CY 2016 Medicare Physician Fee Schedule
Proposed Rule
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Agenda
• The Big Picture
• Payment Policies
• Misvalued RVUs/RVU Targets/Conversion Factors • Advanced Care Planning Code
• Care Coordination/Collaboration Services • Other Proposals of Interest
• Quality and Efficiency Policies
• 2018 Value Modifier, PQRS • Physician Compare
• Feedback on MACRA Transition
• Alternative Payment models
• Feedback on CPCI Expansion
• MSSP ACO
2016 Medicare Physician Fee Schedule
Proposed Rule
• Displayed on July 7; published in Federal Register 7/15
http://www.gpo.gov/fdsys/pkg/FR-2015-07-15/pdf/2015-16875.pdf
• Supplemental materials (including RVU data)
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-
Federal-Regulation-Notices-Items/CMS-1631-P.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending
• Comments due September 8; Final rule expected November 1 – Draft comment letter distributed ~Aug 31
The Big Picture:
Payment
• SGR is repealed, but new RVU targets could still reduce
conversion factor (CF)
• Continuation of “misvalued RVU” initiatives and other
reviews of RVUs
• Major payment changes to gastroenterology and
radiation practice expenses
• New advanced care planning codes
The Big Picture:
Quality and Efficiency
• Policies for 2018 PQRS and Value Modifier (VM)
• LAST YEAR before transition to MIPS
• No increase to amount at risk for VM and PQRS for large group practices
• VM expands to certain non-physician practitioners; excludes certain CMMI programs
• New PQRS Group Option: Qualified Clinical Data Registries • CAHPS for PQRS only required for GPRO Web
• Feedback on MACRA implementation
• Physician Compare
• Benchmarks methodology– part of transition to 5-star rating system
• Feedback on Comprehensive Primary Care Initiative
Expansion
FPSC Will Be Offering Solutions To Help
Members Prepare for 2016
For All FPSC Participants
• November – Data-driven Impact Analysis Webinar on changes in the final Physician Fee Schedule
• December - Member-specific Medicare Impact Analyses based on changes in the final Physician Fee Schedule will be distributed
For FPSC Quality & Efficiency Module Participants
• July 28th Webinar on Strategic Implications of the PFS
• Fall 2015 – 2014 Academic QRUR Benchmarking Study
• November/December – Overview of Final 2016 PFS Implications on Quality & Efficiency
PAYMENT POLICIES
Payment Policies
• Estimate of RVU changes by specialty
• Conversion factor estimates/new targets for
RVU reductions
• New advanced care planning codes
• Discussion re primary care services
• Other items of interest
Path, Gastro, and RadOnc Have Largest RVU Changes
CMS’ Projected Impact on Allowable Charges by Specialty
Largest Expected Increases
• Independent Laboratory (+9%) • Pathology (+8%)
• Allergy/Immunology(+1%) • Dermatology (+1%)
• Diagnostic Testing Facility(+1%) • Hand Surgery(+1%)
• Interventional Pain Management (+1%)
• Interventional Radiology (+1%) • Plastic Surgery (+1%)
Largest Expected Decreases
• Gastroenterology (-5%)
• Radiation Therapy Centers (-9%)
• Radiation Oncology (-3%)
• Colon and Rectal Surgery (-1%)
• Neurosurgery (-1%)
Source: Table 45, 80 Fed. Reg. p.41939
*Estimated impact for all other specialties is 0% change
New Calculation: Targets for RVU Reductions
• Three years of targets to identify RVU adjustments that
produce reductions in PFS expenditures
– Targets
• 2016: 1.0% reduction; 2017: 0.5% reduction; 2018: 0.5% reduction
– Reductions will be measured via changes to RVUs
• Calculation
– If RVU reductions< target, then PFS reduced by difference
– If RVU reductions > target, then no adjustment to PFS, amount over target is applied to next year’s target
• Initial 2016 RVU reduction estimate is less than target
– Estimate=0.25%; target=1.0%; difference=0.75% – Estimate could change with interim final RVU values
Possible Impact to Conversion Factor
Current CF $35.9335 CMS Estimate 2016 CF $36.1096 $35.8387 $36.1096 Possible adjustments if 1% RVU reduction target is missed After Budget Neutrality Adjustments & 0.5% Update RVU Reductions = 0.25% RVU Reductions =1%Worst Case CF Estimate
CF adjustment = 0.75% decrease
Best Case CF Estimate
No Adjustment
Actual RVU reduction likely to fall in between these two scenarios and will published in Final Rule in early November.
