By Mindy Yochelson
Nov. 13 --Physician groups
commenting on a bipartisan congressional draft that would revamp the Medicare
physician (Part B) payment system said they were pleased it would end
Medicare's sustainable growth rate (SGR) formula but worried about a proposed
freeze on annual physician payment updates for 10 years.
physician payments have already trailed inflation for nearly 10 years and
extending this freeze for another decade will result in a cumulative gap
between Medicare payments and the cost of treating patients of nearly 45
percent,” the Alliance
of Specialty Medicine said.
The heart of the draft, which was issued
for comment by the chairmen of the House Ways and Means and Senate Finance
committees Oct. 31 would replace the SGR with a pay-for-value system focused on
medical outcomes rather than procedures .
Comments on the draft were due
to the committees by Nov. 12.
would permanently repeal the SGR update mechanism but provide no updates--that
is, increases in pay-- through 2023.
The SGR is the formula that ties
physician payment updates to the relationship between overall fee schedule
spending and growth in gross domestic product. It has resulted in payment cuts
that lawmakers have stopped annually at the last minute.
reimbursement will be cut by 24.4 percent on Jan. 1, 2014, unless Congress
institutes another patch or a permanent fix.
The Medical Group Management Association (MGMA) said that
instead of a freeze, “a new Medicare physician payment system should adequately
reimburse physician group practices for annual increases in the basic costs of
providing patient care.” Doing so “will provide a solid transitional foundation
to implement new value-based payment mechanisms.”
Osteopathic Association (AOA) called predictable positive annual updates a
necessity. However, if that isn't possible due to fiscal constraints, AOA
suggested that the Department of Health and Human Services “be charged with
monitoring inflation, patient access, and participation rates of physicians in
Medicare.” If beneficiary access to physicians declines, then “changes to the
baseline payment rate can be adjusted.”
The new proposed pay system, called the Value-Based Performance (VBP)
Payment Program, would allow individual physicians and other Part B providers
to earn performance-based incentive payments through a compulsory
The draft would adjust physician payments by
combining the current quality incentive programs--the Physician Quality
Reporting System, the Value-Based Modifier and the Electronic Health Record
Meaningful Use program--into one comprehensive program.
say the one incentive payment program would represent a more streamlined
approach than maintaining the three distinct programs. In addition, under the
draft, penalties that would have been assessed under the three current quality
programs would sunset at the end of 2016.
The AOA applauded the alignment
and harmonization of the current quality reporting programs and said the
administrative burden on physicians would be reduced.
However, the AOA
cautioned that “an immediate transition away from the programs would undermine
the investments that have already been made in these important programs, such
as the costly purchases” of electronic health records systems.
The VBP program would apply to physicians beginning with
payment year 2017; to physician assistants, nurse practitioners and clinical
nurse specialists beginning with payment year 2018; and to all others beginning
with payment year 2019.
The Alliance of Specialty Medicine disagreed
that the VBP program should apply to all physicians beginning with payment year
“Reforms that hold physicians accountable for value need
appropriate time for proper implementation,” according to the Alliance, which
represents about a dozen specialty groups.
“This proposal includes no
mechanisms to ensure careful and incremental implementation, nor does it
differentiate between practices that are better equipped with resources and
experience to fulfill performance-based reporting mandates versus those that
are not,” it said.
Physical Therapy Association said that the legislation should ensure that
physical therapists will be eligible to participate in the quality program.
In addition, the APTA said all providers should be transitioned into the VBP
program at the same time, rather than phased in over several years, to drive
providers toward quality in the near term. “There should not be a delay in
beginning quality reporting and all providers, including physical therapists,
should be eligible for payment beginning in 2017.”
A coalition of 15
Medicare beneficiary advocacy groups, including the Medicare Rights Center and the Center for Medicare
Advocacy Inc., said they were pleased with the proposed VBP program but urged
that the congressional committees include clear criteria for individual
measures, “including documentation of clinical importance, evidence base,
transparency, reliability, validity, feasibility, ability to act on results and
rigorous auditing, in subsequent SGR policy drafts.”
The American Academy of Family Physicians said it was
concerned that the VBP program's budget-neutrality provision would cause
practices not to be “measured by their results in improving quality and
controlling costs against themselves, but rather against the performance of all
Under such a “hypercompetitive environment,” the AAFP
said, a practice might make “significant strides in clinical practices, quality
improvement, resource management, and meaningful use” of electronic health
records but then get little or no financial reward because of “similar or
greater improvements among peer physicians.”
The proposal would encourage physicians to participate in
alternative payments models (APMs), such as medical homes or accountable care
organizations, by exempting them from the VBP program and instead offering them
a bonus payment.
