On July 8, the Centers for Medicare & Medicaid Services (CMS) released its 2016 Medicare Physician Fee Schedule Proposed Rule. Because the Proposed Rule weighs in at 815 pages, we’ve had to expand the usual Top 10 list to the Top 14(we had to cut it off somewhere).
Unlike prior years in which CMS focused on controlling costs associated with specialist care, diagnostic testing, and procedures, there is a heavy emphasis this year on supporting primary care. CMS is announcing several initiatives intended to enhance care management and care coordination.
1. No More SGR. Thanks to the Medicare Access and CHIP Reauthorization Act (“MACRA”), CMS no longer has to apply the sustainable growth rate (SGR) formula in calculating MPFS payments. Instead, physicians will see an across-the-board 0.5% increase in all payments (with the exception of a small number of specific payment adjustments made as part of CMS’ ongoing Misvalued Code Initiative.
2. E/M Add-On Codes for Care Management. Building on new Medicare payment for transitional care management (TCM) and chronic care management (CCM), CMS now is exploring appropriate ways to fairly compensate for the professional work of care management services. While TCM and CCM pay physicians for “the work typically required to supervise and manage the clinical staff,” CMS recognizes there is unique value in “the more extensive cognitive work that primary care physicians and other practitioners perform in planning and thinking critically about the individual chronic care needs of particular subsets of Medicare beneficiaries.”
CMS envisions “codes that could be used in addition to, not instead of, the current [evaluation and management (E/M)] codes.” These codes would be “much like add-on codes for certain procedures or diagnostic test [that] describe the additional resources sometimes involved in furnishing those services.” For example, these codes “could describe the professional time in excess of 30 minutes and/or a certain set of furnished services, per one calendar month for a single patient to coordinate care, provide patient or caregiver education, reconcile and manage medications , assess and integrate data, or develop and modify care plans.”
CMS “strongly encourage[s] stakeholders to comment on this topic to assist [the agency] in developing potential proposals to address these issues through rulemaking in CY 2016 for implementation in CY 2017.”
3. Separate Payment For Collaborative Care. Similarly, CMS recognizes that the management of complex patients “often requires extensive discussion, information-sharing and planning between a primary care physician and a specialist.” The agency invites comments on “how to improve the accuracy of [Medicare]payments for care coordination particularly for patients requiring more extensive care….”
Specifically, CMS is looking for recommendations regarding how such collaborations could be distinguished from current E/M services, what types of beneficiary protections are needed, how to address beneficiary financial liability, and whether there are key technology supports needed to support collaboration among providers. As with the E/M add-on codes, CMS intends to address payments for collaborative care through rulemaking in 2016 for implementation in 2017.
4. Reducing Administrative Burden for CCM and TCM Services. As it has done for the last several years, CMS emphasizes its commitment to making care management services broadly available to Medicare beneficiaries. The agency recognizes, however, “that excessive requirements on practitioners” to provide and bill for transitional and chronic care management “could possibly undermine the overall goals of the payment policies.” Therefore, CMS requests “stakeholder input in how [it] can best balance access to these services and practitioner burdens such that Medicare beneficiaries may obtain the full benefit of these services.”
5. MPFS Payment Rate for CCM Services. Similarly, CMS requests stakeholders to provide information regarding the circumstances under which CCM is furnished, to determine whether the current payment rate adequately reimburses providers for the required resources. CMS also indicates it may be willing to make payment for related CPT codes, including complex care coordination, based on its internal claims analysis and information furnished by providers regarding resource use.
6. RHC and FQHC Payments for CCM Services. When CMS began making payment for CCM at the beginning of 2015, it refused to allow rural health clinics and federally-qualified health centers to bill for this service. Now, CMS proposes to expand CCM to include RHCs and FQHCs, paying these providers at the MPFS national average non-facility payment rate (currently $42.91 per beneficiary per calendar month).
7. “Incident To” Rules. The “incident to” rules, under which certain services furnished by auxiliary personnel may be billed as if furnished by a physician or non-physician practitioner, are among the most complicated rules in the Medicare program. CMS proposes to make these rules even more complicated by requiring “that the physician or other practitioner who bills for ’incident to‘ services must also be the physician or other practitioner who directly supervises the auxiliary personnel who provide the ’incident to‘ service.” The current regulation now states the billing physician or other practitioner does not have to be the supervising physician or other practitioner.
