Primary care gets boost in pay under new CMS fee schedule

CMS would increase payments for primary care, geriatricians, family physicians and mental healthcare under the proposed physician fee schedule for 2017, along with expanding its Medicare diabetes prevention model. 

The changes would total $900 million in additional reimbursements to those physicians, according to a blog post written by CMS Acting Administrator Andy Slavitt and CMS Chief Medical Officer Patrick Conway, MD.

“In the United States, we have historically invested far more in treating sickness than we do in maintaining health. The result of this imbalance is not only poorer health, but more money spent in institutions, hospitals and nursing homes,” Slavitt and Conway wrote. “The road to a better healthcare system means correcting this imbalance. We should reinvest in what we value—primary care—as a practice, as a profession, and as an abundant resource for patients.”

Some of the specific proposals include:

• Increasing reimbursement for office visits for patients with mobility-related disabilities from $73 to $119.
• Increasing payments to geriatricians and family physicians for “core services” under Medicare by 2 percent in 2017, with an eventual increase of 30 to 37 percent if “if all of the practitioners that can provide these services provide them to all eligible patients.”
• Paying for mental healthcare under the behavioral care model.

Along with the increased payments, the proposed fee schedule includes several changes to billing codes aimed at providing accurate payment for primary care practitioners.

The code changes as outlined by a CMS press release include:

• Separating payments for certain existing Current Procedural Terminology (CPT) codes describing non-face-to-face prolonged evaluation and management services.
• Revaluing existing CPT codes describing face-to-face prolonged services.
• New CPT coding for mammography services, reflecting “the use of current technology used in furnishing these services, including a transition from film to digital imaging equipment and elimination of separate coding for computer aided detection services.”
• Separating payments using new codes in areas like patients with cognitive impairment, primary care practices that use interprofessional care management resources to treat patients with behavioral health conditions, and chronic care management for patients with greater complexity.
• Making several changes to reduce administrative burden associated with the chronic care management code.
• Adding new codes to services eligible for telehealth, including end-stage renal disease related services for dialysis, advance care planning services, and critical care consultations.

For the diabetes program, CMS is proposing expanding diabetes prevention into Medicare beginning January 1, 2018. Suppliers of the program would be able to submit claims to Medicare if they’ve been recognized by the Centers for Disease Control and Prevention (CDC).

“Through expansion of the Diabetes Prevention Program, beneficiaries across the nation will be able to access a community-based intervention that prevents diabetes and keeps people healthy. This is part of our efforts for better care, smarter spending, and healthier people,” Conway said in a press release.

The proposed rule defines an eligible patient as having a body mass index (BMI) of 25 or greater (a BMI of 23 or greater for Asian beneficiaries), along with a hemoglobin A1c test with a value of 5.7-6.4 percent, or a fasting plasma glucose of 110-125 mg/dL within the last 12 months, or two-hour plasma glucose of 140-199 mg/dl after the 75 gram oral glucose tolerance test. Eligible beneficiaries could have no previous diagnosis of diabetes or life-threatening conditions, mobility issues, etc. that would prohibit them from participating in the program.

What hasn’t been specifically proposed is the scope of the program or what quality metrics will be used. In its request for comments, CMS is asking for recommendations on what measures used for public reporting (not for payment) and whether the prevention effort should be rolled out nationally or in select markets beyond those used in the 2013 pilot program.