Medicare Physician Payment Reform Research Articles

After the "Doc Fix": Implications of Medicare Physician Payment Reform for Academic Medicine.

The Medicare Access and CHIP Reauthorization Act (MACRA) introduces incentives for clinicians serving Medicare patients to move away from traditional "fee-for-service" and into alternative payment models (APMs) such as accountable care organizations and bundled payment arrangements. Thus, MACRA creates strong reasons for various teaching clinical services to participate in APMs, not only for Medicare patients but for other public and private payers as well. Unfortunately, different APMs may be more or less applicable to the diverse teaching physician roles, academic clinical programs, and patient populations served by medical schools and teaching hospitals. Therefore, this time of transition will complicate the work of academic clinical program leaders endeavoring to sustain the tripartite mission of patient care, health professional education, and research. Nonetheless, payment reforms promoted by MACRA can reward efforts to reinvent medical education to better incorporate value into medical decision making, as well as to give clinical learners the tools and insights needed to recognize their personal financial (and other) conflicts and navigate these to meet their patients' needs. This post-MACRA environment may intensify the need for researchers in academic medicine to stay independent of the short-term financial interests of affiliated clinical institutions. Health sciences scholars must be able to study effectively and speak forcefully regarding the actual benefits, risks, and costs of health care services so that educators and clinicians can identify high-value care and deliver it to their patients.

The American College of Surgeons: an enduring commitment to quality and patient care

This paper describes the American College of Surgeons' 100-plus-year commitment to improving quality and patient care. It summarizes programs that the College established a century ago to improve patient care, including the Hospital Standardization Program, and new initiatives, such as the ACS National Surgical Quality Improvement Program. The College's longstanding experience with quality improvement programs is enabling the organization to play a critical and influential role in helping to ensure that health care reforms, including those in the Affordable Care Act, are implemented in a way that best serves that interests of the surgical patient. Through a combination of these data analysis systems and the application of a finely tuned set of values, the College has become a respected voice in quality and patient safety. The ultimate goal is to create an environment where high value and high reliability take precedence over high volume and where all health care professionals play an active leadership role in delivering optimal, coordinated care. This article further describes how the surgical culture can be reshaped to meet these evolving needs and demands. The American College of Surgeons (ACS) has a longstanding commitment to improving the quality of surgical care through outcome measurement, standards setting, accreditation, and educational activities. This legacy has enabled the ACS to play an influential role in recent developments related to implementation of the Affordable Care Act (ACA) and Medicare physician payment reform.

Medicare Physician Payment Reform

The year-end passage of bipartisan legislation to avert the reduction in Medicare physician payment rates required by Medicare’s sustainable growth rate (SGR) formula is nothing new. The SGR formula, enacted as part of the Balanced Budget Act of 1997—the last substantial legislation to reform Medicare payments and reduce the deficit—adjusts Medicare physician payment rates so that total spending on physician-related services increases in line with the overall economy.

Anesthesiologists and the Transformation of the Healthcare System

Anesthesiologists and the Transformation of the Healthcare System

The Politics of Cost Control and Regulatory Policy

One of the most widespread criticisms of the Patient Protection and Affordable Care Act (ACA) is that it does little to contain health care costs. While some economists argue that the ACA will “bend the cost curve,” Jonathan Oberlander and Thomas Rice contend that the provisions will not control costs substantially any time soon. As the essays in this section attest, this lack of cost control is surprising given the vast number of cost-containment provisions included in the bill. As a result, the final essays in this section focus on specific regulatory or cost-containment provisions, exploring the promise of particular initiatives. Harold S. Luft considers the likelihood that accountable care organizations will take hold in the U.S. delivery system. Michael K. Gusmano examines the politics of cost-effectiveness research and its potential to improve care and control costs. Timothy Stoltzfus Jost examines the benefits and dangers of increased agency discretion under the development of new independent commissions under the ACA, such as an independent Medicare commission, an innovations center, and an Institute of Medicine commission. Finally, Miriam J. Laugesen focuses on the American Medical Association's role in the politics of Medicare physician payment reform and considers how Medicare payment reforms have impacted the entire politics of health care reform.

