Medicare Making Progress on Doctor Pay System


A government watchdog gave the Medicare agency a Christmas present last week when it said that its staff hasn’t done a bad job assembling the new Medicare reimbursement system for clinicians … so far.

The Centers for Medicare & Medicaid Services “has made significant progress towards implementing” the quality payment program, the Health and Human Services Office of Inspector General said in a Dec. 21 report.

“CMS has built a promising foundation for managing the initial transition” from the old hated sustainable growth rate payment formula to the new program for doctors and other professionals, which kicks in Jan. 1, the OIG’s progress report said.

But if you think the agency’s implementation job is winding down, well “Ho Ho Ho.”

Now that Christmas is over, the agency faces a host of specters it must tend to in the coming year.

The OIG said extensive subregulatory guidance promised in the final rule, published in October, needs to be issued. Just as important, the agency’s IT systems must be ready to validate doctors’ reporting data, provide performance feedback, and, of course, adjust payments based on performance.

The hundreds who sent comments to the CMS about the new program in December frequently mentioned these issues:

  • Virtual groups: The law that created the new program allows practices of not more than 10 clinicians to join “virtual groups” and combine their quality reporting. How should these be structured and implemented?
  • Low Volume Threshold: Practices will be excluded from 2017 program requirements if they have no more than $30,000 in Part B allowed charges or 100 Medicare patients. More than half of clinicians, as many as 780,000, are off the hook this year. Can it be lowered further?
  • Nonpatient-facing clinicians: What about doctors, like pathologists, who don’t have face-to-face patient interaction? Will they have sufficient activities to report under the program’s quality performance categories? The American College of Radiology told me Dec. 28 that members are still waiting for information that will determine that. 

And the 2017 transition year with its relaxed quality reporting requirements. Can’t it be continued through 2018, some pleaded.

Those are just a few issues to be tackled.

The CMS also needs to develop its IT system that forgives clinicians’ “errors or missteps” when they're sending data, Thomas Gustafson, a senior health policy adviser with Arnold & Porter in Washington, told me. Doctors who are naïve about how to do reporting shouldn't be penalized to the tune of a 4 percent cut if they press the wrong button, Gustafson, a CMS alumnus, said.

You can find my full article on the OIG report here:

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