AAFP Scrutinizes Proposed Rule, Recommends Changes for 2011 Medicare Physician Fee Schedule

The Academy recently sent a detailed list of comments to CMS regarding the agency's proposed rule for the 2011 Medicare physician fee schedule, which was published in the July 13 Federal Register (670-page PDF; About PDFs).

In a July 28 letter (38-page PDF; About PDFs) addressed to CMS Administrator Donald Berwick, M.D., the Academy expressed its appreciation for the agency's efforts in addressing primary care issues "within the parameters permitted by the current statute."

AAFP Board Chair Ted Epperly, M.D., of Boise, Idaho, reaffirmed CMS' efforts to redistribute work values to the evaluation and management services that most often fall under the purview of primary care physicians. He also commended Berwick for CMS' attention to misvalued CPT codes, improvements in the valuation of immunization administration codes and proposed changes in the e-prescribing incentive program.

"In short, publication of the proposed rule demonstrates CMS' continued recognition that a high-quality, efficient health care system must rest on a foundation of primary medical care," said Epperly.

He also noted that he was pleased that CMS continued to diligently pursue potentially misvalued services in the proposed fee schedule. He pointed to recent studies that show a widening income gap between cognitive and procedural physician specialties. That gap is "dramatically reshaping the physician workforce by influencing both career choice by students and graduate medical education buildup by teaching hospitals," said Epperly.

"There is a direct tie between payment policy and a growing threat to access for primary care services for Medicare beneficiaries," he added.

The AAFP offered suggestions regarding CMS' future relative value unit, or RVU, validation efforts, "especially as (they) relate to estimates of physician time and intensity." Epperly encouraged CMS to support independent research methods currently under way at the University of Cincinnati that investigate physician work intensity using "more modern techniques," and he provided CMS with the lead investigator's contact information.

Epperly reiterated the AAFP's previous recommendation that CMS establish a group of experts separate from the AMA's Relative Value Scale Update Committee, or RUC, which is composed primarily of representatives from subspecialty medical organizations, to help the agency review and revalidate RVUs.

The recommendation, which also is supported by the Medicare Payment Advisory Commission, or MedPAC, would give CMS the benefit of input from a group of experts less invested in the outcome, said Epperly. "In medicine we call this 'Getting a second opinion,'" he added.

The Academy was pleased that CMS expanded its list of approved Medicare telehealth services to include services such as individual and group kidney disease education and diabetes self-management training. "We want to congratulate the agency for its willingness to reconsider past decisions and expand Medicare coverage of telehealth services in ways that we hope will facilitate beneficiary access to care," said Epperly.

A significant portion of the letter was dedicated to comments regarding provisions of the Patient Protection and Affordable Care Act of 2010 that affect Medicare payment to physicians. Included in that discussion were topics such as

The Academy noted that CMS attempted to define the term "annual wellness visit" without first providing a definition for the term "health risk assessment," which, by law, will be incorporated into the design of the annual visit.

"We would encourage the agency to get about the business of defining 'health risk assessment,' so that its proposal can be evaluated appropriately," said Epperly.

Epperly also pointed out that in regard to the new annual wellness visit, CMS would require physicians to provide added patient services as part of the wellness visit -- including the creation of a preventive screening schedule for the next five to 10 years -- and yet the proposed rule undervalues the service and subsequent payment to physicians.

The Academy also suggested that CMS re-examine its e-prescribing program in light of the advent of the "meaningful use" initiative. "Meaningful use provides an opportunity and penalty that did not exist when the original e-prescribing regulations were put in place," said Epperly, calling the situation a form of "double jeopardy" for physicians.

"A physician who gets the first-year 'meaningful use' subsidy via Medicaid could also be penalized for not using e-prescribing," said Epperly. "CMS needs to address these kinds of inconsistencies going forward."

In closing, Epperly commended the proposed rule for covering a lot of ground. However, he encouraged Berwick to do more to "remedy the basic inequity" of the current health care payment system.

"A fundamental reform of the payment system is needed, rather than a tinkering with our current broken system," said Epperly.

"Collectively, we need to start cultivating the environment for such fundamental reform, rather than the piecemeal changes that often introduce as many unintended consequences or challenges as improvements," he added.