Earlier this summer, CMS released its proposed 2017 Medicare physician fee schedule that subsequently was published(www.gpo.gov) in the July 15 Federal Register.
And now, a little more than one month later, the AAFP has responded to CMS Acting Administrator Andy Slavitt's request for comments by providing great detail about what the Academy likes in the proposal -- and which topics must revisited.
AAFP Board Chair Robert Wergin, M.D., of Milford, Neb., began the Aug. 19 letter(56 page PDF) on a high note by recognizing CMS' multiyear effort "to both prioritize and promote primary care as foundational to the Medicare program."
He stressed how important it is that CMS and private payers invest in primary care and noted that, based on the rule's content, CMS was making a commitment to improving payments for family physicians.
- The AAFP is calling for a number of revisions in the 2017 proposed Medicare physician fee schedule but also commended CMS for boosting primary care payment.
- AAFP Board Chair Robert Wergin, M.D., notes that proposals in the schedule are estimated to boost funding to primary care physicians by an additional $900 million.
- Examples of revisions needed include rewriting content on care management and patient-centered services, appropriate use criteria, telehealth services, Medicare Advantage provider enrollment, and the Diabetes Prevention Program model.
"Proposed changes are estimated to result in approximately $900 million in additional funding to primary care physicians," said Wergin.
"By better valuing primary care and care coordination, CMS is helping improve Medicare beneficiaries' access to services they need to stay well," he added. At the same time, CMS recognizes that "patients are better served when people have a team of health care professionals led by a primary care physician managing and coordinating their care."
What follows is a sampling of the Academy's recommendations to Slavitt on how to improve the payment schedule in 2017 to achieve even greater success in supporting family physicians and their patients.
Care Management, Patient-Centered Services
The AAFP applauded CMS' proposals that would increase payments to family physicians on several fronts, including plans to
- improve payment for care management services provided to beneficiaries with behavioral health conditions;
- improve payment for cognitive and functional assessment, as well as care planning for patients with cognitive impairment;
- adjust payment for routine visits provided to patients whose care requires additional resources to accommodate mobility-related disabilities;
- recognize additional CPT codes within the chronic care management (CCM) family;
- adjust payment for visits during which CCM services are initiated;
- recognize CPT codes for nonface-to-face prolonged evaluation and management (E/M) services that currently are bundled; and
- increase payment rates for face-to-face prolonged E/M services.
Wergin called the proposals "another step in the right direction."
He asked for clarification from CMS on behavioral health integration codes, particularly the proposed code for care management services for behavioral health conditions.
Wergin also noted his displeasure with an omission in the proposed rule -- namely, the lack of any plan to improve the value and effectiveness of Medicare's annual wellness visit (AWV). He reiterated a message relayed to CMS on multiple occasions regarding "strong concern about the potential misuse of the AWV by commercial, nonphysician entities."
"Patients may be precluded from AWV benefits due to commercial entities that often have no prior relationship with the patient and have no intention of caring for the patient after the AWV is done," said Wergin. He suggested that, at a minimum, CMS require that anyone doing an AWV send the results of that visit to the patient's primary care physician or usual source of care.
CMS also needs to provide a way for physicians to "determine whether or not Medicare has already paid for an AWV for the patient in the past 12 months," said Wergin.
Appropriate Use Criteria
CMS listed in the proposed rule eight clinical areas that accounted for about 40 percent of Medicare Part B advanced diagnostic imaging services Medicare paid for in 2014. Those areas were chest pain, abdominal pain, traumatic and nontraumatic headache, low back pain, suspected stroke, altered mental status, lung cancer, and cervical or neck pain.
The 2017 proposed rule focuses on Medicare appropriate use criteria (AUC), including those for the priority areas listed above, as well as clinical decision-support mechanism (CDSM) requirements, the CDSM application process and exceptions for physicians and other health professionals for whom consultation with AUC would pose a significant hardship.
Noting that CDSMs are the electronic tools clinicians use when consulting AUC to determine the level of clinical appropriateness for an advanced diagnostic imaging service for a particular patient's clinical scenario, Wergin commented on CMS' estimate that physicians would begin AUC reporting via qualified CDSMs on Jan. 1, 2018.
