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CMS gets to work on new value-based fee structure

November 20, 2015
by Bob Gatty
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Bob Gatty

After years of aggravation and fending off increasingly large physician pay cuts, Congress finally eliminated the sustainable growth rate (SGR) formula for Medicare physician pay when it enacted the Medicare Access and CHIP Reauthorization Act earlier this year.

The new law set payments for physicians under traditional fee-for-service for the next three years, and then established a new merit-based incentive payment system for 2019 and beyond. Obviously, how that system will be constructed is crucial to all Medicare providers, including those in the long-term care industry.

Like many organizations, the American Health Care Association and National Center for Assisted Living (AHCA/NCAL) wants to make certain its members are eligible for coverage under the new structure, which includes a Merit-Based Incentive System (MIPS) and Alternative Payment Models (APMs). The organization, on November 17, submitted recommendations to the Centers for Medicare & Medicaid Services (CMS) to make sure this happens.

The MIPS and APMs are the cornerstones of the value-based payment system that is designed to change compensation from being based on the volume of services provided to the value and quality of those services.

Key recommendations

In a letter submitted to CMS by Daniel E. Ciolek, senior director, therapy advocacy at AHCA/NCAL, the organization made these two key recommendations:

  1. That CMS allow facility-based providers that furnish outpatient physical therapy, occupational therapy and speech-language services via eligible professionals to qualify for the same annual physician fee schedule increases that office-based physicians and therapists in private practice would be eligible to obtain.
  2. That if CMS takes this action to make these professionals eligible for MIPS and/or APM performance-based annual fee schedule adjustments, the agency should work with facility-based outpatient therapy providers to identify the most appropriate setting-specific method of establishing composite performance scores. Those scores would be used for four performance categories of quality, resource use, clinical practice improvement activities and meaningful use of certified electronic health records (EHR) technology.

LTC characteristics

Ciolek pointed out that outpatient therapy services are furnished to Medicare beneficiaries in a variety of settings, including physician offices, private practice offices, hospital outpatient therapy departments, skilled nursing facilities (SNFs), outpatient rehabilitation facilities, comprehensive outpatient rehabilitation facilities, home health agencies and critical access hospitals.

“Under the current RFI (request for information from CMS), it appears that only physicians and therapists in private practice would potentially be eligible for MIPS or APM incentive payments,” he said, adding that the Social Security Act defines physical therapists, occupational therapists, and speech-language pathologists as “eligible professionals.”

But, he added the CMS 2015 Physician Quality Reporting List of Eligible Professionals notes that professionals who do not bill Medicare at an individual National Provider Identifier level would not be eligible in some cases.

“This is not a new barrier, but can be overcome as the MIPS and APM programs are developed over the next several years,” Ciolek told CMS, adding that advances in technology should allow CMS to work with facility-based outpatient therapy providers to either eliminate or work-around those limitations by the time the MIPS incentive payment could be expended to include outpatient therapy services in 2021.

He also pointed out that facility-based outpatient therapy providers, particularly SNFs, typically treat beneficiaries with more complex health conditions and functional impairments than ambulatory care providers, so the current performance measures used for those programs “may not necessarily be appropriate for such patients.”

Preparing for the future

All of this may seem to be a bit “in the weeds,” but the bottom line is that AHCA/NCAL is seeking to make certain that, when the time comes, professionals working in long-term care are covered by the new fee schedule program, despite the setting in which services are provided.

CMS’ deadline for submitting comments to its request for information on how it should structure the new physician payment policy was November 17. The request can be viewed here.

Among other comments submitted were those from the American Medical Association (AMA), which outlined principles it would like the agency to consider, including making requirements flexible enough for a variety of patient populations and organizational structures. The AMA said current programs for obtaining data and measuring Medicare quality cannot simply be tossed into the new system.

“These currently separate programs must be carefully assessed, revised, aligned and streamlined into a coherent and flexible system that is truly relevant to high-value care,” the AMA wrote in its submission to CMS.