LTC-Vital Medicaid Is on the Bargaining Table

Family Physicians Sue to Shine Light on RUC Deliberations, Claim Specialists Skew Reimbursement Against Primary Care

Doctors providing primary care services could earn some additional money next year under a new Medicare proposal that would pay them for coordinating the care of their patients who have been discharged from a hospital or nursing home. Medicare proposes to create a new G code that would allow physicians to bill for postdischarge transitional care services such as obtaining and reviewing the patient's discharge summary; reviewing diagnostic tests and treatments; updating the medical record within 14 business days post-discharge; establishing a new care plan; educating the patient or caregiver within 2 business days post-discharge; and communicating with other health care providers. The G code would apply when a Medicare beneficiary is discharged from an inpatient stay, a skilled nursing facility, an outpatient hospital observation unit, partial hospitalization services, or a community mental health center. Officials at the Centers for Medicare & Medicaid Services estimate that the use of the new G code could increase payments to family physicians by 7%; other doctors who provide primary care services could see a bump of 3%–5% starting in January 2013. “Helping primary care doctors will help improve patient care and lower health care costs long term,” CMS Acting Administrator Marilyn B. Tavenner said in a statement. The addition of the new G codes is a “good step,” said Dr. Glen Stream, president of the American Academy of Family Physicians. The AAFP has been working on this issue for awhile and earlier this year issued recommendations on better ways to pay for primary care services. Dr. Stream said they would next like to see the CMS develop evaluation and management codes that are specific to primary care, rather than simply increase payments for the 99213 and 99214 codes that are used by many specialties. The postdischarge transitional care services plan was part of the 2013 Medicare Physician Fee Schedule proposed rule, which was released July 6. But the fee schedule proposal is not all good news. The proposed rule also details the 27% across-the-board cut to physician fees scheduled to take effect on Jan. 1. The reduction is required by law, based in part on spending targets set under the Sustainable Growth Rate (SGR) formula, which links fees to changes in the gross domestic product. Under the proposal, CMS also is seeking to expand its multiple-procedure payment reduction policy to diagnostic tests in both cardiology and ophthalmology. Starting in January 2013, there would be an across-the-board reduction of 25% to the technical component for second and subsequent procedures performed by the same physician or physicians in the same group practice for the same patient on the same day. The cut will not apply to the professional component of the fee. The proposed rule lists 131 diagnostic cardiovascular services that would be subject to the multiple-procedure payment reduction policy. Dr. William Zoghbi, president of the American College of Cardiology, said the reductions would be bad for both physicians and patients. “This policy disadvantages physicians who aim for efficiency [and] would lead to a major inconvenience to patients.” The 2013 fee schedule proposal also outlines the implementation of the physician value-based payment modifier, which adjusts physician payments based on the quality and cost of care they provide. The program, which was mandated under the Affordable Care Act, will be phased in over 3 years starting in 2015. The proposed rule also would implement the physician value-based payment modifier for all medical groups with 25 or more eligible providers starting in 2015. Groups that do not participate in the Physician Quality Reporting System would see a 1% cut in Medicare payments. Groups that do participate would be paid in part based on their performance. Groups with higher quality and lower costs would be paid more, and those with lower quality and higher costs would be paid less, according to CMS. The payment adjustments made in 2015 will be based on 2013 performance in the PQRS. CMS published the proposed rule in the Federal Register on July 30, and it will accept public comments until Sept. 4. The agency plans to finalize the physician payment rule by Nov. 1.

Are Higher or Lower Medicare Rates Ahead?