"The AAFP has ongoing, significant concerns about the disproportional burden primary care physicians will face when trying to comply with AUC requirements," said Wergin, noting that the requirements would "add an unnecessary level of complexity to the already complex Medicare system that severely overtaxes our members."
Wergin suggested that CMS greatly overestimated the level of health IT interoperability that would be in place when AUC requirements go into effect and added that new value-based payment requirements were already stretching physicians to the limit.
The AAFP "strongly urges CMS to delay the implementation of this program so that AUC would be aligned with the forthcoming MIPS (Merit-based Incentive Payment System) program in 2019 versus being introduced as a stand-alone program," said Wergin.
As telehealth services have a grown in popularity, so has the piling on of conditions that must be met for Medicare to pay for these services.
The AAFP has long supported telehealth services, in part because a good many family physicians practice in rural -- and sometimes remote -- areas across the country, where access to these services helps ensure their patients receive the quality health care services they deserve.
"In light of the growing amount of evidence suggesting the effectiveness of various forms of telehealth services, the AAFP supports revisions to policies that create unnecessary barriers to the responsible and appropriate use of telemedicine services," said Wergin.
He took issue with CMS' proposed stipulation that a patient receiving telehealth services "must be located in a telehealth-origination site," arguing that use of asynchronous store-and-forward technology should be acceptable and reimbursable.
"Synchronous versus asynchronous should not define whether or not a medical service was provided," Wergin asserted.
He applauded CMS' inclusion of CPT codes 99497 and 99498 related to advance care planning but firmly resisted CMS' denial of codes associated with observation visits.
"A physician is capable of assessing a patient's physical condition in an observational setting and determining an appropriate course of treatment via telemedicine routes of delivery. With the physician shortage issues and increasing lack of ideal access to care that can occur in any geographic region -- most especially in rural areas -- it is important that these services be allowed," said Wergin.
He also pushed back on CMS' plan to deny a trio of CPT codes (99281, 99282 and 99283) related to managing emergency department patients via telehealth services.
Medicare Advantage Provider Enrollment
Wergin took advantage of the opportunity to reiterate the Academy's concerns about Medicare Advantage network adequacy.
He pointed to a requirement in the proposed rule that physicians be screened and enrolled in Medicare before contracting with a Medicare Advantage organization and noted physicians who had their Medicare enrollment revoked would be barred from participation.
"Reducing the number of physicians participating in these networks could create access problems for patients," said Wergin. He disagreed with the formula used by CMS to determine network adequacy and, in particular, the "physician-to-covered-persons ratio analysis that does not appear to assess the full-time equivalent status of those physicians."
Wergin noted that physicians frequently practice part time in multiple locations, thereby distorting that ratio. Bottom line, "CMS must ensure that family physicians are appropriately represented in Medicare Advantage provider networks," said Wergin.
In addition, physicians should have 90 days to appeal placement in an "unapproved status," and patients should be given adequate time to find another primary care physician. And if Medicare terminates a Medicare Advantage organization's contract, patients should be allowed to "continue with their physicians on an in-network basis until the next enrollment period," he added.
Diabetes Prevention Model
Lastly, the AAFP "fully supports" CMS' proposed expansion of the Diabetes Prevention Program, said Wergin. The model, described as a structured lifestyle intervention, includes dietary coaching, lifestyle intervention and moderate physical activity. The end goal is to prevent the onset of diabetes in patients with prediabetes.
Wergin commended CMS for its intention to designate the program as a preventive service available under Medicare Part B because doing so would allow Medicare patients to utilize the service without a copay.
However, Wergin expressed concern that, as outlined in the proposed rule, beneficiaries could enroll in the program only once.
"Even a modest amount of weight loss improves health outcomes," argued Wergin, and he urged CMS to give beneficiaries who failed the program once an opportunity to try it again.
Related AAFP News Coverage
Proposed Medicare Fee Schedule Emphasizes Primary Care's Value
AAFP Summarizes Elements Critical to Family Physicians
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Summary of the 2017 Proposed Medicare Physician Fee Schedule(13 page PDF)