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here for you, some of the aggregate statistics about administrative burden. Is that a full quarter percent of healthcare spending today in this country is spent on administrative burden. It's higher than any other part of the free world. You Austin, welcome to off the

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chart, a business and medicine podcast featuring lively and informative conversations with healthcare experts, opinion leaders and practicing physicians about the challenges facing doctors and medical practices. My name is Austin Luttrell. I'm the associate editor of medical economics, and I'd like to thank you for joining us today. In today's episode, physicians practice Managing Editor Keith Reynolds sat down with Anders Gilbert, the Senior Vice President of Government Affairs at the Medical Group Management Association, or MGMA. They were talking about MGMA his latest regulatory burden report, which found that 95% of practices say that administrative and regulatory burden has increased over the past several years. Anders walks through the biggest drivers, including the explosive growth of Medicare Advantage and its impact on prior authorization and the persistent failure of the MIPS to APM transition. He explains why three or more full time administrative staff per physician is now the norm just to manage payer requirements. Anders, thank you, as always, for joining us, and now let's get into the episode.

1:40
Hey there folks. Today we're talking to honors Gilbert, Senior Vice President of Government Affairs for MGMA. How you doing?

1:45
Anders, I'm great. Keith, how are you? I can't complain.

1:49
It's just another day in paradise. Brother. All right, so don't want to take up too much of your time. Let's dig right in. This is referencing a recent report that you guys put out about burden and whatnot. Let's dig right in. Though, according to the report, 95% of practices say burden has gone up over the past three years. You know what's causing that number?

2:12
Yeah. So this is a report we do sometimes on even on an annual basis, but it's important that we stay in touch with our members to understand what their biggest challenges are with respect to regulatory burden, but it also bleeds over into administrative burden. You know, it's probably not the biggest surprise, but 95% just to kind of set the stage here, 95% of our members indicated that their administrative and regulatory burden has gone up in the in the last couple of years, and so what we did in the report was then just go through and identify those areas that that are the most challenging for our members, and then that helps us with our advocacy in Washington to try to fix some of these problems.

3:01
All right, so you know what's what's causing it, though?

3:04
Yeah, it's interesting. You know, since we've been doing this a long time, regulatory burden, you still primarily deal with the the non standardization of a lot of processes. For example, credentialing. Medicare has its own credentialing program called Pecos, and it's very different than what like other insurers might have. So we used to do a lot of that in traditional Medicare, but there's been a big shift over the last couple of years, and that shift is largely a result of the growth of Medicare Advantage. So over half of Medicare beneficiaries are in Medicare Advantage. And what does that mean? It means a lot of the frustrations that MGM members have had with commercial insurers are now bleeding over into the government, quasi government, administration of Medicare, and now that that aspect of Medicare is privatized, Medicare Advantage has just shot to the top of the biggest challenges for our members, and many of the challenges within Medicare that we used to deal with a few years ago have gone by the wayside. So we have new challenges, prior authorization, down, coding of claims, denials of claims, 90% of practices. I've got some of my my data right here, 90% of practices report an increase in prior authorization burden in the last 12 months in traditional Medicare. Almost two thirds of practices remain in the merit based incentive payment program, which was meant to be kind of a bridge 10 years ago, to an alternative payment model system where, you know practice could take on more risk and provide more innovative payment and care models, but so many of our members don't have clinically relevant APMs to get into. They're stuck in MIPS, and so that remains a huge challenge, and they report that to be a reporting burden. Are not a quality improvement exercise. So those are some of the highlights from the report. You can get the report on our website, and

5:07
that's we'll definitely link out to it and all that. So you mentioned Medicare Advantage. I believe that that you know was, you know, three of your top five burdens were tied to, you know, Medicare Advantage. So you know, is the program broken or just, you know, poorly regulated?

5:25
Well, I mean, you have a lot there's two sides of Medicare Advantage. One is the side that a lot of medical groups actually can benefit from, and have used to roll out really patient friendly programs. So a large medical group could have its own Medicare Advantage plan or take downstream risk, and can do innovative things that are not really paid for under fee for service, to keep people out of the hospital, keep them healthier, have healthier communities. So that's one side of Medicare Advantage. That's not the side that our members are frustrated with. It's the commercial administration of Medicare Advantage. So you have a lot of frustration with the contracting process, basically because some of these large commercial insurers have commercial contracts. They'll, they'll bundle in their Medicare Advantage contract into negotiating, you know, annual negotiations with medical practices and and more or less, put something on the table that practices have to take it or leave it, because otherwise they would have to turn down that entire book of business. Other things, abusive, utilization, review tactics, prior authorization denials, audits and appeals. These are all the things that have now risen to the top of our regulatory burden survey, so it gives us real concern about the program. Is it broken? I don't think it's broken. And you have a lot more oversight by Congress right now. You had the CEOs of the big plans up before Congress a couple months ago, and there's just more and more scrutiny has been needed as the dollars have been tighter. It's just been harder and harder to deal with these Medicare Advantage plans, especially the commercial ones.

