Centers for Medicare and Medicaid Releases Final Physician Payment Rule for 2013

On November 1, 2012, the Centers for Medicare and Medicaid (CMS) issued a final rule for Medicare’s payments for physician fees for 2013. Not surprisingly, the rule accounts for the estimated 27.5% cut as a result of the Sustainable Growth Rate (SGR) formula. However, Congress is expected to bypass the automatic cuts before the end of the year.

The final rule also makes some changes to the two quality reporting programs, the Physician Quality and Reporting System (PQRS) and the Electronic Prescribing Incentive Program and updates the Medicare Electronic Health Records (EHR) Incentive Pilot Program. According to CMS, “these changes will simplify reporting and align the various programs’ quality reporting approaches so they support the National Quality Strategy.”

The final rule increases access to services that can be provided by non-physicians practitioners, a provision that NASS actively sought to rescind. This rule allows Certified Registered Nurse Anesthetists to be paid by Medicare for providing all services that they are permitted to furnish under state law.

In addition, the final rule continues the implementation of the physician value-based payment modifier. The value modifier provides adjustments to Medicare payments to physicians based on the quality and the cost of care to their patients. By statute, CMS is required to phase-in the value modifier over three years, with all physician practices being required to participate by 2017. However, for 2015, the final rule adjusts the value modifier to groups of physicians with 25 or more eligible professionals to 100 or more, which is a welcome sign. Throughout this year, NASS, along with the Alliance of Specialty Medicine, have actively petitioned CMS to delay the modifier.

Lastly, the final rule addresses the estimated impact on total allowed charges by specialty. In general, spine specialties were spared of any major cuts. As reported last July, CMS’ rule called for payment reductions of up to 1 percent for orthopedic surgery and neurosurgery and a 3 percent reduction for anesthesiology. However, according to the final rule, orthopedic surgery and neurosurgery have a zero percent change on payments, while specialties that will receive payment increases include anesthesiology (3 percent), interventional pain management (1 percent) and physical therapy (4 percent) among others.

To read the final rule, please click here.

Congressional Hearings Planned for Fungal Meningitis Outbreak

The recent fungal meningitis outbreak stemming from a New England Compound Center has caught the attention of federal lawmakers and has prompted a Congressional inquiry into the matter in the House and Senate. This week, the House Energy and Commerce Committee Subcommittee on Oversight and Investigations announced it will hold a hearing titled “The Fungal Meningitis Outbreak: Could It Have Been Prevented?” on November 14. Witnesses include: Margaret A. Hamburg, FDA commissioner; James Coffey, director, Massachusetts Board of Registration in Pharmacy; and Barry Cadden, owner and director of pharmacy, New England Compounding Center, Framingham, MA.

In addition, the Senate Health, Education, Labor and Pensions Committee announced that it will hold a similar hearing “Pharmacy Compounding: Implications of the 2012 Meningitis Outbreak,” on November 15. Witnesses for this session can be found here. These sessions will both focus on the recent outbreak that has been traced back to a contaminated injectable steroid produced by the New England Compounding Center in Massachusetts. NASS Advocacy is attempting to secure a slot at both hearings for a NASS representative to testify.

In light of the Senate and House hearings, Congressman Markey (D-MA), introduced H.R. 6584, The Verifying Authority and Legality In Drug Compounding Act of 2012. This bill aims to amend the Federal Food, Drug, and Cosmetic Act to require large compounding pharmacies to meet the same sterility, manufacturing and record-keeping standards as those required of large drug makers. The full language of the bill can be found here and a one-page summary of the bill can be found here.

Sources inform NASS that Congresswoman Rosa DeLauro (D-CT) will also introduce legislation after the elections to strengthen FDA’s regulatory authority. NASS advocacy is currently monitoring this issue and will continue to provide updates as they become available.

NASS Responds to GAO Report on Physician Self-Referrals for Imaging

On October 31, the Government Accountability Office (GAO) released a report suggesting that providers who self-refer advanced imaging services are responsible for driving up utilization and costs to Medicare.

The report, Higher Use of Advanced Imaging Services by Providers Who Self-Refer Costing Medicare Millions, estimated that Medicare spent $109 million more in 2010 than it would have without self-referral services. The GAO inferred from their findings that economic incentives for self-referring providers were contributing to the overall increase in referrals. The report also stated that providers who self-referred made 400,000 more referrals for imaging services than they would have if they were not self-referring.

The report was released in response to a request made by Senate Finance Committee members Max Baucus (D-MT), and Chuck Grassley (D-IA), along with House Ways and Means Representatives Fortney Pete Stark (D-CA), Sander Levin (D-MI), and Henry Waxman (D-CA).

In its report, the GAO made three recommendations to CMS to limit the number of self-referrals including: improving CMS’ ability to identify services that are self-referred, implementing a payment reduction for self-referred advanced imaging services and implementing a method to safeguard the suitability of advanced imaging services by self-referring providers.

In response to the report, the Department of Health and Human Services (HHS) said it would consider only one of the GAO recommendations, as HHS questioned whether it has the legal authority to implement the changes.

NASS has released the following statement on the GAO Report:

“Recently the Government Accountability Office (GAO) found that from 2004-2010, provider’s referrals of MRI and CT services increased the year after providers gained an ownership interest in the imaging services. These results were found by analyzing Medicare Part B claims data and interviewing officials from CMS and other stakeholders. NASS encourages the appropriate use of advanced diagnostic imaging consistent with optimal high quality/value clinical care while providing improved access and convenience for our elderly and disabled patients. Timely and accurate diagnoses of conditions or diseases are essential to limiting unnecessary and costly treatments. The answer for achieving appropriate use of advanced diagnostic imaging may be in determining guidelines utilizing comparative effectiveness research rather than eliminating in-office diagnostic imaging.”

NASS will continue to monitor this issue on behalf of our members and patients.