Proposed Medicare Fee Schedule Rewards Primary Care

July 08, 2016

Medicare would pay primary care physicians more for coordinating patient care and treating individuals with cognitive, mobility, and behavioral problems under the program's proposed fee schedule for 2017, released yesterday.

In addition, Medicare would expand a successful diabetes prevention pilot program that physicians can offer to patients with prediabetes.

Andy Slavitt, the acting administrator for the Centers for Medicare & Medicaid Services (CMS), said in a news release that the proposals would "give a significant lift to the practice of primary care and to boost the time a physician can spend with their patients listening, advising, and coordinating their care — both for physical and mental health."

According to the CMS, the changes will more accurately recognize and reward the cognitive work and care management performed by primary care physicians and other clinicians who do not specialize in procedures. For example, the proposed fee schedule creates new codes to pay for certain evaluation and management (E/M) services that previously were bundled into other payment codes and that were considered undervalued by many primary care physicians. The new codes will cover the following:

  • Comprehensive assessment and care planning for patients with dementia and other cognitive impairments.

  • Office visits with patients who have mobility impairments. The CMS said such visits are costlier for physicians to provide.

  • Collaboration with psychiatrists and other mental health specialists to treat patients with behavioral problems.

The CMS also proposes to start paying for prolonged E/M services apart from face-to-face care using existing codes 99358 and 99359, which were previously unreimbursed. In its draft regulations, the agency said the codes would recognize "the extraordinary amount of time outside the in-person visit caring for the needs of individual patients."

Chronic care management (CCM) also gets a raise in the draft regulations. In 2015, Medicare began paying physicians for CCM chores such as helping patients fill out insurance forms, consulting with patients about medication over the telephone, and taking calls from patients during evenings or weekends under payment code 99490. The CMS proposes paying for more complex CCM using two other existing codes, 99487 and 99489. In addition, the CMS floated changes to make it easier for clinicians to furnish and bill for CCM.

Keeping pace with the digital revolution, the CMS said it wants to add three services to the list of those that a physician can provide via telehealth (think videoconference). The proposed additions are critical care consultations, advance-care planning, and certain services related to dialysis for patients with end-stage renal disease.

Prime Time Coming for Diabetes Prevention Pilot

Another major provision of the proposed fee schedule seeks to help Medicare beneficiaries at high risk for type 2 diabetes avoid developing the condition through more exercise, better diet, and weight loss of at least 5%. The means to that end is a diabetes prevention program (DPP) piloted by the the CMS Innovation Center. Created and operated by the YMCA, the program saved an estimated $2650 over 15 months per Medicare beneficiary, putting it in the black, according to the CMS.

DPP participants meet as a group for 16 sessions of dietary coaching, moderate physical activity, and education on topics such as stress management and "healthy eating out." Participants who attended at least four sessions in the pilot lost an average of 9 pounds. Follow-up sessions are designed to help keep the weight off.

In light of these good outcomes, the CMS wants to offer the program on a more widespread scale beginning in 2018, either taking it nationwide or phasing it in, perhaps by geographical area. Potential program sponsors include hospitals, public health departments, community organizations such as the YMCA, medical practices, and churches. Reimbursement after 1 year would max out at $450 per enrollee, with $185 of that contingent on weight loss of 9%.

Medical practices may not necessarily have the staff, money, or inclination to offer the program themselves, but they can refer their patients to organizations that do. The YMCA, for example, partnered with the American Medical Association and other medical societies to encourage clinicians to send their patients to the pilot program.

The deadline for public comments on the proposed fee schedule is September 6. The fee schedule explains how to submit comments.

Follow Robert Lowes on Twitter @LowesRobert


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