Advanced Care Planning
(ACP)
Advanced Care Planning Code (ACP)
Two new CPT codes proposed to be covered under
Medicare in 2016:
99497 (First 30 min in facility): $80.16
99498 (Each additional 30 min in facility): $75.11
• Explanation and discussion of advance directives (e.g. standard forms)
• Face to face with patient, family members, and/or surrogate • Can be billed with or without a standard E/M service
• 99498 should be listed separately from primary procedure • Must document service is reasonable and necessary
Primary Care and Care
Management Services
Care Management Services
• Two recent codes:
– Transitional Care Management (TCM), 99495-99496 in 2013 – Chronic Care Management (CCM), 99490, in 2015
• No new proposals for CY 2016!
• CMS seeks comments regarding improving existing
codes and creating new codes.
• CMS anticipates developing potential proposals to
address these issues through rulemaking in 2016 for
implementation in 2017.
Proposed OPPS Requirements for
Chronic Care Management Services
2015 MPFS CCM Requirements 2016 OPPS CCM Requirements• Clinical staff portion must have an established relationship with the patient and provide care and treatment to the patient during the course of
illness.
• Proper documentation of informing patient and his/her authorization.
• Only one practitioner can furnish and be paid for providing CCM services during the calendar month
• Use of certified EHR technology
• Hospital must have an established relationship with the patient in one of two ways:
o patient is admitted as an inpatient or,
o is registered as an outpatient within last 12
months.
• Must document, in EMR, patient’s agreement to have services provided.
o Patient should be informed about 2 potential copayments
• Only one hospital can furnish and be paid for providing CCM services during the calendar month
Improving CCM and TCM Services
In order to better provide these services and alleviate
some of the extensive requirements—CMS seeks
comments on:
• Ways to improve beneficiary’s access to TCM and CCM
services
• Specific data on utilization of CCM codes to update
changes in payment and coding (e.g. clinical status of
beneficiaries, resource utilization and costs)
(Fed. Reg., p. 41708-41711)
Feedback to Improve Care
Coordination Services
(Fed. Reg., p. 41708-41711)Time and
Intensity
Utilization of
Additional
Resources
Costs of
Additional
Resources
Overlap of
Cognitive
Resources
Factors to
Address
CMS seeks feedback on adding new codes to properly reflect all of the services and resources involved with furnishing comprehensive coordinated care management.
Collaborative Care
• Treating patients with multiple chronic conditions can
require extensive information sharing between a
primary care and a specialist
• In CY 2014, CPT created four codes
(99446-99449)
to
acknowledge telephone/internet consultative services
• Medicare does not pay for these services arguing
these consultations are already bundled in other
services
(already embedded in existing codes)
Establishing Separate Payment for
Collaborative Care
(Fed. Reg., p. 41708-41711)
Question: Should CMS bill a separate code to more accurately track
consultation services between primary care (or whoever is leading the care coordination) and specialists similar to CPT 99446-99449?
CMS seeks data regarding the following:
• Beneficiary’s specific conditions
• Parameters for providing these services and resources • Differentiating these services from existing ones
• Beneficiary protection
• Necessary technology to provide these services
Collaborative Care Models for
Behavioral Health Conditions
CMS seeks feedback regarding:
• Providing collaborative care for patients with common
behavior conditions
• Including PCP, care manager, and a psychiatric consultant
in the model
• How to code and reimburse this specific type of a model
Proposed Telehealth Service Codes
CMS Proposes to add 5 CPT and HCPCS Codes:
• 99356- prolonged service in inpatient or observation setting (1st hr)
• 99357– prolonged service in inpatient or observation setting (each additional 30 minutes)
• 90963– ESRD related services for home dialysis (<2yrs) • 90964 – ESRD related services for home dialysis (2-11yrs)
• 90965 – ESRD related services for home dialysis (12-19yrs)
CMS proposes to amend §410.78 to include CRNAs as practitioners for telehealth services.
