Wednesday, September 9, 2015

ACP to Medicare: Pay internists better!

This is, in a nutshell, what ACP told the Center for Medicare and Medicaid Services (CMS) in a 47-page comment letter on the agency’s proposed rule for the 2016 Medicare Physician Fee Schedule.  Of course, it wouldn’t be effective for ACP to just say that its members should be paid more; we would have to show the agency why (the value to patients) and how (what changes specifically need to be made) to improve Medicare payment policies.

Among its many recommendations, ACP:

- Called on CMS to expand the Comprehensive Primary Care (CPC) Initiative both to additional geographic regions, as well as in existing CPC initiative areas.  The CPC initiative, a Medicare-funded pilot test of the impact of advanced Patient-Centered Medical Homes on quality and cost of care, is currently limited to approximately 500 practices in 7 market areas.  These practices are receiving a risk-adjusted average of $20 per Medicare patient per month, in addition to their usual Medicare fee-for-service payments, and they have the opportunity to share in savings to the program if they can reduce costs while maintaining or improving quality. The College believes that there is sufficient evidence of its effectiveness in improving quality and/or achieving savings to support making it widely available to beneficiaries and practices across the country.  ACP recommended that CMS seek out agreements with other payers in additional regions of the country to join with Medicare to support practices that wish to participate in the CPC initiative, and to open up participation to more practices in the current CPC initiative regions.

- Supported CMS’s proposal to allow Medicare reimbursement for advance care planning services. While this proposal is an important step to improve care for Medicare patients with serious illness, ACP urged that reimbursement for advance care planning be made uniformly available to all physicians and their Medicare patients through a national coverage determination, rather than leaving it to each regional Medicare carrier to decide whether to cover the service.

- Urged CMS to reduce barriers to physicians getting reimbursed for the Chronic Care Management (CCM) Code and allow reimbursement for CCM services that require additional time.  ACP recommended that CMS develop add-on codes for time increments greater than 20 minutes such as 21-40 min; 41-60 min; and greater than 1 hour.  ACP also recommends that the electronic care plan sharing requirement for providing the CCM service be suspended until the time that EHRs have the ability to support such capabilities.

- Encouraged CMS to use payment approaches that are aligned with the goal of moving payments away from volume to value-based care such as by exploring bundling of codes for certain chronic diseases. More specifically, ACP recommended that a code bundle for Diabetic Care Management (DCM) be developed to emphasize better care coordination, communication, and integration of the care team aimed at a better overall outcome cost of care for the Medicare beneficiary.

- Supported CMS’ recognition of the need to value the delivery of behavioral health services within the Physician Fee Schedule.  ACP recommended that the “collaborative care” model described in the proposed rule be implemented through a Center for Medicare and Medicaid Innovation (CMMI) demonstration and be rapidly expanded within Medicare through the Secretary’s authority based upon the results of this demonstration.

- Recommended that CMS investigate the adequacy of payment for physician services that typically take place outside of a face-to-face patient encounter. The College urged CMS to recognize non-face-to-face services-- such as telephone and email consultations-- that facilitate care coordination by internists and other primary care physicians.

ACP ‘s letter also offered comments on:

- Additional specific coding issues, such as Practice Expense (PE) determination, moderate sedation valuation, and surgical global periods.
- Physician Quality Reporting System (PQRS)
- The Value-Based Payment Modifier and Physician Feedback Program
- Physician Compare
- The Medicare Shared Savings Program (MSSP)
- Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging Services
- CMS’s request for comments on issues relating to the  Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) implementation

ACP’s comments were the result of countless hours of analysis by the College’s regulatory affairs staff, and from the volunteer physician leadership on its Coding and Payment Policy Subcommittee, Medical Practice and Quality Committee, Subspecialty Advisory Group on Socioeconomic Affairs, and the ACP representatives to the RVS Update Committee (RUC).

So when someone says the College doesn’t do anything to advocate for its members, or that we care “only” about the big and controversial policy issues like immigration and health, reducing harm from firearms, and LGBT healthcare disparities, it just isn’t so.  While we do care deeply about -- and are proud of our advocacy on -- issues that directly affect individual and population health, we devote at least as much of our advocacy resources and staff to improving the economic and regulatory environment for our members—proudly and justifiably so!

Today’s questions: What do you think of ACP’s recommendations to improve Medicare payments for internists’ services?  What would you recommend?


southern doc said...

" Encouraged CMS to use payment approaches that are aligned with the goal of moving payments away from volume to value-based care such as by exploring bundling of codes for certain chronic diseases."


Seems like ACP has come up with a bunch of proposals to increase the administrative burden on physicians, for which any payments received will completely fail to cover increased overhead. For example, why expand the PCMH programs when practices that aren't massively subsidized find it a financial boondoggle?

Nothing new here.

Jay Larson MD said...

Simple fix...cut procedure RVUs by 50% and increase E and M RVUs by 50%

Am said...

We need a MASSIVE OVERHAUL to the payment structure in this country.Some suggestions-

1.Increase reimbursement for E &M codes with an escalating payment for number of problems addressed in the visit, which will be documented in the progress note

2.Cut down procedures/ surgeries reimbursement by 50 %

3.Limit Medicare payments to hospitals with high administrative costs/ salaries. The doctors / mid levels are working harder to provide an ever increasing number of administrators an ever increasing amount of salary and bonus. If that cannot be done, demand the administrative cost cannot be more than 10 -20 %

Harrison said...

Did you know that Lifeline, that company that for years has offered generally benign although not indicated ultrsound screening exams is now hiring NP's to do annual Medicare Wellness Exams?

And once they do this, with the patients not really being aware of what they are signing up for, the Medicare Annual Exam charge for the year is done and the PCP cannot do it.

Did you know that?

How is that not theft and fraud?
I know it is not but it sure feels like it.

I have had GYN physicians bill this, and they think they are legitimate in doing so, although they really have not included all of the elements or really even any of the elements in their notes.... but at least they are an ongoing physician with whom the patient feels an allegiance.

This is a company famous for doing unnecessary screening, now taking advantage of another revenue stream, and probably doing so by interfering with a visit that would benefit the patient more if done by the PCP.


PCP said...

Harrison, just get used to taking the crumbs left over after everyone else(services needed or not) has feasted on medicare.
Its just what you do as a PCP nowadays. I'm not one bit surprised that this is happening. He who has the lobby gets the rules written to favor him/her.
Aren't you at all concerned about the racket where 'providers' are coached and paid well to see patients often at home and document so that they have higher RAF scores so medicare advantage can get paid a higher rate by CMS? Shouldn't that be the sole proviso of the PCP? What about the fragmentation of immunization records, acute care v chronic care etc etc.
There is so much that has gone wrong with primary care over the years, and arguably it has accelerated over the past 7 yrs since i left the field, and yet our lobby has time on its hands for its particular brand of social advocacy.
Well, you will see a lot more of this going forward, get used to it.

southern doc said...

New study puts the cost of sustaining, not establishing, a PCMH at more than 100K per provider per year, set against a potential increase in revenue of 27k. Do the math.

Internists want to be paid fairly for the work ALREADY BEING DONE, but all
you have given is a list of yet more clerical chores that will further reduce income.

You are the enemy.