2017 Medicare Physician Fee Schedule Proposed Rule: Expanded Payments for Care Management Services

Since 2013, the Centers for Medicare & Medicaid Services (CMS) has been expanding Medicare payments for care management services.  This trend continues in the 2017 Medicare Physician Fee Schedule Proposed Rule.  Specifically, CMS proposes the following:

  1. Simplify the chronic care management (CCM) billing rules.
  2. Pay for complex CCM.
  3. Pay for care plan development.
  4. Pay for non-face-to-face prolonged evaluation & management (E/M) services.
  5. Change the supervision requirements for CCM furnished by rural health clinics (RHCs) and federally qualified health centers (FQHCs).

Additionally, CMS now recognizes the additional work involved in providing care management for patients with behavioral health conditions, proposing a new set of codes for these services.

Despite CMS’ prior efforts, CCM services have been woefully underutilized.  In 2015, only 275,000 Medicare beneficiaries received these services, just a small fraction of those who are eligible.

Now, with the proposed easing of the CCM billing rules and expanded payment for related care management services, physicians should reconsider incorporating a formal ambulatory care management program into their practices.

  1. CCM Simplification

According to a national provider survey, regulatory complexity has been the primary obstacle to CCM adoption.  In response, CMS proposes several revisions to the billing rules, all of which make it easier to provide these services.  (For a complete explanation of the current rules, please refer to PYA’s white paper, Providing and Billing Medicare for Chronic Care Management.)

  • No required consent form. Current rule:  A physician cannot bill for CCM unless and until the physician secures the beneficiary’s signature on a consent form, the contents of which are specified in the regulation.  Proposed rule:  A physician may simply document in the medical record that certain information regarding CCM was furnished to the patient.
  • Initiating visit. Current Rule:  CCM must be initiated by the billing physician during a face-to-face E/M visit (Levels 2-5 E/M visit, an annual wellness visit, or initial “Welcome to Medicare” visit).  Proposed Rule:  Such initiating visit is required only for new patients and patients not seen within the last twelve months.
  • 24/7 access to care. Current Rule:  The physician must provide the beneficiary with a means to make timely contact with healthcare practitioners in the practice who have access to the beneficiary’s electronic care plan.  Proposed Rule:  The requirement regarding access to the beneficiary’s care plan is eliminated.
  • Management of care transitions. Current Rule:  The physician must create and exchange with other providers involved in the beneficiary’s care a clinical summary formatted according to certified EHR technology.  Proposed Rule:  The continuity of care document does not have to be formatted in a specific manner.
  • Sharing of care plan and clinical summaries. Current Rule:  The physician must make the electronic care plan available (a) on a 24/7 basis to all practitioners within the practice whose time counts toward the time requirement, and (b) share care plan information electronically  (by fax only in extenuating circumstances) as appropriate with other providers.  Proposed Rule:  The electronic care plan must be made available timely within and outside the billing practice as appropriate, and care plan information must be shared electronically (can include fax) within and outside the practice with those involved in the beneficiary’s care.
  • Beneficiary receipt of care plan. Current Rule:  The beneficiary must be provided with a written or electronic copy of the care plan.  Proposed Rule:  The specification of the format in which the care plan is to be provided is eliminated.
  • Documentation. Current Rule:  A physician must document (in a qualifying certified electronic health record) communication to and from home- and community-based providers regarding the patient’s psychosocial needs and functional deficits.  Proposed Rule:  Such communications must be documented in the patient’s medical record, but not necessarily a qualifying certified electronic health record.
  1. Complex CCM

CMS proposes to make payment for complex CCM, CPT 99487.  The billing rules for CCM (CPT 99490) and complex CCM are the same, except complex CCM requires 60 minutes of non-face-to-face care management services per month, as compared to 20 minutes for CCM.  CMS also proposes an add-on code for complex CCM, CPT 99489, for each 30-minute increment that goes beyond the initial 60 minutes.