List of Medicare codes and descriptors available at
Physician Self-Referral
• CMS does not propose any changes to the general exception
for academic medical centers
under 42 CFR §411.355(e)• CMS proposes to:
– Update the regulations to accommodate new delivery and payment system reform models, to reduce burden, and to facilitate compliance
– Add two new exceptions: (1) Assistance to employ a nonphysician practitioner, and (2) Timeshare arrangements
• CMS seeks comments on a variety of issues, including
– Self-referral barriers to clinical and financial integration under reform models (such as ACOs, BPCI, APMs etc.), especially for the “volume or value” and “other business generated” criteria
Valuation of Global Services
•
MACRA provisions re Global Services
• Prohibited implementation of 0-Day surgical bundles as
described in PFS 2015 Final rule; CMS can review codes on case-by-case basis
• Authorizes Secretary to begin collecting information on
surgical services no later than January 2017
• Authority to withhold 5 percent of payments to physicians
selected for the sample until they report the requisite data
•
CMS seeking feedback on
• How to obtain auditable, objective data for post-op E/M visits
• Input on the accuracy of the values and description of
component services within the global package
Appropriate Use Criteria (AUC) for Advance
Diagnostic Imaging Services
• Established by Protecting Access to Medicare Act of
2014
• Criteria for physicians to better identify the appropriate
imaging service;
– AUC will identify outlier ordering physicians for services after Jan 2017
– Outlier physicians need prior authorization starting 2020
• First part of implementation –
– Defining AUC development by provider-led organizations – CMS proposes requirements and process for becoming a
“provider-led” organization
Questions on Payment Proposals?
Please use the Q&A panel located on the right hand
side of your screen to submit your questions. Send
to All Panelists.
QUALITY AND EFFICIENCY
POLICIES
Quality & Efficiency Policies
• PQRS/VM Proposals
• Transition to MIPS
• Physician Compare
LAST YEAR for PQRS/Value Modifier
Adjustments
•
2018 payments based on 2016 activity
• 2% PQRS Penalty
• Up to 4% for Value Modifier (for large groups)
•
2019 payments based on either MIPS or APM
• Merit-based Incentive Payment System (MIPS)
• Pay for performance based on quality, resource use, clinical practice improvements, and meaningful use
• Alternative payment models (APM)
• 5% lump sum bonus available
• EPs must meet certain thresholds; APMs must meet certain requirements
• NOTE: Participating in an MSSP ACO or other alternative payment
model does not automatically mean the practice will be in the APM track!!
Potential Incentives 2015 2016 2017 2018 2019-2021 2022
Mcare/Mcaid EHR Incentivea
Varies Varies Mcaid Only Mcaid Only Medicaid Only
--Value-Modifier (Max incentive)b
+1.0(x) +2.0(x) +4.0(x) +4.0(x) --
--MIPS -- -- -- -- TBD – Bonus for Exceptional Performance Same
Potential Reductions 2015 2016 2017 2018 2019 2020 2021 2022 Medicare EHR Incentive -1.0% or-2.0%c -2.0% -3.0% -4.0%Up tod -- -- -- --PQRS -1.5% -2.0% -2.0% -2.0% -- -- -- --Value-modifier (Max reduction)b -1.0% -2.0% -4.0% -4.0% -- -- -- --MIPS -- -- -- -- -4.0% -5.0% -7.0% -9.0% Total Possible Reduction -4.5% -6% -9% -10% -4% -5% -7% -9%
a Medicare and Medicaid incentives and penalties vary by stage individual professional is at. For Medicare, eligible professionals (EPs)have to attest by 2014 to earn any
incentives. For Medicaid, EPs can earn their first incentive through 2016.
b Adjustment could be positive or negative. VM incentive is multiplied by an adjustment factor (x) TBD. There is an additional 1x for practices with high risk populations that
receive incentives. No maximum adjustment is defined in legislation.
c Penalty increases to 2% if EP is subject to 2014 eRx penalty and Medicare EHR Incentive.
Proposed PQRS Changes
• Reporting requirements similar to previous years
• New GPRO reporting option: Qualified Clinical Data
Registry (QCDR)
– QCDR have more flexibility in measure selection
• CAHPS for PQRS
– Optional for group registry/EHR (previously mandatory)
– Required for all GPRO Web (if applicable to practice)
• Proposed New Measures
– New options for cross-cutting measures – 1 new GPRO Web Measure
2016 PQRS Reporting Mechanisms
Reporting Mechanism
Group Indivi-dual
Requirements for 2015 PQRS Incentives Timing / Commitment Other Comments GPRO Web + CAHPS for PQRS X (revised)
Report all measures in the web interface for a sample of patients Group must report on at least 1 measure for which there is Medicare data
(Note: practices can report GPRO Web without CAHPS if CAHPS is not appropriate)
Annual submission
Available to groups with 25 or more EPs. All groups, regardless of size, must report CAHPS. Qualified Clinical Data Registry (QCDR) X (new)
X 9 measures/3 domains for 50% of applicable patients
Must report at least 2 outcome measures OR
at least 1 outcome measure+ 1 resource use, patient experience, efficiency/appropriate use, or patient safety measure
Registry submits data annually.
