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Tuesday Aug 02, 2016

Fee schedule reflects CMS efforts to support primary care

On July 7, CMS released its proposed rule for the 2017 Medicare physician fee schedule(www.gpo.gov) (PFS). The proposed rule updates payment policies, payment rates and quality provisions for services furnished under the Medicare PFS starting Jan. 1. The AAFP is in the process of reviewing and analyzing the proposed rule and will be submitting comments and recommendations prior to the Sept. 6 deadline.  

We have prepared a summary of the proposed rule to assist members in evaluating the new payment policies. You can also access additional resources on our physician payment advocacy web page.    

The proposed rule continues a multi-year effort on the part of the Administration to both prioritize and promote primary care as foundational to the Medicare program. The AAFP continues to assert with CMS and the Administration that to truly realize the value of family medicine and primary care they cannot simply rely on delivery system reforms and alternative payment models. Instead, CMS must make new investments in primary care to truly capture and realize the value proposition of family medicine and primary care. Building new delivery system or payment models on the foundation of a payment system that has methodically undervalued primary care for a generation would be disingenuous to the goals espoused by CMS, private insurers and health policy experts.

CMS has made a commitment to improving payments for family medicine. The 2017 Medicare PFS, according to CMS, results in a 3 percent increase for family physicians compared to other medical specialties. CMS estimates that the changes made in the 2017 Medicare PFS would result in approximately $900 million in additional funding to primary care physicians. In a blog post(blog.cms.gov) that coincided with the release of the proposed rule, CMS Administrator Andy Slavitt and Acting Principal Deputy Administrator and Chief Medical Officer Patrick Conway articulated their commitment to improving the investment in primary care.

In the blog, they said that CMS, through the proposed rule, is attempting to: "reinvest in what we value -- primary care -- as a practice, as a profession, and as an abundant resource for patients. In recent years, we have begun taking a number of meaningful steps to begin this reinvestment process. Today, we are proposing significant actions to improve how we pay primary care physicians, mental health specialists, geriatricians, and other clinicians. By better valuing primary care and care coordination, we help beneficiaries access the services they need to stay well. In addition to keeping people healthy, health care costs are lower when people have a primary care provider and a team of doctors and clinicians overseeing and coordinating their care."

Improving payment for family physicians and primary care physicians is a top priority for the AAFP, and we applaud CMS for its commitment to this cause -- even though we remain convinced that CMS can and should do much more.   

The following highlights a few key areas of the proposed rule.

  • The proposed conversion factor for 2017 would be $35.77.
  • The proposed rule would add an advanced care planning code to the eligible code set for telemedicine services.
  • The proposed rule would implement appropriate use criteria for advanced imaging services created by the Protecting Access to Medicare Act. This policy requires physicians ordering certain imaging services -- magnetic resonance, computed tomography, nuclear medicine, and positron emission tomography imaging -- for Medicare beneficiaries to consult AUC applicable to the imaging modality. The implementation of this policy was delayed due to AAFP advocacy and we will once again encourage CMS to delay the implementation of the program so that AUC would be aligned with the forthcoming MIPS program versus being introduced as a stand-alone program.

Furthermore, the proposed rule makes significant changes to how CMS pays for several care management services. Specifically, the regulation would make separate payments under Medicare for:

  • certain existing CPT codes describing non-face-to-face prolonged evaluation and management services;new codes to describe the comprehensive assessment and care planning for patients with cognitive impairment (e.g., dementia);
  • new codes to pay primary care practices that use interprofessional care management resources to treat patients with behavioral health conditions;
  • new codes to recognize the increased resource costs of furnishing visits to patients with mobility-related impairments; and
  • codes describing CCM for patients with greater complexity.

In addition, the program makes several changes aimed at reducing the administrative burden associated with the CCM codes and revalues existing CPT codes describing face-to-face prolonged services. Both changes are positive for primary care.

Finally, the AAFP has long advocated that CMS should be more assertive in identifying both over and undervalued codes in the PFS. Research has shown that, historically, payments for primary care services provided by primary care physicians are grossly undervalued. We continue to press CMS to use its administrative authority to increase the relative value of primary care codes and, ideally, create new codes explicitly for primary care.  

This policy began to be implemented through the Patient Protection and Affordable Care Act, which required the secretary to identify and adjust payments for misvalued codes through adjustments to the relative values of those services. This provision was strengthened through the Achieving a Better Life Experience Act of 2014, which set a specific target for downward adjustments of misvalued codes of 1 percent in 2016 and 0.5 percent for 2017 and 2018. In 2016, CMS was unable to identify the full 1 percent required by law, thus resulting in a cut to all services to account for the difference. In 2017, CMS has proposed reductions equaling 0.51 percent. This means primary care physicians won't see any reductions in payments.

Wonk Hard
On July 21, the Department of Justice sued to block Anthem’s $48 billion takeover of Cigna Corp and Aetna’s $37 billion takeover of Humana. In both the United States v. Anthem Inc. and Cigna Corp.(www.bloomberglaw.com) and the United States v. Aetna and Humana Inc.(www.bloomberglaw.com) the Justice Department argues that the mergers would raise health care costs and reduce choices for patients. Attorney General Loretta Lynch, when making the announcement, stated: “If the big five were to become the big three, not only would the bank accounts of American people suffer, but the American people themselves.

Shortly after the announcement, both Anthem (www.businesswire.com) and Aetna (news.aetna.com) offered their responses to the Justice Department’s decision. Both have vowed to fight the decision in court.

Posted at 07:00AM Aug 02, 2016 by Shawn Martin

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Shawn Martin, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy.

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