Last night, the Centers for Medicare and Medicaid Services (CMS) released its proposed fiscal year (FY) 2021 updates for the Medicare Physician Fee Schedule and Quality Payment Program (proposed rule, Physician Fee Schedule fact sheet; Quality Payment Program fact sheet; Medicare Diabetes Prevention Program fact sheet), including several policies to permanently expand telehealth services. The rule, released concurrently with the President's Executive Order (EO) to expand rural telehealth access, seeks to advance efforts to improve access and convenience of care for Medicare beneficiaries through telehealth, particularly for those living in rural areas.
Other major changes in this year's proposed rule include: (1) redistributing physician pay as result of the budget neutrality requirements linked to an increase in pay for evaluation and management (E/M) visits; (2) implementing President Trump's EO on Protecting and Improving Medicare for our Nation's Seniors and aims to ensure sustainability of the Medicare program; and (3) strongly encouraging adoption of electronic prescribing of controlled substances (EPCS). Comments on the proposed rules are due by October 5, 2020.
· Background. Since 1992, CMS has used the Physician Fee Schedule to update reimbursement for physician and supplier services within the Medicare program annually, and payments are based on the relative resources typically used to furnish the service. President Trump issued an executive order on May 19, 2020, directing agency heads to examine regulations issued in response to the COVID-19 pandemic and to identify those that should be kept in place going forward. CMS Administrator Verma has been particularly focused on the telehealth flexibilities introduced since January, and has hinted for weeks the administration would look to use rulemaking to make permanent many of the telehealth flexibilities expanded during the pandemic.
Among the key policies changes outlined in the proposed Medicare Physician Fee Schedule:
· Telehealth - As directed by President Trump's Executive Order on Improving Rural and Telehealth Access, CMS will take steps through the proposed rule to extend the availability of certain telemedicine services after the public health emergency (PHE) ends. During the public health emergency, CMS has added 135 services such as emergency department visits, initial inpatient and nursing facility visits, and discharge day management services, that could be paid when delivered by telehealth. CMS is proposing to permanently incorporate some of the PHE expanded telehealth services, including home visits for the evaluation and management of a patient (in the case where the law allows telehealth services in the patient's home), and certain types of visits for patients with cognitive impairments. CMS is seeking public input on other services to permanently add to the telehealth list beyond the PHE in order to give clinicians and patients time as they get ready to provide in-person care again. CMS is also proposing to temporarily extend payment for other telehealth services - such as emergency department visits - through the calendar year in which the PHE ends in order to allow the community time to consider whether these services should be delivered permanently through telehealth outside of the PHE.
· E/M Updates and Impact - Under the Patients Over Paperwork initiative, the administration has increased payment for evaluation and management (E/M) visits - which make up 20 percent of the spending under the Physician Fee Schedule - while reducing pay for other services due to budget neutrality requirements. CMS noted that the administration collaborated with the American Medical Association to simplify the coding and billing requirements, and reported it is expected to save clinicians 2.3 million hours per year once it goes into effect January 1, 2021. Although some specialties saw big bumps in reimbursement in this year's proposed physician fee schedule, many others fell victim to large cuts due to the "redistributive effects" of CMS's E/M policy. The administration explained that the changes are averages, and "may not necessarily be representative of what is happening to the particular services furnished by a single practitioner within any given specialty." The substantial changes in reimbursement are likely to renew calls from stakeholders for Congress to waive budget neutrality requirements, as many argue that they lead to significant disparities in impact among physician subspecialties - as seen in this chart included in the proposed rule. Additionally, advocates have warned that many of the specialties impacted are providing critical care during the pandemic and the decrease in reimbursement will limit patient access. Under the proposed rule, radiologists faced the largest cuts, as well as physical and occupational therapy, pathology, anesthesiology, and critical care, among others.