New reporting option for groups 2 or more in 2016.
Registry X
(revised)
X 9 measures/3 domains (unless fewer than 9 measures apply) for
50% of Medicare Part B Pts.
Report 1 cross-cutting measure if ≥ 1 face-to-face encounter Measures with 0% performance rate are not counted
Registry submits annually.
CAHPS for PQRS no longer required for GPRO registry reporting
EHR X
(revised)
X 9 measures/3 domains (unless fewer apply)
Must use appropriate EHR specifications.
At least 1 measure must include a Medicare patient;
Annual
submission EHR or thru EHR Data Vendor
CAHPS for PQRS no longer required for GPRO EHR reporting
EHR/Registry +
CAHPS for PQRS
X CAHPS for PQRS AND 6 measures/2 domains from
EHR/Registry (see additional requirements for EHR/Registry above)
Groups must use certified survey vendor.
CMS to identify patients to be surveyed. Annual submission.
Available to groups with 2 or more EPs that CHOOSE CAHPS reporting.
Claims X 9 measures/3 domains (unless fewer than 9 measures apply) for
50% of Medicare Part B Pts.
Report 1 cross-cutting measure if ≥ 1 face-to-face encounter Measures with 0% performance rate are not counted
Report
concurrently with claims
submission.
Proposed New Cross-Cutting Measures
• If group or individual EPs have at least one
face-to-face visit, then they must report at least 1
cross-cutting measure
• Proposed new cross-cutting measures
– Preventative Care Screening: Unhealthy Alcohol Use
– Breast Cancer Screening
– Falls: Risk Assessment
– Falls: Plan of Care
Major Proposals for Value Modifier (VM)
• Max penalty for large group remains 4 percent
• Changes to VM Eligibility
– Certain CMMI demonstrations excluded from 2018 VM because of waiver
– Adjust VM eligibility to prepare for MIPS
• Technical calculation changes
– Increase number of measures for MSPB to 100
– Calculate separate benchmarks electronic measures
Proposed 2018 Value Modifier
2015 PQRS Reporting • Group Reporting; • 50% of EPs in TIN; OR • Solo practitioner Quality Tiering Varies based on TIN Sizeand Composition
NO
• TINS with any professionals in selected CMMI
Demos are EXCLUDED from VM including:
• Pioneer ACOs
• Comprehensive Primary Care Initiative
• Other identified models (could include Oncology, Next Gen ACOs, etc)
• MSSP ACOs are still included in the VM
• VM expands to certain non physicians practitioners:
•
YES
No PQRS Reporting
Automatic VM Penalty in 2018 (in addition to 2% PQRS Penalty) <10 EP TIN: -2.0%
10+ EP TIN: -4.0%
Groups without physicians and include NPs, PAs, CNSs, and CRNAs: -2%
Proposed Quality Tiering in 2018 VM
Low quality Avg quality High quality Low cost 0.0% +1.0x* +2.0x* Avg cost -1.0% +0.0% +1.0x* High cost -2.0% -1.0% 0.0%TINs with 10 or more EPs
• Groups with 10 or more EPs have more at risk than smaller groups
• Practices with no physicians and NPs, PAs, CNSs, and CRNAs have no downside risk Low quality Avg quality High quality Low cost 0.0% +1.0x* +2.0x* Avg cost 0.0% 0.0% +1.0x* High cost 0.0% 0.0% 0.0% Low quality Avg Quality High quality Low cost 0.0% +2.0x* +4.0x* Avg cost -2.0% +0.0% +2.0x* High cost -4.0% -2.0% 0.0%
TINs with <10 EPs
TINs with NP, PA, CNS, CRNA (and no physician)
MIPS1 VM PQRS EHR2
MD or DO X X X Both
Dentist3 X X X Both
Doctor of Podiatry X X X Mcare
Doctor of Optometry X X X Mcare
Chiropractor X X X Mcare
Nurse Practitioner X X4 X Mcaid
Physician Assistant X X4 X Mcaid5
CRNA X X4 X
Clinical Nurse Specialist X X4 X
Certified Nurse Midwife Perf Only4 X Mcaid
Others (audiologists, therapists, psychologists)
Perf Only4 X
1 – MIPS eligibility for 2019 and 2020. May expand to other professionals in 2021.
2 – Some EPs exempt from EHR Incentives. (Example – hospital based EPs are exempt from Meaningful Use.)
