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Medicare fee schedule: Proposed pay bump falls short of promise


 

 

Physicians will likely see a 0.31% uptick in their Medicare payments in 2018 and not the 0.5% promised in the Medicare Access and CHIP Reauthorization Act.

Officials at the Centers for Medicare & Medicaid Services were not able to find adequate funding in so-called misvalued codes to support the larger increase, as required by law, according to the proposed Medicare physician fee schedule for 2018.

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CMS also failed to hit its misvalued code target in 2016, resulting in a 0.18% across-the-board reduction to the physician fee schedule in 2017 instead of the statutorily promised 0.5% increase.

Other provisions in the proposed Medicare physician fee schedule may be more palatable than the petite pay raise.

The proposal would roll back data reporting requirements of the Physician Quality Reporting System (PQRS), to better align them with the new Quality Payment Program (QPP), and will waive half of penalties assessed for not meeting PQRS requirements in 2016.

“We are proposing these changes based on stakeholder feedback and to better align with the MIPS [Merit-based Incentive Payment System track of the QPP] data submission requirements for the quality performance category,” according to a CMS fact sheet on the proposed fee schedule.

“This will allow some physicians who attempted to report for the 2016 performance period to avoid penalties and better align PQRS with MIPS as physicians transition to QPP,” officials from the American College of Physicians said in a statement.

Other physician organizations said they believed the proposal did not go far enough.

“While the reductions in penalties represent a move in the right direction, the [American College of Rheumatology] believes CMS should establish a value modifier adjustment of zero for 2018,” ACR officials said in a statement. “This would align with the agency’s policy to ‘zero out’ the impact of the resource use component of the Merit-based Incentive Payment System in 2019, the successor to the value modifier program. This provides additional time to continue refining the cost measures and gives physicians more time to understand the program.”

The proposed fee schedule also would delay implementation of the appropriate use criteria (AUC) for imaging services, a program that would deny payments for imaging services unless the ordering physician consulted the appropriate use criteria.

The American Medical Association “appreciates CMS’ decision to postpone the implementation of this requirement until 2019 and to make the first year an opportunity for testing and education where consultation would not be required as a condition of payment for imaging services,” according to a statement.

“We also applaud the proposed delay in implementing AUC for diagnostic imaging studies,” ACR said in its statement. “We will be gauging the readiness of our members to use clinical support systems. ... We support simplifying and phasing-in the program requirements. The ACR also strongly supports larger exemptions to the program,” such as physicians in small groups and rural and underserved areas.

The proposed fee schedule also seeks feedback from physicians and organizations on how Medicare Part B pays for biosimilars. Under the 2016 fee schedule, the average sales prices (ASPs) for all biosimilar products assigned to the same reference product are included in the same CPT code, meaning the ASPs for all biosimilars of a common reference product are used to determine a single reimbursement rate.

That CMS is looking deeper at this is being seen as a plus.

Biosimilars “tied to the same reference product may not share all indications with one another or the reference product [and] a blended payment model may cause significant confusion in a multitiered biosimilars market that may include both interchangeable and noninterchangeable products,” the Biosimilars Forum said in a statement.

The current situation “may lead to decreased physician confidence in how they are reimbursed and also dramatically reduce the investment in the development of biosimilars and thereby limit treatment options available to patients.”

Both the Biosimilars Forum and the ACR support unique codes for each biosimilar.

“Physicians can better track and monitor their effectiveness and ensure adequate pharmacovigilance in the area of biosimilars” by employing unique codes, according to ACR officials.

“AGA agrees that there should be separate, unique codes for biosimilars; however, we have additional concerns regarding gastroenterological disorders. Specifically, inflammatory bowel disease (IBD) carries unique risks with regard to immunogenicity and currently there is a paucity of clinical data for biosimilars in people with IBD. Real-world use is often the first experience in IBD for these products.”

The fee schedule proposal also would expand the Medicare Diabetes Prevention Program (DPP), currently a demonstration project, taking it nationwide in 2018. The proposal outlines the payment structure and supplier enrollment requirements and compliance standards, as well as beneficiary engagement incentives.

Physicians would be paid based on performance goals being met by patients, including meeting certain numbers of service and maintenance sessions with the program as well as achieving specific weight loss goals. For beneficiaries who are able to lose at least 5% of body weight, physicians could receive up to $810. If that weight loss goal is not achieved, the most a physician could receive is $125, according to a CMS fact sheet. Currently, DPP can be employed only via office visit; however, the proposal would allow virtual make-up sessions.

“The new proposal provides more flexibility to DPP providers in supporting patient engagement and attendance and by making performance-based payments available if patients meet weight-loss targets over longer periods of time,” according to the AMA.

The fee schedule also proposes more telemedicine coverage, specifically for counseling to discuss the need for lung cancer screening, including eligibility determination and shared decision making, as well psychotherapy for crisis, with codes for the first 60 minutes of intervention and a separate code for each additional 30 minutes. Four add-on codes have been proposed to supplement existing codes that cover interactive complexity, chronic care management services, and health risk assessment.

For clinicians providing behavioral health services, CMS is proposing an increased payment for providing face-to-face office-based services that better reflects overhead expenses.

The final rule is expected in early November.
 

gtwachtman@frontlinemedcom.com

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