7:07
Okay, so, you know prior authorization, you know the great boogeyman of you know healthcare over the past, forever, as long as I've been around, you know it jumped. You know, 90% of practices are complaining of it, you know, in the report. What does that really look like, though, on the, you know, the day to day, you know, how does that frustration, you know? What does it look like, as far as you know, actual patient

7:33
care, yeah. I mean, it depends on the practice, it depends on the specialty, but it could run anywhere from a physician wanting to order a test and having to get it authorized. And then delays in those authorizations, denials of the authorization, having to go on the phone with some type of clinician at a managed care plan that doesn't meet the specialty that is making the authorization request of the insurer. And so ultimately, it delays patient care. It shifts costs back on patients when things are not covered. And if you kind of sit back and imagine where our prior authorization system is now, these insurers will say like, oh, well, we have the electronic prior authorization. But what do they have? They have their own unique portal with their own unique workflows. And a typical medical group might have a dozen, two dozen contracts more with managed care plans ma plans, and you know, ultimately, they have to log into each one of those portals to do each one of those different authorizations. So one of the things that we're actually looking forward to this year is that CMS and HHS are moving toward a more standardized approach to prior authorization for Medicare Advantage. So that's a realization of one of our priorities and advocacy for MGMA. So I'm hoping that some of that differentiation, some of that those portals, now we can have a more streamlined, standardized way of approaching it, so, but at this point, our members are viewing it as a huge problem. It has not abated. No matter what the insurers have said recently, it is not abating whatsoever.

9:13
Well, you're telling me that a company has lied in front of Congress. Oh, no, you heard it here first, folks. All right. So you know, practices are hiring, you know, three or more full time admin staff per physician, just to deal with, you know, the burden of dealing with payers, you know, what's that? How's that equating out in dollars and cents, you know, what's that costing? You know, an average practice?

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Well, it depends on the level of staff, obviously, right? You have clinical staff that are there nursing shortages in certain parts of the country, or you have administrative staff that it's challenging because they're more or less minimum wage, just doing things like logging into portals and going through checklists and things like that in the back office, assisting the physicians and so I think. Like, if I could use an aggregate number, some of the aggregate statistics about administrative burden is that a full quarter percent of healthcare spending today in this country is spent on administrative burden. It's higher than any other part of the free world. And you know, medical practices are having to deal with that, just like other providers in the system. So, you know, we're finding that it can be upwards of three administrative staff, even more per FTE physician, just to deal with all the administrative tasks. And that would include prior authorization, you know, doing, responding to audits, just the entire billing processes. And so it's cumbersome. It's not standardized, and it remains a real problem for medical groups that they have to use their resources for that, as opposed to use their resources for clinical care.

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Hey there. Keith Reynolds, here and welcome to the p2 management minute in just 60 seconds, we deliver proven, real world tactics you can plug into your practice today, whether that means speeding up check in, lifting staff morale or nudging patient satisfaction north. No theory, no fluff, just the kind of guidance that fits between appointments and moves the needle before lunch. But the best ideas don't all come from our newsroom. They come from you got a clever workflow, hack an employee engagement win, or a lesson learned the hard way. I want to feature it. Shoot me an email at kreynolds, at mjh, lifesciences.com, with your topic, a quick outline or even a smartphone clip. We'll handle the rest and get your insights in front of your peers nationwide. Let's make every minute count together. Thanks for watching, and I'll see you in the next p2 management minute. So you know the same time that you know everybody's talking about the the issues of prior authorization and the added stress that it's adding or it's putting on the system, the Wiser model is looking like it might bring that same, you know, bringing prior auth to Medicare. You know, the usually, the one thing that didn't really have to deal with that, you know. Why should that, you know? Why should that be raising alarm bells for practices?

12:20
Well, at first, what wiser is intended to do is to introduce as part of like a almost like an alternative payment model of sorts. It's coming out of the Centers for Medicare, Medicaid, innovation of all places, but it introduces, in six states, prior authorization on 17 different procedures and billable services under Medicare. And ultimately, the problem that it poses is these for those practices that have to do this now, they have to go through another utilization review processes with another portal. Interestingly, even though, like what I mentioned, CMS is moving forward with a standardized approach this year for prior authorization, so a physician might be able to identify what needs to be prior authorized in the electronic medical record, submit that authorization, getting a request back from the insurer, all within the confines of the electronic medical record, instead of The portal. Interestingly, CMS has rolled out the Wiser model, which doesn't use the standard that they're now proposing on the other side of CMS. So again, it just exacerbates the fact that it's just one more payer, one more processes, one more cost. And I think our biggest concern in it is that traditional Medicare has not even had prior authorization, so it's kind of a foot in the door slippery slope, and could easily be expanded to more than six states, more than 17 services. So we're watching it very closely.