Here are the projected national payment rates for these three codes.  Note the 3.7% increase in the CCM payment rate for 2017:


  1. Care Plan Development

Acknowledging complaints that the time spent developing the CCM-required care plan currently is not reimbursed, CMS proposes to pay physicians for care plan development under a new code, GPPP7.  The agency proposes the following description for this code:

Comprehensive assessment of and care planning by the physician or other qualified health care professional for patients requiring chronic care management services, including assessment during the provision of  a face-to-face service.

This add-on code is to be listed separately in addition to the primary service and billed separately from monthly care management services.  The projected payment rate for GPPP7 is $63.68 (non-facility) and $46.15 (facility).

  1. Non-Face-to-Face Prolonged E/M Services

CCM and Complex CCM reimburse providers for clinical staff time spent providing care management services, not time spent by physicians.  Recognizing the additional resource costs involved in spending an extraordinary amount of time outside the office visit caring for an individual patient’s needs, CMS proposes to make payment under two codes:

CPT 99358 – Prolonged E/M service before and/or after direct patient care, first hour

CPT 99359 – Prolonged E/M service before and/or after direct patient care, each additional 30 minutes (listed separately in addition to CPT 99358)

In discussing these services, CMS warns the time counted for these codes must be beyond the usual service time for the primary or companion E/M code that is also billed; no time can be counted more than once toward the provision of CPT 99358, 99359, and any other service reimbursable under the Medicare Physician Fee Schedule.  The projected payment rate for 99358 is $113.41 (facility and non-facility); for 99359, it is $54.38 (facility and non-facility).

  1. CCM Supervision for RHCs and FQHCs

For CCM services billed under the Medicare Physician Fee Schedule, the clinical staff providing the non-face-to-face care management services must be under the general supervision of a physician or non-physician practitioner.  Thus, the clinical staff member does not have to be physically present in the same suite of offices when providing this service.

Currently, however, clinical staff providing these services for RCH and FQHC patients are subject to direct supervision, i.e., they must be physically present in the same suite of offices as a physician or non-physician practitioner who is available to provide assistance.

CMS now proposes to amend the regulations concerning RHCs and FQHCs, changing the direct supervision requirement to a general supervision requirement.  This change will afford these rural and safety net providers greater flexibility in providing CCM services for their eligible patients.

Behavioral Health Integration

Broadly speaking, the term “behavioral health integration” (BHI) refers to discussions, information sharing, and planning between a primary care provider and a behavioral health specialist relating to the treatment and management of a patient with behavioral health conditions.  One BHI model, the psychiatric Collaborative Care Model (CoCM), has been proven to improve patient outcomes.

CMS proposes to make separate payment for services using the CoCM beginning January 1, 2017, using three new G-codes, GPPP1, GPPP2, and GPPP3.  These codes describe the requirements for initial and subsequent collaborative care management involving a behavioral healthcare manager working in consultation with a psychiatric consultant under the direction of the patient’s treating physician.

Additionally, CMS proposes a new code for care management services for behavioral health conditions.  With the exception of the qualifying diagnosis, the billing requirements for GPPPX are the same as those for chronic care management.  The proposed reimbursement for this code is approximately $3.00 more than the reimbursement for 99490.  The differential is meant to cover the additional resources required to care for patients with behavioral health conditions.


Next Steps

Taken together, these proposed enhancements to Medicare reimbursement for ambulatory care management should give physician groups more reason to consider providing these services.  In addition to generating immediate revenue, care management services engage patients, improve outcomes, and reduce overall total cost of care.  Thus, a care management program can serve as a bridge between today’s fee-for-service reimbursement and emerging value-based alternative payment models.

This opportunity is not limited to primary care physicians.  Specialists who provide care for patients with chronic conditions can customize care management programs to meet patients’ specific needs.  For example, an oncology practice can fund chemotherapy patient navigator services through care management revenue.  Again, these services improve patient satisfaction and care coordination, thus improving quality and efficiency.

