Family physicians disappointed that CMS continues complex chronic care management regulations.

Nov. 7—The massive final rule for the 2017 Medicare Physician Fee Schedule aims to refocus Medicare on primary care and behavioral health, provide an additional $140 million for such services, and save money through diabetes prevention.

The rule also seeks to ease data collection burdens on surgeons and primary care physicians, while helping accountable care organizations (ACOs) clarify which patients are their responsibility.

“We’ve discussed a number of times how our country’s health care system historically invested far more in treating sickness than maintaining health,” Andy Slavitt, acting director for the Centers for Medicare & Medicaid Services (CMS), and Patrick Conway, MD, acting principal deputy administrator and chief medical officer for CMS, wrote in a blog post. “This imbalance contributes to more spending on institutions, hospitals, and nursing homes, rather than keeping people healthy at home and in their communities. By better valuing primary care, care coordination and prevention, we help people access the services they need to stay well.”

To illustrate the direction it intends to take, CMS spotlighted a diabetes joint effort funded by the Center for Medicare & Medicaid Innovation  and included having the YMCA, American Medical Association (AMA), American Diabetes Association, and the American Heart Association work together to initiate lifestyle changes and other interventions to prevent diabetes in at-risk seniors.

CMS estimated it will spend $42 billion more in 2016 on Medicare beneficiaries with diabetes than those without. This includes estimated per-beneficiary increase in spending of $1,500 on prescription drugs, $3,100 for hospital and facility services, and $2,700 for other clinical services. The diabetes prevention effort will be expanded to include all eligible Medicare beneficiaries starting Jan. 1, 2018.

Chronic Issues

The diabetes program expansion was applauded by the AMA, which also praised CMS for revising its methods for surgical data collection and easing the administrative data-reporting burden for primary care physicians providing chronic care management services.

The American College of Physicians (ACP) internal medicine society also praised the chronic care payment changes. ACP said the payment changes will “reduce barriers to effective care of patients with chronic illnesses by allowing payment for more complex, time-intensive chronic care management (CCM) services.”

The CMS estimated that the new codes for CCM and other patient-centered care services eventually could increase payments to geriatricians, internists and family physicians from 30 to 37 percent. The American Academy of Family Physicians (AAFP), however, was skeptical.

While AAFP noted its support for expansion of the Medicare Diabetes Prevention Program, an AAFP statement called for the elimination of patient co-pays for CCM services and said the fee schedule did not revise enough misvalued payment codes for family physicians to receive a positive 0.5 percent pay increase for 2017 under the Medicare Access and CHIP Reauthorization Act.

The AAFP noted that CMS was “adding regulatory burdens” for primary care physicians, such as having to consult appropriate use criteria for ordering advanced imaging tests. The organization said it was disappointed about ongoing administrative burdens connected to payment for CCM services.

“We remain concerned about the overly burdensome documentation requirements for these services and the level of complexity this adds to the provision of these services,” the AAFP wrote.

In the final rule, the CMS acknowledged this criticism.

“Practitioners have stated that the service elements and billing requirements are burdensome, redundant and prevent them from being able to provide the services to beneficiaries who could benefit from them,” the final rule stated.

Since the establishment of code 99490 in 2015 to pay for up to 20 minutes each month to manage the care for patients with multiple chronic conditions, CMS reports that about 513,000 unique Medicare beneficiaries received the service an average of four times each, resulting in $93 million in total payments. 

ACO Attribution

New provisions in the final rule related to ACOs received praise for encouraging patient engagement and for clarifying the patients for who ACOs are responsible.

“Members of the Premier alliance commend CMS for finalizing a policy allowing beneficiaries to proactively designate an ACO professional as responsible for their overall care,” Blair Childs, a spokesman for Premier, a hospital quality improvement company, said in a statement. “This will help providers better target care and track progress compared to cost and quality goals.”

The AMGA, which is a trade organization of medical groups, agreed.

“ACOs need to know as much as possible about their patient population, and having engaged beneficiaries affirmatively select and be prospectively assigned will help ACOs better care for their patients,” Donald Fisher, PhD, president and CEO of the AMGA, said in a statement.

The ACP agreed, and praised CMS for better aligning quality reporting with proposals for the Quality Payment Program.

Andis Robeznieks is a freelance writer based in Chicago. Follow Andis on Twitter at @AndisRobeznieks.


Publication Date: Monday, November 07, 2016