American Gastroenterological Association - Advancing the Science and Practice of Gastroenterology

On July 1, 2009, CMS posted a proposed rule that would establish new policies and payment rates for physicians and other providers who are paid under the Medicare physician fee schedule for 2010. The rule was published in the Federal Register on July 13, 2009.

Medicare Payment Update

CMS has estimated the overall impact of the 2010 update to the physician fee schedule at - 21.5 percent, absent Congressional intervention. This negative update is required under the sustainable growth rate (SGR) formula and includes the cumulative impact of the Tax Relief and Health Care Act of 2006 (TRHCA).

The rule included an announcement that the Obama Administration will change the definition of physician services under the SGR to exclude physician-administered drugs. The drug costs will be removed retroactive to the 1996/97 base year of the SGR formula, which will greatly lessen the forecast SGR cuts in years after 2010. This action will substantially reduce the legislative cost of congressional proposals to reform physician payments and makes a permanent solution to the SGR formula much more feasible.

Physician Practice Information Survey (PPIS)

The AMA conducted a new Physician Practice Information Survey (PPIS) during 2007 through 2008, which was designed to update the specialty-specific practice expense per hour (PE/HR) data used to develop practice expense (PE) relative value units (PE RVUs) in the physician fee schedule.

The PPIS is a multi-specialty, nationally representative, PE survey of both physician and non-physician practitioners (NPP) that utilized a survey instrument and methods highly consistent with those used for the 1999 Socioeconomic Monitoring System (SMS) and the supplemental surveys. The PPIS gathered information from 3,656 respondents across 51 physician specialty and health-care professional groups. The AGA, ASGE, ACG and AASLD participated in this survey process.

CMS proposes to utilize the PE/HR, developed using PPIS data for all Medicare recognized specialties that participated in the PPIS, for payments effective Jan. 1, 2010. Under this proposal, the gastroenterology PE/HR drops from its 2009 level of $101.30 per hour to $96.78 per hour. The GI societies will be analyzing the impact of this change.

Consultation Codes

A consultation service is an evaluation and management (E/M) service furnished to evaluate and possibly treat a patient’s problem(s). It can involve an opinion, advice, recommendation, suggestion, direction or counsel from a physician or qualified NPP at the request of another physician or appropriate source.

For many years, physicians have been dissatisfied with Medicare documentation requirements and guidance that distinguish a consultation service from other E/M services such as transfer of care, referral and new patient.

CMS proposes to eliminate the use of all consultation codes (inpatient and office/outpatient codes for various places of service except for telehealth consultation G-codes) by increasing the work RVUs for new and established office visits, increasing the work RVUs for initial hospital and initial nursing facility visits, and incorporating the increased use of these visits into their PE and malpractice RVU calculations.

CMS believes the rationale for a differential payment for a consultation service is no longer supported because documentation requirements are now similar across all E/M services. CMS would make this change budget neutral by increasing the work RVUs for new and established office visits by approximately 6 percent to reflect the elimination of the office consultation codes and the work RVUs for initial hospital and facility visits by approximately 2 percent to reflect the elimination of the facility consultation codes.

CMS is soliciting comments on its proposal to eliminate payment for all consultation services codes under the fee schedule and to allow all physicians to bill, in lieu of a consultation service code, an initial hospital care visit or initial nursing facility care visit for their first visit during a patient’s admission to the hospital or nursing facility. Additionally, CMS is soliciting comments on the proposal to create HCPCS G-codes to identify the telehealth delivery of initial inpatient consultations.

Imaging Issues

According to the Government Accountability Office (GAO), spending on advanced imaging services, such as computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET), is growing almost twice as fast as spending on other types of imaging services. CMS is concerned about the rapid utilization and cost of advanced imaging services.

The current payment rates assume that a physician who owns this type of equipment will use it about 50 percent of the time, but recent data from the Medicare Payment Advisory Commission (MedPAC) suggest this expensive equipment is being used more frequently. As the use of this type of equipment increases, the per-treatment costs for purchasing, maintaining and operating the expensive equipment declines, making a reduction in payment appropriate.

