Everything you need to know about the new physician fee schedule

In July 2019, the Centers for Medicare & Medicaid Services (CMS) issued its Proposed Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2020. The new policies will take effect January 1, 2020. The proposed rule includes “proposals to update payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS).”

Among the changes and updates proposed in the 2020 Physician Fee Schedule (PFS) are several adjustments in codes and payment rates:

CY 2020 PFS Rate setting and Conversion Factor

Relative Value Units (RVUs) are applied to each service for physician work, practice expense, and malpractice. They become payments rate after a conversion factor is applied. Those payment rates include an overall payment update specified by statute. The proposed CY 2020 PFS conversion factor is $36.09, a slight increase above the CY 2019 PFS conversion factor of $36.04.

Medicare Telehealth Services

The following codes are proposed for the list of telehealth services: HCPCS codes GYYY1, GYYY2, and GYYY3, which describe a bundled episode of care for treatment of opioid use disorders.

Payment for Evaluation and Management (E/M) Services

The proposed PFS consolidates the Medicare-specific add-on code for office/outpatient E/M visits for primary care and non-procedural specialty care that was finalized in the CY 2019 PFS final rule for implementation in CY 2021 into a single code describing the work associated with visits that are part of ongoing, comprehensive primary care and/or visits that are part of ongoing care related to a patient’s single, serious, or complex chronic condition.

Care Management Services

A number of the Chronic Care Management (CCM) services codes are proposed to be replaced with Medicare-specific codes to allow clinicians to bill incrementally to reflect additional time and resources required in certain cases and better distinguish complexity of illness as measured by time. Physicians involved in CCM provide care coordination and management services to beneficiaries with multiple chronic conditions over a calendar month service period.

Medicare Shared Savings Program (MSSP)

As part of the PFS proposed rule, CMS is soliciting comment on how to potentially align the Medicare Shared Savings Program (MSSP) quality performance scoring methodology more closely with the Merit-based Incentive Payment System (MIPS) quality performance scoring methodology, recognizing that accountable care organizations (ACOs) and their participating providers and suppliers dedicate resources to performing well on quality metrics. The goal is to align quality metrics across programs that will reduce burden and will allow ACOs to more effectively target their resources toward improving care.

Tyler Comstock
September 20, 2019

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How is MIPS changing in 2020

The Centers for Medicare & Medicaid Services (CMS) announced changes to the Merit-based Incentive Payment System (MIPS) on July 29, 2019, that are intended to streamline the Quality Payment Program (QPP). CMS is focused on reducing administrative burden for healthcare providers with its new pay-for-performance program called the MIPS Value Pathways (MVP). In the same announcement, CMS included updates to the Medicare Physician Fee Schedule (PFS) effective January 1, 2020.

One of the goals of the updated policies is to help physicians who care for chronically ill patients. CMS Administrator Seema Verma states that “Today one in five Medicare beneficiaries have multiple chronic diseases.” The proposed rule for 2020 “would increase payments to practitioners for time spent on care management after a patient leaves the hospital ensuring proper follow-up and continuity of care for patients.” In addition, CMS is proposing, for the first time, “to pay for care management services for patients with a single, high-risk chronic condition such as diabetes or high blood pressure.” Under the new rule, physicians would also be paid for “additional time spent on care management activities for patients suffering from multiple chronic conditions.”

The new MVP program would begin in the 2021 performance period, moving MIPS “from its current state, which requires clinicians to report on many measures across the multiple performance categories, such as Quality, Cost, Promoting Interoperability and Improvement Activities, to a system in which clinicians will report much less. Under MVPs, clinicians would report on a smaller set of measures that are specialty-specific, outcome-based, and more closely aligned to Alternative Payment Models (APMs) – new approaches to paying for care through Medicare that incentivize quality and value.”

