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Tuesday Aug 02, 2016

Fee schedule reflects CMS efforts to support primary care

On July 7, CMS released its proposed rule for the 2017 Medicare physician fee schedule (PFS). The proposed rule updates payment policies, payment rates and quality provisions for services furnished under the Medicare PFS starting Jan. 1. The AAFP is in the process of reviewing and analyzing the proposed rule and will be submitting comments and recommendations prior to the Sept. 6 deadline.  

We have prepared a summary of the proposed rule to assist members in evaluating the new payment policies. You can also access additional resources on our physician payment advocacy web page.    

The proposed rule continues a multi-year effort on the part of the Administration to both prioritize and promote primary care as foundational to the Medicare program. The AAFP continues to assert with CMS and the Administration that to truly realize the value of family medicine and primary care they cannot simply rely on delivery system reforms and alternative payment models. Instead, CMS must make new investments in primary care to truly capture and realize the value proposition of family medicine and primary care. Building new delivery system or payment models on the foundation of a payment system that has methodically undervalued primary care for a generation would be disingenuous to the goals espoused by CMS, private insurers and health policy experts.

CMS has made a commitment to improving payments for family medicine. The 2017 Medicare PFS, according to CMS, results in a 3 percent increase for family physicians compared to other medical specialties. CMS estimates that the changes made in the 2017 Medicare PFS would result in approximately $900 million in additional funding to primary care physicians. In a blog post that coincided with the release of the proposed rule, CMS Administrator Andy Slavitt and Acting Principal Deputy Administrator and Chief Medical Officer Patrick Conway articulated their commitment to improving the investment in primary care.

In the blog, they said that CMS, through the proposed rule, is attempting to: "reinvest in what we value -- primary care -- as a practice, as a profession, and as an abundant resource for patients. In recent years, we have begun taking a number of meaningful steps to begin this reinvestment process. Today, we are proposing significant actions to improve how we pay primary care physicians, mental health specialists, geriatricians, and other clinicians. By better valuing primary care and care coordination, we help beneficiaries access the services they need to stay well. In addition to keeping people healthy, health care costs are lower when people have a primary care provider and a team of doctors and clinicians overseeing and coordinating their care."

Improving payment for family physicians and primary care physicians is a top priority for the AAFP, and we applaud CMS for its commitment to this cause -- even though we remain convinced that CMS can and should do much more.   

The following highlights a few key areas of the proposed rule.

  • The proposed conversion factor for 2017 would be $35.77.
  • The proposed rule would add an advanced care planning code to the eligible code set for telemedicine services.
  • The proposed rule would implement appropriate use criteria for advanced imaging services created by the Protecting Access to Medicare Act. This policy requires physicians ordering certain imaging services -- magnetic resonance, computed tomography, nuclear medicine, and positron emission tomography imaging -- for Medicare beneficiaries to consult AUC applicable to the imaging modality. The implementation of this policy was delayed due to AAFP advocacy and we will once again encourage CMS to delay the implementation of the program so that AUC would be aligned with the forthcoming MIPS program versus being introduced as a stand-alone program.

Furthermore, the proposed rule makes significant changes to how CMS pays for several care management services. Specifically, the regulation would make separate payments under Medicare for:

  • certain existing CPT codes describing non-face-to-face prolonged evaluation and management services;new codes to describe the comprehensive assessment and care planning for patients with cognitive impairment (e.g., dementia);
  • new codes to pay primary care practices that use interprofessional care management resources to treat patients with behavioral health conditions;
  • new codes to recognize the increased resource costs of furnishing visits to patients with mobility-related impairments; and
  • codes describing CCM for patients with greater complexity.

In addition, the program makes several changes aimed at reducing the administrative burden associated with the CCM codes and revalues existing CPT codes describing face-to-face prolonged services. Both changes are positive for primary care.

Finally, the AAFP has long advocated that CMS should be more assertive in identifying both over and undervalued codes in the PFS. Research has shown that, historically, payments for primary care services provided by primary care physicians are grossly undervalued. We continue to press CMS to use its administrative authority to increase the relative value of primary care codes and, ideally, create new codes explicitly for primary care.  

This policy began to be implemented through the Patient Protection and Affordable Care Act, which required the secretary to identify and adjust payments for misvalued codes through adjustments to the relative values of those services. This provision was strengthened through the Achieving a Better Life Experience Act of 2014, which set a specific target for downward adjustments of misvalued codes of 1 percent in 2016 and 0.5 percent for 2017 and 2018. In 2016, CMS was unable to identify the full 1 percent required by law, thus resulting in a cut to all services to account for the difference. In 2017, CMS has proposed reductions equaling 0.51 percent. This means primary care physicians won't see any reductions in payments.

