SGR Update: CMS Issues Provider Notice as Fiscal Cliff Negotiations Continue
The future of the Medicare physician payment under the sustainable growth rate (SGR) remains unclear as negotiations continue between the White House and lawmakers on Capitol Hill to avert the “fiscal cliff.” If Congress fails to address this issue by the end of the year, then CMS will begin processing the claims with the new rate as of the first of the year, as required by law, the agency indicated in a Dec. 19 posting on its website.
Absent intervention by Congress, the negative update of 27% under SGR for the 2013 Medicare Physician Fee Schedule is slated to go into effect on Jan. 1. Both Republican and Democratic lawmakers have recently proposed short-term doc fixes to stop the cut, as part of larger fiscal cliff negotiations. “We continue to urge Congress to take action to ensure these cuts do not take effect,” states the CMS notice. “Given the current progress with the legislation, CMS must take steps to implement the negative update.”
It’s important to note that the agency stated that electronic claims are not paid sooner than 14 calendar days (29 days for paper claims) after the date of receipt, indicating some flexibility if lawmakers need until mid-January to hammer out a deal. This also means the earliest that providers would receive a cut is mid-January. The notice also indicated that CMS will notify providers on or before January 11, 2013, with more information about the status of Congressional action to avert the negative update and next steps.
The College is assisting and supporting the AMA’s SGR reform efforts, and urges members to contact their member of Congress through the organization’s Physician Grassroots Network.
Follow Statline on Twitter (@CAPDCAdvocacy) for the latest news on the fiscal cliff and SGR developments.
MedPAC Calls on Congress to Repeal SGR at Dec. Meeting
The uncertainty accompanying the expiring Medicare physician fee “patch” under the sustainable growth rate (SGR) undermines physician confidence, leading to instability in the health care market, stated Medicare Payment Advisory Committee (MedPAC) members at the recent Dec. 6 meeting.
With the current patch expiration date only two weeks away, Medicare physician payments will be cut by nearly 27% as of Jan. 1 absent intervention by Congress. MedPAC, which advises Congress on Medicare payment issues, approved to continue current recommendations to repeal SGR and replace the system with 10 years of legislated updates at this recent meeting.
Financing SGR Repeal
MedPAC does not support paying for the repeal entirely through Medicare, emphasized Chairman Glenn Hackbarth at the meeting. If Congress decides to fund the repeal through Medicare, however, this would require a freeze in primary care payment rates, as well as specialty physician payment reductions. Offsets will also be necessary among other providers, including hospitals and home health, and higher out-of-pocket costs for beneficiaries.
These recommendations also take aim at improving efficiency by calling for collection of data to improve payment accuracy and identify overpriced services. MedPAC is also recommending a shift to ACOs and other coordinated care models built around shared savings reimbursement models.
CMS Begins Issuing Quality Resource Reports
On Dec. 17, CMS began sending Medicare Quality Resource Use Reports (QRURs) to physicians in group practices in nine states based on 2011 performance and cost of care.
All physicians who practice in groups of 25 or more and who live in California, Illinois, Iowa, Kansas, Michigan, Missouri, Minnesota, Nebraska, and Wisconsin will receive the QRURs, which can also be accessed online. The agency is encouraging these physicians to confirm that the applicable information is current in the CMS Provider Enrollment, Chain and Ownership System (PECOS), which is the Medicare provider online enrollment system. CMS officials and contractors will review the program through conference calls with practice groups receiving these reports.
The agency has indicated that QRURs are a precursor to the Value-Based Modifier—a key change in the 2013 Physician Quality Reporting System. More information is available on the CMS website.
Pathology Groups Press IOM Panel on Need for GME Funding
With approximately 40% of practicing pathologists expected to retire over the next 5-10 years, the specialty needs targeted increases in Medicare funding for graduate medical education (GME), according to pathology and laboratory medicine stakeholders, including the College, in a recent letter to an Institute of Medicine (IOM) panel developing recommendations on GME financing.
While the federal government does supply some funding for GME through Medicare, residency funds have been frozen since 1997 with the passage of The Balanced Budget Act. This ad hoc IOM panel is expected to release recommendations on improving GME with an emphasis on the training of physicians.
