Weekly Roundup - June 19 - 23, 2023
Physician payment, coding, coverage, and quality reporting news highlights.
PAYMENT
Consensus on Failure of MIPS at MACRA Hearing but Comprehensive Fix for 2024 Seems Unlikely. On June 22, 2023, the House Energy and Commerce Committee’s Investigations Subcommittee held a hearing on the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. There was a consensus among witnesses and subcommittee members that the Merit-based Incentive Payment System (MIPS) program failed to meet its goals, was overly burdensome, and potentially inherently flawed and beyond repair. Near the end of the hearing Representative Raul Ruiz, MD (D-CA), co-sponsor of H.R. 2474 Strengthening Medicare for Patients and Providers Act, raised the issue of payment cuts facing physicians and how the current system is not keeping up with rising practice costs.
The subcommittee also deliberated on the success and failures of the Advanced Alternative Payment Models created by MACRA. Members noted that the growth of Medicare Advantage, which now covers over 50% of Medicare beneficiaries, compels them to consider it in any overhaul of the physician payment system.
Despite everyone seemingly singing from the same hymn book, a realistic assessment of the Congressional calendar, and considering other competing healthcare priorities facing Congress, a comprehensive fix for physician payment in 2024 seems unlikely. Stakeholders continue to hope for a short-term fix for 2024 with a more substantial overhaul down the line.
JAMA Viewpoint Article Critiques Medicare Physician Fee Schedule. The article's central theme is that there is an inherent conflict of interest in establishing relative value units because the Medicare agency relies on recommendations from the American Medical Association’s (AMA) Relative Value Update Committee (RUC), which they believe is an inherently conflicted process. The authors, Drs. Robert Berenson and Ezekiel Emanuel, have previously published articles criticizing the RUC.
The AMA responded to the article by addressing concerns raised in the original article about conflict of interest and other issues but noting that in the end, it is the Medicare agency that “… has the ultimate responsibility for setting values and payment policy.”
PAYMENT INNOVATION
Registration Opens for Webinar on the Making Care Primary (MCP) Model. The Centers for Medicare and Medicaid Services will host a webinar on June 27, 2023, from 2:00 PM ET to 3:30 PM ET providing an overview of the MCP Model. Announced on June 8, this value-based primary care model will provide participants with additional revenue to build infrastructure and will be tested in eight states over ten years (July 1, 2024-Decembeer 31, 2034). The model provides pathways for small, independent, rural, and safety-net primary care organizations to enter value-based care arrangements.
CMS is excluding accountable care organizations (ACOs) from this model. ACO stakeholders have criticized this model aspect, noting that “…they have urged CMS to establish an option for ACOs to implement population-based payments for primary care.”
COVERAGE
A Trifecta of Medicare Coverage Announcements this Week. It was a busy week for the Medicare coverage team, with three big coverage-related announcements released on June 22, 2023.
Long-awaited notice on Transitional Coverage for Emerging Technologies (TCET) released. This notice provides a pathway for national coverage for certain eligible Breakthrough Devices that are Food and Drug Administration (FDA) market authorized. Manufacturers may self-nominate to participate in the TCET pathway. In the notice, the agency noted that its goal is to finalize the TCET decision within six months after FDA market authorization and to have this temporary coverage only long enough to facilitate the development of evidence that can lead to a long-term Medicare coverage determination. This notice, which is open for a 60-day comment period, replaces a rule issued by the previous administration that the Biden Administration repealed on November 15, 2021. Congress and stakeholders had called on the agency to fulfill its promise to replace the repealed rule.
CMS Announces Plan to Cover New Alzheimer Drugs. CMS announced it will cover FDA-approved drugs that may slow the progression of Alzheimer’s disease. The beneficiary should be diagnosed with mild cognitive impairment or Alzheimer’s disease dementia. The physician must participate in a registry with a clinical team and provide follow-up care. The agency described this decision as similar to its previous coverage decision, Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer’s Disease, issued in 2022. This original decision was considered controversial for a range of reasons.
Guidance Document on Coverage with Evidence Development (CED). The agency is seeking comments on a proposed guidance document on the CED process. It represents CMS' current thinking on the factors it considers in making national coverage decisions using the CED paradigm. Comments are due August 21, 2023.
CODING
Summary of Panel Actions from the May 2023 CPT Editorial Panel Meeting Now Available. The Summary of Panel Actions, which details decisions made by the CPT Editorial Panel on each code proposal on the agenda for their May 2023 meeting, is now available. The May 2023 CPT meeting is the second of three in the 2025 CPT and Medicare Payment Schedule. Category I codes approved by the Panel may go on for review by the RVS Update Committee (RUC). Note that changes are not final until the publication of the CPT book. More information on the CPT/RUC process is available HERE.
For more information and questions please contact:
Sheila Madhani, MA, MPH
Madhani Healthcare Consulting, LLC
Email: smadhani@madhani-health.com
www.madhani-health.com
Tel: (202) 679-2977