Specifically, physicians who obtain a significant share
of their revenue through alternative payment models that involve two-sided
financial risk (meaning loss and gain) and a quality measurement component
would receive a 5 percent bonus payment each year from 2016 through 2021.
The MGMA said it supports the concept but believes there's a need for
continued testing and development of these alternative reimbursement and care
“Moving too quickly toward a payment alternative risks
repeating the mistakes of the SGR,” the MGMA said.
“We must be sure to
allow sufficient time for the testing and development of alternative payment
models and the data they rely on so a viable replacement can be produced which
utilizes sound data, provides all physicians with a chance to succeed and
results in the delivery of high quality, coordinated care for patients.”
The American College of Emergency Physicians reminded the
committees that not all physicians are able to fit into prescribed models.
“ACEP encourages you to discuss the difficulty the Centers for Medicare &
Medicaid Services (CMS) has had to date in developing a sufficient APM model
for emergency care,” ACEP said.
The APMs pursued by private insurers and
the CMS “lend themselves to physicians whose primary role is care coordination
or managing chronic diseases,” ACEP said.
“ACEP urges you to consider
these factors and provide exemptions for emergency care from the VBP and APM
reimbursement systems, at least for some extended period of time to allow
emergency physicians to work with CMS to develop and test models that may be
appropriate for the manner in which we provide care to our patients.”
Another part of the proposal would encourage
care management services for individuals with complex chronic care needs
through the development of new payment codes for such services, beginning in
The Alliance of Specialty Medicine objected to this provision,
saying it wasn't within Congress's purview.
“Processes to develop
billing and reimbursement codes are well established and already consider input
from public and private stakeholders in an open and transparent forum,”
according to the Alliance.
Further, the provision “states that codes
could be billed by specialty physician practices that meet certain criteria,
but it is unlikely many specialty physicians would meet the criteria,” the
However, the American College of Physicians said it was
pleased to see that the draft would solidify in statute new codes that the ACP
believes are an important step in recognizing the full breadth of primary
Similarly, the Marshfield
Clinic in Wisconsin said that major chronic diseases that afflict a
relatively small percentage of individuals account for most of the expense in
“We support your recommendation to encourage care
coordination for individuals with complex chronic care needs, by establishing
payment codes for care management services,” Marshfield said. “Relative values
for such services would be negligible, but for the want of a service code, many
such services are shifted unnecessarily to higher cost settings.”
The proposal also would require physicians
ordering tests for advanced imaging or electrocardiogram services to consult
appropriate use criteria, which would be specified by the Department of Health
and Human Services in consultation with stakeholders. Payment wouldn't be made
if consultation with appropriate use criteria didn't occur.
prior authorization would apply to “outlier” professionals whose ordering is
inconsistent as compared with that of their peers.
The MGMA urged
“caution in labeling physicians as outliers without first conducting a thorough
assessment of the physician's case mix and other variables that may skew an
analysis of his or her ordering patterns.” Physicians should be able to appeal
an outlier designation, MGMA recommended.
In addition, prior
authorization “is extremely burdensome on practices, who must expend staff time
and money in order to facilitate the prior authorization process,” it
Further, authorization requirements “can lead to delays in the
delivery of care, sometimes for a week or more, which can be particularly
difficult for a Medicare patient who may rely on others for transportation to
If this ends up in final legislation, Congress
should “add language requiring that the prior authorization process be
transparent, based on evidence-based, physician developed appropriate use
criteria and not, as is commonly used in the private sector, 'black box' edits
which are not peer reviewed,” the MGMA said.
The Medical Imaging & Technology Alliance (MITA) said it
was encouraged that the prior authorization program was restricted to
“MITA stresses that criteria used in any prior authorization
requirement must be based on physician-developed appropriate use criteria and
such criteria should be totally transparent and in the public domain,” the
group said. “And, the program needs to be structured in such a way that does
not increase the bureaucracy of the Medicare program or delay care for Medicare
beneficiaries, even those with non-urgent conditions.”
contact the reporter on this story: Mindy Yochelson in Washington at firstname.lastname@example.org
To contact the editor
responsible for this story: Ward Pimley at email@example.com
The comments are at http://op.bna.com/hl.nsf/r?Open=bbrk-9deuww (Marshfield
(Alliance of Specialty Medicine), http://op.bna.com/hl.nsf/r?Open=bbrk-9deuzu (groups
including Medicare Rights Center), http://www.medicalimaging.org/wp-content/uploads/2013/11/FINAL-MITA-Comments-re-WM-SFC-SGR-Disc-Draft-11.12.13.pdf
(MITA), http://op.bna.com/hl.nsf/r?Open=bbrk-9dev2t (emergency
(MGMA) and http://op.bna.com/hl.nsf/r?Open=bbrk-9dev4h
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