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CMS Capsules

CMS Capsules

The Center for Medicare and Medicaid Services has released a flurry of rulemaking announcements in recent weeks, touching a broad range of delivery models. We review some notable items here:

End-of-life counseling 

As part of its proposed rule revising the Medicare physician fee schedule, CMS announced it intends to reimburse physicians and other qualified health professionals for conversations with patients and their families regarding end-of-life planning. These new “advance care planning” codes would mark a significant development in Medicare’s treatment of end-of-life care. 

Stark law exception

The physician fee schedule rule also proposed a new exception to the physician self-referral law, known as the “Stark” law, allowing certain health facilities to pay physicians in exchange for assistance in employing "nonphysician practitioners" (nurse practitioners, physician assistants, clinical nurse specialists, certified nurse midwives) in the facility’s service area. Under this exception, physicians could refer patients to the facilities paying for their recruitment assistance without fear of penalties under the Stark law. 

New telehealth services 

The physician fee schedule rule proposed two new reimbursable health services under Medicare: prolonged service in the inpatient/observation setting (CPT 99356-7), and end-stage renal disease (ERSD) services for home dialysis (CPT 90963-5). Reimbursement for these services would be subject to Medicare’s usual geographic restrictions on telehealth. 

Chronic care management in RHCs, FQHCs

Consistent with its introduction of a new code for non-face-to-face chronic care management, CPT code 99490, CMS’s physician fee schedule rule would extend the same payment to rural health clinics (RHCs) and federally qualified health centers (FQHCs). To qualify for reimbursement, the RHC or FQHC must provide at least 20 minutes per month of CCM services to patients with two or more chronic conditions, defined as conditions that are expected to last at least 12 months and place the patient "at significant risk of death, acute exacerbation/decompensation, or functional decline." 

Nursing home CoP overhaul

On July 13, CMS announced a series of major revisions to the Medicare and Medicaid conditions of participation (CoP) for long-term care facilities, the first major rewrite of such rules since 1991. The proposed rule largely brings the CoP into conformity with new technologies and practices that most nursing homes have already adopted, according to the press release. Among the possible impacts, “unnecessary hospital admissions and infections would be reduced, quality care increased, and safety measures strengthened.” 

Home health quality initiative 

On July 7, CMS announced revisions to its home health prospective payment system, including, notably, the introduction of a value-based purchasing program (VBP) for home health. Like hospital VBP, the program would penalize or reward select home health agencies based on quality of performance. The payment adjustment would be a penalty or bonus of up to 5 percent of Medicare payments in 2018 and 2019, increasing to 8 percent by 2021. The list of applicable quality measures can be found here

New joint replacement payment model

Added to the increasing list of innovative payment models tied to quality is CMS’s new “Comprehensive Care for Joint Replacement” program. Like ACOs and other alternative payment models, the new program would make hospitals accountable for the costs and quality of knee and hip replacements, the most common type of inpatient surgery for Medicare beneficiaries. Hospitals that fare comparatively well will be rewarded with bonuses, while those faring poorly will be forced to repay some of their costs. 

More Than a 'Doc Fix': a Look Inside MACRA for Hospitals, CHCs

More Than a 'Doc Fix': a Look Inside MACRA for Hospitals, CHCs

As news outlets have widely reported, the U.S. Senate has followed the House in passing a measure to repeal Medicare’s payment formula, known as the Sustainable Growth Rate (SGR). The bill would replace the SGR formula with a new model tied to quality and value. This is another significant development in healthcare’s increasingly rapid shift toward alternative payment models. 

But the “doc fix” bill, titled the Medicare Access and CHIP Reauthorization Act (MACRA), contains numerous other items impacting health providers. Namely, the legislation offers much-needed (albeit short-term) breaks to hospitals and community health centers. These provisions include: 

  • Medicaid DSH cuts postponed: The Affordable Care Act’s cuts to Medicaid disproportionate share (DSH) payments would be further delayed under the bill. These cuts were to reduce federal subsidies to certain hospital serving a disproportionate number of uninsured patients. Perhaps due to many states’ declining to expand Medicaid under the ACA, the reductions have been postponed multiple times, and are now scheduled to begin in fiscal year 2018. 
  • Community Health Centers receive extension: Unlike its cuts to DSH payments, the ACA offered a bonus to designated Community Health Centers. This federal funding was slated to expire this year, but MACRA would extend it through fiscal year 2017. The nation's 1,302 CHCs would share a fund of $3.6 billion annually under the law. 

President Obama is expected to pass the bill, which received bipartisan support.