After careful review of CMS' proposed 2014 Medicare physician fee schedule in the July 19 Federal Register(www.gpo.gov), the AAFP has provided a thorough response to pieces of the proposal that most strongly affect family physicians and their patients.
In an Aug. 29 letter to CMS Administrator Marilyn Tavenner, M.A.(21 page PDF), AAFP Board Chair Glen Stream, M.D., M.B.I., of Spokane, Wash., applauded CMS for promoting the value of primary care and said the government's commitment "should begin to address the looming shortage of primary care physicians and will improve the delivery of health care in America."
However, Stream was quick to point out that the proposed fee schedule included a 24.4 percent Medicare physician pay cut tied to the flawed sustainable growth rate (SGR) formula. "An AAFP analysis of the proposed cut shows the typical family physician would lose a total of $89,763, and a three-physician practice would lose $269,289 in revenue next year" if the cut goes through, said Stream.
- The AAFP has analyzed and responded to CMS' proposed 2014 Medicare physician fee schedule.
- Although AAFP Board Chair Glen Stream, M.D., M.B.I, applauded CMS for promoting the value of primary care, the letter highlighted the AAFP's continued concerns about the sustainable growth rate formula.
- The Academy also offered recommendations on complex chronic care management services, evaluation and management codes for primary care, and the Physician Quality Reporting System.
"No small business can sustain itself in the face of such drastic revenue reductions," Stream added, and he called on CMS and Congress to avert the "devastating cut" and replace it with a new formula that includes more equitable pay for primary care services. "The AAFP believes that to achieve meaningful health system reform, we must also have meaningful Medicare physician payment reform," said Stream.
From his emphatic request to repeal the SGR, Stream moved on in the 21-page letter to offer specific suggestions for improving the 2014 fee schedule.
Complex Chronic Care Management Services
For example, Stream noted that the AAFP generally supports CMS' proposal to establish separate payment for complex chronic care management (CCCM) services provided to patients with multiple conditions.
"We consider payment for CCCM services as another appropriate, albeit short-term, step in the direction of paying primary care physicians a monthly care management fee for all beneficiaries who are receiving services from a patient-centered medical home (PCMH)," said Stream. He added that establishing such a payment could improve care for patients and decrease the cost of providing that care.
According to Stream, the AAFP is willing to partner with CMS to develop standards for furnishing CCCM services "to ensure that the physicians who bill for these services have the capability to provide them."
Furthermore, the AAFP advised CMS against requiring practices that provide CCCM services to employ an advanced practice registered nurse or a physician assistant. Such a requirement, said Stream, "would deter small and rural practices from offering CCCM services."
In addition, the AAFP urged CMS, in the long term, to expand the Comprehensive Primary Care Initiative (CPCI) approach and pay a risk-adjusted care-management fee for all Medicare beneficiaries as part of a blended-payment model for care provided in a PCMH. "The AAFP believes all Medicare patients can benefit from care management, not just those with complex and multiple chronic conditions," said Stream.
The AAFP also asked CMS to reconsider a capitated monthly payment for primary care management services. "We believe it would be simpler and more efficient that CMS pays for care management on a per-member, per-month basis, as is done under CPCI," said Stream.
In addition, Stream voiced concern about CMS' proposal to create separate "G" codes for CCCM services and encouraged the agency to work with the appropriate groups to revise existing CPT codes that relate to CCCM services so primary care physicians can use CPT codes to bill for such services beginning in 2015.
Finally, Stream urged CMS to consider CCCM services within a 30-day period rather than the proposed 90-day period.
Evaluation and Management Codes
Stream also reiterated the AAFP's concern that current evaluation and management (E/M) codes are not adequate for primary care. "The complexity of the ambulatory evaluation and management services that primary care physicians must 'fit' into the time available for the typical patient visit is sufficiently distinct to merit dedicated codes and higher relative values than are currently assigned to existing office or other outpatient E/M codes," said Stream.
Furthermore, "CMS needs to create dedicated codes for primary care services provided by primary care physicians," said Stream.
He called on CMS to create, as part of the 2014 fee schedule, separate primary care E/M Healthcare Common Procedure Coding Systems codes with correspondingly higher relative values for office or other outpatient services provided to new and established patients.
"While we are disappointed that CMS did not propose these codes within the 2014 rule-making cycle, we also recognize the concept is relatively new and perhaps challenging for CMS to implement through existing regulations and within a fee-for-service payment system," said Stream.
"We stand willing to work with the agency and other stakeholders to develop payment for separate primary care E/M codes," he added.
Physician Quality Reporting System
Regarding physicians' participation in the Physician Quality Reporting System (PQRS), Stream took issue with CMS' recommendation to increase the number of measures that must be reported from three measures to nine.
"The AAFP remains concerned that the burden of reporting multiple quality measures too often falls disproportionately on primary care physicians," said Stream. "Many subspecialists, for whom fewer than nine measures will apply, will not be subject to the same reporting burdens as primary care physicians, who consistently have more reportable measures."
Stream pointed out that given the longstanding payment disparities in the Medicare physician payment system, "the PQRS incentive payment that primary care physicians might receive will continue to be significantly less than that for which subspecialists are eligible."
"CMS is asking primary care physicians to report more measures for less incentive," said Stream. "The AAFP considers this unfair and harmful to primary care."
Stream strongly urged CMS to "explore policies that equalize reporting burdens and incentives across specialties."
Additional Issues Pertinent to Primary Care
The AAFP's letter to CMS covered a great deal of territory. In addition to the above-mentioned items, Stream addressed a variety of other issues, including
- support for efforts to adjust relative value unit amounts for procedures to pay more accurately for services;
- recognition of steps taken to identify and address potentially inappropriately valued CPT codes;
- advocacy for the elimination of all geographic adjustment factors from the fee schedule, except for those designed to achieve a specific public policy goal;
- support for expanded coverage and access to colorectal cancer screening by allowing nonphysician health professionals to order screening fecal occult blood tests with the direct supervision of a licensed physician; and
- concern about Meaningful Use stage two expectations.
Stream also commended CMS for making improvements to its Physician Compare website(www.medicare.gov) -- a site required by the Patient Protection and Affordable Care Act -- but asked CMS to extend the physician preview period from 30 days to a 45- or 60-day preview window.
CMS intends to expand the website beyond basic practice information to include quality measures from a variety of sources. However, Stream pointed out that on a website created for non-clinicians, PQRS quality performance information would likely be incomprehensible to the typical consumer.
He suggested that CMS "develop a method to aggregate performance on these measures into one or more composite scores that could be easily translated into consumer-friendly terms." For example, Dr. Jones scored 4.5 on preventive care, where "1" indicates poor performance and "5" is excellent.
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