Weekly Roundup
October 16-20, 2023
Physician payment, coding, coverage, and quality reporting news highlights.
It was another chaotic week on Capitol Hill, but Medicare physician payment did take center stage during a briefing on Thursday. As we enter the third week of October, it is likely our last week of freedom until the inevitable countdown to the release of the final 2024 physician payment rule is released. So, enjoy your weekend and the brief respite before the craziness begins! And now, on to the Weekly Roundup!
PAYMENT
Medicare Physician Payment Takes Center Stage at Capitol Hill Hearing. A slew of draft legislative proposals on Medicare physician payment were discussed at a House Energy and Commerce Health Subcommittee hearing on Thursday, October 19. While there is a general bipartisan consensus that physician payment needs an overhaul, how to do it and pay for it remains unresolved. The draft proposals discussed at the hearing addressed some key physician payment issues. A selection of these draft proposals include:
Work Geographic Practice Cost Index (GPCI): Extend the 1.00 work GPCI floor, which is set to expire on January 1, 2024.
Alternative Payment Model (APM) Incentive Payments: Extend APM incentive payments and establish a five-year cap or limit on receiving payment incentives.
Medicare Advantage (MA): Require electronic prior authorization for MA plans with prior authorization requirements.
Budget Neutrality: Increase the Medicare physician fee schedule’s budget neutrality threshold. This would mean a higher amount of spending would be needed for budget neutrality to be triggered.
Telehealth: Prohibition on making the home address of the telehealth practitioner public if they provide telehealth services at home.
With the current state of Congress, the likelihood of these proposals or relief from the scheduled 3.34% reduction of the 2024 Medicare Physician Conversion Factor being part of an end-of-the-year package remains uncertain. Any end-of-the-year actions by Congress and policies finalized in the CY 2024 Medicare Physician Fee Schedule Final Rule (scheduled to be released on or around November 1) will set the payment coding and administrative burden tempo for physicians and qualified healthcare professionals in 2024.
PAYMENT INNOVATION
Stakeholders Urge CMS to Extend APM Incentive Payments. On October 18, stakeholders submitted a letter to Congress requesting an extension to the 5% Alternative Payment Model (APM) Incentive payment and an adjustment to the criteria used to become a Qualifying APM Participant (QP). QPs are eligible for APM incentive payments and are not required to participate in the Merit-based Incentive Payment System (MIPS). The requests in the letter are similar to provisions in Section 3 of the Value in Health Care Act (H.R. 5013).
Absent Congressional action, a 3.5% APM incentive payment will expire on January 1, 2024, and the APM revenue threshold (a criterion for qualifying as a QP) will increase from 50% to 75%. A 5% bonus was in place by statute from 2017-2022. The Consolidated Appropriations Act of 2023 extended the bonus at 3.5% for 12 months.
APM advocates argue that APMs have resulted in significant savings for the Medicare program while maintaining the quality of care for beneficiaries. They note that incentive payments encourage clinicians to participate in APMs and, at a practical level, help support technical investments (e.g., digital health tools, quality measurement tools) and enhance data analytics capacity, all of which are often needed when systems and practices transition to value-based care. The AAPM community is concerned that if payment incentive payments were to expire, it could discourage future APM participation.
COVERAGE
Medicare Broadens Coverage of PET Scans for Alzheimer’s Patients. Amyloid PET scans are used to confirm Alzheimer’s diagnosis (previously done post-mortem) and in the treatment of the disease. On Friday, October 13, the Medicare agency lifted its one-per-lifetime limit on PET scans and is now allowing Medicare Administrative Contractors (MACs) to make these decisions.
This expanded coverage of PET scans follows the July 2023 announcement by Medicare that it would cover Lequembiã, which has been shown to slow the progress of early Alzheimer’s for patients with evidence of a buildup of beta-amyloid plaques in the brain. PET scans are typically used before initiating treatment to confirm the presence of beta-amyloid plaques and are also used to monitor how effectively the drug is working.
While stakeholders are pleased with this expanded coverage, there is some concern that relying on MACs may cause confusion and result in inconsistent application of the policy.
OTHER NEWS, IN BRIEF
CMS Solicits Input from Clinicians.
The agency’s Provider Compliance Group is hosting a focus group on improving medical reviews and prior authorization policies on November 2 from 1:00 p.m. to 3:30 p.m. ET.
CMS launched a survey on the Medicare program and billing resources. The agency estimates that the survey, which will help inform a more extensive study, will take 10 minutes to complete. Responses are due on November 9.
Telehealth Resources Released by the Administration this Week.
This document guides clinicians in communicating with patients about telehealth's potential privacy risks.
This is a patient-facing document that provides telehealth privacy and security tips.
Food and Drug Administration (FDA) Solicits Comments on Innovation in Clinical Trial Design and Conduct. The agency seeks comments on the barriers and facilitators to incorporate innovative clinical design approaches in drug development programs. Commenters are asked to consider regulations and compliance requirements, patient-focused trial design, recruitment practices, patient safety issues, clinical trial infrastructure, organizational issues (e.g., culture or capacity), and any overarching barriers. Comments are due on April 19, 2024. The agency is also planning a public workshop in collaboration with the Duke Margolis Center for Health Policy on March 19-20, 2024. In recent months, the agency has released other documents to modernize the design and conduct of clinical trials and advance innovation.
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Sheila Madhani, MA, MPH
Madhani Healthcare Consulting, LLC
Email: smadhani@madhani-health.com
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Tel: (202) 679-2977