APA Urges Revisions to Proposals on Medicare Payment Reform

APA is seeking revisions to a number of payment reform proposals—especially those concerning payment for care of patients requiring chronic care management—included in a proposed rule issued by the Centers for Medicare and Medicaid Services (CMS).

Specifically, APA is urging the agency to include two codes (99490 and 99487) formulated by the AMA and incorporated in the Current Procedural Terminology (CPT) manual to pay for non-face-to-face, collaborative care of patients.

In its proposed rule, CMS offers just one so-called “G” code (analogous to the CPT 99490 code) to use for reimbursement for care of patients with chronic illness. But Irvin “Sam” Muszynski, J.D., director of APA’s Office of Healthcare Services and Financing, told Psychiatric News that the “G” code proposed by CMS would appear to cover care coordination services akin to disease management—identifying and assisting patients with two or more chronic illnesses in managing specific disorders such as diabetes and/or hypertension and depression.

But it would not cover the intensity of work described in the 99487 CPT code, which covers collaboration in services for patients having, for instance, severe mental illness, two or more chronic medical conditions, and multiple care providers.

“The new CPT code and our recommendations, if adopted, will begin to enable key evidence-based integrated care efforts with the psychiatric/substance use disorder population and persons with primary medical conditions and mental health comorbidities to move forward in very important ways,” Levin wrote in comments submitted to CMS Administrator Marilyn Tavenner. “There are other essential psychiatric physician non-face-to-face functions that will need to be recognized, about which we will be communicating further with CMS.”

The CMS proposal was included in the Proposed Rule for Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, Clinical Laboratory Fee Schedule, and Other Revisions to Part B for calendar year 2015, issued in July.

APA President Paul Summergrad, M.D., told Psychiatric News that the U.S. health care system will not achieve quality and equity goals, and patients won’t get the care they need, unless the role of psychiatrists is recognized by all payers of care. “The comorbidities between general medical and psychiatric illness are too frequent and associated with premature death, lifetimes of disability, and high cost,” he said. “We are urging CMS to include the codes that will fully allow psychiatrists to play their essential role in chronic disease management and collaborative care.”

The proposed rule does not address the sustainable growth rate (SGR) formula or the conversion factor used to determine overall physician payment under the Medicare program. A number of proposals are pending in Congress for reform of the payment formula and elimination of the SGR, but Muszynski explained that all of those proposals also call for some form of value-based payment, adoption of electronic medical records, incorporation of performance measures, coordination of care for patients with chronic conditions, and other delivery-system and reporting reforms.

While legislative proposals continue to be debated in a divided Congress, many of these reforms are being driven by regulatory requirements included in the CMS proposed rule, he said.

Coding for reimbursement of collaborative care is a principal concern of APA as public and private health systems move, however slowly, toward integration of care. “Management of mental health conditions is a carefully coordinated effort,” Levin wrote. “There is a substantial evidence base that shows that psychiatric involvement at critical junctures results in better outcomes. A large number of Medicare beneficiaries eligible for such services—those who have two or more chronic conditions—are patients who have serious mental health and/or substance use disorders. There needs to be a mechanism for reimbursement for these types of services that will improve access to care for these often vulnerable patients.”

Levin also highlighted concerns about the agency’s proposals for measures that will be included as part of the Physician Quality Reporting System (PQRS). The PQRS is a program that uses a combination of incentive payments and payment adjustments to promote reporting of quality information by eligible professionals.

Levin pointed out that two critically important measures—one addressing use of antidepressant medication during the acute phase for patients with major depressive disorder and another addressing preventive care and screening for unhealthy alcohol use—appear to be omitted from the list of available measures for 2015, yet are not included on a list for removal following public comment.

“APA supports these measures being included in the PQRS program for 2015,” Levin wrote. “If these measures were selected for removal, APA would strongly object, since they are valuable measures in an underrepresented domain and can be used by a wide variety of physicians, including psychiatrists, family practice physicians, primary care physicians, and geriatricians. We ask that CMS clarify their intent on these measures and either include them for [calendar year] 2015 or put them on the list for removal and allow public comment.”

Additionally, Levin urged CMS to increase the number of cross-cutting measures available for psychiatrists and amenable to psychiatric care to increase participation in the PQRS program and to reconsider several measures that are pertinent to psychiatric practice and slated for removal from the PQRS measure set.

APA’s letter addresses a range of other proposals in the CMS notice. Among these are the following:

Value-based modifier. The value-based modifier (VBM) is a formula for reimbursing physicians based on quality of care and the value of services they provide, rather than according to volume of services provided. The formula will be applied to all physicians and alternative payment models in 2017 and will be based on 2015 performance. But in its comments letter, APA expressed concerns both about the formula itself and the speed with which it is being implemented. Levin urged CMS to slow down the phase-in schedule for the VBM implementation and allow more leeway for small or solo practices, which may have difficulty meeting the deadlines and the thresholds in the proposed rule.