Physician Medicare Payment Rule Needs Several Changes, APA Says

APA is welcoming efforts by the federal government to streamline quality-reporting requirements for physicians participating in Medicare and provide payment for physicians in the program who transition patients from inpatient care to lower levels of care.

But APA continues to express concern about aspects of the government’s move toward alternative physician payment mechanisms, its authorization of payment to nonphysicians for certain somatic services, and its use of a Web site to provide public information about physicians who participate in government quality-reporting programs.

In a September 4 letter to the Centers for Medicare and Medicaid Services (CMS), APA Medical Director James H. Scully Jr., M.D., described areas of concern regarding the proposed rule on the 2013 Medicare Physician Fee Schedule.

Scully reiterated the urgent need for an overall reform of Medicare’s physician payment formula and elimination of the “sustainable growth rate” (SGR) component of that formula. But the September 4 letter also specified APA’s concerns and criticisms about a wide range of highly detailed aspects of the proposed rule.

As part of an effort to trim health care costs and provide incentives for quality care, the government is moving toward alternative payment mechanisms, including the use of a “value-based modifier” (VBM)—described in the proposed rule as “a payment modifier that provides for differential payment to a physician or group of physicians under the Physician Fee Schedule based upon the quality of care furnished compared to the cost during the performance period.”

Beginning in 2015, group practices, which CMS defines as having 25 or more Medicare providers, will be reimbursed using the VBM. Smaller groups and solo-practice physicians will be reimbursed using the VBM in 2017.

CMS has also said that physicians who want to get experience using the modifier prior to 2017 may do so for certain “episodes of care” yet to be defined by CMS.

Scully, in his letter, sought to remind the administration that many medical conditions are often accompanied by co-occurring psychiatric disorders, requiring consultation with a psychiatrist, and he urged CMS to include payment for psychiatrists in its designation of any “episodes of care” to which the VBM may be applied.

He also stressed the need to risk-adjust Medicare reimbursements to account for severity of illness when applying the modifier. And he welcomed the government’s offering of a reporting category for physicians treating high-risk patients that will be paid at a higher rate. “We agree with CMS’s proposal to award physicians … with [additional payment] for achieving higher quality and lower costs while treating patients who comprise the top quarter of Medicare’s highest-risk patients,” he wrote.

Scully also expressed approval of CMS’s move to align physician reporting requirements for its Physician Quality Reporting System (PQRS) with other quality-care initiatives, such as the Medicare Shared Savings Program and the Electronic Health Records Incentive Program.

He praised the proposal by CMS for a service code that physicians could use to receive payment for work involved in transitioning patients from inpatient care to lower levels of care. “Many APA members presently assume the responsibility for coordinating patients’ transitions from institutions, like hospitals and community mental health centers, to the community,” he explained. “We believe that psychiatrists who assume responsibility for transitioning beneficiaries from institutions to the community should be compensated for this work.”

But he expressed serious reservations about the possible misuse by consumers of the government’s Physician Compare Web site. That site was created in conjunction with the Affordable Care Act to list the names of eligible clinicians who meet the requirements of the government’s Medicare Electronic Prescribing (eRx) Program or who have satisfactorily reported quality measures under the PQRS.

“CMS must be careful to not give consumers accessing the Physician Compare Web site an impression that participation in … quality-reporting programs is in any way part of a physician’s legally required standard of care,” Scully emphasized. “Some [APA] members have expressed concern that by simply providing the names of physicians who participate in [quality-reporting programs], consumers who do not find a particular physician’s name on these program lists will equate the physician’s absence [with] an inferior level of care.”

He said that CMS can mitigate the potential for that misreading by including a prominently displayed disclaimer stating that physicians’ participation in the reporting programs is not linked to the legal standard of care to which physicians are bound.

Also, Scully sharply criticized CMS for expanding the list of providers who can order portable X-ray services to include clinical psychologists and clinical social workers. “Clinical psychologists and clinical social workers are not trained or educated to diagnose or treat somatic conditions,” Scully pointed out. “It is not within the scope of these groups of nonphysician practitioners’ education, training, or practice to order X-rays, lab tests, or any measure of physiologic function or pathology.”

The letter from Scully is posted at www.psychiatry.org/advocacy--newsroom/newsroom/apa-submits-comments-on-proposed-rule-for-2013-medicare-physician-fee-schedule.