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Opportunity – In the Eye of the Beholder?


On Nov. 3, 2016, the Centers for Medicare & Medicaid Services (CMS) published the final rule updating the Medicare Physician Fee Schedule (PFS) for calendar year 2017. With all of the attention that the Quality Payment Program (QPP) established under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), there is some risk that meaningful changes may have escaped notice.

There is also a risk that the implications of these payment policy changes, and the opportunities they may create, will not be fully realized or that they will only slowly create positive change in care delivery.

The 2017 PFS update is nearly 400 pages – too much to summarize in this forum. But I'll highlight a couple of changes:

  • The Medicare Diabetes Prevention Program (MDPP) expanded model. MDPP will offer payment for a structured health behavior change program delivered in community and health care settings by trained community health workers or health professionals. This benefit will be available to Medicare beneficiaries with prediabetes, when furnished by a new type of Medicare provider organization - the MDPP supplier.
  • Medicare will offer payment for the non-face-to-face prolonged Current Procedural Terminology (CPT) codes. The intent is for these codes to be used to report extended non-face-to-face time spent by the billing physician or other practitioner on tasks that are not within the scope of the clinical staff.
  • Medicare will offer payment for complex chronic care management (CCM) services - PFS changes include reduced administrative burden for CCM and an add-on code to the CCM initiating visit to reflect the work of the billing practitioner in assessing the patient and establishing the CCM care plan.
  • Medicare will offer payment for codes that describe specific behavioral health services furnished using the psychiatric Collaborative Care Model. In this model, patients are cared for through a team approach, involving a primary care practitioner, behavioral health care manager and psychiatric consultant. CMS is also finalizing payment for a new code that broadly describes behavioral health integration services, including payments for other approaches and for practices that are not yet prepared to implement the Collaborative Care Model.
  • Medicare will offer payment to physicians to perform cognitive and functional assessment and care planning for patients with cognitive impairment (e.g., for patients with Alzheimer's).

In the rule, CMS provides background on the policy principles underlying some of the changes adopted. CMS noted that procedurally-oriented payment models have resulted in a systematic mis-valuation of the type of cognitive and care coordination work that is more common in primary care. CMS describes the 2017 changes as part of an ongoing incremental effort to update and improve the relative value of primary care, care management/ coordination and cognitive services within the PFS. They note that this effort is particularly vital in the context of the forthcoming transition to the QPP.

Do these offers for payment ensure that Medicare beneficiaries with pre-diabetes will have access to MDPP services? Or that their physician will now be able to take the time needed for non-face-to-face care? Or that that patients with multiple chronic conditions will receive care management services? Experience suggests that the answer to these questions is no – or at least not consistently and not soon.

Why would we expect variable access to these services?

Changes to the PFS constitute an offer of payment. The fees offered, services covered and required conditions for payment are policy actions intended to increase use of high-value health care services. Underlying these actions is an implied economic theory of demand for services sufficient to create a supply of those services.

This theory will be tested, in the real world, by potential providers' assessment of a number of factors. This assessment might begin with the question: "would providing this care be a good thing for our patients?" If the answer is yes, at some point, another question will come up: "can we afford to provide this service?" That is an assessment of whether there a viable business model for these services.

I've seen recent examples of how these provider/supplier assessments and actions play out in the real world.

  • In 2015, Medicare began to offer payment for CCM. The offer at that time was about $40 for 20-minutes or more clinical staff time devoted to care management activities for eligible Medicare beneficiaries. In 2016, it was estimated that providers submitted claims for any CCM services for less than 5 percent of the eligible population. With a few exceptions, the supplier/provider market determined that it would not make sense to provide (or to submit claims for) CCM services, under the stipulated requirements and at the payment level offered. This market non-response was cited in the CMS updates to the PFS that increase payment and reduced administrative burden for CCM.
  • In 2011, Medicare began to offer payment for an Annual Wellness Visit (AWV). Since that time, AWV use has been increasing nationally – from about 11.0 percent in 2013 to 17.7 percent in 2015. In 2015, more than 30 percent of Rhode Island and Massachusetts Medicare beneficiaries received an AWV. None of HealthInsight's states had AWV rates greater than 15 percent in 2015.

If we look beyond the overall rates, however, a different view of the supplier/provider market response emerges.

HealthInsight examined AWV rates for New Mexico for 2015. NM had an overall AVW rate of 10.7 percent. We grouped Medicare beneficiaries according to their primary care provider. Among practices with 200 or more attributed patients, we found:

  • About 20 practices with AWV rates above 50 percent (a few even have rates above 75 percent)
  • Over 50 other practices with AWV rates less than 3 percent

We saw examples of high AWV rates across the range of panel sizes (with no relationship between panel size and AWV rates). When we looked at AWV rates, by provider over time, we observe that most active AWV providers remain active once they've begun delivering this service.

That is, compared to CCM before 2017, we see greater variability in the supplier/provider market response to the Medicare offer of payment for AWV. Some have seen this as an opportunity and successfully pursued it; others have not.

CMS and other payers may continue to seek to shape care delivery through these types of payment policy actions. This environment may reward (or demand) not just the capacity to develop and manage efficient and reliable care processes, but also the capacity to make structural adaptations to their business model in order to deliver additional services. Especially in the case of MDPP, capacities to secure startup funding (from public, foundation or even investor sources) and bring a program into production from scratch may be critical. HealthInsight recognizes the challenge this entails and is working to support providers seeking to establish or expand offerings of high-value services.

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