Last year, CMS amended the “incident to” regulations to require only general supervision for TCM and CCM (while direct supervision is required for all other services). This provision now permits non-face-to-face care management services to be furnished through a centralized entity, so long as the staff is properly supervised by a physician or non-physician practitioner. Under the proposed rule, however, the billing physician or other practitioner would have to be the supervising physician or other practitioner, making it significantly more difficult – if not impossible – to provide TCM and CCM in this cost-effective manner.
8. Expansion of CPCI. The Center for Medicare and Medicaid Innovation (CMMI) launched the Comprehensive Primary Care Initiative in seven regions in October 2012. There are approximately 480 practices participating in this multi-payer initiative, which will conclude at the end of 2016. Practices receive a monthly care management fee for each attributed patient to fund “a whole-practice care delivery transformation strategy” as well as the opportunity to receive shared savings payments. CMMI makes available a range of support services to assist CPCI practices in meeting specified milestones.
Although first-year results were not overwhelming (cost savings were roughly equal to care management fees, no significant improvements in quality), CMS now is considering expanding CPCI to additional regions or even nationwide. To that end, the agency is seeking comment on several considerations including practice readiness, practice standards and reporting, practice groupings, interaction with state-level initiatives, learning activities, and provision of data feedback to practices.
9. Advance Care Planning Services. CMS previously has proposed paying physicians to provide advance care planning (ACP), but withdrew its plans in response to “death panels” criticism. The agency now has decided to give it another go, requesting comments on “whether payment is needed and what types of incentives [payment for ACP] creates.”
10. MACRA Implementation. In addition to repealing the SGR, MACRA calls for replacing the current physician value-based purchasing programs with the Merit-Based Incentive Payment System, or MIPS, beginning in 2019. (Our on-demand webinar, De-Mystifying MACRA, provides a detailed introduction to MIPS.) In the proposed rule, CMS begins the process of developing the regulations to implement MIPS. Specifically, the agency seeks public input relating to the low-volume threshold, clinical practice improvement activities, and alternative payment models (APMs).
11. Physician VM Program. Having spent the last several years developing the Physician Value Modifier Program – including the Physician Quality Reporting System (PQRS) and Physician Feedback Reports – CMS’ attention now seems diverted to the development of the MIPS program. Physicians’ performance in 2016 will determine PQRS and VM Program payment adjustments in 2018. Starting in 2017, physician performance will be subject to the yet-to-be developed MIPS measures.
For 2016, CMS continues with the same policies announced last year, with only minor modifications. One area of significant discussion in the Proposed Rule is the application of the VM Program to providers now participating in alternative payment models, including the MSSP and CMMI initiatives.
12. Expanded Coverage For Telehealth Services. CMS continues to be stingy in response to growing demand for expansion of telehealth services. The agency proposes to make only two minor additions to the list of telehealth services: prolonged service inpatient (CPT codes 99356 and 99357) and ESRD-related services (90933 through 90936). CMS continues to refuse to cover ICU telemedicine, claiming there is “no evidence that the implementation of ICU TM significantly reduce[s] mortality rates or hospital length of stay….”
13. New MSSP Quality Measure. To be eligible forany shared savings under the Medicare Shared Savings Program, a participating accountable care organization (ACO) must achieve a certain level of performance on specified quality measures. Since the MSSP began in 2011, CMS has reviewed and revised the measure set to align with updated clinical guidelines and other quality reporting programs. For 2016, the agency proposes one new measure, statin therapy for the prevention and treatment of cardiovascular disease. CMS requests comment on the proper manner to implement this measure.
14. Stark Regulations. Last – but not least – CMS proposes to fine-tune several provisions of the Stark regulations. Most of these changes are intended to avoid the draconian consequences of a technical violation, such as failure to obtain proper signatures on key documents. CMS also is proposing new exceptions for timeshare leases, recruitment of non-physician practitioners, and retention payments in underserved areas.
Shifting gears, CMS also requests comments on the impact of the Stark Law on payment and delivery system reforms. Under MACRA, CMS is required to issue two reports to Congress by April 2016: one addressing the application of the federal fraud prevention laws to alternative payment models and one proposing changes to these laws to permit gainsharing arrangements.
CMS solicits stakeholder input on these reports by presenting a challenging list of questions concerning the application of the Stark Law, the Anti-Kickback Statute, and the Civil Monetary Penalties Act in the context of alternative payment models. These questions will be the subject of our later discussions regarding the Proposed Rule.
Comments on the Proposed Rule are due to CMS by mid-September. Expect CMS to publish the final regulations in November. For more information regarding any of the CMS proposals, or to discuss submission of comments, please contact Martie Ross or Lori Foley at PYA, (800) 270-9629.