APA Protests Plan to End Use of Consultation Codes

Back to table of contents Previous article Next article Government NewsFull AccessAPA Protests Plan to End Use of Consultation CodesMark MoranMark MoranSearch for more papers by this authorPublished Online:1 Jan 2010https://doi.org/10.1176/pn.45.1.psychnews_45_1_011AbstractAPA is strongly objecting to a proposal by the Obama administration to no longer recognize consultation codes for Medicare reimbursement.As part of the 2010 Medicare physician payment update, the federal Centers for Medicare and Medicaid Services (CMS) has announced that it will no longer pay for the outpatient and inpatient consultation codes (99241-99245 and 99251-99255). Instead, the administration is advising physicians to use the new patient, initial hospital care, or initial nursing facility care evaluation and management (E&M) codes for the designated setting; those codes would be paid at a higher rate.The payment update also mandates a 21.2 percent across-the-board cut in physician Medicare reimbursement (Psychiatric News, December 4, 2009).Additionally, it is unclear whether private payers will follow suit regarding payment for consultation codes.The payment decrease for this year and the ruling regarding the consult code were announced in a final rule that appeared in the Federal Register on November 25, 2009. Without congressional intervention, the new Medicare payments and policies outlined in the final rule were to go into effect on January 1.(At press time the Medicare Physician Payment Reform Act, passed by the House of Representatives in November 2009, was under consideration by the Senate. It would replace the proposed payment cut with a small positive adjustment. Additionally, APA is supporting an amendment to the Patient Protection and Affordable Care Act, HR 3590, introduced by Sen. Arlen Specter [D-Pa.], that would delay implementation of the ruling by one year.)In the meantime, APA filed comments with CMS objecting to the proposal regarding consultation codes, saying it could financially discourage care coordination and communication between consulting and admitting physicians. APA also says the ruling would undermine the established process by which the CPT (Current Procedural Terminology) codes are valued by the AMA's Relative Value Scale Update Committee (RUC).“Consultations are a legitimate and important part of medical practice, particularly in the psychiatric setting,” APA stated in comments to CMS. “Physicians often request psychiatric consultations for their most medically complex patients. There is a large amount of work inherently involved in such consultations and the subsequent report back to the requesting physician.”APA's comments also note that a consultation is typically more complicated and labor intensive than “evaluation and management,” the code that is being proposed as a replacement by CMS.The administration has cited, as a reason for the ruling on consultation codes, a 2006 report by the Office of the Inspector General that found that Medicare paid approximately $1.1 billion more than it should have for consultation services in 2001. That report stated that the majority of the errors were “billed as the wrong type or level of consultation” and that the bulk of the rest of the improperly billed codes were errors created by lack of documentation and/or services that did not meet the definition of a consultation.CMS claimed in its ruling that educational outreach efforts, recommended by the inspector general's report and intended to rectify the coding problems, have not been successful.But APA, in its comments to the agency, has questioned that conclusion, noting that CMS offered no evidence that the problems were ongoing. Also, APA recommended that the agency reevaluate whether the miscoding of consultations is still as prevalent as it had been prior to the inspector general's report.“We believe that the proposed solution does not accurately address the current problem, undervalues physician time and expertise, may adversely impact patient care by disincentivizing care coordination,” and undermines the established process by which codes are valued. “We urge CMS to abandon this proposal and seek other ways to reduce coding errors for consultations.”More information is posted at <www.psych.org/Departments/HSF/MedicareMedicaid/Consultation-Codes-under-Medicare.aspx> ISSUES NewArchived

Obama, Physicians Prepare for Health Reform

Obama, Physicians Prepare for Health Reform

Medicare Physician Payment Reform: Changing Incentives to Maintain Access to Quality Surgical Services

Medicare Physician Payment Reform: Changing Incentives to Maintain Access to Quality Surgical Services

