CMS Issues Payment Increase Proposed Rule For Primary Care Providers

Posted on by Frank J. Rosello

The Centers for Medicare & Medicaid Services (CMS) is sending some sunshine in the direction of primary care providers. In a proposed rule issued July 6, CMS is offering payment increases for family physicians and other primary care providers as well as proposals to better pay for the range of care primary care providers give patients.

The payment increase to primary care providers – approximately 7 percent for family physicians and 3 to 5 percent for other practitioners – is part of the proposed rule that would update payment policies and rates under the Medicare Physician Fee Schedule (MPFS) for calendar year (CY) 2013. Under the MPFS, Medicare pays more than 1 million physicians and non-physician practitioners who provide vital health services to Medicare beneficiaries.

“Helping primary care doctors will help improve patient care and lower healthcare costs long term,” said CMS Acting Administrator Marilyn B. Tavenner in a prepared statement.

CMS noted that it is proposing for the first time to “explicitly pay for the care required to help a patient transition back to the community following a discharge from a hospital or nursing facility.” Under the proposed rule, CMS would make a separate payment to a patient’s community physician or practitioner to coordinate the patient’s care in the 30 days following a hospital or skilled nursing facility stay.

The proposed rule also asks for public comment on how Medicare can better recognize the range of services community physicians and practitioners provide as part of treating patients either through face-to-face services in the office or coordinating care outside the office when the patient does not see the physician.

As has been the case every year since CY 2002, CMS projects a significant reduction in MPFS payment rates under the sustainable growth rate (SGR) methodology due to the expiration of the adjustment made for CY 2012 in the statute. For CY 2013, CMS projects a reduction of 27 percent and is required by law to include this reduction in these calculations. However, Congress has acted to avert the cuts every year since 2003. CMS said the Obama administration is “committed to fixing the SGR formula in a fiscally responsible way.”

The proposed rule would also continue the implementation of the physician value-based payment modifier (value modifier) that was included in the Affordable Care Act by providing choices to physicians regarding how to participate. The value modifier adjusts payments to individual physicians or groups of physicians based on the quality of care furnished to Medicare beneficiaries compared to costs. The law allows CMS to phase in the value modifier over three years from CY 2015 to CY 2017.

For the CY 2015 physician payment rates, the proposed rule would apply the value modifier to all groups of physicians with 25 or more eligible professionals. The proposed rule also provides an option for these groups to choose how the value modifier would be calculated based on whether they participate in the Physician Quality Reporting System (PQRS). For groups of 25 or more that do not participate in the PQRS, CMS is proposing to set their value modifier at a 1.0 percent payment reduction. For groups that wish to have their payment adjusted according to their performance on the value modifier, the rule proposes a system whereby groups with higher quality and lower costs would be paid more, and groups with lower quality and higher costs would be paid less. The performance period for the CY 2015 value modifier was established as CY 2013 in the MPFS Final Rule for CY 2012.

The proposed rule also proposes changes to two quality reporting programs that are associated with the MPFS – the PQRS and the Electronic Prescribing (eRx) Incentive Program – as well as the Medicare EHR Incentive Pilot Program which promotes the use of health information technology. The PQRS proposal includes simplified, lower burden options for reporting, and the proposed rule aligns quality reporting across various programs in support of the National Quality Strategy.

In addition, according to CMS, the proposed rule addresses the next phase in a plan to enhance the Physician Compare Website to foster transparency and public reporting of certain information to give beneficiaries more information for purposes of choosing a physician.

Additional provisions of the rule include:

• A proposal to include additional Medicare-covered preventive services on the list of services that can be provided via an interactive telecommunications system.
• A proposal to implement a durable medical equipment (DME) face-to-face requirement as a condition of payment for certain high-cost Medicare DME items.
• A proposal to apply a multiple procedure payment reduction policy to the technical component of the second and subsequent cardiovascular and ophthalmology diagnostic services furnished by the same doctor to the same patient on the same day.
• A proposal to collect data on patient function to improve how Medicare pays for physical and occupational therapy, and speech language pathology services.
• A request for public comments on payment for advanced diagnostic molecular pathology services.
• A proposal to revise a regulation that only allows Medicare to pay for portable X-rays ordered by an MD or DO. The revised regulations would allow Medicare to pay for portable X-ray services ordered by physicians and non-physician practitioners acting within the scope of their Medicare benefit and state law.
• A proposal to clarify when Medicare will pay for interventional pain management services provided by Certified Registered Nurse Anesthetists (CRNAs) when permitted by state law. This proposal will foster access to pain management services in areas where states have determined that CRNAs may provide these services.

CMS said the proposed rule will appear July 30 in the Federal Register. CMS will accept comments on the proposed rule until Sept. 4, 2012, and will respond to them in a final rule with comment period to be issued by Nov. 1, 2012.

Article written by Frank Irving Editor for

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