MedPAC conducted a survey in six sites in the U.S. and found that MRI and CT machines are used much more than the 25 hours per week that CMS assumes. All of the equipment cited in the MedPAC studies is priced over $1 million. Therefore, CMS is proposing to change the equipment usage assumption from the current 50 percent usage rate to a 90 percent usage rate for equipment priced over $1 million. This change will have a redistributive effect in the fee schedule as dollars from expensive imaging services are redistributed. CMS will continue to analyze data regarding equipment priced at less than $1 million dollars but will make no change at this time.

CMS is also proposing to implement a requirement in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MIPPA) that suppliers of the technical component of advanced imaging services be accredited beginning Jan. 1, 2012. The accreditation requirement would apply to mobile units, physicians’ offices and independent diagnostic testing facilities that create the images, but would not apply to the physician who interprets them.

Physician Quality Reporting Initiative (PQRI)

The PQRI is a voluntary reporting program that provides an incentive payment to eligible professionals who satisfactorily report data on quality measures for covered professional services during a specified reporting period.

For gastroenterology, CMS has proposed its first GI specific measure group (hepatitis C) which would be reportable through either claims-based reporting or registry-based reporting. Other individual measures in the 2010 proposal of interest to GI are measures 113 (Colorectal Cancer Screening), 128 (Body Mass Index Screening and Follow-up) and 185 (Colonoscopy Interval for Patients with a History of Adenomatous Polyps –Avoidance of Inappropriate Use). These measures are currently included in the 2009 PQRI measures set.

For 2010, participants in the PQRI program are eligible for an incentive payment equal to 2.0 percent of the estimated total allowed charges. While the PQRI program is only authorized through 2010, additional funding is being addressed in the health reform legislation currently being debated in Congress.

Beginning with the 2010 PQRI, group practices will also be eligible to participate in PQRI. CMS proposes that group practice reporting be required to report on a common set of 26 NQF-endorsed quality measures that target high-cost chronic conditions and preventive care.

The PQRI reporting period for 2010 is Jan. 1, 2010 to Dec. 31, 2010 for claims-based reporting. CMS is inviting comments on its decision not to propose a 6-month reporting period for claims-based reporting of individual PQRI quality measures. The proposed rule does allow for half-year reporting when reporting measures groups, registry-based reporting or reporting of measures through an electronic health record (EHR).

CMS anticipates that by Dec. 31, 2009, it will be able to post a list of those registries qualified for the 2010 PQRI. Data reported through registries would not be due to CMS until Feb. 28, 2011. The AGA is moving forward on registry development efforts, and details will be announced in a future edition of eDigest.

CMS is specifically proposing to add an EHR-based reporting mechanism for the 2010 PQRI in order to promote the adoption and use of EHRs and to provide both eligible professionals and CMS experience on EHR-based quality reporting. CMS would accept data from qualifying EHRs on ten proposed individual PQRI measures, one of which is Measure 113 (Colorectal Cancer Screening). In the 2010 proposal, eligible providers who satisfactorily report data on at least three of the 10 proposed EHR-based individual PQRI measures would be eligible for an incentive payment. CMS does not propose an option to report measures groups through EHR-based reporting on services furnished during 2010.

CMS is considering significantly limiting the claims-based mechanism of reporting clinical quality measures for the PQRI after 2010. This would be contingent upon there being an adequate number and variety of registries available and/or EHR reporting options. CMS would retain claims-based reporting for specific structural measures, such as Measure 124 Health Information Technology (HIT): Adoption/Use of Electronic Health Records (EHR) and circumstances where claims-based reporting is the only available mechanism available for a specific measure.

Title IV of the American Recovery and Reinvestment Act of 2009 (Recovery Act) authorizes CMS to make incentive payments through the Medicare and Medicaid programs to eligible professionals and hospitals who become “meaningful users” of certified EHRs. CMS will address the implementation of the Recovery Act’s incentive program in separate rulemaking.

As required by MIPPA, following the distribution of 2010 incentive payments, CMS will post on its Web site the names of electronic prescribers and group practices who satisfactorily report quality measures.

Electronic Prescribing

Eligible professionals or group practices that meet the Electronic Prescribing Incentive Program requirements for 2010 will be eligible for an incentive payment of 2 percent. CMS is proposing to simplify the reporting requirements for the electronic prescribing measure and to provide eligible professionals with more reporting options. CMS is also proposing a new process for group practices to be considered successful electronic prescribers.

