Pay, Burdens Topline Academy’s 2023 MPFS Guidance

‘CMS Must Continually Invest in Community-based Primary Care,’ AAFP Says

Sept. 15, 2022, 7:01 p.m. News Staff — Physician payment reform, administrative simplification and accelerating family physicians’ breakaway from fee-for-service medicine were uppermost among the concerns the Academy recently voiced to CMS and Congress in response to the proposed 2023 Medicare physician fee schedule and Quality Payment Program. 

Conversion Factor

CMS cites statutory budget-neutrality requirements as the reason why the 2023 fee schedule’s conversion factor, 33.08, is about 4.5% lower than 2022’s conversion factor (33.5848). Congress temporarily increased the conversion factor in 2020 and 2021, but that boost will expire without new legislation, leading to payment cuts for family physicians and all other Medicare Part B clinicians.

“These year-over-year cuts clearly demonstrate that the Medicare physician payment system is broken,” the Academy and numerous other medical societies told congressional leaders in a July 27 letter. 

The Academy is backing the Supporting Medicare Providers Act of 2022 (H.R. 8800) as a possible solution.

Evaluation and Management

The Academy supported the proposal’s adoption of most changes in coding and documentation for “Other E/M visits,” such as ER, inpatient and skilled nursing facility visits, recommended by the AMA’s CPT and RUC panels. However, the AAFP objected to creating Medicare-specific coding for payment of “Other E/M” prolonged services as “confusing and unnecessarily burdensome for physicians and other clinicians.”

“While the AAFP is supportive of updating the Other E/M codes, we are concerned about the negative impact these updates will have on community-based primary care and other physician practices due to budget-neutrality requirements,” the letter said. “This is yet another example of how budget neutrality requirements prevent CMS from adequately investing in and ensuring access to a wide variety of essential services for Medicare beneficiaries, including primary care.”

The Academy advised CMS to implement add-on code G2211 in 2024 (the soonest allowed by law) to better equip family physicians to deliver comprehensive, longitudinal care.

Behavioral Health

In line with recent Academy advocacy, the proposed rule would add flexibility to primary care practices aiming to integrate behavioral health care. The letter said these steps — including the loosening of supervision requirements and allowances for psychologists and social workers to bill directly for behavioral health services they manage or deliver in the primary care setting — would better enable primary care practices to receive payment for integrated behavioral health services.

Telehealth

“We oppose CMS’ proposal to revert to paying for telehealth services at the (lower) facility rate after the end of the (COVID-19) public health emergency,” the Academy said. “This will create barriers to telehealth access for beneficiaries.”

The letter also warned against the proposed rule’s halt to separate coverage and payment for audio-only telehealth services 151 days after the end of the PHE. “Audio-only services are essential for ensuring equitable access to telehealth and must be maintained,” the AAFP said.

The letter called on CMS to implement permanent telehealth policies that

• ensure coverage and access to audio/video and audio-only telehealth services for all Medicare beneficiaries;
• protect care continuity and quality by encouraging telehealth with a patient’s usual primary care physician or another trusted care relationship rather than direct-to-consumer vendors; and
• enable patients, together with their primary care physicians, to determine the best mode of care for each encounter.

The letter also supported a proposed delay of in-person requirements for tele-mental health services, noting that the AAFP backs the Protecting Rural Telehealth Access Act, and the Evaluating Disparities and Outcomes in Telehealth Act.

Medicare Economic Index

The MPFS proposes to rebase and revise the Medicare Economic Index, which measures the price of inputs for physician services and is primarily based on data from 2006. The proposed update would use 2017 data from the U.S. Census Bureau’s Service Annual Survey and would not take effect in 2023.

The Academy objected to this approach and the methodology proposed for reweighting the MEI, laying out several potential flaws and urging CMS to instead “collaborate with the AMA on its new data collection effort to ensure consistency and reliability in physician payment.”

Preventive Vaccine Administration

In a significant win for the AAFP’s advocacy, the 2022 MPFS established a flat payment of $30 for Part B vaccine administration. Next year, CMS proposes annual adjustments to account for changes to the cost of administering vaccines, based on the MEI and adjusted for geography.