With a greater percentage of reimbursement tied to value each year, developing and deploying a care management infrastructure today will improve value-based performance in the near future.  Modest investments in necessary clinical staff and technology – either directly or through third-party contracts – are a wise move in a changing healthcare environment.

Medicare’s Proposed Episode Payment Model: 6 Things to Know Now as You Prepare for Later

time-to-planOn August 2, the Centers for Medicare & Medicaid Services (CMS) published a 248-page proposed rule detailing a new mandatory bundled payment program for heart attacks and bypass surgery.

Like CMS’ current mandatory bundled payment program, Comprehensive Care for Joint Replacement (CJR), the proposed Episode Payment Model (EPM) will make hospitals in select cities responsible for the total cost of care over a 90-day period for certain traditional Medicare beneficiaries.

While CJR targets beneficiaries who have hip or knee replacement surgery, EPM involves beneficiaries who have coronary artery bypass graft surgery (CABG) or who suffer an acute myocardial infarction (heart attack).

Here’s the who, what, how, when, and why for EPM:

  1. Who? CMS will randomly select 98 of 292 eligible metropolitan statistical areas (MSAs) to participate in EPM; the agency deemed 90 of the 382 MSAs identified by the U.S. Office of Management and Budget ineligible.  All hospitals in the selected MSAs will be subject to EPM, with the exception of those located in rural counties.  CMS has not stated when it will announce the 98 counties.
  2. What? An EPM hospital will be responsible for the total cost of care for CABG and heart attack patients from the time of their admission until 90 days following discharge.   “Total cost of care” includes all Part A and Part B payments for services provided during the episode of care, with the exception of specified unrelated services.

    A hospital’s responsibility will take the form of liability for the difference between the actual total cost of care and a target price.  This responsibility comes with a reward:  if the actual total cost of care is lower than the target price, CMS will pay the difference to the hospital.

  3. How? CMS will determine the target price based on historical hospital-specific and regional data.  For Years 1 and 2, that blend will be two-thirds hospital-specific and one-third regional data; in Year 3, it switches to one-third hospital-specific and two-thirds regional data.  In Years 4 and 5, the target price will be based solely on regional data.

    To calculate a hospital’s target price per episode, CMS will apply a discount to the historical costs.  For hospitals with higher overall quality scores, a lower discount rate will be applied, and thus the target price will be higher.  CMS also will adjust target prices based on the relative complexity of the hospital’s episodes of care.  

  1. When? CMS proposes to commence EPM on July 1, 2017, and continue the program through December 31, 2021.

    As with CJR, CMS proposes a phased-in approach.  With respect to downside risk, CMS outlines the following schedule:

  • July 2017 – March 2018:  No repayment
  • April 2018 – December 2018: Capped at 5%
  • 2019: Capped at 10%
  • 2020 – 2021: Capped at 20%

    CMS proposes to phase in rewards as well:

  • July 2017 – December 2018: Capped at 5%
  • 2019: capped at 10%
  • 2020 – 2021 Capped at 20%

CMS will accept comments on the proposed rule through October 3.  Expect the final rule to be published in late 2017 or early 2018.

  1. Why? According to CMS, EPM is intended to incentivize cooperation and collaboration between hospitals, physicians, and other providers.  As with CJR, there is little a hospital can do on its own to reduce total costs of care; it will always receive the same DRG payment.

    With CJR, most of the opportunity lies with post-acute care, i.e., whether a post-surgical patient goes to an inpatient rehabilitation hospital, a skilled nursing facility, or his or her home with supportive services.  Working with its orthopaedic surgeons, a hospital can establish processes to ensure each patient continues recovery in the most appropriate environment.

    The same is somewhat true for CABG:  a hospital will need to work with its cardiovascular surgeons to ensure patients are managed appropriately post-discharge.  With respect to heart attacks, however, a hospital will need to involve a much larger group of physicians, including primary care physicians and cardiologists with established patient relationships.

