CMS Proposes Cut to ‘Conversion Factor’ in Medicare Physician Fee Schedule

WASHINGTON — The Centers for Medicare & Medicaid Services’ (CMS) proposed 2022 Physician Fee Schedule (PFS) rule for Medicare would lower the amount physicians are paid under fee-for-service Medicare and change the requirements for incentives under the Quality Payment Program.

The changes, announced at 8 p.m. Tuesday, include a decrease in the “conversion factor” — the multiplier that Medicare applies to relative value units (RVUs) to calculate reimbursement for a particular service or procedure under Medicare’s fee-for-service system. Due to budget neutrality changes required by law and the expiration of a 3.75% payment increase provided by Congress, “the proposed CY [calendar year] 2022 PFS conversion factor is $33.58, a decrease of $1.31 from the CY 2021 PFS conversion factor of $34.89,” CMS said in a fact sheet. “The PFS conversion factor reflects the statutory update of 0.00% and the adjustment necessary to account for changes in relative value units and expenditures that would result from our proposed policies.”

In addition to the lowered conversation factor, CMS also announced other proposed provisions in the fee schedule:

Refinements to “split” or “shared” evaluation and management visits. CMS is proposing changes to these visits to “better reflect the current practice of medicine, the evolving role of non-physician practitioners (NPPs) as members of the medical team, and to clarify conditions of payment that must be met to bill Medicare for these services.” Split visits are defined as visits provided in the facility setting by a physician and an NPP in the same group. The provider who conducts more than half of the visit would bill for it. Split visits “could be reported for new as well as established patients, and initial and subsequent visits, as well as prolonged services,” the agency said.

Changes to the Quality Payment Program (QPP). The QPP is a value-based payment program that uses financial incentives and penalties as a way to encourage high-quality care. “CMS is proposing to require clinicians to meet a higher performance threshold to be eligible for incentives,” the agency said in the fact sheet. This new threshold aligns with the requirements that are part of Medicare’s Merit-based Incentive Payment System (MIPS), CMS explained. The agency is now proposing its first seven MIPS Value Pathways (MVPs) — – measures used to meet MIPS reporting requirements.

“The initial set of proposed MVP clinical areas include: rheumatology, stroke care and prevention, heart disease, chronic disease management, lower extremity joint repair (e.g., knee replacement), emergency medicine, and anesthesia,” the fact sheet explained. “MVPs will more effectively measure and compare performance across clinician types and provide clinicians more meaningful feedback.”

CMS also is revising its definition of eligible clinicians to include clinical social workers and certified nurse-midwives. Another change will allow physician assistants (PAs) to bill Medicare directly for services furnished under Part B, rather than requiring the PA’s employer to bill for the service.

Changes to the Diabetes Prevention Program. The Medicare Diabetes Prevention Program (MDPP) was developed to prevent Medicare enrollees with pre-diabetes from developing type 2 diabetes. Participating providers give structured, coach-led sessions in community and healthcare settings using a CDC-approved curriculum to provide training in dietary change, increased physical activity, and weight loss strategies. CMS is proposing to waive the provider enrollment Medicare application fee for all organizations that submit an application to enroll as a diabetes prevention program supplier on or after January 1, 2022.

The agency waived the fee during the pandemic “and observed an increase in supplier enrollment,” CMS said in a separate fact sheet on the diabetes program. “We believe that granting a waiver of the fee for MDPP suppliers to extend beyond the COVID-19 Emergency Declaration Blanket Waiver may increase MDPP supplier enrollment, which will ultimately improve beneficiary access.” The agency also is proposing to increase performance payments when patients in the program achieve a 5% weight loss goal and also meet program attendance requirements.

Extension of telehealth benefits. CMS is proposing to implement rules adopted by Congress to let patients use telehealth from any location for diagnosis, evaluation, and treatment of mental health disorders. In addition, “CMS is proposing to expand access to mental health services for rural and vulnerable populations by allowing, for the first time, Medicare to pay for mental health visits when they are provided by Rural Health Clinics and Federally Qualified Health Centers to include visits furnished through interactive telecommunications technology,” the agency said in the fact sheet. “This proposal would expand access to Medicare beneficiaries, especially those living in rural and other underserved areas.”

Medicare also will pay for mental and behavioral health services provided via audio-only phone calls under certain conditions, which would be especially helpful for Medicare enrollees in areas with poor broadband services and those who can’t use devices with video, the agency said. CMS also proposes to continue paying for all telehealth services that were added during the pandemic until the end of 2023.

“This will allow us time to collect more information regarding utilization of these services during the pandemic, and provide stakeholders the opportunity to continue to develop support for the permanent addition of appropriate services to the telehealth list through our regular consideration process, which includes notice-and-comment rulemaking,” the agency said.

Physician groups gave the proposed changes mostly positive reviews. The National Association of Accountable Care Organizations (NAACOS) was happy with another provision in the proposed rule, one that would allow ACOs to keep using the internet interface to report on quality measures under CMS’s new electronic clinical quality measure (eCQM) reporting program, rather than aggregate data from sometimes-disparate electronic health record systems. The proposed rule also would phase in eCQM over 3 years instead of starting it next year.

“NAACOS over the last year has cited potential negative consequences to patient care among the many reasons why such a rapid shift to eCQM reporting was bad policy,” NAACOS president and CEO Clif Gaus, ScD, said in a statement.

He added that the organization is pleased that the Biden administration listened to these concerns and is taking action, as “delaying last year’s changes is the right thing to do.”

“The healthcare industry, including ACOs, electronic health record (EHR) vendors and government payers, need more time before mandating electronic quality measures, and we are pleased to see CMS provide this necessary transition time,” Gaus said.

The American College of Rheumatology also responded positively.

“We applaud CMS’s continued implementation of adjustments to Evaluation and Management (E/M) code reimbursement to better reflect the work and expertise needed to treat complex patient populations,” said Government Affairs Committee Chair Blair Solow, MD, adding that the organization was “encouraged to see that policymakers are moving to recognize the true value of these services.”

Solow said she was also encouraged by CMS’ proposal to extend several of the telehealth flexibilities implemented at the start of the pandemic emergency through the end of 2023, and to see if these changes should be made permanent.

“The COVID-19 pandemic has made clear that telehealth is an effective tool to provide quality care for patients living with musculoskeletal and rheumatic diseases and we look forward to continued engagement with CMS,” she added.

The Medical Group Management Association (MGMA) had a more mixed response.

“MGMA is concerned about the potential impact of the proposed 3.75% reduction to the conversion factor due to budget neutrality requirements and will seek congressional intervention to avert the cut,” Anders Gilberg, MGMA’s senior vice president for government affairs said in a statement. (Gilberg is a member of the MedPage Today editorial board.)

On the other hand, he continued, “MGMA is encouraged that CMS heeded our call to expand coverage for audio-only mental health services and views this proposal as a positive step to increase access to vulnerable populations that would otherwise go without care.”

CMS is accepting comments on the proposed rule until 5 p.m. on Sept. 13.