CMS’s proposed rule includes:

  • CY 2020 PFS rate setting and conversion factor
  • Medicare telehealth services
  • Payment for evaluation and management services
  • Physician supervision requirements for physician assistants
  • Review and verification of medical record documentation
  • Care management services
  • Comment solicitation on opportunities for bundled payments
  • Medicare coverage for opioid use disorder treatment services furnished by opioid treatment programs
  • Bundled payments for substance use disorders
  • Therapy services
  • Ambulance services
  • Ground ambulance data collection system
  • Open Payments Program
  • Medicare Shared Savings Program
  • Stark advisory opinion process

The public is invited to comment on the CY 2020 Physician Fee Schedule proposed rule and the CY 2020 Quality Payment Program proposed rule. Comments must be received within the 60-day comment period, which closes on September 27, 2019. When commenting refer to file code: CMS-1715-P.

Tyler Comstock
August 26, 2019

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Medicare for All: An overview for independent practices

When Medicare was created in 1965, it was intended to eventually cover all Americans as a universal healthcare plan, not to remain as an insurance program exclusively for the elderly. In 1972, minor changes were made to Medicare eligibility, including as recipients those with disabilities and with end-stage renal disease. The idea of a national health insurance plan was also re-introduced in the early 1970s but was defeated each time it was proposed. Republican Senator Jacob Javits proposed expanding Medicare to cover all Americans in 1970 and was the first one credited to have coined the phrase “Medicare for all.”

From 2003 to 2017, Democratic Representative John Conyers introduced and reintroduced his Expanded and Improved Medicare for All Act. In 2006, Democratic Senator Ted Kennedy introduced a Medicare for All Act, which proposed the idea that was the original intent of the Social Security Administration staffers who set up Medicare, to gradually expand Medicare to include all citizens and legal residents.

In recent years, “Medicare for all” has re-emerged in political campaigns. Today, the concept refers to a single-payer type of health insurance that would virtually eliminate private health insurance or exist alongside private insurance, depending on the proposal.

Various versions of the universal healthcare concept are being proposed. Essentially the idea of “Medicare for all” includes the basic healthcare benefits of the current Medicare system such as provider visits, certain outpatient services, and hospitalization. Some proposals expand that coverage to include dental, vision, hearing, and long-term care services with no premiums, deductibles, or co-pays. Other proposals include a “public option” that would not eliminate private insurance but would be considered a “government insurance plan” offered as an option to those seeking health insurance.

“Medicare for all” is sometimes referred to as “single payer” or “universal” healthcare. Single-payer means that there would only be one payer for the cost of the universal health coverage and that would be the federal government. Taxes would probably increase to cover part of the costs, but how much and who would be taxed are also issues up for debate.

Medicare coverage for all Americans would ensure that everyone in the country has healthcare coverage, a concept that has been embraced by every wealthy, developed nation except the US. With rising healthcare costs, including the costs of health insurance, one in ten Americans is uninsured today and many of those with insurance are challenged financially by their medical bills.

Tyler Comstock
August 14, 2019

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2019 Medicare Advantage and Part D Prescription Drug Program updates

Enrollment in Medicare Advantage plans is up and premiums are down, according to data released by the Centers for Medicare & Medicaid Services (CMS). Medicare Advantage plans cover what is sometimes referred to as Medicare Part C. Advantage plans are administered by private companies and require the patient to pay an additional premium for services covered by the plan. Medicare then pays those companies a fixed amount for the patient’s care.

CMS projects that there will be record enrollment in Medicare Advantage plans in 2019, estimating that 36.7% of Medicare beneficiaries will enroll in an Advantage plan this year. CMS also states that “Medicare Advantage premiums, on average, have steadily declined since 2015 from the actual average premium of $32.91. For 2019, CMS estimates the Medicare Advantage average monthly premium will decline by $1.81 to $28.00 from 2018.”

Approximately 99 percent of Medicare beneficiaries will have access to a Medicare Advantage plan as well as a prescription drug plan in 2019. Prescription drugs are covered under Medicare Part D, which is generally included in most Advantage plans. Additional benefits, such as vision, hearing, dental, and/or health and wellness programs, may also be included in Medicare Advantage plans.

CMS also states that “Due to new flexibilities available for the first time in 2019, nearly 270 Medicare Advantage plans will be providing an estimated 1.5 million enrollees new types of supplemental benefits, including:

  • Expanded health-related supplemental benefits, such as adult day care services, and in-home and caregiver support services; and
  • Reduced cost sharing and additional benefits for enrollees with certain conditions, such diabetes and congestive heart failure due to the agency’s reinterpretation of uniformity requirements.

