The Centers for Medicare and Medicaid Services (CMS) on July 8 released the 2016 Physician Fee Schedule proposed rule, covering payments and related policies for services provided by physicians or in the physician office setting. The rule indicates that physicians will see a 0.5 percent payment increase on Jan. 1, 2016. Next year will be the first of several years of predictable payments resulting from the legislation that permanently repealed the Sustainable Growth Rate (SGR) this spring. CMS estimates that the physician rule will neither increase nor decrease payments to cardiologists from 2015 to 2016. This estimate is based on typical practice and can vary widely depending on the mix of services provided in a practice. The ACC is currently reviewing the rule in preparation to submit comments at the end of the summer.

Some of the key provisions of the Physician Fee Schedule rule include:

Appropriate Use Criteria

CMS presents the first phase of proposals addressing the requirement for clinicians to consult with appropriate use criteria (AUC) when ordering advanced imaging services (i.e. SPECT, MPI, CT, MR) starting on Jan. 1, 2017. This rule focuses on how the agency will identify the applicable AUC used under the program, including:

• The definition of a “provider-led entity” eligible to develop AUC for the program
• The qualifications required of an AUC developer, including the structure of the development team, methodology, and transparency practices
• Whether or not CMS should focus on implementing the program in priority clinical areas based on the incidence and prevalence of diseases, as well as the volume, variability of utilization, and strength of evidence for imaging services.

This rule does not propose policies related to clinical decision support, specific requirements that must be met at the practice level, or the process for identifying outliers in 2020. CMS intends to address these aspects of the program in later rulemaking.

Potentially Misvalued Services

The agency seeks review of 118 services with Medicare allowed charges of $10 million or more as a prioritized subset of codes under the newly established statutory category of "codes that account for the majority of spending under the physician fee schedule." This list includes SPECT MPI, transthoracic echocardiography, stress echocardiography, 3D electrophysiology mapping and cardiac device monitoring services.

Merit-based Incentive Payment System

CMS invites informational comments on how best to implement the Merit-based Incentive Payment System created by legislation that repealed the SGR. The program takes effect January 2019 and will be based upon data collected during 2017. CMS specifically requests feedback on which activities should fit the definition of clinical practice improvement and how to set a low-volume threshold to exclude eligible providers who would not have adequate data to use for payment adjustments. Additional topics and questions will be made regarding alternative payment models through future requests for information.

Changes to Physician Self-Referral Rules

CMS is proposing a number of changes to the physician self-referral (Stark) regulations “to accommodate delivery and payment system reform, to reduce burden, and to facilitate compliance.” In addition to attempting to address comments received in response to the Self-Referral Disclosure Protocol issued in 2010, CMS is particularly interested in the effects of the Stark regulations on the ability to achieve the clinical and financial integration needed for health care delivery and payment reform.

Advance Care Planning and Other Cognitive Services

CMS proposes to establish separate payment for advance care planning services provided to beneficiaries by physicians and other practitioners. These services are currently covered under the “Welcome to Medicare” visit, but may not be necessary at that time. Creating separate payment for these services at a separate point in time offers greater flexibility to patients and their families.

CMS also discussed the idea that existing evaluation and management (E/M) codes do not adequately reflect the extensive cognitive work that primary care physicians, specialty physicians and other practitioners perform in planning and thinking critically about the complex care of many patients. CMS seeks comments on new ways to recognize the different resources involved in cognitive work for delivering broad-based, ongoing treatment that extends beyond the current E/M codes.

Physician Quality Reporting System

CMS proposes to maintain most policies applicable to the Physician Quality Reporting System (PQRS) for the 2016 performance year. Under most individual reporting options, including Qualified Clinical Data Registry (QCDR) participation, eligible professionals will continue to report at least nine measures across at least three National Quality Strategy domains. Failure to successfully report PQRS quality measures in 2016 will continue to result in a -2 percent payment adjustment in 2018. 

Value-Based Modifier

CMS proposes expanding application of the Value-Based Payment Modifier (VM) to nonphysician eligible professional solo practitioners (i.e. physician assistants, nurse practitioners and clinical nurse specialists) and group practices consisting only of nonphysician eligible professionals starting with the 2018 payment period. VM adjustments will be determined based on 2016 performance.

Physician Compare

CMS proposes to incorporate VM information into Physician Compare starting in 2016. Eligible professionals with favorable VM performance based on the quality tiering scoring would receive a checkmark indicator on their Physician Compare profile. CMS also proposes adding additional VM data such as quality and cost tiering scores, payment adjustments, and whether or not an eligible professional successfully reported measures in a data file accessed through the website.

CMS also proposes to include an indicator in the profiles of clinicians who successfully report the updated PQRS Cardiovascular Prevention measures group in support of the Million Hearts initiative.

Qualified Clinical Data Registry

As authorized by the Medicare Access and CHIP Reauthorization Act of 2015, CMS proposes to allow QCDR participation as a reporting mechanism for the PQRS Group Practice Reporting Option. CMS continues to implement policies requiring the public reporting of QCDR data. In 2016, QCDRs will continue to have the option of publicly reporting measure performance through Physician Compare or the QCDR’s own website.

Keywords: Advance Care Planning, Centers for Medicare and Medicaid Services, U.S., Cost of Illness, Fee Schedules, Physicians

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