    For both CABG and heart attack patients, there are many more variables in play than the site of service for post-acute care.  Variables include medication management, nutrition counseling, exercise regimes, and follow-up appointments.  Thus, hospitals will need to work with these patients’ physicians to design and implement effective transitional care management programs.

    To facilitate these hospital-physician relationships, CMS again has authorized gainsharing arrangements as a means to bring physicians to the table.  These arrangements permit hospitals to share with other providers the amount received by the hospital for beating the target price as well as the hospital’s internal cost savings realized  through care re-design and improvement.

  1. What else? In addition to EPM, the August 2 proposed rule also expands CJR’s scope to include hip and femur fracture surgeries.  CMS, however, does not propose to expand CJR participation; these new “bundles of joy” will apply only to current CJR hospitals.

    CMS also is proposing new incentive payments to encourage the use of cardiac rehabilitation services with CABG and heart attack patients:  $25 per service for the first 11 services and $175 per service thereafter.  The total number of services would be capped per Medicare coverage policy.

    Hospitals may use this incentive payment to coordinate cardiac rehabilitation and support beneficiary adherence to the cardiac rehabilitation treatment plan to improve cardiovascular fitness. Hospitals in 90 to-be-selected MSAs will be eligible for these payments:  45 EPM MSAs and 45 non-EPM MSAs.

Now is the time to start analyzing the details of the EPM program.  Hospital leaders should become educated regarding program requirements. These leaders, in turn, should invite potential EPM collaborators into conversations regarding the program, and begin to build the trust and relationships that will be the key to success.

PYA has extensive experience supporting providers participating in CJR and CJR’s older sibling, BPCI, both with technical compliance and development and implementation of care redesign plans.  PYA can partner with your organization to develop and implement a successful EPM strategy.

  • PYA offers interactive educational opportunities for leadership teams to understand the details of the EPM program and its impact on the organization.
  • PYA’s performance improvement experts can identify and support implementation of strategies to improve key quality scores and reduce costs.
  • PYA can assist hospitals with developing and implementing processes to ensure full compliance with EPM regulatory requirements.
  • PYA Analytics’ computational scientists have deep and wide experience extracting knowledge from CMS claims data, including opportunities for greater efficiency and cost savings.
  • Drawing on its extensive experience in the development and operation of clinically integrated networks and clinical co-management and gainsharing arrangements, PYA can facilitate communications between a hospital and potential EPM collaboratives, and support development of mutual strategies for success.
  • PYA provides financial modeling to help an organization understand and respond to the potential financial impact of EPM.

MACRA Delay? Don’t Count On It

magic-eight-ball-dont-count-on-it-photo-researchers-incYou may have seen a headline or two last week stating that the Centers for Medicare & Medicaid Services (CMS) may delay MACRA’s effective date.  However, the agency has not announced any such delay.  Instead, CMS’ top official indicated the agency is considering some adjustments to the initial performance period.

The U.S. Senate Finance Committee held a hearing on MACRA last week, and CMS Acting Administrator Andy Slavitt was called upon to testify.  In his prepared remarks, Slavitt highlighted CMS’ outreach activities, beginning last year, intended to inform the rulemaking process, but never used the word “delay.”   Instead, during questioning, Senator Orrin Hatch (R-Utah), the committee chair, noted that many physician groups have been calling for a six-month delay, and stated that the statute gives CMS the flexibility to move the start date for the reporting period back.  In response, Slavitt acknowledged that CMS had received significant feedback on this point, and that the agency remained open to the option of an alternative start date and shorter performance period.

In the proposed rule, CMS has stated the initial performance period will be January 1, 2017, to December 31, 2017.  Physicians then will report on their 2017 performance on the MACRA measures during the first part of 2018.  CMS will announce individual physician composite performance scores in late 2018.  Then, starting January 1, 2019, physicians’ Medicare payments will be adjusted based on those composite performance scores.

The potential delay discussed during the committee hearing last week would mean a shortening of the initial performance period.  Instead of measuring performance for the entirety of 2017, CMS may elect to measure only the last six months, for example.  That would afford physicians extra time to identify relevant measures, focus on performance improvement, and figure out reporting mechanisms.  But it would not delay the release of the first round of composite performance scores or the start of payment adjustments January 1, 2019.

