September 3, 2015
Centers for Medicare & Medicaid Services
Department of Health and Human Services
P.O. Box 8013
Baltimore, MD 21244-8013
File Code: CMS–1631–P
Re: Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2016; Proposed Rule
Dear Mr. Slavitt:
The Healthcare Financial Management Association (HFMA) would like to thank the Centers for Medicare & Medicaid Services (CMS) for the opportunity to comment on the 2016 Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2016; Proposed Rule (hereafter referred to as the Proposed Rule) published in the Federal Register on July 15, 2015.
HFMA is a professional organization of more than 40,000 individuals involved in various aspects of healthcare financial management. HFMA is committed to helping its members improve the management of and compliance with the numerous rules and regulations that govern the industry.
HFMA would like to commend CMS for its thorough analysis and discussion of the myriad Medicare physician reimbursement decisions addressed in the 2016 Proposed Rule. Our members would like to comment on the proposals related to:
- Advance Care Planning Services
- Application of the Physician Value Modifier to participants in the Medicare Shared Savings Program (MSSP)
- Converting quality measures in the Medicare Shared Savings Program from pay-for-performance to pay-for-reporting
Below please find specific comments on the items listed above.
Advance Care Planning Services
CMS proposes to change the status for two advance care planning CPT codes (listed below) from inactive to active.
- CPT code 99497 (Advance care planning, including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed) by the physician or other qualified health professional; first 30 minutes, face-to-face with the patient, family member(s) and/or surrogate)
- CPT code 99498; and add-on code; (Advance care planning, including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health professional; each additional 30 minutes (List separately in addition to code for primary procedure)).
While CMS is not issuing a national coverage determination (NCD) for these codes, it would allow Medicare Administrative Contractors (MACs) the discretion to cover them. The proposed rule further states that CPT codes 99497 and 99498 (when applicable) should be reported when the services are “reasonable and necessary for the diagnosis or treatment of illness or injury.” The rule then provides an example of the services provided during an office visit in which an E/M code is billed related to a patient’s diabetes and heart failure.
HFMA strongly supports coverage for advance care planning services. We believe it is a crucial element of patient-centered care. As we state in our five key principles for payment reform, “Care decisions should be made through a shared decision making process where consumers’ values and preferences are identified and respected.1” Furthermore, in HFMA’s Value Project initiative, we identified the concerns that patients have in evaluating the quality of care they receive. These concerns include access, safety, outcomes, and respect. Respect for the patient’s needs comprises several elements. Respect involves asking about and discussing with patients their hopes and expectations for care, including open conversations about care alternatives and the attendant costs and benefits that will enable patients to make decisions about the level of care that is best for them. And it means respecting such fundamental patient needs as privacy, comfort, convenience of care, and security. Care delivery that respects each patient in these ways lead to higher patient and family satisfaction. At the same time, a clear understanding of what the patient wants may help avoid costs for care that the patient would prefer not to receive. Unfortunately, this shared decision making process does not occur as frequently as it should due to the sensitive, time-consuming nature of these conversations. Providing adequate physician reimbursement for the time and cognitive work related to these crucial conversations is key to ensuring that patients are appropriately educated on their options and fully engaged in their long-term care plan. All patients should have the opportunity, if they desire, to have their preferences documented, thereby helping ensure the care they receive is aligned with their values.
HFMA strongly believes CMS should issue an NCD for these services. Making the code “active” is a good first step. However, it is insufficient to further the cause of care that empowers patients to become active partners in their care planning. If CMS fails to issue an NCD, it creates the possibility that beneficiaries in some MAC jurisdictions will not have the opportunity to explore their options with their caregiver and have their preferences documented, even though other beneficiaries in a jurisdiction with a different MAC have access to this service. It would be unfortunate if some beneficiaries, at a crucial juncture in life, received care that is contrary to their values as an accident of geography.
Beyond ensuring access for all fee-for-service Medicare beneficiaries, issuing an NCD covering advance planning services would have a beneficial effect on Medicaid and commercial health plans. While many payers already provide coverage for advance care planning services, the signal effect of Medicare issuing an NCD would likely spur the remaining plans and Medicaid programs that do not provide such coverage to do so.
In the proposed rule, CMS asks if payment for advance care planning is appropriate beyond circumstances where the conversation occurs in conjunction with an office visit for an existing condition. HFMA strongly believes CMS should provide beneficiaries coverage for optional advance care planning services in other settings. Examples include, but are not limited to, an annual physical or the “Welcome to Medicare visit.” Instead of waiting for the onset of illness (particularly a catastrophic event, patients (and their families) should have the opportunity to carefully discuss and document their preferences with their care provider in a setting that is conducive to careful, contemplative decision making. The annual wellness visit is an ideal time for this discussion. Nothing in the proposed rule would prevent the beneficiary from subsequently discussing changes with their care provider and documenting their preferences in an updated care plan.