Congress and MedPAC Weigh Options for Medicare Physician Payment Reform

Congress and MedPAC Weigh Options for Medicare Physician Payment Reform

Partners in Cancer Care: The American Medical Association

The delivery of quality health care in America today faces significant challenges on many fronts. Through a positive, mutually supportive and collaborative relationship, the American Medical Association (AMA) and ASCO are working together to meet these challenges. It is only through the efforts of passionate, informed physicians like you that the AMA can improve the future of health care for physicians and their patients nationwide. And it is only through organizations such as ASCO that this spirit takes root at the local level. Michael D. Maves, MD, MBA Our organizations have collaborated in a number of constructive ways recently. During the debate surrounding Medicare drug reimbursement cuts as proposed in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, the AMA worked with ASCO and other affected specialties to try to limit the impact of these cuts. The AMA also joined ASCO and other specialties in calls for more physician-friendly regulations, and created a special work group to develop new drug administration codes that resulted in payment increases that offset some of the losses on the drug side of the reimbursement equation. ASCO has also worked with the Physician Consortium for Performance Improvement (the Consortium) to develop evidence-based clinical performance measures. The Consortium, which was convened by the AMA, includes representatives from more than 70 state and specialty medical societies, the Agency for Healthcare Research and Quality, the Centers for Medicare & Medicaid Services, and others. ASCO's work with the Consortium makes it more likely that oncologists will have measures that meet the standards and qualify them for additional payments if they participate in Medicare and private plans' pay-for-performance programs. In terms of advocating for the medical profession and physicians nationwide, the AMA has three primary goals: medical liability reform (MLR), Medicare physician payment reform and regulatory relief, and expanding coverage for the uninsured and increasing access to care. On the MLR front, the AMA continues to lead an aggressive, multiyear campaign to reduce medical liability premiums in order to preserve patients' access to care. At the federal level, the AMA is fighting Congress for MICRA-like reforms (MICRA is California's Medical Injury Compensation Reform Act of 1975), including a $250,000 cap on noneconomic damages in medical liability cases. At the state level, the AMA is providing resources to support similar state reforms. As the leading force in Washington, DC, for Medicare reform, the AMA is relentlessly pursuing fixes to replace the flawed Medicare physician payment formula and has stopped physician payment cuts in each of the last 4 years. While that was a major accomplishment, we understand that Medicare payments are no longer keeping up with your costs, and we urge you to join us in pressing for a long-term replacement to the current formula. Visit www.ama-assn.org to obtain a kit designed to help physicians talk to patients and members of Congress about the urgent need to prevent future cuts. The AMA can also use your help as we search for solutions to the health coverage crisis. The AMA is strongly advocating for incremental measures to expand coverage for children and lower-income families and individuals, and it is working diligently to build political pressure for action on both coverage and access to care. In the longer term, the AMA will continue to press for the adoption of a consumer-driven, market-based plan to expand coverage through tax credits and insurance market reforms. Efforts of interest to oncologists include the AMA's Science News section, which recently held a media briefing in New York to increase awareness of revolutionary new cancer treatments and how they allow physicians to focus on both patient survival and quality of life. Also, the Journal of the American Medical Association (JAMA) and the Archives specialty journals regularly publish the latest medical research on oncology-related issues. Joining the AMA—the nation's largest medical association—is one way ASCO members and other oncologists can help address the public health, public policy, and professional issues facing medicine today. Membership also allows you to voice your opinion on medicine's top issues, influence our annual health care agenda and participate in members-only activities such as Member Connect Surveys. In addition, AMA membership offers ASCO members the latest clinical research and professional publications: free subscriptions to JAMA, free online access and discounted print subscriptions to Archives specialty journals, and discounts on AMA bookstore products. Let's continue to join together to make a positive difference in the world of our patients and our profession. For more information, go to www.ama-assn.org.

The medicare program and thoracic surgery: challenges for the new century

The medicare program and thoracic surgery: challenges for the new century

Medicare physician payment reform and the utilization of cardiovascular procedures.