The 2009 Proposed Rule for Prospective ESRD Payment: Perspectives From a Large Dialysis Organization

LTC Codes Get Bigger Raise in New Schedule

Here Comes the Sun: Medical Professionalism and the Implications of the Sunshine Act for Gastroenterology Practice

Back to table of contents Next article Government NewsFull AccessAPA-Backed Bill Would Head Off Medicare Fee CutsKate MulliganKate MulliganSearch for more papers by this authorPublished Online:7 Dec 2001https://doi.org/10.1176/pn.36.23.0001To lend weight to a Senate bill that would protect physician Medicare reimbursement rates, APA has joined more than 40 other medical associations to support the Medicare Physician Payment Fairness Act (S 1660).The bill is sponsored by Sens. Jim Jeffords (I-Vt.) and John Breaux (D-La.). It was introduced in the House of Representatives last month.The impetus for the proposed legislation was the announcement on October 31 by the Centers for Medicare and Medicaid Services (CMS) that the factor used to update payment rates for individual medical services will go down by 4.8 percent next year, and the conversion factor will be even lower, at 5.4 percent below the 2001 level.Jay Cutler, J.D., APA’s government relations director, told Psychiatric News, “The negative payment update problem is particularly acute for psychiatrists, who must also contend with underlying limitations in the Medicare program on reimbursement for psychiatric services, such as Medicare’s discriminatory 50 percent copayment requirement. APA is joining the AMA and all of medicine in efforts to correct the problem this year.”In an interview, Edward Gordon, M.D., chair of the APA Medicare Advisory Committee, emphasized the harmful effect the decrease could have on patient care. “Already many psychiatrists are unwilling or unable to take Medicare patients under the current fee schedule,” he said. “In New York, for example, Medicare payment is one-third to one-half lower than the prevailing rate for psychiatrists. It is a particularly difficult time to decrease the availability of mental health services when the whole country is under stress.”In announcing the physician payment changes, CMS Administrator Tom Scully said, “The law designing the physician update is incredibly prescriptive.The formula locks us in.”Unless Congress acts to change the formula or delay its implementation, the cuts will take effect on January 1, 2002. In fact, although CMS and medical associations differ on whether the formula has been beneficial to physicians, both sides agree that the federal government currently has little latitude in terms of implementation.The intent of the complex formula that determines physician reimbursement for treating Medicare beneficiaries is to change payment rates annually to reflect changes in physician practice costs. But, in addition to costs, the formula must also consider a target: the sustainable growth rate (SGR).The target is based on four factors: gross domestic product (GDP), enrollment in the traditional Medicare program, input prices, and spending due to new laws or regulations.When actual spending in a given year is inconsistent with the previously established target, the next year’s update must be adjusted to bring spending in line. In 2001 revisions to previous year estimates of GDP, increases in physician spending, and the economic slowdown produced the average decrease of 5.4 percent in physician rates for 2002.Congress adopted the Medicare fee formula as part of the Balanced Budget Act of 1997. CMS claims that the formula worked well for physicians between 1998 and 2001. The cumulative increase was 15.9 percent, which CMS compares with a medical-cost inflation increase of 9.3 percent.In their letter supporting the new legislation, however, the medical association signatories charge, “[The 2002 decrease] would be the fourth broad-scale reduction in physicians’ and other practitioners’ fees since 1992 and would bring the average increase in Medicare fees between 1991 and 2002 down to just 1.1 percent a year, or 13 percent less than the government’s own estimate of practice cost inflation.”The November 19 issue of American Medical News reports, “In 1998, when the SGR was introduced, GDP growth for both the current and upcoming year was underestimated by 2 percent. That has lowered the spending target by billions of dollars, increasing the magnitude of the reduction.”That same issue also reports that nearly 30 percent of family physicians are not accepting new Medicare patients.The most immediate impact of the Medicare Physician Payment Fairness Act would be to trim the decrease in physicians’ rates from 5.4 percent to .9 percent in 2002. In addition, the bill also would require the Medicare Payment Advisory Commission to conduct a study on replacing the SGR as a factor in determining the update for physician payments with a factor that more accurately reflects changes in the costs of providing physicians’ services. The bill has been referred to the Senate Finance Committee, which has not yet acted on it.The final rule describing revisions to payment policies under the Medicare physician fee schedule for calendar year 2002 can be found at www.hcfa.gov/regs/pfs/. The text of the Medicare Physician Payment Fairness Act can be accessed on the Web at thomas.loc.gov by searching on “S 1660.” ▪ ISSUES NewArchived

Trends in shoulder and elbow procedures: declining inflation-adjusted Medicare reimbursement for hospitalizations.