· Additionally in the proposed rule, CMS proposes to increase the value of many services that are comparable to or include office, outpatient, and E/M visits, such as maternity care bundles, emergency department visits, end-stage renal disease capitated payment bundles, physical and occupational therapy evaluation services and others. In justifying the proposed adjustments, which the agency notes are based on recommendations from the American Medical Association, CMS says they aim to "ensure that [Medicare] is appropriately recognizing the kind of care where clinicians need to spend more face-to-face time with patients," and take into account "the changes in the practice of medicine, recognizing that additional resources are required of clinicians to take care of the Medicare patients, of which two-thirds have multiple chronic conditions."
· Permanent PHE Flexibilities - CMS is proposing to make permanent several flexibilities enacted during the PHE to ease clinician burden and expand the health workforce capacity. Such proposed changes include:
· Allowing nurse practitioners, clinical nurse specialists, physician assistants, and certified nurse-midwives (instead of only physicians) to supervise others performing diagnostic tests consistent with state law and licensure, provided that they maintain the required relationships with supervising or collaborating physicians as required by state law;
· Clarifying that pharmacists can provide services as part of the professional services of a practitioner who bills Medicare;
· Allowing physical and occupational therapy assistants (instead of only physical and occupational therapists) to provide maintenance therapy in outpatient settings; and
· Allowing physical or occupational therapists, speech-language pathologists and other clinicians who directly bill Medicare to review and verify (sign and date), rather than re-document, information already entered by other members of the clinical team into a patient's medical record.
· Electronic Prescribing of Controlled Substances (EPCS) - The proposed rule begins to implement Section 2003 of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (the SUPPORT Act) which requires that prescribing of certain controlled substances under Medicare Part D be done electronically. While CMS strongly encourages adoption of EPCS, the agency also states "it is sympathetic to the unique challenges faced by prescribers during this PHE for the COVID–19 pandemic." Accordingly, the agency is proposing to balance these competing priorities by requiring EPCS by January 1, 2022. According to CMS, allowing time to solicit and consider feedback from the recently issued Request for Information is necessary for implementation of the EPCS requirements for waivers from the requirements and penalties.
· Communication Technology-based Services (CTBS) - CMS discusses the recent changes it has made allowing separate payment for several services that use telecommunications technology but are not considered Medicare telehealth services. These communication technology-based services (CTBS) include certain kinds of remote patient monitoring (RPM), a virtual check-in, and a remote asynchronous service. CMS writes that these services are different than the kinds of services specified in section 1834(m) of the Act, which describes telehealth services, and therefore are not subject to the same restrictions.
· The agency is seeking comments on whether there are additional services that fall outside the scope of telehealth services under section 1834(m) of the Act where it would be helpful for them to clarify that the services are inherently non-face-to-face, so do not need to be on the Medicare telehealth services list in order to be billed and paid when furnished using telecommunications technology rather than in person with the patient present.
· CMS is also seeking comment on physicians' services that use evolving technologies to improve patient care that may not be fully recognized by current PFS coding and payment, for example, additional or more specific coding for care management services.
· Substance Use Disorder Payment Updates - CMS proposes several updates to the Medicare Part B benefit category for OUD treatment services furnished by opioid treatment providers (OTPs) as established by Section 2005 of the SUPPORT Act as of January 1, 2020. In the CY 2020 PFS final rule CMS implemented coverage requirements and established new codes describing the bundled payments for episodes of care for the treatment of OUD furnished by OTPs. The agency also proposes to extend the definition of OUD treatment services to include opioid antagonist medications, such as naloxone, that are approved by FDA under section 505 of the FFDCA for emergency treatment of opioid overdose. Further, for CY 2021, CMS is proposing several refinements, including modifications to facilitate initiation of medication assisted treatment (MAT) and the potential for either referral or follow-up care during an emergency room visit. In response to earlier feedback, CMS also proposes to expand its bundled payment program to be inclusive of other substance use disorders, not just opioid use disorder (OUD). The agency writes that doing so could expand access to needed care.
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