Premiums for prescription drug plans are also declining, with the basic premium projected to decline for the second year in a row. The average monthly premium for a basic Medicare prescription drug plan is projected to decrease in 2019 by 3.2%, to an estimated $32.50 per month.

CMS is encouraging health plan providers to offer more choices in their Medicare Advantage plans, with policies for Medicare health and drug plans for 2019 that provide “new tools to improve quality of care.”

Tyler Comstock
July 23, 2019

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Comprehensive Primary Care Plus (CPC+): what are the updates for 2019?

The Centers for Medicare and Medicaid Services (CMS) recently launched an Innovation Center that “supports the development and testing of innovative health care payment and service delivery models.” One of those innovations is Comprehensive Primary Care Plus (CPC+), a national advanced primary care medical home model. The CMS Innovation Center has published a number of updates and changes to the 2019 CPC+ program in its report, “CPC+ Payment and Attribution Methodologies for Program Year 2019.”

According to the Innovation Center, CPC+ includes two primary care practice tracks with incrementally advanced care delivery requirements and payment options to meet the diverse needs of primary care practices in the United States. CPC+ is a five-year model that began in January 2017 for 2017 Starters and will begin in January 2018 for 2018 Starters.

In addition to the information provided in the Innovation Center’s publication, a new track initiative that will reduce the reporting requirements for quality care is expected in 2019 as well. The new initiative should relieve independent physicians of many of the current reporting burdens they face in delivering value-based healthcare.

In 2019, CMS is providing the Care Management Fee (CMF) to CPC+ practices to support them in the expectation that CPC+ practices provide “wrap-around” primary care services. CMF is a non-visit-based fee that will be paid to practices in both tracks quarterly. The amount of the CMF is determined by (1) the number of beneficiaries attributed to a given practice per month, (2) the case mix of the attributed beneficiary population, and (3) the CPC+ track to which the practice belongs.

In its report on 2019 payment and attribution methodologies, the Innovation Center specifies that practice performance is measured against absolute performance thresholds. The minimum and maximum thresholds are determined from a reference population external to CPC+ participation. In turn, a practice’s own performance relative to these thresholds determines the incentive amount the practice retains. In addition, minimum and maximum performance goals are established using absolute thresholds that are the same for all practices. The performance goals are the same for both tracks and for all Starters.

CMS states that “In Program Year 2019, the minimum threshold is set to the 30th percentile of performance in the reference population for clinical quality and patient experience of care, and to the 50th percentile of performance in the reference population for utilization. Practices are not eligible to retain any of the PBIP (Performance-Based Incentive Payment) for the relevant measure if their performance score on an individual measure falls below this minimum threshold. This requirement ensures that practices are not rewarded for poor performance and encourages practices to place the highest priority on measures with very low scores to bring them above the minimum threshold.”

Damien Neuman
July 8, 2019

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Why Elation Health supports CMS’ proposal to send discharge or ADT feeds from hospitals for improved interoperability

On June 3rd, Elation Health joined 33 other organizations to submit a letter in support of a CMS proposal which would require hospitals participating in Medicare or Medicaid to send event notifications – also known as admission/discharge/transfer or ADT feeds – to other health care facilities or community providers.

Why is this important? If adopted, hospitals would be required to tell independent practices when a patient is admitted. This allows primary care physicians to know that their patients have been admitted to the hospital, which can drive critical follow-up and longer-term preventative activities to reduce readmissions.

Currently, many hospitals choose not to share ADT feed alerts for competitive reasons, even though they have the ability to share this information. As the organizations in the letter stress, “these notifications are critical to improving patient safety through better care transitions and are key to enabling value-based care at scale.” By having access to ADT feeds, independent physicians can spend less time trying to understand pertinent details around admissions, discharges, transfers, and encounters for their patients to ensure optimal follow-up care.

Elation Health strongly supports any initiative that attempts to streamline data sharing, especially when it is in the interest of patient care. A number of studies have demonstrated how valuable this kind of data exchange could be for readmission rates and other areas of patient care.

