Population health insights

CMS updates: fee schedule and MACRA

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Aug 08, 2017

As usual during the summer months, CMS has issued proposals for major programs and reimbursements for 2018. Highlights include the annual Physician Fee Schedule, MACRA changes for next year and annual spending for home health services. Home health is up for another round of steep cuts if CMS’ proposal for its reimbursement holds up.

Physician Fee Schedule

Telehealth and chronic care management continue for 2018 as expansion themes in recent years, as does FQHC/RHC reimbursements and overall care management. Also for 2018 comes movement within behavioral health, in part tied to Medicare ACOs.
  • Telehealth – Here CMS proposes five new billing codes around tomography visits, “interactive complexity,” health risk assessment, care planning for chronic care management and psychotherapy for crisis. The expansion is accompanied by language that CMS is seeking comment on ways to further expand telehealth “within our current statutory authority.” This speaks to the office-based and geographic limitations in federal rules seen as holding back real telehealth expansion. To that end, timed up with the fee schedule release was yet another Congressional bill seeking waivers of these restrictions. House bill 3482 joins a pretty long list of Congressional efforts to unlock telehealth. The Senate-driven Chronic Care Act seeks the same, and there’s some hope it may be attached to CHIP reauthorization due up this year.
  • Behavioral health – Interesting movement here and a matter of connecting some dots. The fee schedule seeks to increase payment for “office-based face-to-face” services with patients. In another section of the fee schedule, it’s noted within language for CMS ACOs that the agency is offering three new behavioral health integration (BHI) codes for 2018, done to add BHI to the definition of primary care services used in ACO assignment methodology. That’s all good news, for example, for primary care providers working within CMS’ CPC+ program, which itself seeks to add behavioral health programs – and attendant health IT certification – beginning in 2019. Meantime, Congress is again in the mix, with a July 25 House bill (3331) that would push CMS to create a demonstration model around incentives for behavioral health professionals to adopt EHRs. We’ll see, as this was also tried in 2013 and 2016, as lawmakers tried to include behavioral health professionals in meaningful use.
  • Care management/care coordination – On the procedural front, the fee schedule is looking on one hand to move care management services billing from Medicare G codes to CPT codes. For FQHCs and RHCs, the agency wants to create two new and specific FQHC/RHC codes for care coordination on complex chronic care, general behavioral health integration and psychiatric services. These payments would be on top of visit payments. Back over to CMS ACOs, the fee schedule seeks to add three new chronic care management codes also added to the definition of primary care services for ACO assignment methodology.
An overview fact sheet of the fee schedule proposed rule can be found here, and its entirety can be found here. Public comment is being taken by CMS through Sept. 11, 2017.

MACRA 2018

Expect MACRA program tweaks annually, and the advent of a new HHS administration surely accelerated changes, so there are a lot of MACRA changes proposed for the 2018 reporting year, such as:
  • The threshold to be exempt from MIPS increases. If Medicare Part B billing is $90,000 or less or if 200 or fewer patients are seen, individual clinicians would not have to report to MIPS. (Clinicians would still be subject to overall MACRA reporting and scoring if they reside within a CMS ACO or the CPC+ model, for example, on the Advanced-Alternative Payment Model (A-APM) side of the house, but that too means no outright MIPS reporting.
  • Up or down payment adjustments for the 2018 performance year go from 4% to 5%, and that’s per the overall MACRA law so it will hold up through the rules process.
  • Speaking of the A-APM models, 2018 would introduce the new CMS ACO called Track 1+. Here is a detailed look at its risk levels and timelines.
  • Back on the MIPS side, the minimum score to avoid a negative payment adjustment is proposed at 15, which is a jump up from the 3 points needed during the current 2017 performance year, but in a nod to the pick your pace approach this year, clinicians can still choose to score 3 points on the quality category – by sending in one quality measure – toward the 15 total points needed.
  • MIPS scoring weights are proposed at 60% for quality, 15% for improvement activities and 25% for advancing care information (ACI), the former meaningful use.
  • Getting some love is the anticipated introduction of virtual groups. Beginning in 2018, groups of 10 or less clinicians not tied by practice or geography can report to MIPS as a group. A deadline to declare for it comes this December.
  • There’s no love, though, for telehealth in the proposal. Right now, the MIPS improvement activity scoring weight for using telehealth as part of Expanded Practice Access would move from a high-weighted to low-weighted score.
  • In another well-received move, the proposal will allow MIPS clinicians to report in 2018 using 2014 Edition certification. Prior, the 2015 Edition was to be required for 2018 for all vendors and their healthcare provider customers reporting to MIPS. The proposal does offer 10 bonus points to MIPS clinicians who are completely on the 2015 Edition as of Jan. 1, 2018. (Clinicians can also be on a 2014-2015 combo by upgrading throughout 2018 but not receive bonus points. Also, at this writing, some A-APM participants are still required to be on the 2015 Edition as of Jan. 1, 2018. Confusing yes, and CMS is being pushed for clarity or alignment as the rulemaking process continues.)
  • There are also bonus points available for clinicians caring for complex patients using CMS HCC risk scoring.
  • And finally, for now, clinicians in ambulatory surgical centers would not have to report to the MIPS ACI category.
All of this is part of HHS’ stated intentions to simplify the MACRA process and reduce reporting requirements for small practices.

About the author

Greg Fulton
Greg Fulton,
Industry & Public Policy Lead, Philips
Greg Fulton is Industry & Public Policy Lead for Philips PHM. He has extensive health IT experience in government relations at Congressional, Health & Human Services, state and industry organizational levels. He is a current member of the CommonWell Health Alliance Government Affairs Advisory Council and the HIMSS Government Relations Roundtable.

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