Wonk Hard
On July 21, the Department of Justice sued to block Anthem’s $48 billion takeover of Cigna Corp and Aetna’s $37 billion takeover of Humana. In both the United States v. Anthem Inc. and Cigna Corp. and the United States v. Aetna and Humana Inc. the Justice Department argues that the mergers would raise health care costs and reduce choices for patients. Attorney General Loretta Lynch, when making the announcement, stated: “If the big five were to become the big three, not only would the bank accounts of American people suffer, but the American people themselves.

Shortly after the announcement, both Anthem and Aetna offered their responses to the Justice Department’s decision. Both have vowed to fight the decision in court.


the AAFP continues to try and for that they should be congratulated. but a full generation of of underpayment and what we have is fewer and fewer American trained primary care doctors.the country gets what it deserves....too many orthopedic surgeons and cardiologists and not enough of us in the trenches. and I donot blame one bit the med school graduates not choosing primary care. they would be foolish to do so and when they do so few want to go into office medicine[it is hospitalist for them]. a lost generation. how shameful. and thus why concierge medicine has taken off, I am 61, near the end thank goodness. may god bless us all in the trenches. it is getting harder and I cant wait to leave. I will miss the patient interactions but not all the rest of medicine.

Posted by mark vanhusen on August 02, 2016 at 12:05 PM CDT #

"primary care physicians are grossly undervalued"
"primary care physicians won't see any reductions in payments."

Boy am I excited - I can see the line now!
Add MACRA to this mess
Now I am really excited

True reality is I need my income doubled....All this talk about a few percentages is really not going to solve either the manpower issue nor the burnout!

Corporate take over of independent care is not going to solve the issue either.

How do we get real?

All the battles where we got small rewards or new fee codes that require a lot of work are not going to get us to where the system need primary care to be.

Posted by Scott Macleod on August 02, 2016 at 01:57 PM CDT #

The basic problem remains the failed primary care financial design - the result of suppression of market forces. Demand increases should have resulted in decades of steady increases in cognitive payments with increasing delivery capacity. But decades of health policy and political activities have prevented any real change by CMS which is why they can only talk and do small change rather than address the required support of primary care. CMS faces ACA and political designs which both limit increases in overall spending for decades to come. Despite the talk, there will not be major spending change in primary care even with the reality of increasing elderly, increasing complexity, and major increase in demand for primary care. CMS has made matters worse with 8 - 10 billion more each year required from primary care for regulation costs (EHR, MU, MIPS, MACRA, certifications). Hundreds of hours a year have been converted from patient care to EHR focus (Health Affairs) with resultant loss of productivity. Real change in funding would require cutting costs in hospital, drug, subspecialty, or specialty costs. The opposition to these changes is far too strong and has much better organization. This is why the inequities have persisted since the 1980s. Since 2010 over 400 billion has been cut from hospitals (AHA) and they will prevent further cuts. Similarly academic and largest systems will prevent cuts in specialty and subspecialty spending to redirect dollars to cognitive services as in past decades. Despite numerous recommendations via panels (the attempts of FM leaders to facilitate important changes) and numerous research and association and leader efforts, the end result has been failure to address financial design inequities. CMS has chosen the only route left. They will continue to create and promote numerous small change programs, grants, and demos with small change dollars - grossly insufficient to address the hemorrhage from regulation. CMS can only do numerous small change funding changes, grants, and demonstrations. A steady and well timed stream can prevent awareness of the reality. Even worse, we do their promotion by seizing upon any appearance of help (in desperation?). We fail to expose their rhetoric. We fail to expose their regulation cost increases that deplete our team members in number, distribution, morale, outreach, integration, coordination, and all of the functions that our nation needs primary care to address. Family physicians have been forced out of family medicine (25% lost to EM, urgent, hospitalist, other specialties) and small practices and independent practice. It is very clear that MACRA will hit hardest on family physicians. FM docs are most closely associated with small practices and small hospitals and patients that have lesser outcomes due to patient factors - behaviors, situations, determinants. Even worse, ACA and CMS changes are killing off the team members that could help these patients change behaviors, situations, and other patient factors that most shape health outcomes. How many dozens of studies does it take to demonstrate the discrimination of pay for performance? Why do we tolerate discrimination by pay for performance - a scheme long known to penalize providers because of the types of patients that they care for? How long does it take to see that CMS payment designs cause the workforce deficits that we see. The places short of primary care and overall workforce are places with higher concentrations of Medicaid and Medicare patients. Yet family physicians remain where needed, despite the aberrant design. We should stand up to those who suppress us - in violation of their mission statements to care for all Americans.

Posted by Robert C. Bowman, M.D. on August 15, 2016 at 11:58 PM CDT #

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About the Author

Shawn Martin, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy.

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The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.