National Kidney Foundation Summary of the 2016 Physician Fee Schedule Final Rule
On October 30, 2015 the Centers for Medicare & Medicaid Services (CMS) released the final rule on physician payment under Medicare Part B, Revisions to Payment Policies under the Physician Fee Schedule (PFS) and Other Revisions to Part B for CY 2016 CMS-1631 – F.
The National Kidney Foundation (NKF) commented on the proposed rule in August 2015 and focused on issues that may impact patient’s access and quality of care. Below is a summary of the final rule and how CMS responded to NKF’s concerns.
Improved Payment for the Professional Work of Care Management Services
CMS solicited comments on how Medicare could better account for the resource costs of managing patients long term and for a more robust interdisciplinary consultation within the current structure of PFS payment. CMS specifically asked for comments on services that could be included in a payment that would go beyond current evaluation and management (E/M) and chronic care management (CCM) codes. CMS also asked whether there are conditions for which it might be appropriate to make separate payment for telephone and internet consult services to pay for collaborations between primary care practitioners (PCPs) and specialists. In addition, CMS sought comments on how beneficiaries could be better protected by ensuring that they are fully aware of the involvement of the specialist in the beneficiary’s care and the associated benefits of the collaboration between the primary care physician and the specialist physician prior to being billed for such services.
In response, NKF issued comments recommending separate chronic care management (CCM) codes for the management of specific diseases. For CKD, NKF recommended a tiered approach whereby PCPs could bill for CKD care management in stages 1-3. The CKD 1-3 codes could be multipliers added on to other disease specific CCM codes, if created, to account for the added complexity of also managing CKD. For example, if CMS created a CCM for diabetes management, a CKD add-on code could be applied. For CKD stage 4-5, NKF recommended higher valued CCM codes be developed that both PCPs and nephrologists could use to collaborate on care of the more advanced CKD patient. In our comments, NKF detailed out the types of services that could be included in each CKD management code.
CMS is exploring strategies to better pay for and care management and interdisciplinary consultation in 2017. New proposals will likely be released in July 2016 in the 2017 proposed PFS rule. NKF will continue to advocate for payment of CKD specific care management and collaboration with CMS and Legislators.
Medicare Telehealth Services
NKF is pleased that CMS finalized the proposal to add four home dialysis related codes (90963, 90964, 90965, and 90966) to the list of telehealth services. These codes reflect services that do not always require in-person care, such as nutrition adequacy assessments, growth and development assessment, and caregiver counseling for children as well as appropriate assessments and monitoring for the adult home dialysis population. NKF is also pleased with the clarification that nephrologists can use telehealth to communicate with their patients during the month, after the first in-person visit has occurred, and receive payment under the Monthly Capitated Payment (MCP).
NKF also commented that a patient’s home and dialysis facility be accepted as a telehealth originating site. CMS noted in the final rule that current statute does not permit this change. NKF will continue to advocate for broader availability of telehealth services to ensure more beneficiaries have access to the flexibility and improved quality of life these services may provide.
Physician Quality Reporting System (PQRS)
NKF made several recommendations to protect and improve kidney patients’ quality of care by aligning payment incentives with important quality measures under PQRS.
- NKF strongly supported a new measure be include in PQRS that would help ensure patients with ESRD are referred to hospice care if they decide to discontinue dialysis. NKF is pleased CMS finalized this measure as we believe it will help patients and families receive beneficial end-of-life services.
- NKF and other commenters disagreed with CMS’s proposal to remove hemodialysis and peritoneal dialysis adequacy measures from PQRS and we are disappointed that CMS decided to finalize its proposal.
- NKF and one other commenter disagreed with CMS’s proposal to remove the Hemodialysis Vascular Access Decision-Making by Surgeon to Maximize Placement of Autogenous Arterial Venous (AV) Fistula from PQRS. NKF believes this measure has fostered the increased use of AV fistulas and, while performance is high on the measure, viewed it as important to ensuring this trend continues and to aligning physician payment incentives with dialysis facility incentives. Unfortunately, CMS decided to remove the measure. NKF will monitor whether removal of this measure from PQRS has a negative effect on dialysis adequacy.
- NKF also recommended new areas for CMS to prioritize measures or invest in measure development. NKF recommended that CMS replace the current measure related to detecting kidney disease in diabetics with a new measure that actually requires physicians to have a serum creatinine and albumin to creatinine ratio recorded for all diabetic patients. NKF also recommended CMS develop a patient safety measure on NSAID avoidance and one on PCP and nephrology co-management of CKD stage 4 patients. NKF will continue to advocate for these measures and will work with partners to develop and test the NSAID avoidance measure and co-management measures for future inclusion in PQRS.
The Merit-based Incentive Payment System (MIPS)
In 2019, the current physician value based purchasing programs (PQRS, meaningful use, and the physician value based modifier) will be rolled into one program that also includes measurement on participation in clinical improvement activities. CMS sought early comments on suggestions for clinical improvement activities. NKF recommended the creation of a CKD detection and management CIA that could help reduce risk of cardiovascular events, acute kidney injury and progression to ESRD if adopted by PCPs. NKF also recommended that these activities along with the new CKD quality measures recommended above be included in Alternative Payment Models (APM). NKF will continue to advocate and have discussions with CMS on the development of MIPS and new APMs.