In light of this, providers should continue preparing for MACRA, rather than merely hoping it will go away.  Right now, the focus should be on education—helping physicians understand how MACRA works and the impact on their practices—and strategies for maximizing their composite performance scores.

2017 OPPS Proposed Rule: 4 Things to Know and 4 Things to Think About Regarding Site-Neutral Payments


The recently published 2017 Outpatient Prospective Payment System (OPPS) Proposed Rule provides additional information regarding the site-neutral payment provisions included in Section 603 of the Bipartisan Budget Act of 2015. The Proposed Rule explains certain aspects of the provisions that will prohibit newly established off-campus hospital outpatient departments (HOPDs) from billing services and receiving payments under OPPS. Listed below is a summary of items “to know” regarding the Proposed Rule, along with items “to think about” when considering the impact on your organization.

To Know…

  • Provider-based outpatient departments (excluding ERs) that are located off-campus and have not billed as such prior to November 2, 2015, will be precluded from billing under the OPPS payment system effective January 1, 2017.
  • On-campus facilities, as currently defined under 42 CFR §413.65, are excluded from the site-neutral payment provisions. These include facilities located in physical areas immediately adjacent to the hospital’s main buildings or other areas that are not strictly contiguous but within 250 yards of the main buildings.
  • Considerations for established off-campus HOPDs that began billing prior to November 2, 2015, include:
    • Established off-campus HOPDs should be reported on the hospital’s CMS 855A Medicare Enrollment Form. This form may be used in the future to confirm HOPD billing status.
    • Claims for services provided by established off-campus HOPDs require a modifier during calendar year 2016. The billed modifier also may be used by CMS to confirm HOPD status.
    • Established off-campus HOPDs will lose the potential payment benefit under OPPS if relocated to another physical address. Exceptions to this provision are being considered and will be addressed in the Final Rule.
    • Established HOPDs that provide new services after November 2, 2015, outside the current clinical service family, will be precluded from billing the new services under the OPPS payment system.
    • Should ownership of established off-campus HOPDs change, the payment benefit under OPPS will not be extended to new owners unless the main hospital is also acquired and the Medicare provider agreement is accepted.
  • For CY2017 only, off-campus HOPD services not meeting the exception criteria will be paid under the physician fee schedule with the physicians billing the claims, unless reassigned.

To Think About…

  • Hospitals with existing HOPDs should take stock of the services currently being billed under the OPPS payment system and ensure off-campus facilities are included on their CMS 855A Medicare Enrollment Form. Although an established off-campus provider-based facility may be excluded from the proposed payment provisions, future changes to a facility’s location or services will impact the facility’s billings and payments under OPPS.
  • Hospitals should review facilities currently billed as provider-based that are close in proximity to the hospital’s main campus, and also review any previously filed provider-based attestations regarding such sites. Facilities located on-campus are excluded from the site-neutral payment provisions, regardless of operational or physical changes.
  • No changes have been proposed to date regarding the Medicare cost report form, but may be forthcoming in the Final Rule. Future cost report revisions should be monitored closely for implications to other programs and services, such as Medicaid, 340B, Medicare bad debt, etc.
  • The Proposed Rule states specific challenges regarding implementation of the OPPS payment provisions. Services provided by off-campus HOPDs during CY2017 that do not meet the exception criteria will be billed and paid along with the practitioner’s services under the Medicare physician fee schedule non-facility rates.  This payment methodology may prove problematic for HOPDs serviced by independent healthcare professionals.  Public comments have been requested for consideration in developing a new billing and payment policy for periods after CY2017.  Given these stated concerns regarding implementation, modifications to the proposed provisions are expected in the Final Rule.

Comments regarding the 2017 OPPS Proposed Rule are due to CMS on or before September 6, 2016.

