On July 6, the Centers for Medicare and Medicaid Services (CMS) released the proposed 2013 Medicare Physician Fee Schedule, which sets payment levels and other associated policies for next year. The ACC has analyzed the impacts of the proposed rule and its impacts on cardiology. In particular, the document provides information on proposed cuts included in the rule as part of a new transitional care management code, multiple procedure reductions for cardiology and the 4^th year phase-in of the PPIS practice expense survey. Other topics addressed, include e-prescribing and Physician Quality Reporting System (PQRS) requirements, value-based purchasing, quality and research use reports and Physician Compare. The ACC will be submitting detailed comments on all of these proposals at the end of August. If you have any thoughts or suggestions that would help to shape these comments, please contact the ACC Advocacy Division.  

 

Element	Impact on cardiology
4th year of PPIS practice expense survey	-1%
New Transitional Care management code	-1%
Multiple Procedure Reductions for cardiology	-1%* (estimated)
Total	-3%

4^th Year of PPIS Practice Expense Survey

This is the fourth year of implementation of the AMA PPIS practice expense survey for indirect practice expense. This means it is the fourth and final year of overall negative impacts for cardiology codes from this survey. The impact has gone down each year due to the creation of new codes that were automatically priced at the full implementation schedule. CMS makes no reference to any future changes in this area.

New Transitional Care Management Codes

CMS proposes to pay for 30 days of care management for a patient following discharge from a hospital or a SNF. The proposal would not require a face to face visit, which is unusual for a paid Medicare service. CMS would limit the payment of this service to a single physician – whomever sends in the bill first. In addition, the physician billing for this service must have an established relationship with the patient as proven by having billed for an evaluation and management service in the 30 days before or the 14 days after the discharge.

The physician who bills for the discharge from the hospital would not be eligible to also bill for the transitional care management. Typically, CMS extends the definition of the physician to include all members of the same group. This would mean that if a patient with an acute myocardial infarction (AMI) was discharged by a cardiologist from the hospital, no one in his group could bill for this care management, even though many of the issues of care management might be most appropriately managed by a cardiologist.

CMS impact analysis indicates that this would have a negative impact on cardiology due to their requirements to maintain budget neutrality within the fee schedule. However, this would give some cardiologists the opportunity to be paid for these services and could have a positive impact for practices that care for a significant number of patients in transition.

Multiple Procedure Reductions for Cardiology Services

CMS has a long history of payment reductions for services that are performed together. There are long standing rules related to multiple surgeries, for example. In recent years, CMS has expanded this policy to include the technical component of noncardiovascular diagnostic imaging. In this rule, CMS proposes to expand this policy to cardiovascular services, which includes both cardiovascular imaging, cardiovascular tests such as EKG and stress tests, and services such as pacemaker device checks. They propose a 25 percent reduction on the technical component for the lower paid service. The technical component covers the clinical staff, supplies and equipment. CMS makes this proposal because they believe that there are duplicate services associated with providing multiple services. According to the Agency, duplicated services include items such as greeting the patient, gowning and consent. 

The ACC has announced opposition to this policy and will be working to demonstrate to CMS that there are significant differences among various cardiovascular services that would make this proposed reduction inappropriate. 

Implantable Loop Recorder

Medtronic requested that CMS review the practice expense and work values for codes for implantable loop recorders so that they are priced to be performed in the office – they are currently only provided in a hospital. In the rule, CMS request that the RUC review the work and practice expense for this service. It is unknown what the impact of this review would be on the payment for the service. 

Electronic Prescribing

By statute, the incentive payment for those who successfully e-prescribe in compliance with the program’s requirements will be 0.5 percent for 2013. Those who did not report e-prescribing at least 25 times in 2011 or 10 times between Jan. 1 and June 30, 2012 and did not successfully apply for a hardship exemption will see their 2013 payments cut by 1.5 percent.

Based on comments and complaints CMS has received from ACC and other stakeholders, CMS proposes two additional hardship exemption categories for both the 2013 and 2014 e-prescribing payment adjustments for those that achieve and those who demonstrate intent to qualify for electronic medical record meaningful use.

Physician Quality Reporting System

Transition from bonus to penalty

The PQRS will transition from a bonus only program into a bonus/penalty program in 2013. Physicians who do not participate in 2013 will be subject to a 1.5 percent penalty in 2015. One significant proposal is the introduction of an opportunity to report on PQRS by merely asking CMS to calculate claims-based performance measures. A number of these measures are related  to cardiovascular care. 

In order to ease the transition into a penalty phase, CMS has created standards for avoiding the 1.5 percent penalty in 2015 that are less strict than the standards to receive the 0.5 percent penalty. CMS proposes that physicians that report on only a single measure will avoid the penalty as opposed to requiring three to receive a bonus – CMS does indicate that it intends to reexamine these standards in the future and make them more closely resemble the standards for receiving the bonus. 

Measures

CMS has proposed the addition of several measures for PQRS that may be of interest in addition to the many existing measures that are already reported by cardiologists.  Measures include:

• Participation in a systematic clinical improvement registry (structural measure)
  
• Cardiac stress imaging appropriate use
  -In low risk surgery patients
  -After PCI
  -In asymptomatic low risk patients
  
• Atrial fibrillation – chronic anticoagulation therapy

CMS has also proposed that several measures that had been available for reporting in previous years no longer be available.  Measures include: 

• Coronary artery disease – symptom and activity assessment
  
• Heart failure – patient education
  
• Hypertension plan of care

Quality and Resource Use Reports

CMS includes proposal for the distribution of confidential physician feedback reports which will be released to all physicians by 2014.  These reports will provide confidential information to physicians on the quality of care and resources provided to their patients in previous years. CMS has released sample reports to physicians in four states as of July 2012 with plans to expand to nine states for sample reports in the fall of 2012. These reports have included both PQRS data as well as claims-based performance measures

Physician Compare

CMS proposes further development of the physician compare website that allows members of the public to review information about physicians. The site is currently limited to demographic information but CMS proposes an expansion to include quality data elements generated from PQRS reports starting in 2014. CMS proposes to report the actual performance percentages from the measures on the site – CMS does not indicate how it might differentiate various reporting methods (registry, data submission, claims based) within this reporting. 

CMS proposes in future years to add additional measures of quality to physician compare, including patient satisfaction measures compiled through survey data but limiting this reporting to those who are participating through a large group practice reporting option or who are part of an accountable care organization. 

Value-Based Modifier

As required by the Affordable Care Act, CMS proposes a method to adjust physician payment based on quality of care and resource use.   The value-based modifier will be implemented starting in 2015 for physicians who are in groups of 25 or more. Those physicians will be given the choice to participate or not.

As a condition of participating in value-based purchasing, the group must participate successfully in the PQRS. Failing to participate in the PQRS would result in an automatic 2.5 percent reduction from baseline payments. If a physician group participates in the PQRS, that group can opt in to the value-based purchasing program. If a group opts into this program, the maximum penalty allowed will be 1 percent. Although CMS does not propose a maximum penalty, it appears that it will be not much greater than 2 percent.

The value-based purchasing program itself is a tiering program that compares physicians based on PQRS measures, outcomes measures calculated based on claims, and resource use measures. Resource use is measured on a total per patient basis but CMS proposes that in future years it will also measure resource use as part of a particular episode of care (i.e. 90 days after AMI). 

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