The changes HFMA recommends above (issuing an NCD and expanding the circumstances in which advance care planning coverage is available) are necessary but not sufficient to create an environment where patients are fully engaged partners in their care. Given the misconceptions around advance care planning, Medicare needs to undertake initiatives to educate beneficiaries on what the service is and is not. HFMA believes that beyond describing the service in the Medicare and You handbook, CMS should engage in partnerships with senior advocacy groups to educate beneficiaries. Very few individuals realize that, absent clearly documented care preferences, providers are compelled to render all available services. This will occur even under circumstances where the beneficiary, if given an option, would not want the level of care provided.
Beyond the suggestions for improvement above, HFMA believes CMS needs to clarify the frequency with which CPT code 99497 can be billed. While we recognize that CMS needs to balance judicious stewardship of Medicare Part B funds, we would encourage CMS to provide opportunities for beneficiaries to update their plans with their caregivers. Preferences are subject to evolve as health status changes, creating the potential for care plans developed at one point in time to be misaligned with what the beneficiary currently values. HFMA believes beneficiaries should have the opportunity to discuss their advance care plans with their physicians at least annually or immediately following a significant change in health status. (Examples include, but are not limited to, after a diagnosis of cancer or a stroke.)
Application of the Physician Value Modifier to Participants in the Medicare Shared Savings Program
HFMA strongly supports CMS’s proposal to use its waiver authority under section 1115A (d)(1) of the Social Security Act to exempt group practices and eligible professionals who are participating in the Pioneer ACO Model, Comprehensive Primary Care Initiative, Next Generation ACO Model, Oncology Care Model, and the Comprehensive ESRD Initiative from the physician value modifier.
HFMA believes the criteria (listed below) CMS articulated in the proposed rule to determine when an initiative should be exempt from the value modifier are appropriate.
- The model or initiative evaluates the quality of care and/or requires reporting on quality measures.
- The model or initiative evaluates cost of care and/or requires reporting on cost measures.
- Participants in the model or initiative receive payment based at least in part on their performance on quality and/or cost measures.
- The potential for conflict between the value modifier scoring methodology and the methodology used in the initiative.
- Other relevant factors specific to a model or initiative.
HFMA believes the Medicare Shared Savings Program (MSSP) fits the criteria above as well. As such, participating group practices and eligible providers should be exempt from the value modifier. Otherwise, CMS runs the risk of either rewarding or penalizing providers for the same performance twice. While CMS has stated it does not believe it has the authority to exempt MSSP participants from the value modifier, HFMA believes the Affordable Care Act provides sufficient flexibility. If the agency truly lacks the prerequisite authority, it should work with Congress to establish an appropriate waiver.
Converting Quality Measures in the Medicare Shared Savings Program from P4P to Pay-For-Reporting
In recognition that measures can become misaligned with clinical practice as care protocols evolve, CMS proposes to allow measures that no longer represent best practice to be converted to pay-for-reporting. CMS states that it would then make any necessary changes to the measure’s status in the next rulemaking cycle for the physician fee schedule. HFMA believes it is important that measures in the MSSP and other CMS programs are aligned with current clinical best practice. Therefore, with reservations, we support CMS’s proposal. HFMA recommends that in instances where a measure owner finds its measure is obsolete or potentially harmful to patients, CMS should stop collecting the measure immediately. Instead of requiring continued reporting, CMS should communicate this change through sub-regulatory guidance.
HFMA looks forward to any opportunity to provide assistance or comments to support CMS’s efforts to refine and improve the 2016 Physician Fee Schedule. As an organization, we take pride in our long history of providing balanced, objective financial technical expertise to Congress, CMS, and advisory groups.
We are at your service to help CMS gain a balanced perspective on this complex issue. If you have additional questions, you may reach me or Richard Gundling, Vice President of HFMA’s Washington, DC, office, at (202) 296-2920. The Association and I look forward to working with you.
Joseph J. Fifer, FHFMA, CPA
President and Chief Executive Officer
Healthcare Financial Management Association
HFMA is the nation’s leading membership organization for more than 40,000 healthcare financial management professionals. Our members are widely diverse, employed by hospitals, integrated delivery systems, managed care organizations, ambulatory and long-term care facilities, physician practices, accounting and consulting firms, and insurance companies. Members’ positions include chief executive officer, chief financial officer, controller, patient accounts manager, accountant, and consultant.
HFMA is a nonpartisan professional practice organization. As part of its education, information, and professional development services, HFMA develops and promotes ethical, high-quality healthcare finance practices. HFMA works with a broad cross-section of stakeholders to improve the healthcare industry by identifying and bridging gaps in knowledge, best practices, and standards.
1 Healthcare Financial Management Association. 2008. Healthcare Payment Reform: From Principles to Action .