Wins and losses in the physician fee schedule final rule

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Providers are weighing in on the 2024 Medicare Physician Fee Schedule Final Rule, which finalized payment amounts in 2024 that will be reduced by 1.25% overall compared to 2023.

CMS has finalized payment increases for services such as primary and longitudinal care.

Provider groups are speaking out against the finalized 2024 conversion factor of $32.74, a decrease of $1.15, or 3.4%, from 2023, and are calling on Congress to address these cuts.

"The Medicare physician payment schedule released today is an unfortunate continuation of a two-decade march in making Medicare unsustainable for patients and physicians," said Dr. Jesse M. Ehrenfeld, president of the American Medical Association. "For 2024, the new rule indicates there will be another downward adjustment of 3.4%, on top of the 2% payment reduction in 2023. At the same time, the payment schedule confirms the Medicare Economic Index (MEI) increase at 4.6%, the highest this century and on top of last year's 3.8%. MEI is the government measure of inflation in medical practice costs."

Ehrenfeld continued, "This is a recipe for financial instability. Patients and physicians will wonder why such thin gruel is being served."

Medical Group Management Association (MGMA) SVP of government affairs Anders Gilberg said the reduction to the 2024 Medicare conversion factor further increases the gap between physician practice expenses and reimbursement rates.

"Thankfully," Gilberg said, "CMS heeded our call and refrained from increasing the MIPS performance threshold from 75 to 82 points, which by its own estimates would have resulted in a majority of eligible clinicians receiving a negative payment adjustment."

American Academy of Family Physicians president Dr. Steven P. Furr said, "The American Academy of Family Physicians applauds the Centers for Medicare and Medicaid Services for finalizing new policies in the 2024 Medicare physician fee schedule to better support Medicare beneficiaries' access to high-quality, comprehensive primary care. However, despite these improvements, the finalized reduction to the Medicare conversion factor will result in untenable payment cuts for family physicians and reiterates the urgent need for long-term Medicare payment reform." 

"America's Physician Group's (APG's) key concern is the impact of the payment cut in Medicare physician fees inherent in the new rule," said president and CEO Susan Dentzer. "At $32.74, the so-called conversion factor for 2024 – the dollar multiplier used to convert adjusted relative value units into payment amounts for physician services – will now be $1.15, or 3.4% below the conversion factor for 2023."

As a result, she said, "Medicare physician fees will continue to fall even as inflation and practice expenses climb, and many physicians continue to leave the practice of medicine. The situation is unsustainable, and we look forward to working with Congress and other policymakers to redress these fee cuts soon."

For anesthesia in 2024, CMS finalized a conversion factor of $32.7375 and $20.4349, a decrease of -3.4% and -3.3%, respectively, over final 2023 rates. 

American Society for Radiation Oncology (ASTRO) board chair Dr. Jeff M. Michalski said, "ASTRO is deeply disappointed that CMS finalized an additional 2% cut to reimbursement for radiation therapy in today's MPFS final rule."

WHAT'S THE IMPACT? WINS

Wins in the final rule include an extension through 2024 of a telehealth policy allowing physicians to list their practice address, rather than their home address, on their Medicare enrollment.

Telehealth services furnished to patients in their homes will be reimbursed at the typically higher, non-facility physician fee schedule rate.

It allows direct supervision by a supervising practitioner through real-time audio and video interaction telecommunications through 2024.

It continues coverage and payment of telehealth services included on the Medicare Telehealth Services List through 2024.

American Telemedicine Association (ATA) SVP of public policy Kyle Zebley, said, "Telehealth services, both audiovisual and audio-only, have enabled individuals in rural and underserved areas to have improved access to care. With nearly all of the flexibilities established during the COVID-19 public health emergency (PHE) extended until the end of 2024, we can expect a telehealth policy 'Super Bowl' at the end of next year.'" 

MIPS

CMS received over 20,000 comments on the proposed rule.

Based in part on the comments, CMS is retaining the performance threshold for the 2024-Merit-Based Incentive Payment Systems (MIPS) performance period/2026 MIPS payment year at 75 points. 

CMS said it recognizes that the 2017-2019 performance periods for the Quality Payment Program may not be truly reflective of clinicians' performance, because many transition policies were still in place and recovery was ongoing from those significantly impacted by the COVID-19 Public Health Emergency.

However, CMS said it plans in the future, over time, to set the MIPS performance threshold to better reflect MIPS eligible clinicians' performance and continue to encourage participation in Advanced Alternative Payment Models.

ACOS AND VALUE-BASED CARE

CMS is also finalizing changes to the financial benchmarking methodology to better encourage participation by ACOs serving complex populations, as well as changes that continue to support ACOs in their transition to digital quality measurement and use of interoperable digital data. 

