The Centers for Medicare & Medicaid Services (CMS) used the proposed 2015 Medicare Physician Fee Schedule (MPFS) to create some carrots and sticks to encourage moving the care of more patients, particularly the growing percentage of beneficiaries with multiple chronic illnesses, into the lower-cost outpatient primary care setting.

Chief among these is the proposed creation of a separate payment for chronic care management (CCM) services beginning in 2015. This new billable service would be for qualifying Medicare beneficiaries with two or more significant chronic conditions — exactly the type of patients that under an accountable care model could drag down a primary care practice’s efficiency and outcomes. The new separate payment makes the hard-to-treat chronically ill a better payment prospect by allowing for the billing of CCM services as frequently as monthly. The proposed payment rate for CCM is $41.92, and if billed monthly, that would be more than $500 extra per year per qualified chronically ill Medicare patient.

Under the payment proposal, Medicare providers would also have a great deal of flexibility in using staff to provide many of the CCM service components. It would not be up to the physician alone to care for chronically ill seniors, and nurses and medical assistants could do much of the work necessary for CCM.

In addition, primary care physicians who are seeking to lower the cost of care in an accountable care or shared savings model, will get more leeway in using telemedicine with Medicare beneficiaries. The rule proposes adding annual wellness visits, psychoanalysis, psychotherapy and prolonged evaluation and management services to the number of services that can be furnished to Medicare beneficiaries under the telehealth benefit.

Along with proposing some additional quality metrics, streamlining existing ones and soliciting ideas for new metrics, the rule adds a new incentive payment for accountable care organizations (ACOs). These already earn incentives for quality improvement, but if the rule is adopted, ACOs could also earn an award based on annual quality improvement in traditional Medicare, just as they do now for Medicare Advantage plans.

Money to pay for the additional CCM service and quality improvement incentives come in part from savings Medicare found in 80 codes it said were misvalued. Because CMS concentrated its review on high-paying codes, these continue the shift in reimbursement from specialty care to primary care.

Additional key provisions in the proposed rule included:

• A change to eliminate the exception of continuing medical education (CME) from industry payment reporting under the Sunshine Act, which seeks to publicize to patients potential relationships between physicians and device and pharmaceutical developers and marketers.
• A change to include full anesthesia, rather than just sedation, in a colonoscopy in order to eliminate the need for beneficiaries to pay an anesthesia co-pay for a preventive care service that should have been co-pay free under Medicare Part B.
• A requirement that hospitals and physicians next year must begin to report a claim modifier for services furnished in an off-hospital-campus provider-based department on both hospital and physician claims. (This requirement also appears in the proposed hospital outpatient prospective payment system [OPPS] rule.)
• A change in how the MPFS will be set starting with 2016 rates that CMS believes will make the process more transparent and allow for greater public input prior to payment rates being set. Under the new system, payment changes will go through the government’s full policy change notice and comment rulemaking process before being adopted.

CMS made a point of saying that it was not addressing the looming mandatory application of the sustainable growth rate (SGR) formula to Medicare physician payments, which it estimated would cause a cut in excess of 20 percent. Congressional action has averted the cut until March of 2015, and CMS noted that it expected Congress to pass another bill to avert the cut then, as Congress has in nearly every other year since the SGR was first implemented in 1997.

The Federal Register will officially publish the proposed rule on July 11, 2014, and CMS will accept comments until Sept. 2, 2014. The payment and policy changes would become effective on January 1, 2015.