Reinvesting in primary care will encourage a shift in American health care from treating sickness to maintaining health, resulting in saved money and better health outcomes. As part of its reinvestment, CMS released its Proposed rule for the Medicare Physician Fee Schedule (PFS) for calendar year (CY) 2017, which will publish in the Federal Register on July 15, 2016. If finalized, the proposed regulations would improve Medicare payment for services provided by primary care physicians for patients with multiple chronic conditions, mental and behavioral health issues, and cognitive impairment or mobility-related disabilities. It also includes proposals to expand the Diabetes Prevention Model, modify the Medicare Shared Savings Program (MSSP) to align it with the Quality Payment Program, update the Medicare Advantage (MA) provider network requirement, and add data transparency requirements for MA and Part D. Comments on the Proposed rule are due to CMS by September 6.
In a blog post, CMS Acting Administrator Andy Slavitt said that the Proposed rule builds on years of "meaningful steps" by taking "significant actions" to better value primary care and care coordination. CMS also provided a fact sheet on its proposals.
PFS conversion factors for CY 2017. The PFS pays for Medicare services furnished by physicians and other practitioners in all sites of service based on the relative resources typically used to furnish the service. Each service is assigned a relative value unit (RVU) and paid after applying a yearly conversion rate. For CY 2017, CMS estimates the PFS conversion factor to be 35.7751, which reflects required adjustments for budget neutrality and a 0.5 percent update required by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (P.L. 114-10). The CY 2017 anesthesia conversion factor is estimated at 21.9756, reflecting the same overall adjustments.
Coding and payment changes. As part of its focus on primary care, the Proposed rule would revise the PFS billing code set to more accurately recognize the work of primary care and other cognitive specialties. The proposed changes include making separate payments using existing or new codes for the following:
- certain existing Current Procedural Terminology (CPT) codes describing non-face-to-face prolonged evaluation and management services;
- describing the comprehensive assessment and care planning for patients with cognitive impairment (e.g., dementia);
- paying primary care practices that use interprofessional care management resources to treat patients with behavioral health conditions;
- recognizing the increased resource costs of furnishing visits to patients with mobility-related impairments; and
- describing chronic care management for patients with greater complexity.
CMS also proposes to revalue existing CPT codes describing face-to-face prolonged services and reducing administrative burden associated with chronic care management codes to remove potential barriers to furnishing and billing for these services. It proposes valuation changes and new codes for moderate sedation services, as well as new coding for mammography services.
New telehealth codes. CMS proposed adding codes to the list of services eligible to be furnished via telehealth. The new codes are for end-stage renal disease (ESRD) related services for dialysis; advance care planning services; and critical care consultations furnished via telehealth using new Medicare G-codes.
Diabetes prevention. The Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) created a number of wellness and prevention programs, including the National Diabetes Prevention Program. In 2011, the CMS Innovation Center, which tests innovative models to improve the quality of patient care without limiting coverage or benefits while costing the same or less than existing models, awarded a grant to test the Diabetes Prevention Program for three years. In March 2016, the independent Office of the Actuary for CMS certified the model for expansion into the Medicare program beginning in 2018, marking the first time a preventive service model from the Innovation Center obtained that certification. The Actuary determined that expanding the program would reduce net Medicare spending and improved beneficiary health.
As it expands the prevention program, CMS proposed and sought comments on:
- Medicare Diabetes Prevention Program supplier enrollment;
- payment structure;
- information technology (IT) considerations and capabilities;
- eligible beneficiaries;
- program integrity initiatives;
- site-of-service requirements;
- learning and technical assistance requirements;
- quality measurement and reporting; and
- whether the Medicare Diabetes Prevention Program should be expanded nationally in the first year of the program or whether it should be phased in.
Other provisions. The proposed regulations include a number of other provisions. It would require health care providers and suppliers to be screened and enrolled in Medicare in order to contract with an MA organization to provide Medicare-covered items and services to beneficiaries enrolled in MA health plans. This would bring MA requirements into alignment with the health care provider and supplier enrollment requirements for Parts A, B, and D.
CMS is also proposing to release two new data sets related to MA and Part D plan participation. The first would be bidding information from MA organizations, released five years after the bids were placed, on an annual basis, and excluding proprietary information. The second set of data is from the ACA’s medical loss ratio (MLR) for MA organizations and Part D sponsors. Commercial MLR data must be public, but Medicare MLR data does not have the same requirement; CMS is proposing to provide that information to beneficiaries making enrollment decisions.
The Proposed regulations also deal with promoting the use of appropriate use criteria for advanced imaging services, and updates to accountable care organizations (ACOs) participating in the Medicare Shared Savings Program (MSSP).
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