Physician groups denounce 4.5% payment cut in final rule

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While the Centers for Medicare and Medicaid Services is touting the behavioral health and other benefits of the physician fee schedule final rule released Tuesday, physicians are denouncing its 4.5% payment decrease caused by statutory-mandated cuts.

The 2023 Medicare Physician Fee Schedule final rule reflects the end of the temporary 3% supplemental increase from 2022.

The 2023 PFS conversion factor is $33.06, a decrease of $1.55 from the 2022 conversion factor of $34.61. This conversion factor reflects the statutorily required update of 0% for 2023, the expiration of the temporary 3% supplemental increase in 2022 payments that were provided by the Protecting Medicare and American Farmers From Sequester Cuts Act, and the statutorily required budget neutrality adjustment to account for changes in payment rates, according to CMS.

Physician groups are pressing for Congress to intervene to stop the cuts. Many are pushing for Congress to pass the Supporting Medicare Providers Act, H.R. 8800.

Combined with a 4% Medicare cut stemming from the Statutory Pay-As-You-Go Act, physicians said they were looking at a nearly 8.5% Medicare cut on January 1, 2023.

American Medical Association President Dr. Jack Resneck Jr. said Tuesday, "The Medicare payment schedule released today puts Congress on notice that a nearly 4.5% across-the-board reduction in payment rates is an ominous reality unless lawmakers act before January 1. The rate cuts would create immediate financial instability in the Medicare physician payment system and threaten patient access to Medicare-participating physicians. 

"Earlier this year, the AMA offered detailed comments on the proposed payment schedule. It was immediately apparent that the 2023 Medicare physician payment rates not only failed to account for inflation in practice costs and COVID-related challenges to practice sustainability but also included the damaging across-the-board reduction. Unless Congress acts by the end of the year, physician Medicare payments are planned to be cut by nearly 8.5% in 2023 – partly from the 4% PAYGO sequester – which would severely impede patient access to care due to the forced closure of physician practices and put further strain on those that remained open during the pandemic."

The final rule confirms the nearly 4.5% cut to surgeons and anesthesiologists, harming patient access to needed surgical care, the Surgical Care Coalition said. 

"At a bare minimum, Congress must pass H.R. 8800 to prevent these cuts whose effects would be to harm Americans most in need of care," said Dr. Patricia L. Turner, CEO and executive director of the American College of Surgeons. "Without congressional action, vulnerable seniors' nationwide access to timely, high quality and essential surgical care will be negatively impacted. If allowed to go into effect, these reductions will be yet another blow to an already stressed healthcare system."

The American Academy of Family Physicians President Dr. Tochi Iroku-Malize said the AAFP fears the final rule would result in unsustainable Medicare payment cuts for family physicians and put patients' timely access to essential primary care at risk. 

"The AAFP calls on Congress to pass legislation safeguarding Medicare beneficiaries' access to comprehensive primary care and other essential services by averting payment cuts set to go into effect in 2023," Iroku-Malize said. "Congress must also invest in positive annual updates to Medicare physician payment to account for inflation in practice costs. It's past time to end the untenable physician payment cuts – which have now become an annual threat to the stability of physician practices – caused by Medicare budget neutrality requirements and the ongoing freeze in annual payment updates.
 
Medical Group Management Association Senior Vice President Government Affairs Anders Gilberg said, "As expected, CMS finalized a substantial reduction to the conversion factor – negatively impacting physician reimbursement across the board. It is more critical than ever that Congress act to avert these cuts, as well as the 4% PAYGO sequestration, before the end of the year. Ninety percent of medical practices reported that the projected reduction to 2023 Medicare payment would reduce access to care. This cannot wait until next Congress – there are claims processing implications for retroactively applying these policies."

FINAL RULE IMPACTS

The final rule expands access to behavioral healthcare, cancer screening coverage and dental care, as well as makes changes to the Medicare Shared Savings Program. 

Expanding and Enhancing Accountable Care

CMS is finalizing changes to the Medicare Shared Savings Program, the nation's largest Accountable Care Organization program, covering more than 11 million people with Medicare and including more than 500,000 healthcare providers. 

These policies represent some of the most significant reforms since the program was established in 2011 and ACOs began participating in 2012, CMS said. 

Through these policies, which are central to the Medicare Value-Based Care Strategy, CMS wants to have 100% of traditional Medicare beneficiaries in an accountable care relationship with their healthcare provider by 2030. 

