population health, quality, and the patient experience, and continuing to move toward value-based care, will make for a stronger health care system than we had going into the pandemic.

Thank you for your attention to the above comments. Again, we reiterate our robust support for the next iteration of COVID-19 pandemic related stimulus. It is important that Congress continues to work with stakeholders to most effectively respond to the ongoing public health emergency. We look forward to continuing to work with you throughout this process. Please feel free to contact Valinda Rutledge, Senior Vice President, Federal Affairs, (vrutledge@apg.org) if you have any questions or if America’s Physician Groups can provide any assistance as you consider these issues.

Sincerely,

Donald H. Crane
President and CEO
America’s Physician Groups

Please click here to download a copy of the letter.