May 31 Deadline for 2017 Medicare Shared Savings Program

An organization interested in participating in the Medicare Shared Savings Program (MSSP) as an accountable care organization (ACO) must file a non-binding notice of intent (NOI) by 5:00 pm EDT Tuesday, May 31.  Only those organizations that file an NOI will be permitted to file an MSSP application, which will be due by 5:00 pm EDT Friday, July 29.

The NOI must be submitted electronically.  Detailed instructions are available on the MSSP website.  Keep in mind the NOI is non-binding; there is no prejudice to an organization that submits an NOI, but later elects not to file an MSSP application.  Nor is there any prejudice to an organization that files an MSSP application, but later elects not to sign a Participation Agreement.

Since the program’s inception in 2012, the number of MSSP ACOs has grown by approximately 100 each year.  We anticipate another bumper crop of MSSP ACOs this year, as physicians see the advantage of MSSP participation vis-à-vis the soon-to-be-launched Merit-Based Incentive Payment System, or MIPS.  A physician participating in an MSSP ACO will not be required to report separately on MIPS performance measures.  Instead, CMS will convert the ACO’s performance on the required MSSP quality measures into a MIPS composite score for participating physicians.  For a much more detailed explanation of how MIPS composite scores are calculated and how they impact physician payments, please see our earlier blog post on the MIPS proposed rule.

PYA has assisted numerous now-successful MSSP ACOs in evaluating the opportunity, filing the NOI, preparing and submitting an MSSP application, and establishing ongoing operations.  For more information, contact Martie Ross or David McMillan, (800) 270-9629.

MIPS Proposed Rule: Big Changes to Medicare Physician Payments Starting in 2017


Good news:  2016 is the last year physicians have to report performance measure scores to the Centers for Medicare & Medicaid Services (CMS) to avoid up to a 9% reduction in Medicare Physician Fee Schedule (MPFS) payments under the Physician Quality Reporting System (PQRS), the Value-Based Modifier Program, and the Meaningful Use Program.

Not-so-good-news:  A physician’s 2017 scores on measures in four weighted performance categories – quality, resource use, advancing care information, and clinical practice improvement activities – will dictate that physician’s 2019 composite performance score (CPS) under the new Medicare Incentive Payment System, or MIPS.  The CPS, expressed as a number from 1 to 100, will be used by CMS to determine the physician’s 2019 MPFS payment rate.  CMS also will report the physician’s score publicly on Physician Compare.

So what just happened?   Back on April 16, 2015, the President signed into law the Medicare Access and CHIP Reauthorization Act.  MACRA repealed the much-despised sustainable growth rate (SGR) formula for determining MPFS payments.  In its place, Congress directed CMS to implement MIPS as a new physician payment system that incentivizes quality and efficiency rather than merely rewarding volume.

A year later, on April 26, 2016, CMS published its much-anticipated 962-page MIPS proposed rule.  According to the agency, it has striven to “propose a program that is meaningful, understandable and flexible with a critical focus on transparency, effective communication with stakeholders and operational feasibility.”

The underlying MIPS concept is relatively straightforward:  a physician whose CPS is above the national performance threshold will receive an upward adjustment to his or her MPFS payments (up to 4% in 2019, increasing to 9% by 2023), while a physician whose CPS is below that threshold will be subject to a corresponding downward adjustment.  CMS’ proposed processes for identifying specific performance measures, compiling data and calculating each physician’s CPS, establishing performance thresholds, and making payment adjustments, however, are anything but straightforward. Continue Reading

Addressing Confusion Around Comprehensive Primary Care Plus


In the immediate aftermath of the Center for Medicare and Medicaid Innovation’s (CMMI) announcement of Comprehensive Primary Care Plus (CPC+), we have fielded numerous questions regarding the interplay of this new program with other Medicare initiatives.  Specifically, we have been asked how a provider should decide between participating in CPC+ and joining or continuing to participate in a Medicare Shared Savings Program (MSSP) accountable care organization.

