Practicing Physicians Advisory Council (PPAC) Update for August 30, 2004It is my pleasure to share with you my report on the August 30 meeting of the Practicing Physicians Advisory Council, a group of 16 physicians from across the country who advise CMS on the effect of Medicare policy on the practice of medicine. PHYSICIAN FEE SCHEDULE The Physician Fee Schedule was published in the federal register, confirming that for 2005 there will be a 1.5% increase, as required by Congress. However, the flawed Sustainable Growth Rate (SGR) formula still stands and will cause a decrease in the conversion factor of 5% per year for 6 years starting in 2006 unless action is taken by Congress. In May, PPAC asked for a report from CMS on the assumptions that the Office of the Actuary's Medical Economic Index (a formula developed in the 1970s) accurately reflects the practice environment physicians face today. At the August meeting, the office of the Actuary explained to us that apartment rents are used to compare differences between regions for purposes of calculating the GPCI to estimate differences in office rents, because there is no easily obtained data on office rents. The Office of the Actuary uses data from the Bureau of Labor statistics and the Bureau of the Census to determine Labor costs, and three to four year old data to estimate the increase in Professional Liability Insurance as an expense. PPAC members pointed out to the actuary that data was being used from PLI companies who were no longer writing PLI policies, and that the enormous increases in premiums occurred in the last few years. We also pointed out that they have never shown us any proof that apartment rent rates correlate with office rental space, or that general labor markets are a good proxy for the market for nursing and technical workers. Once again, PPAC requested that CMS use its regulatory ability to remove Physician administered drugs from the SGR, as this is a rapidly increasing medical expense over which physicians have no control, but this time we requested that the change be made retroactively to 1996, the year when the SGR was based. This would be a significant help in ameliorating the expected drop in physician Medicare fees for the next six years. NEW BENEFITS IN THE MMA CMS has included a welcome to Medicare exam, which is described as a comprehensive medical history and physical examination as well as social history, review of the individual's functional ability and level of safety, EKG, education and counseling and referral for screening (mammography, colonoscopy screening, Pap and pelvic or prostate exam , diabetes screening and outpatient self management training services, bone mass, glaucoma, cardiovascular blood tests, risk for depression, and vaccinations for pneumococcus, influenza and hepatitis B. This is admirable, and it is long overdue for Medicare to pay for prevention, but CMS proposes to pay a physician for all of those services at a 99203 level plus the EKG!! PPAC recommended that CMS only specify those components of the exam which are specified by the statute, and that the specific other services be left to the physician with billing codes selected in the usual manner based on the extent of the service. I would advise that any office undertaking these exams develop a checklist and consider the use of physician extenders, as the amount of time required to perform all these tasks appears to me to be more than a 99203 visit. PHYSICIAN ADMINISTERED DRUGS At the May PPAC, we had requested that CMS publish the Average Selling Price (ASP) for all affected drugs by June, and CMS intended to do so, but the published proposed rule only includes 32 drugs. Testimony from the American Society of Clinical Oncology (ASCO) commented that it was Congress' intent to have the 2005 rates stay approximately the same as the 2004 rates. However, payments for drug administration will drop about 21%, and payment at ASP +6% leaves some drugs being reimbursed at less than their purchase price. Those patients with no Medigap insurance will be the patients most likely to be unable to obtain therapy in physicians' offices, and will incur larger copays at the hospital, if the hospital will treat them at all. With only a few months left and the full list not available, all specialists who administer drugs in the office are having a very difficult time formulating a business plan. PPAC recommended that CMS should publish the complete list of covered drugs' prices on the CMS web site by early September so that physicians can develop comments before the September 24 deadline for comments on the proposed rule. In addition, drug payment rates published in the November rule should be considered "interim" so that they will be subject to further refinement as more data is gathered on the payment changes. PPAC also recommended that CMS proceed with caution in implementing the Average Sales Price (ASP) rates. CMS should make broad use of any discretionary authority it might have to make exceptions to, revisions to, or delays in ASP rates. If CMS does not believe it has the authority to delay these changes until it has complete and reliable data, it should ask Congress for such authority. Currently work is underway to develop more reasonable administration codes for infusible drugs, and these codes are not required to be budget neutral. PPAC recommended that CMS give serious consideration to the coding and relative values changes for drug administration codes as suggested by the RUC and the CPT committee, and that these remain exempt from budget neutrality as specified in the MMA. There is serious concern among oncologists, urologists, rheumatologists neurologists, ID doctors and many others that these changes will make it impossible for infusions and injections to be offered in the office setting, and therefore subject patients to delays in care, or lack of access at all. Rural clinics may be especially affected. PPAC therefore recommended that CMS should also establish a system for monitoring access to drugs affected by the new ASP methodology. CMS should continually evaluate whether:
In 2006 drug reimbursement will decrease to ASP +3% or physicians can get drugs through a competitive bidding company. It is unclear as to how this will be structured. PPAC recommended that the competitive bidding apply to all specialties and that CMS involve PPAC in the development of the competitive bidding process. SKILLED NURSING FACILITIES At the last meeting PPAC had several recommendations to assist physicians with obtaining payments for provided services, especially technical fees. We had requested CMS to address the concerns of the physician community that the current system is inefficient, and results in physicians having to attempt to collect from the SNF payment for part B services. CMS has attempted to clarify the issues on the MedLearn Matters website where SNF consolidated billing is addressed, and is reviewing sample notices to inform physicians. CMS agrees that the technical component of service supplied to a SNF patient is the responsibility of the SNF, but offers no intention of expanding the list of exempted services and still feels that physicians should negotiate contracts with the SNFs. Research is underway to evaluate the SNF system. MEDICAL CARE FOR UNDOCUMENTED ALIENS CMS has elected to allocate money by states without creating distinct pools for hospitals, ambulance services and physicians, as PPAC had suggested in May. However, they plan to allocate money by state, and pay bills as they are submitted by all providers quarterly, as the money allows. If the hospital elects to receive the money, and then pay the physician from their money, CMS can encourage, but not require, the hospital to actually share the money with the doctor. CMS stated they do not have the legal authority to deny information obtained on undocumented aliens to the Immigration and Naturalization Service. PROVIDER ENROLLMENT CHAIN AND OWNERSHIP SYSTEM (PECOS) At the last meeting, PPAC discussed the problems that CMS is having with the backlog of enrolling physicians in the PECOS system, and senior leadership at CMS is doing site visits to ensure that the backlog of enrollment is eliminated. CMS will pay interest on clean claims, and admits this does not help physicians who have not been able to file claims because they have no provider number. CMS requests that if physicians are having financial hardship such as cash flow difficulties, that we should notify Allen Gillespie at agillespie@cms.hhs.gov. CMS is hoping to have an interactive website where the 855 can be completed on line, and changes can be made. PECOS is still struggling with access, security electronic signatures, and other issues. NATIONAL PROVIDER IDENTIFIER (NPI) Each of us will be required to have a national provider identifier number by 2006, and we will all be applying through the PECOS web application. This number is not the DEA or the UPIN, but a new number we must have. More information is available on the CMS Provider Enrollment page. CHRONIC CARE IMPROVEMENT CMS is evaluating applications for the Chronic care improvement Programs, hoping that this type of program will eventually save money. The programs are required to decrease costs compared to the control group of patients with equivalent problems (CHF, Diabetes and COPD) by 5% or the program is at risk of having to return the money to CMS. Awards for this program will be made by December 8, 2004. PPAC expressed concerns that all of the grants will be given to large companies and that none will follow the model of providing management fees to primary care physicians. We would like to see if given the opportunity and resources, a physician cannot improve the measured parameters just as well as an externally imposed company. We also expressed concern that shifting nurses to phone triage from the bedside might exacerbate the nursing shortage. In the private sector, the disease management companies often have nurse-staffed hot lines, which, if the nurse feels unable to resolve the problem, result in the patient being directed to the ED, thus contributing to overutilization in that setting. Disease management programs may be effective at keeping the patient out of the hospital, at the expense of more office visits, thus causing the volume of services to rise and trigger the SGR. POWER WHEELCHAIRS PPAC did not feel that a face to face visit should be required for provision of DME as a mechanism to avoid the fraud which resulted in a huge expense for power wheel chairs, but felt that was acceptable for power wheelchairs in light of this situation. CALLCENTER ACCURACY The draft agenda included an item on the accuracy of information provided through call centers, but this was not part of the final agenda. Hopefully it will appear on future agendas, as the GAO report documented 300 calls to 34 centers, and found only a 4% accuracy rate.
Thank you for your time in reading this. Respectfully submitted, Barbara L. McAneny, MD, FACP
Official CMS documents for this PPAC meeting: Zip Download |