As the only EHR platform that signed onto this letter, we are eager to continue advocating for improved interoperability standards. At the same time, we’ve invested in features like our Collaborative Health Record to put the patient’s story in the center of their care experiences, whether that includes visits to physicians in-network or out of network.

Click here to learn more about our commitment to improving interoperability.

Tyler Comstock
June 21, 2019

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What are the ways MACRA has changed in 2019?

The Centers for Medicare & Medicaid Services (CMS) published its Quality Payment Program Year 3 Final Rule in November 2018. The document details a number of changes for the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) for independent physicians in 2019. In its fact sheet, CMS highlights the following changes:

  • Expanding the definition of MIPS eligible clinicians to include new clinician types (physical therapists, occupational therapists, speech-language pathologists, audiologists, clinical psychologists, and registered dietitians or nutrition professionals), adding a third element to the low-volume threshold determination, and giving eligible clinicians who meet one or two elements of the low-volume threshold the choice to participate in MIPS (referred to as the opt-in policy).
  • Adding new episode-based measures to the Cost performance category, restructuring the Promoting Interoperability (formerly Advancing Care Information) performance category, and creating an option to use facility-based Quality and Cost performance measures for certain facility-based clinicians.
  • Increasing the small practice bonus to 6 points but including it in the Quality performance category score of clinicians in small practices instead of as a standalone bonus.
  • Continuing to award small practices 3 points for submitted quality measures that don’t meet the data completeness requirements.
  • Allowing small practices to continue submitting quality data for covered professional services through the Medicare Part B claims submission type for the Quality performance category.
  • Providing an application-based reweighting option for the Promoting Interoperability performance category for clinicians in small practices.
  • Continuing to provide small practices with the option to participate in MIPS as a virtual group.
  • Offering a no-cost, customized support to small and rural practices through the Small, Underserved, and Rural Support (SURS) technical assistance initiative.
  • Overhauling the MIPS Promoting Interoperability (formerly Advancing Care Information) performance category to support greater electronic health record interoperability and patient access while aligning with the Medicare Promoting Interoperability Program requirements for hospitals.
  • Moving clinicians to a single, smaller set of objectives and measures with scoring based on measure performance for the Promoting Interoperability performance category.
  • Allowing the use of a combination of collection types for the Quality performance category.
  • Retaining and increasing some bonus points: MIPS performance threshold will be raised from 15 points to 30 points; the exceptional performance threshold will be raised from 70 points to 75 points
  • For the Cost or Quality performance categories, providing the option to use facility-based scoring for facility-based clinicians, who are planning to participate in MIPS as a group. This option does not require data submission. A facility-based scoring preview is expected to be released in Q1 of 2019.

Damien Neuman
May 30, 2019

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CPC+ and population health management

In 2012, the Centers for Medicare & Medicaid Services (CMS) launched an initiative designed to strengthen primary care. The Comprehensive Primary Care Initiative (CPCI) was designed as a four-year initiative to offer population-based care management fees and shared savings opportunities to participating primary care practices to support the provision of a core set of comprehensive primary care functions. In January 2017, CMS launched Comprehensive Primary Care Plus (CPC+), based on the foundational model of the CPCI.

With a renewed focus on population health, CPC+ is “a national advanced primary care medical home model that aims to strengthen primary care through regionally-based multi-payer payment reform and care delivery transformation. CPC+ includes two primary care practice tracks with incrementally advanced care delivery requirements and payment options to meet the diverse needs of primary care practices in the United States.”

Track 1 is designed for those practices that are ready to build the capabilities they need to deliver comprehensive primary care for their patients. In 2017, 1365 practices participated in Track 1. Track 2 is for those practices that are ready to take the additional step of increasing the breadth and depth of their care, focusing on patients with complex needs. In 2017, 1511 practices participated in Track 2.

Through its CPC+ initiative, CMS “seeks to improve quality, access, and efficiency of primary care.” Payment elements may vary, depending on which track the practice is in, but payment elements include a Care Management Fee, a Performance-Based Incentive Payment, and Payment under the Medicare Physician Fee Schedule.

Participants in CPC+ are expected to make changes in the way they deliver care for their patients. Those changes are centered on key Comprehensive Primary Care Functions: (1) Access and Continuity; (2) Care Management; (3) Comprehensiveness and Coordination; (4) Patient and Caregiver Engagement; and (5) Planned Care and Population Health.

