July 15, 2021

CMS Proposes Physician Payment Rule to Improve Health Equity, Patient Access

CMS is proposing changes to address the widening gap in health equity highlighted by the COVID-19 Public Health Emergency (PHE) and to expand patient access to comprehensive care, especially in underserved populations. In CMS’s annual Physician Fee Schedule (PFS) proposed rule, the agency is recommending steps that continue the Biden-Harris Administration’s commitment to strengthen and build upon Medicare by promoting health equity; expanding access to services furnished via telehealth and other telecommunications technologies for behavioral health care; enhancing diabetes prevention programs; and further improving CMS’s quality programs to ensure quality care for Medicare beneficiaries and to create equal opportunities for physicians in both small and large clinical practices.

“Over the past year, the public health emergency has highlighted the disparities in the U.S. health care system, while at the same time demonstrating the positive impact of innovative policies to reduce these disparities,” said CMS Administrator Chiquita Brooks-LaSure. “CMS aims to take the lessons learned during this time and move forward toward a system where no patient is left out and everyone has access to comprehensive quality health services.”

CMS Seeks Feedback on Health Equity Data Collection:

CMS is committed to addressing the significant and persistent inequities in health outcomes in the U.S. by improving data collection to better measure and analyze disparities across programs and policies. In the proposed PFS rule, CMS is soliciting feedback on the collection of data, and on how the agency can advance health equity for people with Medicare (while protecting individual privacy), potentially through the creation of confidential reports that allow providers to look at patient impact through a variety of data points - including, but not limited to, LGBTQ+, race and ethnicity, dual-eligible beneficiaries, disability, and rural populations. Access to these data may enable a more comprehensive assessment of health equity and support initiatives to close the equity gap. In addition, hospitals and health care providers may be able to use the results from the disparity analyses to identify and develop strategies to promote health equity.

Expanding Telehealth and Other Telecommunications Technologies for Behavioral and Mental Health Care:

In the proposed rule, CMS is reinforcing its commitment to expanding access to behavioral health care and reducing barriers to treatment. CMS is proposing to implement recently enacted legislation that removes certain statutory restrictions to allow patients in any geographic location and in their homes access to telehealth services for diagnosis, evaluation, and treatment of mental health disorders. Along with this change, 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 (RHCs) and Federally Qualified Health Centers (FQHCs) to include visits furnished through interactive telecommunications technology. This proposal would expand access to Medicare beneficiaries, especially those living in rural and other underserved areas.

To further expand access to care, CMS is proposing to allow payment to eligible practitioners when they provide certain mental and behavioral health services to patients via audio-only telephone calls from their homes when certain conditions are met. This includes counseling and therapy services provided through Opioid Treatment Programs. These changes would be particularly helpful for those in areas with poor broadband infrastructure and among people with Medicare who are not capable of, or do not consent to the use of, devices that permit a two-way, audio/video interaction for their health care visits.

“The COVID-19 pandemic has put enormous strain on families and individuals, making access to behavioral health services more crucial than ever,” said Brooks-LaSure. “The changes we are proposing will enhance the availability of telehealth and similar options for behavioral health care to those in need, especially in traditionally underserved communities.”

Boosting Participation in the Medicare Diabetes Prevention Program:

CMS is proposing a change to expand the reach of the Medicare Diabetes Prevention Program (MDPP) expanded model. MDPP was developed to help people with Medicare with prediabetes from developing type 2 diabetes. The expanded model is implemented at the local level by MDPP suppliers: organizations who provide structured, coach-led sessions in community and health care settings using a Centers for Disease Control and Prevention approved curriculum to provide training in dietary change, increased physical activity, and weight loss strategies.

Approximately one in three American adults (over 88 million) have prediabetes, and more than eight in 10 do not even know they have it. Many are at risk for developing type 2 diabetes within five years. Several underserved communities ̶̶ including African Americans, Hispanic/Latino Americans, American Indians, Pacific Islanders, and some Asian Americans ̶̶ are at particularly high risk for type 2 diabetes.

