Representatives of several physician groups say a monthly payment for managing patients' chronic conditions is the most significant provision of CMS's proposed 2015 Physician Fee Schedule.
Physician reimbursement for currently unpaid time spent dispensing non-face-to-face care, an expanded payment modifier, and cuts for some common codes used by specialists are among the provisions in Medicare's Physician Fee Schedule proposal getting attention from physicians groups.
Reid Blackwelder, MD, |
The Centers for Medicare & Medicaid Services' 609-page proposal released July 3 outlines how doctors will be paid starting Jan. 1, 2015.
While representatives of several physician groups interviewed last week said they were still reviewing the proposed rule, there was general consensus that the G-code monthly payment is the document's most significant provision.
Though it was contained in the 2014 final Physician Fee Schedule issued last November, an actual G-code amount—$41.92 per beneficiary—was not proposed until now.
Primary care physicians, for the first time, would be paid for taking care of Medicare beneficiaries with two or more chronic conditions without providing a face-to-face patient encounter. That could mean coordinating care provided by specialists; managing lab and imaging reports, medications and care plans; and talking with families and patients on the phone.
These are tasks physicians commonly provide, but for which they are not specifically paid.
"We're certainly pleased there's a step in the direction of recognizing the care we provide," says Reid Blackwelder, MD, president of the American Academy of Family Practitioners. "Our Medicare patients are getting more and more complicated and complex, and 60% will have four or more chronic conditions."
"They may have been in the hospital recently, might have home health coming to see them, or have seen a specialist, and I have to go through all those reports, keep up with medications, and a lot of that doesn't happen in the office, yet it's stuff we, and I, do routinely because our patients need it."
G-Code Poses 'Administrative Burden'
Shari Erickson, vice president for governmental and regulatory affairs for the American College of Physicians, adds that "CMS appears to be loosening some of the requirements for doctors to be able to receive" this G-code. And that's a good thing."
An ACP review, however, suggests the amount should be more in the range of $70. "Whether $41.92 is enough to make this work—that's what we're having to take a look at.," Erickson says. "There's a big difference between $70 and $41.92."
Another concern is that the G-code will be difficult to bill for, Erickson says.
The proposed rule requires physicians to have electronic health record systems that are certified under 2014 meaningful use standards, and to have care plan and structured data capabilities that capture claims information, but the 2014 MU standards don't require that.
CMS is essentially asking doctors to adhere to a standard that does not yet exist, Erickson says. "We’re going to need to get a clarification, obviously."
Adds Blackwelder, "The main concern for payments that are tied to G-codes is the documentation required to figure the payment. There's an increasing administrative burden placed on physicians to get additional paperwork for the care we provide. That administrative burden takes us away from taking care of patients."
Quality & Efficiency Measures
Another provision of the proposed fee rule garnering attention and concern, says Erickson, is further implementation of the complex value-based payment modifier, through which a portion of doctors pay up to 6% into a pool to reward doctors who score high in efficiency and quality outcome measures.
For 2015, she says, CMS plans to add a measure for efficiency—how much the care the physician ordered actually cost—in relation to outcomes. "So it's not just quality data that's going to be reported," she says.
Payment for value "is the way payment is going, and we're certainly very supportive of that. More broadly, though, is this program perfect? No. But none of them are. We just have to figure out a way that's fair and reasonable." She hopes CMS continues to be open to suggestions on how to make that happen.
Consumers and payers can expect to see a greatly expanded list of quality measures reported by group practices starting in 2015 under the CMS proposed rule.
According to CMS "we now propose to expand public reporting of group-level measures by making all 2015 physician quality reporting system (PQRS) group practice reporting option (GPRO) measure sets across group reporting mechanisms —GPRO web interface, registry and EHR—available for public reporting on Physician Compare in CY 2016 for groups of two or more eligible professionals, as appropriate."
Specialists' Concerns
Also high on the list of concerns over CMS's proposed fee changes are cuts in payments for certain common codes used for colonoscopy and upper endoscopy procedures by gastroenterologists and other specialists, says Colleen M. Schmitt, MD, president of the American Society for Gastrointestinal Endoscopy.
In the proposed 2014 rule issued this time a year ago, CMS had very few reduced payment changes, but in the final rule, dozens of common procedures were cut as much as 30%.
"We're concerned this year that the same thing could happen, especially for colonoscopy, without an opportunity for us to participate in feedback with CMS about the changes they're making," says Schmitt.
"Keep in mind that many of the practices in the U.S. are small groups. They're essentially small businesses, and they have responsibilities to employees. And adjustments like this they have to make quickly have significant ramifications."
CMS also is proposing to do away with the current ability of anesthesiologists to bill CMS separately for sedation services during colonoscopies, and instead cover the entire service as a bundle. That way, patients won't be billed twice for separate Part B co-payments, one for the gastroenterologist and another for the anesthesiologist.