Medicare Physician Payment

AAFP Chides CMS for Missed Opportunities in 2016 Fee Schedule

January 12, 2016 06:19 pm News Staff

The AAFP exited 2015 by making a few final comments to CMS regarding how the agency will reimburse physicians in 2016.

[Male physician touching virtual button on the virtual screen with numbers 2016]

In a Dec. 24 letter(3 page PDF) to CMS Acting Administrator Andy Slavitt relating the Academy's views on the 2016 Medicare physician fee schedule(, AAFP Board Chair Robert Wergin, M.D., of Milford, Neb., noted his extreme disappointment that CMS was "unable or unwilling to identify the full 1.0 percent reduction in relative value units (RVUs) required in 2016."

He noted that CMS was required by two separate laws passed in 2014 -- the Protecting Access to Medicare Act (PAMA) and the Achieving a Better Life Experience Act (ABLE) -- to meet targets for net reductions in fee schedule expenditures associated with misvalued services.

Those reductions were defined as 1.0 percent in 2016 and 0.5 percent in both 2017 and 2018.

Story Highlights
  • In an end-of-the-year letter to CMS, the AAFP admonished the agency for missed opportunities in the 2016 Medicare physician fee schedule.
  • The Academy expressed frustration that CMS was unable or unwilling to identify a full 1 percent reduction in relative value units.
  • Failure to meet that target required a corresponding downward adjustment in the conversion factor that affected all physicians, but the AAFP argued that primary care should have been excluded.

"Failure to meet a given target requires a corresponding downward adjustment in the conversion factor," Wergin noted. He reiterated that the agency was only able to identify 0.23 percent of the mandated target for 2016 and called CMS' inability to identify sufficient overvalued codes "inconceivable."

"CMS is, in essence, saying that codes comprising 99.77 percent of Medicare physician fee schedule payments are not overvalued. We do not believe that claim," said Wergin.

He reminded Slavitt of an existing list of CPT codes that potentially are misvalued given that the AMA/Specialty Society Relative Value Scale Update Committee regularly identifies and reviews problematic codes.

"CMS should have taken the initiative to explore adjustments to the RVUs for these codes rather than reduce all physician payments by 0.77 percent due to PAMA and ABLE requirements," Wergin chastened the agency, especially since physicians were expecting a 0.5 percent increase in the Medicare conversion factor.

"For a variety of reasons, payments to primary care services have repeatedly suffered under the Medicare physician fee schedule," said Wergin. And so when CMS applied the 2016 target recapture amount to all physician services, "it made the disparity in primary care payment even more pronounced," he noted.

Primary care services should be been spared, Wergin admonished -- especially patient care covered by evaluation and management codes, annual wellness visits, transitional care management services, chronic care management services and the new advance care planning codes.

CMS has "consistently undervalued" the care that primary care physicians provide to their patients, said Wergin, and, therefore, the agency must prevent future reductions in payment for these specific physicians in 2016 and beyond.

On a more positive note, Wergin pointed to CMS' authority to adjust codes so physicians are paid more appropriately for the services they provide to Medicare patients.

To that end, the AAFP encouraged CMS to

  • gather the information it needs to accurately value surgical services from a representative sample of physicians because "the current global surgical packages are incompatible with current practice and provide unreliable building blocks for new payment methodologies";
  • establish coverage and payment for advance care planning services beginning in 2016 and thereby prevent "inconsistent local interpretations"; and
  • specify that annual wellness visits are primarily the responsibility of patients and physicians, and as such, the billing physician or other health care professional should manage the ongoing provision of such services to the patient in addition to providing a minimum of direct supervision.

"Such requirements for the annual wellness visit are consistent with the tenets of continuity of care," which allows the patient and the physician to be partners in management of the patient's care, said Wergin.

Furthermore, Wergin concluded, "Continuity of care is rooted in a long-term patient-physician partnership in which the physician knows the patient's history from experience and can integrate new information, such as that obtained from an annual wellness visit, and decisions from a whole-patient perspective."

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AAFP Expends Huge Effort to Shape New Payment System


No Pay Raise in 2016, but Shift to Value-based Pay Continues
AAFP Blasts CMS' Broken Promise of Positive Update in Fee Schedule


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