The American College of Physicians is known for its advocacy on behalf of the “big” issues facing American health care, and deservedly so. The College prides itself on offering innovative and evidence-based ideas to solve problems, from combating rising health care costs to ensuring that all Americans have access to affordable coverage. Often overlooked, though, is ACP's advocacy to change things that make internists' professional lives more difficult than they should be, from out-of-control red tape to inadequate payments.
On this score, there is progress to report. As a direct result of ACP's advocacy, most internists will see substantially higher Medicare and Medicaid payments starting this month, and relief from some intrusive administrative requirements. Here is a list of 10 of such changes advocated by ACP. You can learn more about them by visiting our ACP advocacy website.
1. Medicare began paying physicians this year for the work involved in helping patients transition from the hospital to the home or community setting. In the past, Medicare would pay for the patient's face-to-face visit with a doctor after a hospital discharge, but not for the physician and staff time (much of which falls outside the visit) involved in planning for a successful transition.
Now, internists can be reimbursed as much as $231 each time they bill for this service under new Current Procedural Terminology (CPT) codes. This amount assumes that Congress halts scheduled across-the-board cuts in payments to doctors caused by the Medicare sustainable growth rate (SGR) formula and budget sequestration, which appeared likely at press time.
Because of this change, and other improvements in Medicare payments advocated by the College, the Centers for Medicare and Medicaid Services (CMS) projects that internists will gain an average of 4% to 5% in total Medicare payments this year.
2. Medicaid payments to internists for their visits and vaccine administration will be no less than the comparable Medicare rates—a very substantial increase in Medicaid payments in most states—starting on Jan. 1 and continuing through 2014. These increases were mandated by the Affordable Care Act (ACA) and apply to both Medicaid fee-for-service and Medicaid managed care contracts. And, in a big win advocated by the College, CMS agreed that internal medicine subspecialists, along with primary care physicians, can qualify for the higher payment.
3. The higher Medicare and Medicaid payments in 2013 are in addition to the 10% Medicare primary care bonus payments (also mandated by the ACA) that have been in effect since 2011 and will continue at least through 2015. ACP has determined that a typical internist can expect to gain $8,000 annually from the 10% primary care bonus, or $40,000 over all five years.
4. CMS agreed to add two additional hardship exemptions to prevent penalties on internists who are unable to successfully participate in the CMS Electronic Prescribing (e-Rx) Incentive Program under certain defined circumstances. Starting in 2013 and continuing through 2014, internists or group practices can be exempted from the penalties if they achieve meaningful use of electronic health records (EHRs) during certain e-Rx payment adjustment reporting periods and/or demonstrate intent to participate in the EHR Incentive Program and adopt certified EHR technology.
5. Five hundred primary care practices (many of which are internal medicine practices) in seven geographic regions will receive substantial increases in Medicare revenue, plus financial and other support services from other payers in their communities, for providing patient-centered, coordinated care. ACP has been actively advising on this pilot project, called the Comprehensive Primary Care Initiative, from its inception.
CMS is paying the participating primary care practices a risk-adjusted care management fee, initially set at an average of $20 per beneficiary per month, to support enhanced, coordinated services on Medicare patients' behalf. The monthly payments to these practices will be on top of their usual Medicare fee-for-service payments. And, if the initial pilot results in improvements in outcomes and cost savings as expected, Medicare can roll it out to practices nationwide.
6. Under another change mandated by the ACA, physician practices will receive claim payments electronically from their insurance companies and then be able to automatically match (reassociate) explanations regarding any adjustments to these payments by the health plans with the correct claim. This change, which will apply to both public and private payers starting in 2014, is one of a series of forthcoming rules that will standardize and streamline health insurance administrative requirements, so that physicians can spend more time with patients and less time on paperwork.
7. Most internists will have more time before the Medicare value-based payment modifier (VBPM) will be applied to their payments. The VBPM is a program within the ACA that will modify Medicare fee-for-service reimbursements depending on how well a physician scores on measures of cost and quality of service.
ACP strongly advocated for CMS to phase in the program before applying it to all physicians in 2017. Therefore, CMS has decided to apply the VBPM to groups of 100 or more eligible professionals during the first year instead of practices of 25 eligible professionals or more, its original plan.
8. CMS will align the VBPM attribution method with the methodology used for the existing Medicare Shared Savings Program and the Physician Quality Reporting System (PQRS), easing potential hassles for internists that might have come if each program had a different way of attributing costs and quality outcomes to each physician.
9. Although this is still a work in progress, CMS has made a commitment to significantly increase alignment of program requirements across its quality initiatives, including the eRx Incentive Program, the EHR Incentive Program, the Medicare Shared Savings Program and the VBPM.
10. CMS has created a new administrative reporting option for physicians to meet the PQRS “successful participation” requirements if they have not yet been able to effectively use the traditional reporting mechanisms (claims, registries, or EHRs) or have otherwise not been able to meet the criteria for successful reporting for the 2013 and/or 2014 incentives.
Granted, even with all of these changes, most internists still will not be paid what they are worth, and their paperwork will not have magically vanished. But because of ACP's advocacy, most internists will be paid substantially better and hassled somewhat less. The College will continue to advocate for additional changes to improve internists' professional and practice experiences, even as it advocates for health insurance coverage for all patients.