During the COVID-19 PHE, CMS has been waiving the Medicare enrollment fee for new MDPP suppliers and has observed increased supplier enrollment. CMS is proposing to waive this fee for all organizations that submit an application to enroll in Medicare as an MDPP supplier on or after January 1, 2022. Additionally, CMS is proposing changes to make delivery of MDPP services more sustainable and to improve patient access by making it easier for local suppliers to participate and reach their communities by proposing to shorten the MDPP services period to one year instead of two years. This proposal would reduce the administrative burden and costs to suppliers. CMS is also proposing to restructure payments so MDPP suppliers receive larger payments for participants who reach milestones for attendance and weight loss.

Advancing the Quality Payment Program:

CMS is taking further steps to improve the quality of care for people with Medicare through changes to the agency’s Quality Payment Program (QPP), a value-based payment program that promotes the delivery of high-value care by clinicians through a combination of financial incentives and disincentives.

CMS is proposing to require clinicians to meet a higher performance threshold to be eligible for incentives. This new threshold aligns with the requirements established for the QPP’s Merit-based Incentive Payment System (MIPS) under the Medicare Access and CHIP Reauthorization Act of 2015.

To ensure more meaningful participation for clinicians and improved outcomes for patients, CMS is moving forward with the next evolution of QPP and proposing its first seven MIPS Value Pathways (MVPs) - subsets of connected and complementary measures and activities, established through rulemaking, 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. MVPs will more effectively measure and compare performance across clinician types and provide clinicians more meaningful feedback. CMS is also proposing to revise the current eligible clinician definition to include clinical social workers and certified nurse-midwives, as these professionals are often on the front lines serving communities with acute health care needs.

Additionally, CMS is proposing to implement a recent statutory change that authorizes Medicare to make direct Medicare payments to Physician Assistants (PAs) for professional services they furnish under Part B. Beginning January 1, 2022, for the first time, PAs would be able to bill Medicare directly, thus expanding access to care and reducing the administrative burden that currently requires a PA’s employer or independent contractor to bill Medicare for a PA’s professional services.

Updating Vaccine Payment Rates:

The COVID-19 pandemic has highlighted the importance of access to vaccines. The Biden-Harris Administration has taken steps to increase American’s access to COVID-19 vaccinations and is committed to meeting people where they are and making it as easy as possible for all Americans to get vaccinated. That commitment extends to other, more common vaccinations.

Medicare payments to physicians and mass immunizers for administering flu, pneumonia, and hepatitis B vaccines have decreased by around 30% over the last seven years. In the PFS proposed rule, CMS is requesting feedback to help update payment rates for administration of preventive vaccines covered under Part B. In addition to seeking information on the types of health care providers who furnish vaccines and their associated costs, CMS is looking for feedback on its recently adopted payment add-on of $35 for immunizers who vaccinate certain underserved patients in the patient’s home. CMS is also seeking comments on the treatment of COVID-19 monoclonal antibody products as vaccines, and whether those products should be treated like other monoclonal antibody products after the COVID-19 PHE.

Proposal to Phase Out Coinsurance for Colorectal Screening Additional Services:

CMS is also proposing to implement a recent statutory change to provide a special coinsurance rule for procedures that are planned as colorectal cancer screening tests but become diagnostic tests when the practitioner identifies the need for additional services (e.g., removal of polyps). Currently, the addition of any procedure beyond the planned colorectal screening (for which there is no coinsurance) results in a patient having to pay coinsurance.

Under the proposed change, beginning January 1, 2022, the amount of coinsurance patients will pay for such additional services would be reduced over time, so that by January 1, 2030, it would be down to zero.

More Information:

• Proposed rule
• Medicare PFS Proposed Rule fact sheet
• QPP fact sheet
• MDPP Expanded Model fact sheet