A proposed rule from the Centers for Medicare & Medicaid Services to set the Medicare physician fee schedule for 2013 drew more than 2,900 comments from a variety of stakeholders.
While there was general support for many of the provisions in the 765-page proposed rule, the comments provide insight into the complicated fee structure that providers must contend with in the delivery of healthcare services to Medicare beneficiaries. The comment period ended Sept. 6.
As first proposed in July, CMS says the changes to how fees are calculated would increase payments to family physicians by 7% while payments for other primary care practitioners would increase by 3% to 5%. On the surface that’s good news but commenters also took issue with the complicated calculations required to arrive at the payment increase.
Other provisions of the proposed rule would update payments for Medicare Part B drugs, add Medicare-covered services that can be provided via telehealth, clarify when Medicare will pay for interventional pain management provided by certified registered nurse anesthetists, and implement portions of the Patient Protection and Affordable Care Act by establishing a face-to-face encounter as a condition of payment for certain durable medical equipment items, and provide additional payments for care coordination.
Based on a sample review of 25 comments from a mix of stakeholders, comments focused on six broad areas: care coordination, misvalued codes, multiple procedure payment reductions, Medicare telehealth services, scope of practice for certified registered nurse anesthetists, and the physician value-based payment modifier. All comments are available on regulations.gov.
Care coordination
In an effort to advance care coordination and reduce hospital readmissions, the proposed rule calls for CMS to make a separate payments to coordinate patient care for those critical 30 days following a stay at a hospital or skilled nursing facility. Reaction to this proposal was surprisingly mixed. Stakeholders support the idea of care coordination but have some problems with its implementation.
While the Medical Group Management Association (MGMA) supports post-discharge care management, it is concerned that CMS will pay for this new service "by decreasing reimbursement to specialties outside of primary care." The group wants CMS to "explore ways to pay for this service using the actual savings it will achieve under Part A."
The Society of Nuclear Medicine and Molecular Imaging (SNMMI) is concerned that the proposed care transitions code is not well-defined enough to meet the goals of the program. "There is nothing to limit the billing of the code to only those clinicians providing comprehensive primary care…the code could be billed by any physician…with only limited or no prior contact with the beneficiary. Because the proposed rule does not require a face-to-face visit, beneficiaries may not be aware that a clinician is billing for coordinating their care."
Kaiser Permanente, a California-based integrated delivery system, also supports care coordination but opposes the requirement that the coordinating physician must have seen a patient 30 days before a hospitalization. "Large multi-specialty medical groups provide team-based care. Patients have a designated primary care physician, but they may be seen by other members of the care team or specialists before and after the hospitalization."
Misvalued codes
As part of healthcare reform, CMS is directed to periodically identify and review the fees paid for services to assess if increased use or new technologies may have affected the value of those services. For 2013 CMS proposed the review of evaluation and management service furnished as part of global surgical services.
In its comment letter, the American Academy of Family Physicians (AAFP) said it has "long argued" that global surgical packages are inflated in terms of "the number and level of post-operative visits" assumed to be included in the value of the codes.
MedPac, the independent Congressional agency established to advise Congress on issues affecting the Medicare program, expressed concern about the pace of validating the fee schedule's estimates of the time providers spend furnishing services.
MedPac noted that the estimates rely "on surveys conducted by physician specialty societies," which have a stake in the process. The commission suggests that CMS establish time estimates with data collected from physicians' offices and other settings where physicians and other healthcare professionals provide care.
Multiple procedure payment reductions (MPPR)
When outpatient or surgical services are furnished to the same patient on the same day, Medicare reduces payment for the second procedure to account for efficiencies. That process is in place for CT scans, MRIs, and some ultrasound and nuclear medicine studies. CMS wants to expand MPPR to include the technical component of additional cardiovascular and ophthalmology diagnostic procedures.
MedPac supports this step but wants CMS to also include the professional component of the services. "When multiple tests are performed together, certain physician activities…such as reviewing records…are likely to occur only once."
SNMMI opposes the expansion. It contends that the proposed policy is based on flawed assumptions regarding potential efficiencies. The group also said the CMS line item methodology to support payment reductions was not published in the proposed rule and is "necessary for complete public comment."
Concern about the negative impact on free-standing radiation oncology centers led the Rochester, MN-based Mayo Clinic to also oppose the change. "Before CMS makes significant reductions in the practice expense, CMS should be certain that it is using the most comprehensive and accurate information to value the full practice expense relative value weight."
Telehealth services
CMS proposes to expand telehealth services to include alcohol and substance abuse assessment and intervention services. This is especially important for rural areas where specialist may not be available onsite to see patients.
It comes as no surprise that the American Psychiatric Association, representing more than 36,000 psychiatric physicians, supports allowing services such as annual depression screenings and behavioral counseling for obesity to be delivered via telehealth. The group noted that the "prevalence of psychiatric disorders in primary care is well-documented" and contends that providing PCPs with the opportunity to bill for these preventive services will "facilitate timely referral to specialists."
Kaiser Permanente would like CMS to use its regulatory authority to broaden "eligible telehealth settings, locations and services under Medicare." Kaiser sees opportunities to leverage the consumer adoption of mobile medical apps as a way to improve the delivery of healthcare services.
Scope of practice for certified registered nurse anesthetists (CRNA)
Physicians are very protective of their practices and adamantly oppose any effort to allow nonphysicians to encroach on the delivery of medical services. CMS has proposed to permit certified registered nurse anesthetists to furnish and bill for chronic care management in states that allow CRNAs to provide those services.
The California Medical Association and other physician groups oppose this move. Its comment letter noted that the change would "effectively allow the safety and welfare of Medicare beneficiaries to be determined on a state-by-state basis." The CMA presents familiar arguments ii opposing the move: interventional pain management is the practice of medicine and CRNAs do not have the education or the skills required to furnish chronic pain management services.
The American Nursing Association took a different approach. It stated that chronic pain "is a significant public health challenge" and that there is a "deficit of qualified professionals to treat chronic pain." With their advanced education, training and experience CRNAs are "uniquely qualified" to address the challenge.
The ANA cited the Council on Accreditation of Nurse Anesthesia Educational Programs standards, which mandate that nurse anesthesia programs provide content in anatomy, physiology and pathophysiology, pharmacology and pain management.
Rep. Jim Cooper (D-TN) also commented in support of direct reimbursements to licensed advanced practice nurse (APN), including CRNA for pain management procedures. "There is no evidence that trained and qualified APNs compromise patient safety or lead to over utilization of procedures. Research has shown that these providers increase access and decrease the cost of healthcare."
Physician value-based payment modifier (VBPM)
The ACA requires CMS to establish a value-based modifier that provides for differential payments based on the quality of care furnished compared to the cost of the care. The VBPM is required to be revenue neutral so increased payments to some physicians result in decreases for others
The AAFP is concerned that budget neutrality considerations limit CMS's ability to "specify the exact amount of the upward payment adjustment." The AAFP said it "will be challenging" for groups to subject themselves to "a new and untested program without prior knowledge of a potential award."
MGMA is concerned that several technical issues related to the VBPM have not been addressed. MGMA questions if the modifier can even be implemented for the first measurement year in 2013 and urges CMS "to withdraw this proposal until methodological and technical issues" are resolved. Among its concerns is that more time is needed to "test valid measures of cost, outcomes and quality as well as mechanisms to accurately adjust for risk before moving forward with a program that modifies physicians' payments based on CMS' definition of value."
CMS is expected to release the final physician fee schedule rule in November.
Margaret Dick Tocknell is a reporter/editor with HealthLeaders Media.
