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Cut the Red Tape, Not the Care
Cut the Red Tape, Not the Care
AMGA is calling Congress to scrap or modernize Medicare rules that add paperwork and delay care without improving quality.
Why it matters: Medicare's rules were written for 1965-era care, centered on hospitals and solo practices. Today's team-based, outpatient, and virtual care keeps running into them. Patients end up navigating a maze, and providers spend time on rules instead of care.
The big picture: This is the fourth of six pillars in AMGA's MACRA and Value-Based Care Task Force report.
- Despite MACRA and years of demonstrations, the rules haven't caught up with team-based care, home-based services, or new technology.
- The goal: Let medical groups and integrated systems deliver the right care, at the right time, in the right setting.
- The test: If a rule doesn't improve access or quality, it should go.
1. Quality Measures
The problem: Providers report hundreds of measures to different payers. Most don't improve care.
By the numbers: Practices in four common specialties spend more than $15.4 billion a year on quality reporting, plus 785 hours per physician.
The fix: Adopt AMGA's 14-measure Value Measure Set, built around outcomes patients care about.
- CMS' Universal Foundation measure set already drew on AMGA's work.
- AMGA wants its set used in Medicare, then Medicaid.
2. Self-referral laws
The problem: The Stark Law was built to stop conflicts of interest in fee-for-service. Now it complicates accountable care organizations (ACOs) and bundled payments.
The fix:
- Automatically exempt value-based models, as the incentives Stark guards against do not exist there.
- Let providers share preferred lists of post-acute facilities, chosen on readmission rates and patient satisfaction.
Why it matters: Preferred lists steer patients to higher-quality care and simplify referrals.
3. Documentation and billing
The problem: Much of the paperwork exists for compliance, not clinical need.
Zoom in:
- Good model: TEAM builds its quality score from data hospitals already report.
- Bad model: A proposed transplant rule would require telling waitlisted patients about every organ declined on their behalf.
- Ongoing pain: Electronic Clinical Quality Measures (eCQM) reporting burdens and frequent risk-adjustment coding changes that force retraining and new forecasts.
The fix: Use templates, EHRs, and AI tools. Keep coding standards stable. Pass H.R. 483, the Health Care Efficiency Through Flexibility Act, to delay ACOs' shift to eCQMs.
4. Medicare Advantage prior authorization
The problem: New deadlines (7 days for standard requests, 72 hours for expedited) have not ended delays.
By the numbers: More than 80% of appealed denials were overturned, fully or partly, each year from 2019 to 2023.
Zoom in: One member delays MRI scheduling 14 days just to manage denials.
The fix: Eliminate prior authorization where possible; value-based care already removes the overuse incentive it was meant to police.
5. Post-acute payment silos
The problem: Skilled nursing facilities (SNFs), inpatient rehab, home health, and long-term care hospitals each have separate payment systems and rules.
Why it matters: Fragmented rules mean more admin work and slower handoffs between settings.
The fix: A unified framework allows patients to move smoothly from one setting to the next.
6. The three-day SNF rule
The problem: Medicare covers SNF care only after a three-day inpatient stay. The rule dates from an era of longer hospitalizations.
The evidence: Waivers for ACOs, Medicare Advantage (MA) plans, and during the COVID-19 emergency brought lower costs, fewer readmissions, and better coordination.
The fix: Eliminate the rule and let clinicians make decisions based on medical need.
7. Annual Wellness Visits
The problem: The required forms repeat what is already in the patient's record.
- Visits are limited to prevention.
- Addressing a chronic condition requires a billing modifier, which can trigger audits and a surprise copay.
- Patients either book a second visit or get a bill for one they thought would be free.
The fix: Simplify the rules and allow chronic care during the visit.
8. Telehealth access
The problem: Before the pandemic, Medicare covered telehealth mostly at approved rural facilities, not at home.
Why it matters: Pandemic waivers let groups build telehealth into daily practice. Losing them would disrupt care.
The fix: Permanently drop geographic and originating site limits, as the CONNECT for Health Act would allow.
Bonus: Let clinicians deliver telehealth from outside their usual facility, which adds scheduling flexibility and eases burnout.
9. Telehealth prescribing
Why it matters: Virtual prescribing is key for rural patients and those managing chronic conditions, pain, or mental health.
The fix: Permanently allow controlled substances to be prescribed during virtual visits, with safeguards against misuse.
10. National licensing
The problem: State-by-state licenses block care across state lines.
The fix: A national framework or an expanded interstate compact.
- Helps rural patients reach specialists.
- Fits integrated systems that operate in more than one state.
What’s Next?
What's Next?
AMGA calls on providers, payers, policymakers, and patient advocates to work together so Medicare's 1960s promise matches today's care. Learn more about AMGA's MACRA and Value-Based Care Task Force today.
This summary was prepared with AI assistance and reviewed by AMGA staff.
