What Healthcare Challenges Are Being Faced Because of CMS?

The healthcare industry is constantly changing, and in many ways, it's for the better. Policies are improving access to care, technology is offering solutions to greater automation and data analysis, and trends continue to fuel the future of healthcare. However, the industry is not without its challenges, especially among healthcare providers. Some of the greatest issues in recent years surround payment and regulatory concerns linked to CMS policy changes in healthcare. Here’s what to consider and how you can align your practice management to meet those challenges. 

What Is CMS in Healthcare?

CMS meaning in medical terms:

CMS in healthcare stands for Centers for Medicare and Medicaid Services, which provides coverage to over 100 million people through Medicare, Medicaid, the Children's Health Insurance Program, and the Health Insurance Marketplace. This agency administers federal healthcare programs, assisting the U.S. Department of Health and Human Services. In addition to administering major healthcare insurance programs, CMS collects and analyzes data, creating reports to improve healthcare systems and access to them. However, CMS is creating some challenges for healthcare professionals — most of which relate to payments and revenue. So, what challenges is the CMS creating?

Related: What Does CMS Stand for in Medical Billing?

Concerns Surrounding Payment Cuts

Nearly 20% of the U.S. population has health insurance coverage through the federal Medicare program. When reviewing the numbers, Medicare spending accounted for 21% of national healthcare spending (13% of the federal budget) in 2021. Part B services, including physician-administered drugs, physician services, and outpatient services, comprised the largest share of total Medicare spending at 48%. Each year, CMS rulemaking establishes and modifies the programs that CMS administers. One such update concerns Medicare payments to physicians and other clinicians. In late 2023, CMS finalized a 3.4 decrease in the physician fee schedule conversion factor. While the impact varies across specialties, the result was a 1.25% decrease in overall payments. While these payment reductions are temporarily mitigated (from March 9, 2024 to December 31, 2024), concerns continue to rise. These cuts create a trickle-down effect, as many physicians are pressured to see more patients in less time. As a consequence, patient care and quality could suffer, and physician burnout continues to increase. 

Revenue Loss and a Lack of Relevant APMs

Physicians and other professional healthcare groups are opposing these cuts for obvious reasons. Lower reimbursements and lost revenue are at the forefront of this discussion, which may result in another issue—physicians deciding to opt out of the Medicare program. This domino effect would result in significant access problems among Medicare beneficiaries. While most physicians accept Medicare patients, they are not required to do so. There are also issues with how programs are being implemented — many physicians have expressed that the current system and offerings don't work for them.

Value-Based Payment Model Concerns

CMS faces challenges in attracting more fee-for-service medical practices that don't participate in Medicare's accountable care organizations (ACOs) and other value-based payment models, especially among specialty practices. While CMS aims to get 100% of traditional Medicare beneficiaries to join ACO or another accountable care relationship by 2030, recent findings show a clear disconnect. 

Despite most expressing interest in one, the Medical Group Management Association (MGMA) reported that 79% of medical groups say Medicare doesn't offer their specialty a clinically relevant, advanced alternative payment model (APM). Unfortunately, due to the CMS, this concern will remain a significant barrier until it is addressed, meaning medical care for the millions of Americans who depend on Medicare could drastically change.

Many professional associations state that the CMS is focusing too heavily on a one-size-fits-all approach to value-based care, focusing primarily on primary care, chronic care management, and large ACOs.

Issues Surrounding Regulatory Requirements

For physicians to receive reimbursements, they must report a steady stream of data to CMS. Despite CMS's efforts to streamline this process, many agree it's a headache and will likely become more complicated. Dealing with these administrative tasks is a burden and takes crucial time away from patient care.

The reporting duties required by Medicare Access and MACRA are on most physicians' minds—especially since there have been some significant concerns in recent years. There have been serious issues surrounding CMS' miscalculations of quality data, from complaints of poor communication to potential physician penalties. These inaccuracies may have misled some patients trying to make choices about the healthcare they receive. 

Data gaps persist, sparking the development of new requirements. These requirements focus primarily on increased regulatory compliance, overloading physicians, nurses, and caregivers with administrative work. 

Here are some findings, as reported by the American Hospital Association:

• Hospitals, health systems, and post-acute care (PAC) providers must comply with 629 regulatory requirements (across nine domains).

• Quality reporting requirements are commonly duplicative and have inefficient reporting processes.

• Physicians, nurses, and health staff comprise over one-quarter of the full-time equivalents (FTEs) dedicated to regulatory compliance.

TempDev Can Help You Work With CMS

TempDev's team of NextGen developers, consultants, and trainers can support your needs whether you want to switch, implement, or upgrade your current EHR system. More efficient practice management will allow you to address some of your most pressing challenges, including quality metrics, employee efficiency, and reimbursement.

From dashboards and revenue cycle consulting to automation and workflow redesign, TempDev offers the tools to maximize your NextGen EHR system.

Want to learn more? Contact us today!