MP23-15 EXPLORING PRACTICE PATTERNS AND REGIONAL PARTICIPATION OF UROLOGISTS IN ONCOLOGY CARE MODEL

Introduction: The Centers for Medicare and Medicaid Services (CMS) recently released detailed information on services provided to Medicare beneficiaries by physicians for 2012 and 2013. The information provides individual provider information based on HCPCS code, number of services and payment. Additionally, demographic information is provided for each physician. We analyzed these databases to determine the number of cardiac MRI services provided, physician payment, characteristics of providers and changes over time to provide insight into the practice of cardiac MRI in the United States. Methods: The 2012 and 2013 Medicare Provider Utilization and Payment Data: Physician and other Supplier Public Use File (PUF) was downloaded and searched for cardiac MRI HCPCS codes (75557-75564). Statistics were calculated for the number of providers, number of services, payment, geographic location and type of facility. Additionally, provider degree, gender and clinical specialty were analyzed. Changes from 2012 to 2013 were statistically compared. Results: In 2012, there were 311 (84% male) providers with 11,473 cardiac MR scans. The number of MRI scans per provider (36.9±39.2; range: 11-260) varied widely. In 2013, the number of providers increased to 337 (85% male) with 12,076 cardiac MR scans (35.8±36.7; range: 11-246). Physician identified specialty was 48% Cardiology and 46% Diagnostic Radiology. Payment (2013) was less (p<0.001) in facilities ($125.8±8.6; n=10,107) compared to non-facilities ($451.75±123.3; n=1,969). In Figure 1, the number of MR scans (2013) are displayed geographically and by HCPCS code. Conclusions: Cardiac MR utilization slightly increased and payment decreased from 2012 to 2013. Usage was split evenly between Cardiology and Diagnostic Radiology, but providers were predominantly male.

The delivery of quality health care in America today faces significant challenges on many fronts. Through a positive, mutually supportive and collaborative relationship, the American Medical Association (AMA) and ASCO are working together to meet these challenges. It is only through the efforts of passionate, informed physicians like you that the AMA can improve the future of health care for physicians and their patients nationwide. And it is only through organizations such as ASCO that this spirit takes root at the local level. Michael D. Maves, MD, MBA Our organizations have collaborated in a number of constructive ways recently. During the debate surrounding Medicare drug reimbursement cuts as proposed in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, the AMA worked with ASCO and other affected specialties to try to limit the impact of these cuts. The AMA also joined ASCO and other specialties in calls for more physician-friendly regulations, and created a special work group to develop new drug administration codes that resulted in payment increases that offset some of the losses on the drug side of the reimbursement equation. ASCO has also worked with the Physician Consortium for Performance Improvement (the Consortium) to develop evidence-based clinical performance measures. The Consortium, which was convened by the AMA, includes representatives from more than 70 state and specialty medical societies, the Agency for Healthcare Research and Quality, the Centers for Medicare & Medicaid Services, and others. ASCO's work with the Consortium makes it more likely that oncologists will have measures that meet the standards and qualify them for additional payments if they participate in Medicare and private plans' pay-for-performance programs. In terms of advocating for the medical profession and physicians nationwide, the AMA has three primary goals: medical liability reform (MLR), Medicare physician payment reform and regulatory relief, and expanding coverage for the uninsured and increasing access to care. On the MLR front, the AMA continues to lead an aggressive, multiyear campaign to reduce medical liability premiums in order to preserve patients' access to care. At the federal level, the AMA is fighting Congress for MICRA-like reforms (MICRA is California's Medical Injury Compensation Reform Act of 1975), including a $250,000 cap on noneconomic damages in medical liability cases. At the state level, the AMA is providing resources to support similar state reforms. As the leading force in Washington, DC, for Medicare reform, the AMA is relentlessly pursuing fixes to replace the flawed Medicare physician payment formula and has stopped physician payment cuts in each of the last 4 years. While that was a major accomplishment, we understand that Medicare payments are no longer keeping up with your costs, and we urge you to join us in pressing for a long-term replacement to the current formula. Visit www.ama-assn.org to obtain a kit designed to help physicians talk to patients and members of Congress about the urgent need to prevent future cuts. The AMA can also use your help as we search for solutions to the health coverage crisis. The AMA is strongly advocating for incremental measures to expand coverage for children and lower-income families and individuals, and it is working diligently to build political pressure for action on both coverage and access to care. In the longer term, the AMA will continue to press for the adoption of a consumer-driven, market-based plan to expand coverage through tax credits and insurance market reforms. Efforts of interest to oncologists include the AMA's Science News section, which recently held a media briefing in New York to increase awareness of revolutionary new cancer treatments and how they allow physicians to focus on both patient survival and quality of life. Also, the Journal of the American Medical Association (JAMA) and the Archives specialty journals regularly publish the latest medical research on oncology-related issues. Joining the AMA—the nation's largest medical association—is one way ASCO members and other oncologists can help address the public health, public policy, and professional issues facing medicine today. Membership also allows you to voice your opinion on medicine's top issues, influence our annual health care agenda and participate in members-only activities such as Member Connect Surveys. In addition, AMA membership offers ASCO members the latest clinical research and professional publications: free subscriptions to JAMA, free online access and discounted print subscriptions to Archives specialty journals, and discounts on AMA bookstore products. Let's continue to join together to make a positive difference in the world of our patients and our profession. For more information, go to www.ama-assn.org.

