Practicing Physicians Advisory Council (PPAC) Update for March 6, 2006I am pleased to send you an update on the March 6, 2006 meeting of the Practicing Physicians Advisory Council, a group of 15 physicians charged with advising the Secretary of HHS about the effect of CMS regulations on the practice of medicine. This is my final update, as I was not reappointed to PPAC. PHYSICIAN FEE SCHEDULE As everyone is by now aware, the Deficit Reduction Act held the 2006 conversion factor at the 2005 levels, instead of implementing the 4.4% decrease required by the Sustainable Growth Rate Formula (SGR). CMS has adopted policy to automatically amend claims to reflect this without requiring physicians to resubmit claims, and is forwarding the change to the secondary payers. PPAC expressed its gratitude to CMS, but echoed the concerns of the AMA that this short-term fix does not solve the problem. Unless the SGR is replaced by another mechanism of calculating physician fees, we will face a 34% decrease in fees through 2015. One PPAC member, who is a primary care doctor in an inner city practice that sees 75% Medicare patients, commented that he is leaving his practice as he cannot stay in business any longer. COVERAGE WITH EVIDENCE DEVELOPMENT At the last PPAC meeting there was discussion of Medicare's plans to pay for colon cancer therapy through a clinical trial model, but no data collection payment is included. PPAC had passed a resolution recommending that CMS get information from the NIH on the cost of data collection, but CMS interpreted this resolution to be about clinical trials in general, and not those trials under the new Coverage with Evidence Development Program. Therefore PPAC recommended that the CMS measure the costs of data collection incurred by physicians in the planned Coverage With Evidence Development program and recommended that as these programs are developed, those costs be conveyed to Congress for inclusion in the physician fee schedule, and furthermore, that these trials be conducted with the same regulatory requirements as any other trial, such as participation in an IRB, and not penalizing patients who decline to participate. PHYSICIAN REGULATORY ISSUES TEAM (PRIT) Dr. Bill Rogers heads the PRIT, which responds to physician complaints about specific issues with CMS regulations. The National Provider Identifiers were discussed, and PPAC recommended that a directory of NPI's be made available on line to physicians for ease of finding referring physician's numbers for billing purposes. At the last meeting, PPAC had discussed with the PRIT that commercial carriers often use the Relative Value Units forwarded by the AMA's Relative Value Update Committee (RUC), and for some pediatric and neurosurgery codes, the publication of these values would be useful for developing charges, even if CMS has made a non-coverage decision. PPAC recommended that CMS publish all these codes in the proposed and final physician fee schedule rules. PPAC also discussed the Medically Unbelievable Edits, which are edits designed to replace codes that would be impossible, such as hysterectomy in a male. However, there are concerns that this process has been expanded to other issues, such as the denial of pathology charges for all but the first two biopsies, when it is the standard of care to perform 6-12 prostate biopsies. PPAC recommended that CMS withdraw the proposal to create a list of medically unbelievable edits and resubmit the proposal through the formal rulemaking process and work with the medical community. PAY FOR PERFORMANCE (P4P) CMS reviewed the process used in the hospital setting where hospitals were paid an increase of 0.4% for submitting data to CMS, and compared it with the Physician Voluntary Reporting Program, where it is hoped physicians will submit quality data through the mechanism of G-codes with no reimbursement attached. They had no data yet on how many physicians were participating, but did not expect a large number. The G-codes are now less numerous and more appropriate than were originally proposed. The measures currently include both process and outcome measures. PPAC felt that the methodology to assess outcomes controlling for the variables of patient compliance, co-morbidities, socio-economic status and shared care were not well developed. PPAC recommended that CMS initially focus on process measurements rather than proceeding immediately to outcome measurements. PPAC also supports the efforts of CMS to explore the possibility of finding incentives to encourage beneficiaries to be more compliant. CMS requested information from PPAC members regarding the use of P4P measures by commercial payers, most of which indicated that commercial P4P measures focused on economic rather than quality issues, and that there is a lack of acknowlegement that certain levels of complications occur despite quality care, and still must be paid for. CMS also plans to use the Physician Voluntary Reporting Program to confidentially notify physicians on their use of resources. PPAC members pointed out that the benefits to CMS often accrue to the Part A inpatient system through increased utilization of the services in the outpatient Part B setting. Given that many pay for performance measures will require more part B services, which will increase future volume and intensity of physician services and lower future conversion factors as calculated through the SGR formula, thus penalizing physicians for doing the quality measures CMS has requested, PPAC recommended that CMS delay the implementation of P4P measures until the SGR is replaced with an equitable system. Congress is determined to have P4P implemented however, so pilot projects are underway. Currently the pilots involve large integrated groups and CMS is discussing whether to use a bonus system to pay for performance, or a differential where some physicians are paid more and others less depending on their ratings. PPAC felt that there is concern that in rural or inner city areas where practices are small and cannot afford the Information Technology required to participate in the current P4P programs, a decrease in reimbursement would threaten the viability of the practice. PPAC recommended that some P4P pilot projects be directed toward small practices, especially those with diverse geographic and socio-economically disadvantaged demographics, rather than all being directed toward the large vertically integrated systems. PPAC also recommended that the payment methodology be a bonus rather than a differential payment, in order to avoid damaging practices serving patients who are economically disadvantaged or non-compliant. The AMA testimony demonstrated that the AMA continues to be committed to improvements in quality