13:56
So you mentioned earlier that, you know, there are a lot of practices still stuck in MIPS years after, you know, VBC was supposed to take over. You know, why? What's, what's gone wrong with that, that transition

14:10
well over a decade ago, the idea was, is that MIPS would be a pathway into alternative payment models that would put more risk on practices, on physicians, but allow them to benefit in sharing and savings and to really kind of self direct what the patients in their community need to have a little more autonomy and move away from fee for service so focusing on value as well as improve quality and cost. So the ultimate problem with the MIPS has been the development of alternative payment models, and MIPS is essentially the practices that do really well at MIPS do really well at quality reporting, which is a administrative process for the most part, and it doesn't necessarily work as a good proxy for. Quality. But the idea was, is that by now, we would have all these alternative payment models through something called the physician Technical Advisory Committee at HHS, who would advise the CMMI and roll them out for specialties like surgeons and primary care and all kinds of different sub specialties. But ultimately we have zero there's, over the last decade, there hasn't been a single program or APM rolled out of the PTAC, the physician Technical Advisory Committee, and so CMI has just rolled out its own program. Some have been successful, some have been pretty good, but for the most part, they're primary care focused. We're focused on maybe cardiac care, orthopedics, some big ticket items in Medicare. And for the vast majority of medical practices that don't do those specific things, they're stuck in MIPS because there's no alternative.

15:54
All right, so, according to the report, you know, 77% of your members are linking, you know regulatory burden to burnout. You know it's, it's a, it's a tale as old as time. You know they go together like chocolate and peanut butter. You know what happens to patients when physicians start to leave due to that burnout?

16:16
Well, certainly access can be jeopardized. Mg may had an opportunity, about a month ago, to testify before the United States Senate on this very issue, and one of the things we were gathering data for this report at the time, so we put a few questions in about burnout and administrative burden, like what we've talked about today is one of the highest drivers for burnout. Physicians want to go to medical school to take care of patients, and when they don't, when they get tired of it and get tired of the paperwork, oftentimes, retire early, leave communities, go work for a larger system so their employees, they don't have to deal with it themselves. And those rural areas and areas that need access to primary care and other types of physicians, you know, they then have access problems that can't easily be solved. So I think solving some of the administrative burden in healthcare could help with burnout, because it seems to be constantly reported as the number one source, along with things like work life balance, which are often related to the fact that physicians will have to stay up late at night working on charts and doing administrative work when they spend all day doing clinical work in the practice.

17:33
Yeah, they call it Pajama Time, which sounds a lot more fun than it actually is. Yeah. All right, so honors. You know, we've been chatting for years, and this, you know, I've introduced the concept a few interviews ago of, you know, God Emperor Anders. You know, if you can control the world. You know, if you could control the world, you know, if Congress does one thing this year, which I know is a big ask, but if they could do one thing this year, what should it be?

18:07
Well, I would step away from the administrative burden for a second, and what they really need to do is an oldie but goodie, which is to reform physician payment and to do away with some of the problems with the current system. And that does involve MIPS, which would be to remove what we call the tournament model from MIPS, which basically requires certain positions to get cut in order to pay quality bonuses to other physicians, so it's all budget neutral. To do away with the tournament model and then reform the physician payment system to align it with inflation. We've had several years of pretty hot inflation and basically flat payments for Medicare right now to physicians. If we did those two things, address some of the administrative burden, but then fundamentally reform physician payment systems so we don't have to come back every year. You and I talk about it every year. At the end of the year, there's going to be a cut, and there will be there'll likely be one next year, if we don't do something about it. So you know, one of our priorities, and the priorities of some of the major physician organizations, is to deal with this once and for all and get us back on a good trajectory that aligns payment with inflation.

19:19
Alright, sounds good, although that would mean that I'd have to find another topic to talk to. You know about honors, and I don't know if I've got the bandwidth for that at this moment. Alrighty, that's all the questions I've got for you. Is there anything else you want to add? Anything you think I'm overlooking?

19:36
No, I appreciate you highlighting our report again. We're going to use this report to identify these issues like we have, and then to use that to advocate on behalf of physician practices. So we appreciate this opportunity. I always appreciate the opportunity to talk to you and share what we're finding. So hopefully we'll have some good news at the end of the year on things like prior authorization and payment reform

19:59
from your mouth. To God's ears. Alrighty. Thank you so much, Anders, it's always a pleasure to chat with you. Thanks, Keith, once again, that

20:11
was Anders Gilbert, Senior Vice President of Government Affairs at the Medical Group Management Association, or MGMA, speaking with physicians practice Managing Editor Keith Reynolds, on behalf of the whole medical economics and physicians practice teams, I'd like to thank you for listening to the show and ask that you please subscribe so you don't miss the next episode. As always, be sure to check back on Monday and Thursday mornings for the latest conversations with experts, sharing strategies, stories and solutions for your practice. You can find us by searching off the chart, wherever you get your podcasts, and if you'd like the best stories that medical economics and physicians practice published delivered streams. Published delivered straight to your email six days of the week. Subscribe to our newsletters@medicaleconomics.com and physicianspractice.com off the chart, a business of medicine podcast is executive produced by Chris mazzolini and Keith Reynolds and produced by Austin Luttrell. Medical economics and physicians practice are both members of the MGH Life Sciences family. Thank you.