American Gastroenterological Association - Advancing the Science and Practice of Gastroenterology

AGA Continues to Fight for Fair Medicare Reimbursements

CMS has released the 2012 Medicare physician fee schedule (MPFS) final rule, which reduces reimbursement rates for physician services in 2012 by  27.4 percent — a drastic cut that AGA is committed to fighting. Important for GIs is a provision in the 2012 Physician Quality Reporting System (PQRS) that allows eligible professionals (EPs) to earn a 0.5 percent incentive for successfully reporting measures, including a new AGA IBD measures group. The measures need to be captured via registries only and are supported by the AGA Digestive Health Outcomes Registry^®.

The AGA understands and appreciates the concerns about government spending, but believes steps must be taken to protect and strengthen the Medicare program. We support CMS in its call to Congress to fix the current sustainable growth rate (SGR) formula. Before access to care is further threatened for the millions of patients who depend on the Medicare program, Congress must replace the SGR formula with a stable and equitable payment mechanism that reflects the costs of caring for Medicare beneficiaries and ensures access to high-quality care.

AGA, along with all of organized medicine, will continue to advocate for a permanent solution to the broken payment system that provides fair, equitable and predictable reimbursement to physicians.

Reimbursement Rate Changes
CMS calculates the CY 2012 MPFS conversion factor to be $24.6712. By law, CMS is required to make these reductions, which can only be averted by an act of Congress. CMS notes in the rule that, while Congress has provided temporary relief from these reductions every year since 2003, a long-term solution is critical. They will work with Congress to fix this untenable situation so doctors and beneficiaries no longer have to worry about the stability and adequacy of Medicare payments under the physician fee schedule.

Other changes include:

• CMS clarified that the measures contained in the IBD measures group should not be reported as individual measures and need to be captured via registries only such as the AGA  Registry. The IBD measures included in the 2012 PQRS program were developed by the AGA via the Physician Consortium for Performance Improvement^® independent process.
• For the 2012 PQRS, EPs can earn a 0.5 percent incentive for successfully reporting measures. For 2012 and beyond, CMS finalized the proposal to specify a 12-month reporting period for satisfactorily reporting PQRS quality measures for claims, registry and electronic health record (EHR)-based reporting. CMS also finalized a six-month reporting period (July 1 – Dec. 1 of the respective year) for reporting measures groups via registry. Penalties will begin in 2015 for those who do not satisfactorily submit quality data (-1.5 percent for 2015, -2 percent for 2016 and beyond). CMS finalized its proposal to establish CY 2013 (Jan. 1, 2012 – Dec. 31, 2013) as the reporting period for the 2015 payment adjustment.
• EPs and group practices who are successful e-prescribers may earn an incentive payment based on their estimated total allowed charges for physician fee schedule services provided during the CY reporting period (1 percent in 2012, 0.5 percent in 2013). Those who are not successful e-prescribers will encounter the following payment reductions: 1 percent in 2012, 1.5 percent in 2013 and 2 percent in 2014. CMS also finalized an additional reporting period for the 2013 payment adjustment to include a six-month reporting period (Jan. 1, 2012 — June 30, 2012), in addition to the current 12-month reporting period. For the 2014 payment adjustment, CMS finalized two reporting period options: a six-month reporting period (Jan. 1, 2013 — June 30, 2013) and a 12-month reporting period (Jan. 1, 2012 — Dec. 31, 2012).
• CMS finalized its proposal to allow EPs to continue to report clinical quality measure results as calculated by certified EHR technology by attestation for the 2012 payment year. CMS finalized its proposal for a PQRS-Medicare EHR incentive pilot that would allow eligible professionals to satisfy the clinical quality measure reporting requirements for both the PQRS and the EHR incentive program for the 2012 payment year.
• CMS finalized its proposal to send a list of high expenditure/high volume potentially misvalued codes to the AMA Relative Value Scale Update Committee for review, which included codes 45378 diagnostic colonoscopy and 43235 upper GI endoscopy, diagnosis. CMS noted the list of codes were selected for review based on the fact that they have not been reviewed for at least six years and, in many cases, the last review occurred more than 10 years ago.
• CMS finalized quality and cost measures that will be used in establishing a new value-based modifier to adjust physician payments based on quality of care. CMS will use CY 2013 as the initial performance year for purposes of adjusting payments in CY 2015. The modifier will apply to some physicians and physician groups in 2015, with expansion to all physicians by 2017. CMS will address implementation of the value modifier in future rulemaking.

The rule will appear in the Federal Register on Nov. 28, 2011. CMS will accept comments on those provisions that are subject to comment until Jan. 3, 2012, and will respond in the MPFS for CY 2013.

Review the final rule. Read the CMS press release and fact sheets:

• CMS Announces Policy, Payment Rate Changes for the Physician Fee Schedule in 2012
• Final Changes for Calendar Year 2012 Physician Incentive Programs  
• Value-Based Payment Modifier and the Physician Feedback Program  

AGA is analyzing the rule and preparing a briefing on what GIs need to know. Continue to read AGA eDigest and the AGA Washington Insider for the latest updates.