APA Urges Government to Revamp Medicare Payment System

Budget Neutrality and Work Adjuster

For the second year in a row, CMS is applying a “budget neutrality adjuster” to work values in the fee schedule formula.

“APA agrees with the view of the American Medical Association (AMA) Specialty Society Relative Value Update Committee that CMS should apply any necessary adjustments to the conversion factor rather than to physician work relative value units (RVUs),” wrote APA Medical Director James H. Scully Jr., M.D., in comments to CMS. “We also agree with the AMA's statement that CMS must work with Congress to avert Medicare fee-for-service physician pay cuts by enacting positive physician payment updates that accurately reflect increases in medical practice costs, as indicated by the Medicare Economic Index. In addition, over the long term, CMS must work with Congress to repeal the sustainable growth rate and replace it with a system that keeps pace with increases in medical practice costs.”

Neuropsychological Testing as a Telehealth Service

In the proposed rule, CMS intends to include neurobehavioral status examinations as a category 1, Medicare-covered telehealth service, but does not include neuropsychological testing in that category.

Among the reasons CMS cites are that neuropsychological testing“ requires administration by a trained professional and involves a unique interactive dynamic between the physician, practitioner, and/or technician who administers the test and the patient.”

But Scully countered in his comments that “it is unclear why an off-site patient could not have these testing dynamics easily reproduced, such as being blind-folded or having numbers assigned to fingers, with the help of someone on site with them, while the testing is done via telecommunications. These testing functions are already largely computerized, so the differences between on-site and off-site testing should be minimal and not prohibitive of Medicare coverage.”

CMS also expressed doubts about “whether a patient with suspected or confirmed brain damage or mental illness such as schizophrenia can be taught how to use a computer by a practitioner who is in a remote location. Therefore, [CMS also requests] specific comments as to whether a neuropsychological patient could be instructed and supervised adequately to take the Wisconsin Card Sorting Test through an interactive audio and video telecommunications system.”

In his comments, Scully noted that cognition and other basic brain processes of neuropsychiatric patients vary broadly across a spectrum, as evidenced in the diverse expression of symptoms in such disorders as schizophrenia, Alzheimer's dementia, major depression, and mental retardation.

“Neuropsychological testing may be more challenging for some patients than others, but that would be true whether this is done face to face or by telecommunications,” he wrote. “Patients who require immediate help in person can arrange to have someone, such as a nurse or medical technician, to assist them at their location during the teletesting. Medicare coverage should be available for those patients who can accomplish neuropsychological testing via telecommunications.”

Reimbursement for Administrative Mandates

“Medicare needs to reimburse psychiatrists and other physicians for the substantial time that they will continue to expend to deal with a panoply of demands imposed by federal programs, including Medicare Part D,” Scully wrote. “This is especially important, considering the projections for ensuing years of net diminution in physician reimbursements under Medicare. We are concerned that inequitable reimbursements will create a disincentive to continue treating patients under federal programs. We continue to encourage CMS to work toward inclusion of this time outlay in reimbursement schemes.

“Results of a national study by the American Psychiatric Institute for Research and Education (APIRE) on the Medicare Part D program's effects on patients and psychiatrists were recently published,” Scully added.“ Part of the findings concerned administrative requirements of the Part D program for psychiatrists and their staff. This provides a snapshot of just one element of one federal program that has substantially increased the level of uncompensated administrative time for psychiatrists. Psychiatrists reported that they or their staff spent on average 45.6 minutes on administrative issues related to prescription drug plan coverage (including filling out paperwork and Internet, telephone, or other time with patients, prescription drug plans, pharmacies, or the Centers for Medicare and Medicaid Services) for every hour of direct patient care provided since January 1, 2006.”