By Linda Rouse O’Neill
Vice President, Government Affairs, HIDA
A glimpse into physician reimbursements post-SGR
In July, the Centers for Medicare & Medicaid Services (CMS) issued its proposed calendar year (CY) 2016 fee schedule updates for physicians and other practitioners. Physicians can expect a 0.5 percent Medicare reimbursement increase for CY 2016 under the proposed rule.
This year’s proposed rule also carried particular industry significance as many were interested to see how CMS would approach the physician fee schedule in light of Medicare’s recent Sustainable Growth Rate (SGR) formula repeal. As you may recall, the Senate and House overwhelmingly approved a bill in April to repeal the SGR formula used to control physician payment rates and replace it with a new payment system that seeks to reward quality, efficiency, and innovation.
The rule is complicated, but the key takeaway you should know is that your physician customers need to meet CMS’s quality data reporting standards if they want to continue getting paid for Medicare services without penalty.
CMS Gets Serious on Quality Reporting
CMS has several initiatives intended to encourage quality data reporting. The Physician Quality Reporting System (PQRS) uses a combination of incentives and penalties to promote quality data reporting by physicians and other eligible professionals paid for services under the physician fee schedule. For example, those who do not adequately comply with data reporting requirements could receive up to a 2 percent cut in 2017 Medicare payments.
In order to better facilitate PQRS reporting, CMS proposes several changes to the reporting system, including:
- In lieu of meeting PQRS quality data reporting standards, providers can report data in any qualified clinical data registry as long as similar reporting criteria are met.
- In 2018, eligible professionals must report on nine quality measures from at least three of the six Department of Health and Human Services National Quality Strategy (NQS) domains – such as patient safety, clinical processes/effectiveness, and care coordination.
- The list of individual quality reporting measures, totaling 300 overall measures, will be revised by adding new and retiring other metrics.
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) – the legislation that repealed the SGR formula—also requires CMS to implement a merit-based incentive payment system for physicians, which will ultimately replace the current the Value-Based Payment Modifier (VBPM) system beginning CY 2019. CMS is committed to ensuring a smooth transition between the two programs and we will closely monitor any developments that could immediately affect your physician customers.
Open Payments transparency increasing
CMS also proposed adjustments to its Open Payments program for CY 2016. The program, a result of the Physician Payments Sunshine Act, requires applicable prescription drug, biological, and device manufacturers to report payments and values of transfer to physicians and teaching hospitals.
The Open Payments website has published two years’ worth of payment data for public review, most recently with its June 30 release of 2014 information. Two proposed changes of note that could be of use in your customer discussions include:
- An added indicator on profile pages showing eligible professionals who satisfactorily report PQRS data, an easy check to ensure your customers are compliant with reporting requirements.
- Utilization data for eligible professionals will be made publicly available and downloadable in the database, which could be used internally to create comparative analyses of similar customers to identify potential product standardization opportunities.
The Clinical Laboratory Fee Schedule (CLFS), which is usually released in conjunction with the physician fee schedule proposed rule, was delayed by CMS due to the complexity of coming lab reimbursement changes. The proposed rule should be released no later than September. The Protecting Access to Medicare Act of 2014 (PAMA) set statutory deadlines for a rebasing of the CLFS based on private payer rates. PAMA also states that CMS should begin collecting private payer data on Jan. 1, 2016 and start making payment adjustments based on the new CLFS methodology beginning Jan. 1, 2017.
For more information, visit us at www.HIDA.org or contact us at HIDAGovAffairs@hida.org.