CMS is finalizing proposals to incorporate advance shared savings payments to certain new ACOs that can be used to support their participation in the Shared Savings Program, including hiring additional staff or addressing the social needs of people with Medicare. 

CMS is also finalizing a health equity adjustment to an ACO's quality score, revising the benchmarking methodology, and allowing longer periods of time for ACOs to become accustomed to accountable care before being liable for downside risk, all of which are expected to increase participation in rural and underserved areas.

The rule gives ACOs more time before being forced to take on financial risk; provides advance shared savings payments to some ACOs that serve underserved populations; adds a health equity quality adjustment; and creates benchmarks that account for prior shared savings to help mitigate the lowering of an ACO's benchmark over time.
 
The National Association of ACOs (NAACOS) praised most of the changes but voiced concern over the benchmarks.

"However, we remain concerned with CMS' use of a prospectively projected administrative growth factor for ACO benchmarks or their financial spending targets," NAACOS President and CEO Clif Gaus said. "As we stated in our comments on the proposed rule, more than a third of ACOs would be harmed by this change. Instead, we ask for more collaboration between CMS and the ACO community to build a better bridge to a more sustainable benchmarking strategy. Specifically, CMS should consider correcting the 'rural glitch,' where ACOs no longer benefit from the regional adjustment when lowering the spending of their assigned patients. This change would greatly help ACOs but remains in effect even after today's changes."
 
Behavioral Health Services and Opioid Use Disorder Treatment

In line with the 2022 CMS Behavioral Health Strategy, CMS is strengthening access to behavioral health services by allowing behavioral health clinicians like licensed professional counselors and marriage and family therapists to offer services under general (rather than direct) supervision of the Medicare practitioner. Medicare will pay Opioid Treatment Programs that use telecommunications with patients to initiate treatment with buprenorphine. CMS is also clarifying that Opioid Treatment Programs bill for opioid use disorder treatment services provided through mobile units, such as vans, in accordance with Substance Abuse and Mental Health Services Administration (SAMHSA) and Drug Enforcement Administration (DEA) guidance. These policies may increase access in rural and other underserved areas, CMS said.
 
CMS is also finalizing policies to pay for clinical psychologists and licensed clinical social workers to furnish integrated behavioral healthcare as part of a primary care team. Finally, Medicare will provide a new monthly payment for comprehensive treatment and management services for patients with chronic pain. These new services offer a whole-person approach to care.
 
Reducing Barriers and Expanding Coverage for Colon Cancer Screening

Colon and rectal cancers continue to be a leading cause of death in the United States with even higher new cases and death rates for Black Americans, American Indians and Alaska Natives. 

Medicare will now reduce the minimum age for colorectal cancer screening from 50 to 45 years, in alignment with recently revised policy recommendations by the U.S. Preventive Services Task Force. 

Additionally, Medicare will now cover as a preventive service a follow-on screening colonoscopy after a non-invasive stool-based test returns a positive result, which means that beneficiaries will not have out-of-pocket costs for both tests.
 
Finalizing Payment for Dental Services That Are Integral to Covered Medical Services

CMS is codifying current policies in which Medicare Parts A and B pay for dental services when that service is integral to treating a beneficiary's medical condition. Medicare will also pay for dental examinations and treatments in more circumstances, such as to eliminate infection preceding an organ transplant and certain cardiac procedures, beginning in 2023, and prior to treatment for head and neck cancers, beginning in 2024.

Finally, CMS is establishing an annual process to review public input on other circumstances when payment for dental services may be allowed.
 
THE LARGER TREND

The rule directly supports President Biden's Cancer Moonshot goal to cut the death rate from cancer by at least 50% and also supports the administration's commitment of strengthening behavioral health, which the president outlined in his first State of the Union Address, and the comprehensive strategy to tackle the nation's mental health crisis, which HHS leaders have furthered through the National Tour to Strengthen Mental Health.

ON THE RECORD

"Access to services promoting behavioral health, wellness, and whole-person care is key to helping people achieve the best health possible," said CMS Administrator Chiquita Brooks-LaSure. "The Physician Fee Schedule final rule ensures that the people we serve will experience coordinated care and that they have access to prevention and treatment services for substance use, mental health services, crisis intervention and pain care."

Twitter: @SusanJMorse
Email the writer: SMorse@himss.org