“It is vital that Medicare payment policies support primary care physicians’ ability to offer recommended immunizations in their practices, as they continue to be the primary setting beneficiaries get their vaccines,” the Academy wrote. “We applaud CMS for taking steps to improve access to preventive vaccines under Medicare Part B and urge CMS to finalize these proposals.”

The letter objected, however, to a proposed automatic payment reduction for COVID-19 vaccine administration to equal payment for other Part B preventive vaccines after the emergency use authorization ends.

Transitioning COVID-19 vaccine purchasing, distribution, coverage and payment away from emergency policies and processes, the letter said, could cause challenges for primary care practices that lead to delays and access challenges for Medicare beneficiaries.

Advanced Alternative Payment Models

The proposed rule verifies that the AAPM bonus expires after the 2024 payment year and acknowledges that this statute-mandated change may send current and potential participants to the Merit-based Incentive Payment System rather than to an AAPM.

“The AAFP shares CMS’ concern and is strongly urging Congress to pass legislation that

would extend the AAPM bonus,” the letter said. “The AAPM incentive payments have served as an important tool for attracting physicians to participate in advanced APMs and the expiration of the AAPM bonus will have negative impacts on family physicians’ ability to transition to value-based payment models.”

Regardless of bonuses, however, the Academy reminded CMS that primary care AAPMs “should provide risk-adjusted prospective payments that represent a meaningful increased investment” while reducing administrative complexity.

The Academy also expressed strong concern that statute-mandated increases to qualification thresholds for some Medicare participants will slow the transition toward value-based payment.

“Based on CMS’ estimates, thousands of eligible clinicians may fall back into fee-for-service due to these increases,” the letter warned. “Many primary care practices that are looking to move into APMs will not be able to meet these thresholds and will be forced to stay in FFS. We are urging Congress to stop the increases … and provide CMS with the authority to establish them in the future.”

MIPS Value Pathways

As finalized in the 2022 MPFS, the Quality Payment Program’s MIPS Value Pathways was implemented on Jan. 1 to give physicians and other clinicians “a more meaningful, less burdensome” reporting option.

“The AAFP has been supportive of this goal and the development of MVPs while also raising concerns about whether MVPs will meaningfully improve participation for family physicians and better facilitate the transition to alternative payment models,” the Academy wrote, noting that FPs “continue to report significant frustration with MIPS participation.”

The letter cautioned that MIPS reporting today “is both costly and administratively burdensome for family medicine practices” and reiterated previous guidance that CMS “eliminate siloed, category-based scoring in MVPs and adopt a multi-category scoring approach.”

“The AAFP has also consistently opposed the use of the Total Per Capita Cost measure. This and other cost-based measures, such as the Medicare Spending Performance Benchmark, hold primary care physicians accountable for costs they cannot control, penalize physicians for increasing utilization of recommended preventive health measures and fail to capture long-term cost savings generated by high-quality, longitudinal primary care.”

The letter also cited the winding down of the Comprehensive Primary Care Plus as contributing to a shortage of APM model options, leaving a number of practices “effectively stuck in MIPS.”

“Primary care physicians need a range of model options that span the value spectrum and are aligned across payers, including models that provide an on-ramp to participation and practice transformation,” the AAFP said.

Medicare Shared Savings ACO Program

The Academy noted that several of the rule’s proposals would help more family medicine practices transition into value-based care through ACOs, allowing successful participation in the Medicare Shared Savings program. In particular, the letter offered strong support for finalizing — but expanding — an option that would make “advance investment payments” to ACOs that treat underserved populations, are low revenue, inexperienced with performance-based risk Medicare ACO initiatives or are new to the program.

“The AAFP recommends CMS consider expanding access to AIPs to some existing ACOs, such as those that are smaller or serve beneficiaries with high needs, as well as new applicants that may be considered high revenue but are serving beneficiaries with high needs,” the letter said, emphasizing federally qualified health centers and rural health centers.

“The AAFP recommends CMS consider other criteria which are more reflective of an ACO’s level of capital and inclusive of the patient populations they serve to avoid unintended consequences that may hinder efforts to advance VBP, improve health outcomes, reduce costs and reduce health-related disparities,” the Academy added.

The letter then recommended improving and finalizing proposals to address issues with benchmarking, and to implement a longer and more flexible transition for ACOs to assume financial risk. These proposals reflect longstanding AAFP advocacy to improve the ACO program and enable more family medicine practices to participate successfully in it.