3 – Dentists are labeled as physicians in the Medicare program but may not be affected because they do not bill PFS services 4 – VM payments adjustments apply to physicians and proposed to apply to NPs, PAs, CRNAs in 2018. Other PQRS
professionals are included in performance, but not in payment adjustment.
Quality Measures
– PQRS reported measures – 3 claims-based outcome
measures
• Acute prevention quality indicators composite
• Chronic prevention quality indicators composite
• All cause readmission
– CAHPS for PQRS (included for
MSSP, optional for other groups)
Cost Measures
– Cost measures – not condition specific
• Total cost per capita
• Medicare Spending per Beneficiary
– Per capita costs for 4 condition populations
• COPD
• Heart Failure
• Coronary Artery Disease • Diabetes
2018 Value Modifier Measures
No New Measures for Value Modifier!
• Proposed changes to MSPB: Increase to Number of Admissions from 20 to 100 and include admissions from Maryland
VM and ACOs
• MSSP ACOs
– Rules to assign quality score if TIN/EPs are in more than one ACO (starting 2017 VM)
– CAHPS for PQRS included in the quality composite (starting 2018 VM)
• Pioneer ACOs and other models (starting in 2017)
– TIN waived if at least one EPs is in one of the identified CMMI models (Exception – VM still applies if the TIN is in an MSSP ACO)
Feedback on MACRA
(SGR Repeal)
Three Main Parts of the SGR Replacement
Predictable Updates Merit-Based Incentive
Payment System (MIPS)
Alternative Payment Models (APM) • Repeals SGR
• Replaces with small updates through 2020
• Freeze for six years • Two conversion factors after 2025 • Consolidates penalties from existing three Medicare reporting/ performance
programs into one large pay-for-performance program • Incentives to move to Alternative Payment Models • Bonus for 5 years • Higher update after 2025
Feedback on MACRA Provisions- MIPS
• CMS seeking feedback on MIPS definitions,
particularly low-volume threshold, clinical
practice improvement activities
• How to define low volume threshold
– EPs with low volume can be exempt from MIPS
• Min number of Medicare beneficiaries • Min number of items and services • Min amount of allowed charges
– Should CMS use thresholds like what is in MU?
• Possible Example: EP does not have at least 10% of their patient volume derived from Part B encounters
Feedback on MACRA Provisions- MIPS
• How to define Clinical Practice Improvement
Activities
– Seeking feedback on activities that could be classified as practice improvement
– Categories mentioned in legislation: • expanded practice access,
• population management, • care coordination,
• beneficiary engagement,
• patient safety/practice assessment, • participation in APM
– Legislation mentioned maximum credit for certified PCMH
Feedback on MACRA Provisions- APM
• Upcoming Request for Information (RFI), but CMS
welcomes initial feedback
• Topics covered include:
– Criteria for assessing physician-focused payment models
– Criteria and process for submission of physician-focused payment models eligible APM
– Qualifying APM participants
– Medicare payment threshold option and combination all-payer and Medicare payment threshold option
– Time period used to calculation eligibility for APM – Definition of nominal financial risk
Physician
Compare
Key proposals:
• Proposed benchmarking algorithm
• New data on Physician Compare Website
– New indicators for VM upward adjustment, reporting on the cardiovascular prevention measures group,
– All PQRS measures including CAHPS and QCDRs
• New data in Downloadable data file
– Add utilization data
– Value modifier quality tier and payment adjustment
• Feedback for future rulemaking:
– Should CMS stratify measures by race, ethnicity, gender, other ideas? – Add Medicare Advantage information?
– Add VM cost and quality scores? – Add Open Payments data?
Physician Compare: Benchmarking
• Propose using Achievable Benchmarking for Care (ABC
tm)
– For each measure - rank order physicians/group by highest performance
– Go through list until 10 percent of the beneficiaries (not providers) in denominator are selected
– Calculate benchmark as the score for all patients in the
denominator
– Adjustments for low denominators
• Benchmark calculated every year; no discussion about
different benchmarks for different data sources
• ABC methodology “can be used to systematically assign stars
for … 5-star rating”
Questions on Q&E Proposals?
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ALTERNATIVE PAYMENT
MODELS
Potential CPCI Expansion
• Comprehensive Primary Care Initiative (CPCI) basics
– CMMI model; Ends December 2016
– Collaborating with commercial payers and Medicaid – Practices:
• Receive per beneficiary per month payment for each Medicare (and sometimes Medicaid) beneficiary
• Has to provide comprehensive services in five different
primary care areas
• Has to report 9 or 13 electronic quality measures at practice site level