2013 Proposed Fee Schedule

AAFP Recommends Strategies to Strengthen Medicare Using Primary Care as Core

August 27, 2012 04:35 pm News Staff

Congress must repeal the sustainable growth rate (SGR) formula to stabilize Medicare physician payments, and CMS needs to adopt a series of short-term and long-term strategies that would strengthen the Medicare program by enhancing the role of primary care physicians, says the AAFP in comments recently submitted to CMS in response to the proposed 2013 Medicare physician fee schedule.

[Stock photo-hands with fee schedule and calculator]

"An investment in primary care is the most efficacious way to improve the quality of health care services provided to Medicare beneficiaries while simultaneously restraining rising health care costs," says AAFP Board Chair Roland Goertz, M.D., M.B.A., of Waco, Texas, in an Aug. 22 letter to CMS Acting Administrator Marilyn Tavenner.

In the letter, the AAFP notes its support of CMS' proposal to create a post-discharge transitional care management code as a short-term payment strategy, but the Academy also is urging CMS to restrict use of the code to primary care physicians.

"This proposal is an important step, within the restrictions of fee-for-service, toward recognizing the value of the many nonface-to-face services an effective primary care team offers a patient," Goertz says. But, he notes, the AAFP is puzzled "that CMS did not propose to restrict the use of this code to actual primary care physicians," particularly in light of its acknowledgement that the post-discharge transitional care management code likely would be used primarily by primary care physicians.

story highlights

  • The AAFP has submitted comments to CMS on the proposed 2013 Medicare physician fee schedule and is urging CMS to adopt a series of short-term and long-term strategies to strengthen primary care and the Medicare program.
  • If implemented, the AAFP proposals would better reward the provision of primary care services, thereby enhancing the role of primary care in the Medicare program.
  • The AAFP proposal addresses a range of issues, including the Academy's response to the proposed creation of a new payment code for post-discharge transitional care management.

"It is quite possible … that the beneficiary may visit more than one physician in either the 30 days prior (to) or 14 days post-discharge," says Goertz of the new code. "In this scenario, CMS' proposal to pay only the first claim containing the new code creates an uncoordinated race to bill among the various physicians involved, rather than recognizing and rewarding the physician or practice that is actually coordinating the patient's post-discharge care. Thus … (the) AAFP recommends that CMS restrict the use and payment of this code to the patient's primary care physician."

In the letter, Goertz also addresses CMS' need to create parameters for the definition of advanced primary care practices. This definition will be necessary if CMS decides in the future to provide enhanced payment for primary care services delivered by advanced primary care practices.

"The AAFP understands the importance of using the proposed advanced primary care practice (APCP) framework to ensure that enhanced payments made to primary care physicians are tied to a corresponding expansion of the scope of primary care services to include effective care coordination and continuous quality improvement," says Goertz in the letter.

He suggests using the five comprehensive primary care functions developed for the CMS Comprehensive Primary Care (CPC) initiative as a basis for any Medicare APCP program. "The use of the comprehensive primary care functions in a Medicare APCP would ensure that stakeholders across the health care industry can develop a better understanding of CMS' support for primary care providers and the expected returns in both quality improvement and cost control," says Goertz.

Another area Goertz addresses in the letter is CMS' expanded authority to identify, review and adjust values for potentially misvalued relative value units (RVUs) and to focus on RVUs that are most likely to be misused. CMS is asking for public input on the more than 1,000 potentially misvalued codes discussed in the 2013 Medicare physician fee schedule.

According to Goertz, the Academy is pleased that CMS is using its enhanced authority to regulate RVUs. "We remain fully committed to CMS and the agency's contractors in efforts to properly validate RVUs for the identified and potentially misvalued codes," says Goertz.

Goertz also notes that the Academy

  • thinks CMS should not implement the Institute of Medicine's recommendations pertaining to geographic practice cost indices and should instead refocus efforts on ensuring a properly distributed health care workforce that is meeting the demands of a growing beneficiary population;
  • supports proposals to add recently covered "additional preventive services" to the list of Medicare telehealth services for 2013;
  • agrees with a proposal to add coverage of additional preventive services, but questions several of the proposed payment amounts;
  • considers reasonable a proposal to require that a physician has a face-to-face encounter with a beneficiary within 90 days before or 30 days after a written order for certain Medicare-covered durable medical equipment;
  • appreciates that CMS proposes to establish a Physician Quality Reporting System (PQRS) informal review process and to continue most of the program uninterrupted.
  • supports a CMS proposal to create new criteria for being a successful electronic prescriber for groups of two to 24 eligible professionals using the electronic prescribing group practice reporting option, as well as a proposal to establish an informal review process.
  • strongly supports CMS' proposal to streamline the implementation of the PQRS incentive and reporting programs within the context of the Medicare Shared Savings Program;
  • generally supports CMS' proposal to begin applying the value-based payment modifier only to groups of 25 or more eligible providers in 2015 so the agency can begin learning how to properly fulfill statutory requirements, but the AAFP remains concerned with CMS' inability to specify the exact amount of the upward payment adjustment.

CMS is accepting public comments on the proposed fee schedule through Sept. 4. The final 2013 Medicare physician fee schedule is expected to be released in November.