The redesigned CPC+ includes a “robust learning system.” One of the CPC+ strategies is empanelment, which “pairs patients with a practitioner or care team as a foundation for population health management and patient relationships.” The rate of empanelment for practices participating in CPC+ grew steadily throughout 2017. CMS states that the CPC+ initiatives “ensures practices have the infrastructure to deliver better care, resulting in a healthier patient population.”

Greg Miller
March 27, 2019

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Suggestions to improve MACRA and MIPs

Administrative burdens that detract from a provider’s ability to focus on patient care are at the heart of challenges independent physicians have with the Quality Payment Plan (QPP) that is part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Providers participating in either of the two QPP payment tracks, the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (Advanced APMs), have raised questions and made suggestions for improvement.

The main theme at a hearing held in July 2018 on how to improve Medicare was to reduce the administrative burdens on providers. Other concerns focused on the quality measures involved in MIPS, particularly whether they were relevant across the board. Healthcare providers participating in the hearing suggested that the reporting process be simplified and that it incorporate more meaningful measures.

Frank Opelka, MD, FACS, ACS’ Medical Director of Quality and Health Policy, noted that for quality reporting that did not impose an administrative burden to physicians, “CMS needs measures that accurately and meaningfully target the episode of care being assessed, providing useful information to physicians and patients. This is not currently the case.”

In addition, as reported by Revcycle Intelligence, “The American Medical Association’s (AMA) immediate past president David O. Barbe, MD, MHA, also provided a list of suggestions for decreasing administrative burden in the Quality Payment Program. His recommendations included:

  • Reducing the number of measures a physician must report for the MIPS Quality performance category
  • Permitting providers to report for a minimum of 90 days in all MIPS performance categories
  • Expanding facility-based definition to include providers in all settings, such as post-acute care and long-term care facilities.”

Physicians are urging the Centers for Medicare & Medicaid Services (CMS) to make improvements to MIPS to encourage more healthcare providers to participate. Those who are currently participating do not feel they are being rewarded adequately for meeting the quality measure requirements. Smaller, independent physicians should be assisted with participating, perhaps with the option of an alternative MIPS pathway.

Greg Miller
March 22, 2019

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What industry leaders think about the new proposed interoperability rules

Rules proposed by the Centers for Medicare & Medicaid Services (CMS) and by the Office of the National Coordinator for Health IT (ONC) in February 2019 focus on interoperability of electronic health records (EHRs) to make patient data more useful and transferrable. CMS proposed the Interoperability and Patient Access Proposed Rule, which includes policy changes to support its My HealthEData initiative. ONC’s proposed rule “promotes secure and more immediate access to health information for patients and their healthcare providers and new tools allowing for more choice in care and treatment.”

Several industry leaders have responded to the new proposed CMS and ONC rules in a positive manner. As reported by Health Data Management, “Matt Eyles, president and CEO of America’s Health Insurance Plans, said that healthcare payers are committed to establishing new, innovative ways to integrate and share data with patients and providers.” Eyles noted that “AHIP and our members support seamless access to health information by providers and patients to make better choices about care and treatment.”

Organizations such as the College of Healthcare Information Management Executives (CHIME) support interoperability of electronic health information and have asked members to provide input on the new proposed rules. Liz Johnson, chief innovation officer at Tenet Healthcare and vice chair of the CHIME Policy Steering Committee, stated that “Speeding interoperability and patient access to their records are priorities for our members.”

Don Crane, president and CEO of America’s Physician Groups, noted that the proposed rules “puts power back in the hands of patients by streamlining their ability to access health information literally from the palm of their hand.” Crane added that “Having this information readily accessible can help patients and providers make more informed choices about their care more quickly. And it can help preserve valuable healthcare resources by reducing waste, such as duplicate tests and unnecessary procedures.”

CMS is accepting comments on the major provisions in this proposed rule and the RFIs (CMS-9115-P) until early April (exact date will be updated upon posting at the Federal Register); it can be downloaded from the Federal Register at: https://www.federalregister.gov/public-inspection.

Greg Miller
March 5, 2019

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