Health Care Matters | June 20, 2025
The Medicare Participation Requirements That Providers Want Cut
Health care providers are pushing back against Medicare conditions of participation they view as excessively burdensome, responding to the Trump administration's call for input on regulatory rollbacks. Major organizations including the Federation of American Hospitals and the American Medical Association (AMA) are specifically targeting new obstetric care requirements that mandate improved staffing and training standards, arguing these could force more maternity ward closures in underserved areas. The AMA is also seeking reforms to reduce the regulatory burden with the Merit-based Incentive Payment System (MIPS), while hospitals want CMS to make the Transforming Episode Accountability Model (TEAM) voluntary rather than mandatory. Read more here, here, and here.
Why It Matters
These requests reflect well-documented challenges in Medicare's current regulatory framework rather than resistance to accountability. The AMA isn't seeking to eliminate MIPS entirely but proposes substantial reforms including awarding multi-category credit, ensuring MIPS Value Pathways are clinically relevant for patient comparisons, reducing unnecessary reporting burdens, fixing longstanding cost measure inaccuracies, sharing timely performance data with physicians, and maximizing EHR usage while minimizing "check the box" exercises. These concerns are backed by data showing MIPS costs physicians $12,800 and over 200 hours annually to comply with a program that a JAMA study found may be ineffective at measuring and incentivizing quality improvement among US physicians. We expect CMS to respond by implementing targeted reforms in areas such as data sharing, cost measure methodology, and EHR optimization.
At the same time, CMS is facing mounting calls to reconsider the mandatory structure of the proposed TEAM model. The AHA, FAH, AMA, and others have urged the agency to exclude certain hospitals, particularly those in rural areas or those serving high proportions of dual-eligible or underserved patients, from mandatory participation. CMS has yet to publish a final TEAM rule, but the agency has signaled openness to tailoring the model’s implementation. With precedent for delaying, phasing in, or even canceling mandatory models (e.g., Radiation Oncology Model, BPCI Advanced), there is a possibility that TEAM could move forward with carve-outs, staggered rollouts, or exception processes.
Look for the Helpers: From Care to Action: Community Organizing Meets Clinical Practice
The Health Equity And Leadership (HEAL) initiative at Oregon Health and Science University demonstrates how health systems can embed community organizing directly into clinical settings to address structural health inequities. Through a four-step relational organizing model that centers on listening to lived experiences and building community power, HEAL has empowered patients and community members to lead local clinical improvements and state policy efforts on critical issues like housing and language access. This innovative approach shows how health care providers can move beyond traditional care delivery to partner with communities in creating systemic change that addresses the root causes of health disparities. Read here.
What We Are Reading
State Health Care Cost Growth Targets: Moving From Aspiration To Evidence To Action
Chris Koller published a recent article in Health Affairs Forefront examining how eight states have implemented comprehensive health care cost growth target programs modeled after Massachusetts' pioneering effort. Recent data shows spending increases, including Connecticut's 8.0% per capita growth in 2023, more than double its 2.9% target, are driving policy action including proposals to tie commercial hospital prices to Medicare rates and establish prescription drug affordability boards. Read here.
Helping Mothers and Children Thrive: Rethinking CMS’s Transforming Maternal Health (TMaH) Model
The Milbank Memorial Fund released an opinion piece claiming that CMS’s Transforming Maternal Health (TMaH) Model’s current $17 million per state allocation over 10 years is insufficient to fully implement all model components, including scaling doula services, establishing standardized data systems, and expanding the scope to include coordinated mother-child care during the critical first two years of life. Read here.
How Value-Based Care With Provider Enablement Improves Maternal and Infant Outcomes in Medicaid
A study published in The American Journal of Managed Care found that Medicaid members whose obstetric care providers participated in a supported value-based care program with dedicated clinical liaisons experienced significantly better maternal and infant outcomes, including nearly 10% more women receiving timely prenatal care, 2 fewer days in NICU stays, and reduced birth costs by $450 per delivery. Read here.
ACO REACH PY2026 Explained: What is Changing and Why it Matters
Milliman's recently published analysis reveals the upcoming changes to the ACO REACH model for 2026 will generally increase financial pressure on participating ACOs through stricter risk score caps, reduced regional benchmarking weights, and higher quality withholds. Read here.
What We Are Digesting
The Trump administration’s health IT agenda centered on interoperability, digital identity, and infrastructure modernization is prompting robust engagement across the health care industry. In response to recent RFIs, national groups like the AMA, MGMA, and AHA are aligned in urging the administration to prioritize open standards (like FHIR and TEFCA), reduce provider burden, and pair policy goals with clear financial incentives. Their feedback signals strong support for CMS and ONC’s direction, while also pressing for practical guardrails to ensure reforms are both sustainable and scalable. For more, read the following:
New Resource
Mental Health Parity Index
A new interactive tool, the Parity Index, offers a groundbreaking look at how commercial insurers stack up in treating mental health and substance use disorder (MH/SUD) care compared to physical health services. Developed by the AMA, The Kennedy Forum, and Third Horizon, the tool draws from Illinois pilot data to spotlight persistent inequities especially in provider network size and reimbursement levels for MH/SUD care. To view the tool, click here.
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