Physicians in the United States have been affected by significant changes in the pattern(s) of medical practice evolving over the last several decades. These changes include new measures to 1) curb increasing costs, 2) increase access to patient care, 3) improve quality of healthcare, and 4) pay for prescription drugs. Escalating healthcare costs have focused concerns about the financial solvency of Medicare and this in turn has fostered a renewed interest in the economic basis of interventional pain management practices. The provision and systemization of healthcare in North America and several European countries are difficult enterprises to manage irrespective of whether these provisions and systems are privatized (as in the United States) or nationalized or seminationalized (as in Great Britain, Canada, Australia and France). Consequently, while many management options have been put forth, none seem to be optimally geared toward affording healthcare as a maximized individual and social good, and none have been completely enacted. The current physician fee schedule (released on July 12, 2007) includes a 9.9% cut in payment rate. Since the Medicare program was created in 1965, several methods have been used to determine physicians' rate(s) for each covered service. The sustained growth rate (SGR) system, established in 1998, has evoked negative consequences on physician payment(s). Based on the current Medicare expenditure index, practice expenses are projected to increase by 34.5% from 2002 to 2016, whereas, if actual practice inflation is considered, this increase will be 90%. This is in contrast to projected physician payment cuts that are depicted to be 51%. No doubt, this scenario will be devastating to many practices and the US medical community at large. Resolutions to this problem have been offered by MedPAC, the Government Accountability Office, physician organizations, economists, and various other interested groups. In the past, temporary measures have been proposed (and sometimes implemented) to eliminate physician payment cuts. At present, the US Senate and House of Representatives are separately working on 2 different mechanisms to address and rectify these cost-payment discrepancies. The effects of both the problem and the potential solutions on interventional pain management may be somewhat greater than those on other specialties. Physician payments in interventional pain management may evidence cuts of 10% to 15%, whereas if procedures are performed in an office setting, such cuts may range from 29% to 39% over the period of the next 3 years if the proposed 9.9% cut is not reversed. Medicare cuts also impact other insurance payments, incurring a "ripple effect" such that many insurers will seek to pay at or around the Medicare rate. In this manuscript, we discuss universal healthcare systems, the CMS proposed ruling and its attendant ripple effect(s), historical aspects of the Medicare payment system, the Sustained Growth Rate system, and the potential consequences incurred by both proposed cuts and potential solutions to the discrepant cost-payment issue(s). As well, ethical issues of policy development upon the infrastructure and practice of interventional pain management are addressed.

CMS Proposes Rule to Reimburse for Psychiatric Collaborative Care

Evolution in Reimbursement for Sleep Studies and Sleep Centers

CMS Highlights Special Focus Facilities