MIPPA established a five-year program of incentive payments to electronic prescribers who are successful electronic prescribers. Beginning in 2012, the program will impose penalties on physicians who are not successful e-prescribers.

Incentive payments for electronic prescribers will be:

• 1.0 percent for 2011
• 1.0 percent for 2012
• 0.5 percent for 2013

Penalties will be incurred for non-successful electronic prescribers starting in 2012. The reductions in fee schedule payments will be:

• 1.0 percent for 2012
• 1.5 percent for 2013
• 2.0 percent for 2014

Physician Resource Use Measurement and Reporting Program

CMS was required under MIPPA to establish and implement by Jan. 1, 2009 a Physician Feedback Program using Medicare claims data and other data to provide confidential feedback reports to physicians (and as determined appropriate by the Secretary, to groups of physicians) that measure the resources involved in furnishing care to Medicare beneficiaries.

CMS solicited initial comments on this feedback program in the 2009 final physician rule. Commenters were in favor of using both the per capita and the per episode measurement methodologies proposed by CMS. Commenters were overwhelmingly in favor of including E/M services, imaging services, laboratory services, outpatient services, procedures, and post-acute services and using three years of data.

CMS intends to finalize the feedback conditions in the upcoming final rule for 2010 to include:

• Congestive heart failure.
• Chronic obstructive pulmonary disease.
• Prostate cancer.
• Cholecystitis.
• Coronary artery disease with acute myocardial infarction.
• Hip fracture.
• Community-acquired pneumonia.
• Urinary tract infection.
• Diabetes.

Based on the high cost and high volume conditions, CMS included the following physician specialties in phase I of the Physician Resource Use Measurement and Reporting Program: general internal medicine, family practice, gastroenterology, cardiology, general surgery, infectious disease, neurology, orthopedic surgery, physical medicine and rehabilitation, pulmonology, and urology. CMS will continue to include these physician specialties in the final rule.

CMS is soliciting public comment on the use of proprietary products to measure episodes of the care in the Program. CMS is also soliciting public comment on the design and elements of the sample resource use report used in phase I.

For phase II of the Program, CMS is proposing to expand it in ways that will make the information more meaningful and actionable for physicians. CMS is proposing to add reporting to groups of physicians, recognizing that physicians practice in various arrangements. CMS is also proposing to add quality measurement information as context for interpreting comparative resource use.

Physician Value-Based Purchasing

CMS continues to develop its Physician Value-Based Purchasing Program (PVBP). Therefore, CMS is soliciting public comments on the appropriateness of resource use measurement and reporting for different types of groups of physicians.

CMS has adopted the following goal to improve Medicare beneficiary health outcomes and experience of care by using payment incentives and transparency to encourage higher quality, more efficient professional services. In pursuit of this goal, the PVBP Workgroup has defined the following objectives:

• Promote evidence-based medicine through measurement, payment incentives and transparency.
• Reduce fragmentation and duplication through accountability across settings, alignment of measures and incentives across settings, better care coordination for smoother transitions, and attention to episodes of care.
• Encourage effective management of chronic disease by improving early detection and prevention, focusing on preventable hospital readmissions, and emphasizing the importance of advanced care planning and appropriate end-of-life care.
• Accelerate the adoption of effective, interoperable HIT, including clinical registries, e-prescribing and electronic health records.
• Empower consumers to make value-based health-care choices and encourage health professionals to improve the value of care by disseminating actionable performance information.

The goal and objectives of PVBP were captured in a CMS Issues Paper. AGA provided formal comments to CMS on this paper and will continue to provide public input on this process. CMS is required to submit a report to Congress next year on PVBP.

MedPAC

The Medicare Payment Advisory Commission (MedPAC) has in the past recommended the establishment of a group panel of experts separate from the AMA Relative Value Update Committee (RUC) to review relative value units (RVUs). The idea of a group of experts separate from the AMA RUC, to help the agency improve the review of relative values, raises a number of issues. CMS seeks input on the following questions and other aspects of such an approach:

• How could input from a group of experts best be incorporated into existing processes of rulemaking and agency receipt of AMA RUC recommendations?
• What, specifically, would be the roles of a group of experts (for example, identify potentially misvalued services, provide recommendations on valuation of specified services, review AMA RUC recommendations selected by the Secretary, etc.)?
• What should be the composition of a group of experts? How could such a group provide expertise on services that clinician group members do not furnish?
• How would such a group relate to the AMA RUC and existing Secretarial advisory panels such as the Practicing Physician Advisory Committee?