With only 450 to 500 new residency graduates entering the pathology workforce each year, the current number of training positions cannot meet the demand for pathologists, noted the letter, whose signors included the AMA Pathology Section Council and the Association of Pathology Chairs, among others.
In addition, there has been a decrease in the number of pathology residency training slots, with five residency program closings since 2009, according to the American Association of Medical College’s 2012 Physician Specialty Data Book. “We urge you to consider this evidence of shortage, and our consequent request to add pathology to the list of specialties recommended for targeted increases in Medicare funding for graduate medical education,” concluded the letter.
CAP Requests HHS Clarify Genetic Testing’s Inclusion in Essential Health Benefits
The College is recommending that the Department of Health and Human Services (HHS) clarify that genetic and genomic testing be included as a “laboratory service” now required to be covered by qualified health plans under a state or federally operated health exchange, as mandated by the Patient Protection and Affordable Care Act (ACA) reform law. The CAP comments are in response to a Nov. 26 HHS proposed rule governing the operation of state health exchanges and the standards applicable to qualified health plans made available through these state or federally operated exchanges.
“The CAP notes with concern that several states, in evaluating existing health plans for adoption of their essential health benefit benchmarks, differentiated "genetic testing" from "laboratory services" which is one of the ten mandated essential health benefits under the Affordable Care Act (ACA),” stated the letter from CAP to CMS. “The lack of clarity in the types of laboratory services that must be included in a qualified health plan may lead to a wide disparity in health care treatment options and outcomes.”
The letter also underscored the integral role that genetic testing plays in treatment for many diseases, including cancer. “If state health exchange benchmarks do not include genetic and genomic testing as a covered benefit, the quality of cancer diagnosis and treatment for patients enrolled in qualified health plans will be suboptimal, or even potentially inadequate, by denying patients life-saving diagnosis and treatment options,” the letter concluded.
NCQA Accredits First ACO
The National Committee for Quality Assurance (NCQA) has announced that Houston’s Kelsey-Seybold Clinic has been named the first accredited accountable care organization (ACO).
To receive this three-year accreditation, Kelsey-Sebold was evaluated on standards related to structure and operations, access to needed providers, patient-centered primary care, care management, care coordination and transitions, patient rights and responsibilities, as well as performance reporting and quality improvement.
The College provided comments to the NCQA on its draft ACO accreditation criteria.
Colorado Direct Billing Law Goes into Effect Jan. 1
CAP-supported direct billing legislation in Colorado will be effective Jan. 1, ensuring that patients are billed for anatomic pathology (AP) services only by the physician performing or supervising the service.
The law, which was signed by Gov. John Hickenlooper (D) in late March, protects patients from having a “mark-up” charge added to their laboratory billing by an ordering physician. In addition, if a patient receives a bill that violates this law, they can take action to recover the actual amount paid for the bill.
The College worked with the Colorado Society of Clinical Pathologists to pass the legislation, which unanimously passed the state House of Representatives and Senate.
New Jersey Genetic Counselor Bill Advances in Assembly
Lawmakers in the New Jersey Assembly Regulated Professions Committee have unanimously passed a bill to remove from the genetic counselor’s scope of practice the statutory authority to interpret genetic tests. The bill, A. 1757/S. 555, also categorically exempts physicians from the licensure law.
The bill, S. 555, which passed the full Senate in June and will now go to the full Assembly, amends the state’s current genetic counselor law to conform to the scope of practice agreement between the CAP and the National Society of Genetic Counselors (NSGC). The College is working with the New Jersey Society of Pathology to pass the bill in the Assembly.
Register Now for 2013 CAP Policy Meeting
Registration is now open for the 2013 CAP Policy Meeting, to be held on May 6-8 at The Fairmont, in Washington, DC. This unique CAP members-only event is an important opportunity to engage and discuss key health policy issues with pundits, including this year’s speaker, NBC News analyst Charlie Cook, as well as lawmakers, CAP leaders, health care policy decision makers, and colleagues. Experience in-depth panel discussions and a chance to visit with your member of Congress on Capitol Hill to talk about the issues impacting your profession. More information is available on the CAP Advocacy website.
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