Numerous payment policies could see significant changes under the 2016 Medicare Physician Fee Schedule proposed rule. Several of them are especially important for physicians and their Medicare patients.
Among these changes are eight issues physicians are urging the Centers for Medicare & Medicaid Services (CMS) to correct or improve before the rule is finalized in November:
- Payment for primary care and care coordination. CMS began paying for transitional care management services in 2013 and chronic care management services earlier this year. In a comment letter submitted last week, the AMA called on the agency to pay for services in six additional categories beginning next year. The letter says services that fall under anticoagulant management, education and training for patient self-management, medical team conferences, telephone services, analysis of computer-transmitted data, and complex chronic care management have long been recognized to improve care coordination and team-based care. Claims for these services also could easily be processed because CPT® codes already have been defined for them.
- Payment for collaborative care. Primary care and other physicians have said that funding for physicians to consult with each other and jointly develop treatment plans is an important part of efforts to improve patient care and population health outcomes. The AMA told CMS it strongly supports Medicare coverage of collaborative care models for patients with common behavioral health conditions.
- Savings from “misvalued” services. New legislation adopted last year established an annual target for reduction in Medicare expenditures based on adjustments to relative values of misvalued codes, with a target of 1 percent for next year and 0.5 percent for 2017 and 2018. “With an estimated total allowed charges of $88.4 billion for calendar year 2016, 1 percent would roughly equate to a net reduction target of $884 million,” the AMA comment letter points out. And while efforts to improve the accuracy of service values have resulted in redistribution of more than $3.5 billion since 2006 (largely based on physician recommendations made through the AMA/Specialty Society Relative Value Scale Update Committee), CMS needs to better communicate how it is calculating savings targets. “CMS should publish the exact target reduction number and individual service-level impacts for each year,” the letter states.
- Payment for advance care planning services. Under the proposed rule, Medicare will pay for these services beginning next year, in accordance with AMA policy adopted this summer that highlights the need for conversations between patients and physicians to establish and communicate the patient’s wishes in responding to various medical situations. Unfortunately, CMS is proposing at the same time to include payment for these services in calculating the 2016 savings target for “misvalued” codes, which will lead to a reduction in the conversion factor and a higher savings target. Because Medicare is just beginning to cover these services in 2016, their cost should be counted instead as a “redistribution” that helps meet this target, the letter points out.
- Expansion of coverage for telehealth services. CMS is limited by statutory restrictions that the AMA has been asking Congress to modify, but the agency in the meantime has been using an evidence-based approach to include additional services. Among the codes that will be added are several end-stage renal disease codes and prolonged service in the inpatient or observation setting requiring unit/floor time beyond the usual service.
- Modification to “incident-to” language. A proposed change to the regulatory language about who can bill for “incident to” services might lead Medicare administrative contractors and recovery audit contractors to prohibit billing by a supervising physician who isn’t managing the patient’s overall care, even though CMS says that was not its intent. If that were to happen, group practices that provide recurring services such as chemotherapy would run into considerable problems in the common scenario when the physician who supervises administration of treatment in not the physician managing the care. The AMA is urging CMS to keep the original language that would allow the needed billing flexibility.
- Implementation of appropriate use criteria for advanced diagnostic imaging. The AMA comment letter acknowledges the merits of appropriate use criteria. But the letter also observes that the proposed rule would give physicians less than two months to comply with a law requiring them to consult these criteria prior to ordering diagnostic testing services. Either the timeline should be modified or the required use of criterial should be phased in slowly, the letter states.
- Development of alternative payment models. The Medicare Access and CHIP Reauthorization Act (MACRA), which repealed the Medicare sustainable growth rate formula, provides incentive payments for physicians who participate in these new models. As an initial step in the MACRA rulemaking process, CMS intends to publish specific questions in a forthcoming request for information. The AMA letter advocates for the inclusion of questions related to the definition of financial risk, standards for organizations that take on that financial risk, participation thresholds, evaluation of the models, communications to patients and application of electronic health record requirements.
Other important topics covered in the proposed rule and addressed in the AMA letter include the Physician Compare website, the Physician Quality Reporting System, the value-based payment modifier, Medicare opt-out status for physicians and waivers of physician self-referral prohibitions.
