Physicians cheered and jeered parts of a lengthy final rule (PDF) the CMS issued last week that includes Medicare's 2015 physician fee schedule and also revises the agency's policies on telehealth and paying different rates for the same service depending on where it was delivered.
Looming over all of it, however, was the potential that physician payments will be subject to a 21.2% cut driven by Medicare's sustainable growth-rate payment formula on April 1 unless Congress intervenes.
The rule was released last Friday evening, and Anders Gilberg, the Medical Group Management Association's senior vice president for government affairs, said he was handing out Halloween candy when he received his first call about the rule.
“We're still looking through it,” Gilberg said this week, but he noted that the creation of a monthly care-management fee for patients with two or more chronic conditions is one of the highlights of the rule.
The CMS set the fee at $42.60, according to a fact sheet on the rule, and backed away from a previously proposed requirement that only physicians using 2014 edition-certified software would be able to collect the fee. The final rule allows doctors using 2011 edition EHRs to collect the fee as well.
Physician groups are commending the CMS for rewarding care coordination, but they're also expressing concern that administrative burdens associated with documenting non-face-to-face management services could outweigh the benefits of the new payment. Shari Erickson, vice president of governmental affairs and medical practice for the American College of Physicians, said the internal medicine specialty society believes the care-coordination fee should be higher “given the level of work involved.”
Specifically, the rule calls for paying for “clinical staff time directed by a physician or other qualified healthcare professional, per calendar month, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; comprehensive-care plan established, implemented, revised, or monitored.”
Karen Ferguson, senior director of public policy for the American Medical Group Association, said the organization plans to survey its members in 2015 to see if they are using the new chronic care-management codes or if the requirements for doing so “have proven to be too onerous.”
The CMS noted that it would be doing some monitoring of its own. “We intend to evaluate this service closely to assess whether the service is targeted to the right population and whether the payment is appropriate for the services being furnished,” the agency stated in the rule.
The agency also clarified that the 481 practices participating in the CMS Comprehensive Primary Care Initiative would not be eligible for the care-management fee because they already receive a per-member, per-month fee for similar service as part the federal government's mega medical home demonstration.
The rule also set a fee of $56.92 for remote monitoring of patients with chronic conditions and issued new payments for annual wellness visits and psychotherapy (including family sessions) delivered via telehealth.
“It has been a long time coming, but this rulemaking signals a clear and bold step in the right direction for Medicare,” Jonathan Linkous, CEO of the American Telemedicine Association, said in a news release.
To the relief of specialists, the CMS announced maintaining current payments for gastroenterological procedures and for hip- and knee-replacement surgeries, which were the subject of sharp price reductions in the recent fee schedules.
The MGMA's Gilberg, however, questioned the CMS plan to phase out bundled 10-day and 90-day global payments for post-surgical services and to have separate billing for different services such as treating complications, managing pain, and removing sutures and staples, lines, wires, tubes, drains, casts, and splints. “It's a strange step in the opposite direction toward bundled payments that CMS had been taking,” Gilberg said.
The agency acknowledged this concern in the rule but said that there are “fundamental difficulties” in establishing appropriate values for global payments for post-surgical care and a “potential to create unwarranted payment differentials among specialties.”
The CMS also took action on the Medicare Payment Advisory Commission's recommendation for site-neutral reimbursement for similar services delivered in different settings. MedPAC wants to make rates the same whether the patient is seen in a hospital or a physician's office.
The CMS plans to study the issue by creating new codes designating whether services were provided off or on a hospital campus so it can examine the trends in Medicare payment and beneficiaries' cost-sharing as hospitals acquire physician practices and bill services they deliver as hospital-based outpatient care.
Gilberg noted that the issue has gained some steam because the concept of site-neutrality payments has been floated as a method for paying for the repeal of the sustainable growth-rate formula. While the CMS plan to study the issue has merit, Gilberg said Congress needs to seize the opportunity to repeal the SGR during the upcoming post-election “lame-duck” session that takes place before new members are seated in January.
The MGMA has advocated for putting back in play a bipartisan, bicameral bill to replace the SGR that appeared headed for passage this past spring before disagreements over how to cover the $138 billion cost killed the measure last March.
Gilberg said it's unlikely a new Congress will be able to come up with new legislation before cuts take effect April 1, so he said it would be politically expedient for the Republicans to get something passed this year. If they wait, Gilberg said, Republicans “will own this issue lock, stock and barrel.”
Follow Andis Robeznieks on Twitter: @MHARobeznieks