The Medicare Physician Fee Schedule Final Rule holds promise for advancing value-based care, Dentzer said.

"We're very pleased to see the many changes in store for the Medicare Shared Savings Program, which will only increase the odds that more healthcare providers will participate in the program," Dentzer said. "Clearly CMS has listened closely to physicians with long experience in ACOs in making these changes."

The National Association of Accountable Care Organizations said the rule finalizes several policies that support clinicians in accountable care organizations, including improvements in quality reporting, more fair benchmarking policies, a smooth transition to a new risk adjustment model, keeping advanced payments for new ACOs which transition to risk, helping ACOs who serve high-cost beneficiaries and others. Despite the positive changes, NACCOS said it was disappointed that several favorable policies only apply to new or renewing ACOs in 2024, leaving out existing ACOs.

THE LARGER TREND: OTHER FINALIZED POLICIES

Also in the rule, CMS has finalized policies to support primary care, advance health equity, assist family caregivers and expand access to behavioral and certain oral healthcare. 

The final rule implements E/M add-on code G2211 and defines the "substantive portion" of a split (or shared) E/M visit to mean more than half of the total time spent by the physician or nonphysician practitioner or a substantive part of the medical decision-making.

CMS will pay for certain caregiver training services in specified circumstances, so that practitioners are paid for engaging with caregivers to support people with Medicare and their caregivers in carrying out their treatment plans. 

AARP EVP and Chief Advocacy and Engagement Officer Nancy LeaMond said, "AARP commends CMS for issuing its final rule which will allow Medicare to pay doctors, nurse practitioners, and other healthcare providers solely to train family caregivers, who are often unprepared to care for their loved ones. As the backbone of our nation's long-term care system, family caregivers are increasingly taking on medical duties at home, including giving injections, tending to wounds, and managing multiple medications."

The rule finalizes a new reimbursement code for patient navigation services focused on patients with serious illnesses such as cancer.

"This ruling is a game changer, wherein all boats rise through enhancing access to oncology navigation services," said Dr. Karen E. Knudsen, CEO of the American Cancer Society and the American Cancer Society Cancer Action Network. "Patient navigation increases understanding of cancer care plans, improves patient outcomes, reduces unnecessary treatment cost, and increases patient satisfaction."

CMS is also finalizing separate coding and payment for community health integration services, which include person-centered planning, health system coordination, promoting patient self-advocacy and facilitating access to community-based resources to address unmet social needs that interfere with the practitioner's diagnosis and treatment of the patient.

This rule also finalizes coding and payment for social determinants of health risk assessments, which can be furnished as an add-on to an annual wellness visit or in conjunction with an evaluation and management or behavioral health visit. 

The rule allows marriage and family therapists and mental health counselors, including eligible addiction, alcohol or drug counselors who meet qualification requirements for mental health counselors, to enroll for the first time in Medicare starting today and bill for their services starting January 1, 2024.

The rule also increases payment for crisis care, substance use disorder treatment and psychotherapy. Based on public comments, CMS also finalized increased payment for psychotherapy performed in conjunction with an office visit and for Health Behavior Assessment and Intervention services.

CMS is finalizing payment for certain dental services linked to several different cancer treatments, including, but not limited to, chemotherapy.

In addition, CMS finalized changes to promote care for individuals with diabetes by enhancing the Medicare Diabetes Prevention Program (MDPP) Expanded Model to further increase participation and access in underserved communities. This rule will extend the MDPP Expanded Model's Public Health Emergency Flexibilities for four years, which will allow all MDPP suppliers to continue to offer MDPP services virtually through December 31, 2027, as long as suppliers maintain an in-person Centers for Disease Control and Prevention organization code. 

Premier has spoken out against a CMS ruling on Appropriate Use Criteria, saying, "While Premier recognizes the significant challenges in operationalizing the real-time claims processing aspect of the Appropriate Use Criteria (AUC) program, abandoning the program altogether as CMS does in the CY 2024 Physician Fee Schedule final rule is not the solution and will have a chilling effect on future innovation."

ON THE RECORD

"CMS remains steadfast in our commitment to supporting physicians and ensuring that people with Medicare have access to the care they need to stay healthy as well as navigate health conditions they are facing," said CMS Administrator Chiquita Brooks-LaSure. "CMS is taking important steps toward those goals in this rule by improving payment for primary care and access to mental health care, paying for new navigation services to help people with cancer and other serious illnesses navigate their treatment, supporting family caregivers, paying for services involving community health workers to address health-related social needs that impact care, and enhancing access to dental care for people with certain cancers."

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