Competitive Acquisition Program

CMS is proposing a number of changes to the Competitive Acquisition Program (CAP) to make the program more flexible and workable for physicians and suppliers to encourage participation in program.

The CAP resulted from the Medicare Modernization Act of 2003 (MMA) as an alternative to the average sale price methodology of obtaining certain Part B drugs used incident to physicians’ services. Physicians who choose to participate in the CAP obtain drugs from vendors selected through a competitive bidding process and approved by CMS. Under the CAP, participating physicians agree to obtain all of the approximately 180 drugs on the CAP drug list from an approved CAP vendor. The approved CAP vendor retains title to the drug until it is administered, bills Medicare for the drug and bills the beneficiary for cost sharing amounts once the drug has been administered. The participating CAP physician bills Medicare only for administering the drug to the beneficiary. For gastroenterologists, drugs included under the CAP program include Remicade^®, Tysabri^® and Photofrin^®.

The 2009 CAP was postponed due to contractual issues with the successful bidders. As a result, CAP physician election for participation in the CAP in 2009 was put on hold, and CAP drugs have not been available from an approved CAP vendor for dates of service after Dec. 31, 2008.

CMS is proposing many changes to the CAP program for 2010 including:

• Reporting of timely quarterly data.
• Improving the CAP list of available drugs.
• Addressing the emergency restocking option.
• Easing the restriction on physicians transporting CAP drugs to settings other than the physician’s office.
• Addressing the dispute resolution process for the CAP for both vendors and physicians.

CMS is hoping these changes will improve the CAP program.

Geographic Practice Cost Indices (GPCIs)

As required under MIPPA, beginning on Jan. 1, 2010, the 1.000 work GPCI floor will be removed except for the 1.500 work GPCI floor for Alaska, which will remain in place. In the 2009 proposed physician rule, comments were accepted on an Interim Locality Study Report to address potential GPCI changes and reconfiguration of states, specifically in California. CMS did not make any changes for 2009. CMS intends to review the suggestions made by the commenters and consider the impact of each of the potential alternative locality configurations. A final report will be posted to the CMS website after further review of the studied alternative locality approaches.

At this time, CMS is not proposing changes in the physician fee schedule locality structure. In the event CMS decides to make a specific proposal for changing the locality configuration, CMS will provide extensive opportunities for public input.

Malpractice Relative Value Units (RVUs)

CMS is required to review its resource-based malpractice RVU methodology at least every five years. The proposed malpractice RVUs were developed by Acumen, LLC under contract to CMS. The methodology presented in this proposed rule conceptually follows the specialty-weighted approach used in the CY 2000 and CY 2005 PFS final rules with comment. CMS revised the current specialty-weighted approach to accommodate additional data gathered during the malpractice premium data collection. The specialty-weighted approach bases the malpractice RVUs upon a weighted average of the risk factors of all specialties furnishing a given service. This approach ensures that all specialties furnishing a given service are accounted for in the calculation of the final malpractice RVUs. CMS provides its proposed methodology and requests comments from interested parties.

Initial Preventive Physician Exam (IPPE)

CMS is proposing to increase the payment rates for the Initial Preventive Physical Exam (IPPE), also called the “Welcome to Medicare” visit, to be more in line with payment rates for higher complexity services. The IPPE benefit was mandated by MIPPA to pay for an initial assessment of key elements of a beneficiary’s health status within six months of the beneficiary’s enrollment in Medicare Part B. Subsequently, Congress has extended the time period for the IPPE benefit to within one year of the beneficiary’s enrollment in Part B.

Conclusion

CMS will accept comments on the proposed rule until Aug. 31, 2009 and will respond to all comments in a final rule to be issued by Nov. 1, 2009. The new payment rates and policies will apply to services furnished to Medicare beneficiaries on or after Jan. 1, 2010.