of care, but in a voluntary reporting system using evidence-based physician level measures developed collaboratively across physician specialties, that can be reported with minimal administrative cost and burden. MEDICARE PART D CMS admitted that Medicare Part D got off to a rocky start, but commented that they have staff working continuously to solve the problems. For example, they have allowed long term care facilities to fax in lists of their patients, and have eligibility faxed back the next day, so that these beneficiaries are not paying copays. More than 500,000 faxes have been answered. There was discussion of complicating factors: The same drug can come under part B and part D depending on use, such as methotrexate used for cancer under Part B, and under Part D when it is used for arthritis. CMS said there are no plans to convert the infusable Part B drugs to Part D. Benzodiazepines and barbiturates are excluded from Part D coverage by statute, but 49 of 50 state Medicaid programs have elected to cover these drugs. As an increasing amount of chemotherapy is oral, and will be in the Part D benefit, there is concern that CMS will have difficulty covering off-label use. (Currently, many infused chemotherapy drugs are given for indications that were not part of the original package insert, and have not yet made it into the compendia, but have valuable indications documented through peer reviewed journals.) PPAC recommended that CMS use evidence-based medicine published in peer-reviewed journals to allow off label usage of medications covered on Part D. Not all pharmacy benefit plans will include all drugs, or may include drugs at variable levels of copays. Physicians will be asked to intervene for patients through the appeals process when patients get switched to new medications, and may need to see patients in the office for new problems arising from medication changes. CMS has worked with the AMA to streamline the appeals process, but efficient practices will need to have processes in place to handle these appeals. PPAC recommended that CMS monitor the amount of time physicians spend appealing part D pharmacy coverage decisions, and the costs of care related to substitutions of medications. A G-code demonstration process would be a good way to both measure the need and reimburse physicians for this needed care. MEDICARE ADMINISTRATIVE CONTRACTORS (MACs) Dr. Thomas Gustafson gave an update on the progress of the implementation of the Medicare Administrative Contractors. The same contractor will be administering Parts A and B, which should help break down the lack of ability to correlate savings in Part A with the transfer of services to Part B. The first MAC areas have had contractors selected, but there are some legal challenges involved. CMS plans to use competitive bidding and evaluation processes involving user satisfaction surveys to improve contractor performance. We were given a demonstration of the survey being used to evaluate the contractors, and suggested that practice administrators might be better able than physicians to evaluate the response times, accuracy of information and other indicators. The information on the survey is available online. IMAGING REIMBURSEMENT In the physician fee schedule, regulations were developed to decrease the technical fees for 11 "families" of imaging services for contiguous areas by 50% in 2006 for physician outpatient facilities, but not for Hospital outpatient facilities. The comment was made at the last meeting that many fees were higher in the physician outpatient setting than in the hospital outpatient setting for radiology procedures. PPAC members found that this did not reflect their experience, and requested data. Of 600 radiology services, approximately 150 have higher technical rates in the physician setting. CMS plans to lower the physician fee schedule technical fees to match the OPPS fees for 2007. RECOVERY AUDIT CONTRACTORS In Florida, New York, and California, a demonstration project is underway in which CMS has hired contractors to find billing errors. The contractors are paid a contingency fee based on the money recovered. At the last meeting PPAC recommended that CMS find a way to pay these contractors for underpayments as well as overpayments, and CMS has done so. The contractors will be paid a contingency fee from the CMS administrative money and the physicians will be paid the correct fee. PPAC also recommended that the Carrier Medical Directors be briefed on the Recovery Audit Contractor Demonstration Project, and this occurred. At this meeting, PPAC requested that we be given a copy of the demand letter sent to physicians when an overpayment occurs, and this occurred at this meeting. Physicians who have responded to requests for information will be told the status of the investigation within 60 days. More information is available on the CMS web site, or you may e-mail to 'CMS_RecoveryAuditDemo at cms.hhs.gov'. (Replace the ' at ' with '@' *.) MEDICARE HEALTH SUPPORT CMS has embarked on a disease management pilot project where beneficiaries with either diabetes or congestive heart failure are randomized to a program where nurses call them to answer questions, discuss medications, explain the care plan and offer advice, versus a control group without these services. Examples given of the efficacy of this program involved a hospital patient discharged without understanding of her medications due to a language barrier, and another where a nurse reviewed the medications with a patient and was able to help the patient with multiple social concerns. PPAC felt that if primary care physicians were paid to provide these services and had access to translators and social workers paid by CMS, that equivalent quality of care could be achieved, without the intervention of an expensive layer of bureaucracy between the patient and the physician. PPAC recommended that CMS run a pilot program giving the resources for disease management, such as paying for translators, social service fees, management fees, etc to primary care physicians and compare the costs of providing the same services through the disease management industry. FINALE It has been my pleasure to provide you with these updates for the last four years. I will miss the interaction with CMS, my colleagues on PPAC, and the responses I have received from many of you. Thank you for allowing me this opportunity. Respectfully submitted, Barbara L. McAneny, MD, FACP
(Pending) Official CMS documents for this PPAC meeting: Zip Download (Not yet available from CMS) *The e-mail address is broken up this way as it is now considered good practice to avoid placing actual e-mail addresses in web pages to prevent spammers from gathering addresses online. |