The 2,188 providers in the 445 practices now participating in the predecessor to CPC+, the Comprehensive Primary Care Initiative (CPCI), applied for that program in 2011, prior to the launch of the MSSP.  Because CPCI providers are eligible to receive shared savings payments, they have not been eligible to participate in the MSSP.

Unlike CPCI, CPC+ does not have a shared savings component.  Instead, CPC+ providers will receive a prepaid incentive payment of $2.50 (Track 1) or $4.00 (Track 2) per beneficiary per month.  The provider will be required to repay some, or all, of this amount based on specified quality and efficiency measures scores.  Despite the lack of any shared savings payment, CPC+ providers will be prohibited from participating in the MSSP.

CMMI’s decision to prohibit dual participation in CPC+ and MSSP threatens to undo the significant gains many MSSP ACOs have made in care coordination and collaboration among primary care providers, specialist physicians, and other providers.  ACOs will now face the difficult challenge of proving to primary care providers – on which ACOs rely for beneficiary attribution – that waiting several months for any payout is a better deal than the immediate payment received under CPC+.  If unable to meet this challenge, these ACOs may be forced out of the MSSP, as they lose current primary care participants and are unable to recruit new primary care participants.

As we noted in our prior blog entry, this problem is compounded by the fact primary care providers will not know until late June or early July whether their region has been identified for CPC+ participation.  Thus, it is likely these providers will agree to participate (or continue to participate) in an MSSP ACO conditioned upon their selection for CPC+.  Such uncertainty makes it difficult for all parties to make the investments necessary for MSSP success.  Certainly this is not what CMMI intended with CPC+, but now it needs to deal with this unintended consequence head-on.

CMS Announces New Alternative Payment Model for Primary Care Providers

bird in the handBack in 2012, the Center for Medicare and Medicaid Innovation (CMMI) launched the Comprehensive Primary Care Initiative (CPCI), joining with 38 payers to support 500 practices across 7 regions in transforming primary care.  With CPCI scheduled to end later this year,  CMMI announced (April 11) the launch of its largest investment in advanced primary care to date: the Comprehensive Primary Care Plus (CPC+) model.

Application Process.  CPC+ is set to commence on January 1, 2017, and continue for five years.  To implement the program, CMMI is seeking commercial health plans and State Medicaid programs to participate.  Eligible payers must be willing to utilize a similar payment model (discussed below), align quality measures, and provide claims data to participating practices.  Interested payers must submit a proposal to CMMI by June 1, 2016.

CMMI then will select up to 20 regions to participate in CPC+ based on levels of payer participation.  Practices in these regions will have until September 15 to submit an application.  CMMI intends to have up to 5,000 CPC+ practices, 10 times the number of participants in CPCI.

Selected practices will use defined, stepwise requirements to develop the capacity to provide five comprehensive primary care functions: (1) access and continuity, (2) risk-stratified care management, (3) planned care for chronic conditions and preventive care, (4) patient and caregiver engagement, and (5) comprehensiveness and coordination of care. Continue Reading

2016 Medicare Physician Value Modifier Results – More of the Same

more-of-the-same-aheadWhat Happened in 2016?

The Centers for Medicare & Medicaid Services (CMS) has now released the official results for the second year of the Medicare Physician Value Modifier Program (VM Program).  Groups of 10 or more eligible professionals (EPs) are subject to adjustments in their 2016 Medicare Physician Fee Schedule payments based on their 2014 performance.

Last year, the VM Program impacted only those physician groups with 100 or more EPs. The 2015 VM Program impacted payments for a few hundred groups, many of which did not even qualify for tiering under the VM Program because they failed to successfully participate in the Physician Quality Reporting System (PQRS). The total dollar amount for funds that were shifted from poor to high performers was just over $11 million.

The 2016 results are consistent with the 2015 results, with one major exception: the program has impacted many more groups. Compared to 2015, there are significantly more groups that will experience a payment reduction in 2016. This year, it is projected that nearly $80 million will be redistributed from poor to high performers. Continue Reading