(This story was updated July 9.)
In a draft of Medicare's first physician payment rule since Congress scrapped the sustainable growth-rate formula, the CMS proposes paying for end-of-life counseling and revises several quality-incentive programs that will be rolled into a new comprehensive program in 2019.
The proposed changes to the 2016 Medicare physician fee schedule (PDF) includes a provision activating two new advance care-planning codes and assigning them value. These codes would be used to pay for a provider's time discussing patient choices for advance directives and completing necessary forms. One code would cover the first 30 minutes and the other would cover any additional 30-minute blocks that are needed.
The activation of the code “does not mean that Medicare has made a national coverage determination regarding the service,” the agency said in the rule. “Contractors remain responsible for local coverage decisions in the absence of a national Medicare policy.”
The CMS is also considering making advance care planning “an optional element” of a beneficiary's annual wellness visit.
The American Medical Association's CPT Editorial Panel developed the codes, and its Specialty Society Relative Value Scale Update Committee, better known as the RUC, developed values for those codes. The CMS wrote that it is proposing to adopt the RUC-recommended values beginning Jan. 1, 2016, and will “consider all public comments” it receives. The proposed fee schedule did not include the RUC-recommended payments for these codes and the CMS emphasized that it was not setting a value at this time.
The RUC scores codes with relative value units (RVUs), which calculate the work involved, the expense to the practice and a malpractice expense for a particular service. Using data taken from 273 physician interviews, the RUC calculated that the first 30-minute encounter for advance care planning was worth 1.5 RVUs and that the subsequent 30-minute blocks were worth 1.4 RVUs.
The committee concluded the underlying medical issues would be of moderate to high severity and that 25 minutes would be spent face-to-face with patients and their families, with 10 minutes of post-service time and five minutes of pre-service preparation.
"This is a patient-centered policy intended to support a careful planning process that is assisted by a physician or other qualified healthcare professional," AMA President-elect Dr. Andrew Gurman said in a statement praising the proposed policy. "This issue has been mischaracterized in the past and it is time to facilitate patient choices about advance care planning decisions."
Other provider and advocacy organizations also quickly praised the proposal.
“Patients deserve assistance with advance care planning and it's essential that these conversations take place before a crisis happens,” Donald Schumacher, president and CEO of the National Hospice and Palliative Care Organization, said in a news release.
The American Academy of Family Physicians also quickly endorsed the proposal to pay physicians for advance care planning.
“Helping families understand the medical underpinnings for such decisions requires deliberate conversations based on the family physician's expertise,” AAFP President Dr. Robert Wergin said in a news release. “This service is a vital part of medical care that merits compensation, and we look forward to working with CMS to ensure inclusion in the physician fee schedule.”
As required by the Medicare Access and CHIP Reauthorization Act of 2015, the law that eliminated the SGR, physicians will get a modest payment increase of 0.5% this year. That increase and other provisions mean Medicare will pay physicians and other clinicians $670 million more than in 2015. Beneficiaries are expected to see a $100 million reduction in out-of-pocket costs as a result of the proposed changes to the fee schedule.
The CMS also intends to make several tweaks to Medicare's telehealth policy, including payments for in-home treatments for end-stage renal disease. The agency stressed, however, that clinical examination of the catheter-access site must be done “hands-on” by a doctor, certified nurse specialist, nurse practitioner or physician assistant.
The CMS rejected requests to pay for telehealth evaluation and management, tele-rehabilitation services, palliative care, pain management and patient-navigation services for cancer patients. Certified registered nurses anesthetists would be added to Medicare's list of qualified telehealth providers for certain services—including evaluation and management.
Another provision would make federally qualified health centers and rural health clinics eligible to get paid for providing chronic-care management, which Medicare established for other providers in 2015.
The CMS is also seeking comments on how to better pay for collaborative care consultations between primary-care doctors and specialists requiring “extensive discussion, information-sharing and planning.”
While per-patient per-month fees for such services may become more common under accountable care or medical home-type arrangements, the CMS noted, establishing proper payment for these services in a fee-for-service world has not yet been established.
The draft rule would make a variety of changes to the Physician Quality Reporting System, the incentive program for the meaningful use of electronic health records and the value-based payment modifier, all of which are slated to become components of the new Merit-based Incentive Payment System. It also proposes several new components the CMS plans to add to Medicare's Physician Compare website, including a green check mark next to the name of providers who received an upward adjustment for cost and quality.
The CMS solicits feedback in the rule on whether to expand the Comprehensive Primary Care Initiative. The program, administered by the CMS Innovation Center, is testing the clinical benefits and financial sustainability of medical-home practices that provide enhanced patient access and continuity of care, planned chronic and preventive care, risk-stratified care management, patient and caregiver engagement, and coordination of care across a “medical neighborhood.”
The CMS is accepting public comments on the proposed rule until Sept. 8.