Congress must repeal the sustainable growth rate formula to stabilize Medicare physician payments, and CMS needs to adopt a series of strategies that would strengthen the Medicare program by enhancing the role of primary care physicians, said the American Academy of Family Physicians in a recent letter to CMS.
The scope of suggestion, engaged by the AAFP following the proposed 2013 Medicare physician fee schedule, was in flux. The AAFP at once called for Congress to repeal the sustainable growth rate (SGR) formula as a means to stabilize Medicare physician payments, then narrowed its lens to focus on CMS, which needs to adopt short-term and long-term strategies to strengthen Medicare through the enhancement of the physician’s role, according to the physician organization.
"An investment in primary care is the most efficacious way to improve the quality of health care services provided to Medicare beneficiaries while simultaneously restraining rising health care costs," wrote AAFP Board Chair Roland Goertz, MD, MBA, of Waco, Texas, in the Aug. 22 letter to CMS Acting Administrator Marilyn Tavenner.
Although the AAFP did cite support for CMS’s proposal to create a post-discharge transitional care management code system as an example of a short-term payment strategy, the organization was confused as to why CMS did not restrict code usage to primary care physicians, especially given the government entity’s acknowledgement that the coding would be used almost exclusively by PCPs.
“It is quite possible... that the beneficiary may visit more than one physician in either the 30 days prior [to] or 14 days post-discharge," Goertz noted on the topic of the new code. "In this scenario, CMS' proposal to pay only the first claim containing the new code creates an uncoordinated race to bill among the various physicians involved, rather than recognizing and rewarding the physician or practice that is actually coordinating the patient's post-discharge care. Thus...[the] AAFP recommends that CMS restrict the use and payment of this code to the patient's primary care physician."
Among other foci, Goertz mentioned the necessity for CMS to fine-tune the definition of advanced primary care practices.
"The AAFP understands the importance of using the proposed advanced primary care practice [APCP] framework to ensure that enhanced payments made to primary care physicians are tied to a corresponding expansion of the scope of primary care services to include effective care coordination and continuous quality improvement," Goertz wrote.
This could be a comprehensive, five-fold task Goertz added: "The use of the comprehensive primary care functions [a five-function approach developed for the CMS Comprehensive Primary Care Initiative] in a Medicare APCP would ensure that stakeholders across the healthcare industry can develop a better understanding of CMS' support for primary care providers and the expected returns in both quality improvement and cost control.”
Other Academy stances were articulated by Goertz as follows:
- CMS should not implement the Institute of Medicine's recommendations pertaining to geographic practice cost indices and should instead refocus efforts on ensuring a properly distributed healthcare workforce that is meeting the demands of a growing beneficiary population;
- supports proposals to add recently covered "additional preventive services" to the list of Medicare telehealth services for 2013;
- agrees with a proposal to add coverage of additional preventive services, but questions several of the proposed payment amounts;
- considers reasonable a proposal to require that a physician has a face-to-face encounter with a beneficiary within 90 days before or 30 days after a written order for certain Medicare-covered durable medical equipment;
- appreciates that CMS proposes to establish a Physician Quality Reporting System (PQRS) informal review process and to continue most of the program uninterrupted;
- supports a CMS proposal to create new criteria for being a successful electronic prescriber for groups of two to 24 eligible professionals using the electronic prescribing group practice reporting option, as well as a proposal to establish an informal review process;
- committed to CMS and the agency's contractors in efforts to properly validate RVUs for the identified and potentially misvalued codes;
- strongly supports CMS' proposal to streamline the implementation of the PQRS incentive and reporting programs within the context of the Medicare Shared Savings Program; and
- generally supports CMS' proposal to begin applying the value-based payment modifier only to groups of 25 or more eligible providers in 2015 so the agency can begin learning how to properly fulfill statutory requirements; however, the AAFP remains concerned with CMS' inability to specify the exact amount of the upward payment adjustment.
CMS is asking for public comment on the fee schedule through Sept. 4. The 2013 Medicare physician fee schedule is anticipated to be finalized and released in November.