Effective 1992, the US Congress implemented the Resource-Based Relative Value Scale (RBRVS) for pricing and reimbursing Medicare physician services. This study evaluates the post-1991 impacts of RBRVS on the utilization volumes of two leading cardiovascular procedures--Percutaneous Transluminal Coronary Artery (PTCA) and Coronary Artery Bypass Grafts (CABG). The regression model results based on HCFA-supplied data suggest that the new reimbursement policy reduced (increased) utilization volumes of the more (less) expensive CABG (PTCA) procedures. Physician adjustments to tightened HCFA reimbursements are partly aided by the increased percentage of Medicare patients enrolled in Medigap. The RBRVS fee schedule appears to be meeting its intended cost containment policy goals for the leading cardiovascular procedures.

Administrative Procedures and Political Control of the Bureaucracy

Positive theorists have argued that administrative procedures enhance political control of the bureaucracy, in part by predisposing agencies toward policy choices preferred by legislators' favored constituents. Although this “deck-stacking” argument has been both influential and controversial, few scholars have subjected it to empirical examination. This article assesses the operation of a prominent administrative procedure—the notice and comment process—in the context of Medicare physician payment reform, a fundamental restructuring of the way in which the Medicare program pays for physician services. I find, contrary to the deck-stacking thesis, that the Health Care Financing Administration (HCFA) was more responsive to physicians expecting reductions in fees than to the intended beneficiaries of the new payment system. Although these results do not necessarily imply that Congress exerted little influence over HCFA decision making, they suggest that certain administrative procedures do not operate as instruments of political control.

Medicare Physician Payment Reform: implications for nurse practitioners.

In January 1992, the federal government implemented a package of physician payment reforms for use in the Medicare program. Among these reforms is a resource-based fee schedule that replaces the customary, prevailing, and reasonable (CPR) method of payment that has been used since Medicare's inception. This article describes the recommendations of the Physician Payment Review Commission, a Congressional advisory group, concerning the implications of the resource-based fee schedule on nurse practitioners and other non-physician practitioners. Absent changes in current law, services provided by nurse practitioners will be paid based on the same formulas that were used under CPR. This author advises that these payment formulas be revised to reflect the differences in resource costs borne by physicians and nonphysicians. Furthermore, revisions to the payment formulas should be made in the near future before the Medicare fee schedule and the rules governing its use are adopted by other public (e.g., Medicaid) and private payers.

The Trials of Medicare Physician Payment Reform

IS MEDICARE physician payment reform in jeopardy? Physicians' organizations, including the American Medical Association (AMA), specialty societies, and state medical associations, have expressed alarm about the content of the Notice of Proposed Rulemaking (NPRM) that was published on June 5 by the Health Care Financing Administration (HCFA) to implement the Medicare Fee Schedule. For editorial comment see p 1566. What are the problems that are causing so much concern among physicians? Did physicians misinterpret the 1989 legislation that reformed physician payment? Or did HCFA propose rules that do not reflect the intent of Congress and fall short of physicians' expectations concerning accurate resource-based relative values? In this Commentary, we discuss these issues from the perspective of the Physician Payment Review Commission (PPRC). <h3>Background</h3> In December 1989, Congress passed a comprehensive physician payment reform for Medicare that included a resource-based fee schedule, limits on balance billing, and a mechanism to update

The trials of Medicare physician payment reform

The trials of Medicare physician payment reform

Medicare physician payment reform. An introduction to the new fee system and its implications for hospitals.

Set to go into effect on October 1, the new Medicare physician-reimbursement system attempts to bring Medicare payments ever closer in line with physicians' actual costs. Among other things, the new fee schedule should eventually reduce the disparity between specialty and family-practice physicians' reimbursements and encourage more med students to enter primary care. Hospitals should be aware, however, that some things--like conflict between their and physicians' financial incentives--will not change.

Medicare Physician Payment Reform: The Challenges and Opportunities to Physiatry

Medicare Physician Payment Reform: The Challenges and Opportunities to Physiatry

Medicare Physician Payment Reform

Medicare Physician Payment Reform

I. Legislation: Medicare Physician Payment Reform

I. Legislation: Medicare Physician Payment Reform