Medicare Proposes Substantial Improvements to Paying for Care Coordination and Planning, Primary Care, and Mental Health in Doctor Payment Rule

CMS News

FOR IMMEDIATE RELEASE
July 7, 2016

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Medicare Proposes Substantial Improvements to Paying for Care Coordination and Planning, Primary Care, and Mental Health in Doctor Payment Rule
Medicare also expands the Diabetes Prevention Program 

Today, the Centers for Medicare & Medicaid Services (CMS) proposed changes to the Physician Fee Schedule to transform how Medicare pays for primary care through a new focus on care management and behavioral health designed to recognize the importance of the primary care work physicians perform. The rule also proposes policies to expand the Diabetes Prevention Program within Medicare starting January 1, 2018. This is the first time a preventive service model from the CMS Innovation Center would be expanded into the Medicare program.

The rule’s primary care proposals improve how Medicare pays for services provided by primary care physicians and other practitioners for patients with multiple chronic conditions, mental and behavioral health issues, as well as cognitive impairment or mobility-related impairments.

These changes will improve payment for clinicians who are making investments of time and resources to provide more coordinated and patient-centered care. These proposed coding and payment changes will better reflect the resources involved in furnishing contemporary primary care, care coordination and planning, mental health care, and care for cognitive impairment, such as Alzheimer’s disease. In addition, these proposed changes further reinforce Medicare’s transformation to better align priorities and reward physicians for quality care through the Quality Payment Program.

“Today's proposals are intended to give a significant lift to the practice of primary care and to boost the time a physician can spend with their patients listening, advising and coordinating their care -- both for physical and mental health,” said CMS Acting Administrator Slavitt. “If this rule is finalized, it will put our nation's money where its mouth is by continuing to recognize the importance of prevention, wellness, and mental health and chronic disease management.”

To learn more about these efforts to support and improve access to primary care, please visit the CMS Blog at https://blog.cms.gov/2016/07/07/focusing-on-primary-care-for-better-health/.

In March 2016, CMS announced that the Diabetes Prevention Program met the statutory eligibility criteria for expansion into Medicare. Today, CMS is proposing to expand the Diabetes Prevention Program into Medicare beginning January 1, 2018. Our proposal would allow Medicare Diabetes Prevention Program suppliers, recognized by the Centers for Disease Control and Prevention, to submit claims to Medicare for providing diabetes prevention services. CMS is proposing a process for suppliers to enroll in the program so they can furnish services and bill Medicare as soon as possible after the program becomes effective.  

“Through expansion of the Diabetes Prevention Program, beneficiaries across the nation will be able to access a community-based intervention that prevents diabetes and keeps people healthy. This is part of our efforts for better care, smarter spending, and healthier people,” said Patrick Conway, Acting Principal Deputy Administrator and CMS Chief Medical Officer.  “Today’s proposal is an exciting milestone for prevention and population health.”

CMS hopes that the expansion of the Diabetes Prevention Program into Medicare can serve as a model for employers and insurers who may want to initiate diabetes prevention programs in their populations as well. To learn more about the Diabetes Prevention Program, please visit: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-07-07.html.

The annual Physician Fee Schedule updates payment policies, payment rates, and quality provisions for services provided in calendar year 2017. These services include, but are not limited to visits, surgical procedures, diagnostic tests, therapy services, and specified preventive services. In addition to physicians, the fee schedule pays a variety of practitioners and entities, including nurse practitioners, physician assistants, physical therapists, as well as radiation therapy centers and independent diagnostic testing facilities. Additional policies proposed in the 2017 payment rule include:

• Primary Care and Care Coordination: The rule proposes revisions to payment for chronic care management, including payment for new codes and for extra care management furnished by a physician or practitioner following the initiating visit for patients with multiple chronic conditions. This proposed change is a significant update to the Physician Fee Schedule and will support primary care when and where patients need it most.

• Mental and Behavioral Health: CMS is proposing to pay for specific behavioral health services furnished using the Collaborative Care Model, which has demonstrated benefits in a variety of settings. In this model, patients are cared for through a team approach, involving a primary care practitioner, behavioral health care manager, and psychiatric consultant. CMS is also proposing to pay more broadly for other approaches to behavioral health integration services.

• Cognitive Impairment Care Assessment and Planning: CMS is proposing a new code to pay for cognitive and functional assessment and care planning for patients with cognitive impairment (e.g., for patients with Alzheimer’s). This is a major step forward for care planning for these populations.

• Care for Patients with Mobility-Related Impairments: CMS is proposing to pay physicians more accurately for furnishing services to beneficiaries with mobility-related impairments. This increase in payment will improve quality and access for this vulnerable population.  

In addition, CMS evaluated concerns about payment adjustments to Puerto Rican clinicians based on local costs and is proposing a change that would more accurately reflect these costs and significantly increase payments in the Commonwealth. Other changes in the proposed regulation would enhance program integrity and data transparency in the Medicare Advantage program.

For more information, please visit: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-07-07-2.html.

CMS will accept comments on the proposed rule until September 6, 2016, and will respond to comments in a final rule. The proposed rule will appear in the July 15, 2016, Federal Register and can be downloaded from the Federal Register at: https://www.federalregister.gov/public-inspection.