CY2013 FINAL PAYMENT RULES RELEASED

On November 1, the Centers for Medicare and Medicaid Services (CMS) released the CY2013 Physician Fee Schedule (PFS) Final Rule, and the CY2013 Hospital Outpatient Prospective Payment System (HOPPS) / Ambulatory Surgical Center (ASC) Final Rule. 

ASGE is analyzing both rules and, in the weeks ahead, will provide ASGE members detailed information necessary to begin preparing their practices for payment and policy changes.

PHYSICIAN PAYMENT UPDATE

Absent congressional intervention, the conversion factor for calculating physician fees under the sustainable growth rate (SGR) formula will be -26.5% effective January 1, 2013. As has been the case every year since 2003, Congress has overridden scheduled PFS reductions due to the SGR. The final rule states, however, that a long-term solution to the SGR is needed.

Not including the effect of the negative January 2013 conversion factor change under current law, the 2013 impact on total allowed charges for gastroenterology is as follows:

PAYMENT AND HEALTH CARE DELIVERY

Physician Quality Reporting System (PQRS)
For 2013 and 2014, the Affordable Care Act (ACA) authorizes a 0.5% incentive payment for physicians, group practices, and other eligible professionals who successfully participate in PQRS. The law also calls for payment reductions of 1.5% and 2.0% in 2015 and 2016, respectively, for eligible professionals who do not satisfactorily report data on quality measures for covered professional services during the reporting year. It is important to note that 2013 is the reporting year for the 2015 payment adjustment.

ASGE-supported measures available for 2013 reporting and beyond include:

• Preventive Care and Screening: Colorectal Cancer Screening (#113)
• Endoscopy and Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use (#185)
• Endoscopy and Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients (#TBD)
• Participation by a Hospital, Physician or Other Clinician in a Systematic Clinical Database Registry that Includes Consensus Endorsed Quality Measures (#TBD)

All four of the above measures can be reported by individuals using either claims or registry reporting. GIQuIC, the ASGE/ACG registry, now offers registered physicians an opportunity to submit PQRS measures using the registry mechanism at no additional cost, thanks to its partnership with the Outcome PQRS registry.

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The final rule allows group practices with two or more eligible professionals to participate in PQRS through the Group Practice Reporting Option (GPRO). Group practices wanting to participate in the GPRO must self-nominate and elect their reporting mechanism by October 15, 2013.

To avoid the payment adjustment in 2015, CMS has finalized for eligible professionals and group practices three options for meeting the criteria for satisfactory reporting:

• Meet the criteria for the 2013 PQRS incentive;
• Report one applicable measure or, for eligible professionals only, a measures group; or
• Elect to be analyzed under an administrative claims-based reporting mechanism.

Physician Value-Based Payment (VBP) Modifier
CMS is required by law to apply a VBP modifier to specific physicians and groups of physicians beginning January 1, 2015. By 2017, the VBP modifier must be applied to all physicians and groups of physicians. For 2015, the VBP modifier will be applied to physicians who practice in groups of 100 or more eligible professionals. Groups of physicians eligible for the VBP modifier will be separated into one of two categories based on how they have chosen to participate in the PQRS GPRO.

Category 1: Groups that self-nominate for the PQRS GPRO and: a) satisfactorily report criteria for the PQRS 2013 incentive payment; b) report at least one PQRS measure; or c) elect the PQRS administrative claims option for 2013. VBP modifier = 0.0%, meaning no payment adjustment will be applied in 2015.

Category 2: Groups that do not fall into Category 1. VBP modifier = -1.0%, meaning physicians will receive 99.0 percent of the paid amounts for PFS items and services.

Additionally, groups in Category 1 can choose to have their VBP modifier calculated using a quality-tiering approach. This option would allow these physician groups to earn an upward adjustment for high performance and to be at risk for a downward payment adjustment (which could be no lower than –1.0) for poor performance. Because the value-modifier is being implemented in a budget neutral manner, CMS cannot specify the exact amount of the upward payment adjustment.

Because CMS is required to apply the VBP modifier to all physicians and physician groups by 2017, CMS is urging solo physicians and small group practices to participate in PQRS now because CMS anticipates basing the quality composite on PQRS quality data.

Electronic Prescribing (eRx) Incentive Program
For 2013, eligible professionals and group practices that are successful electronic prescribers will receive a 0.5% incentive payment. The minimum group practice size for participation in the eRx Group Practice Reporting Option is two. For a group practice of 2-24 eligible professionals, to be a successful electronic prescriber the group must report the electronic prescribing measure at least 75 times between January 1, 2013 and December 31, 2013. To avoid the 2014 payment adjustment of –2.0%, the group practice must report at least 75 times between January 1, 2013 and June 30, 2013.

The proposed rule also adds two new hardship exemptions for avoiding the 2013 and 2014 eRx payment penalties: 1) Eligible professionals or group practices that achieve EHR meaningful use during certain eRx payment adjustment reporting periods; and 2) eligible professionals or group practices that demonstrate intent to participate in the EHR Incentive Program and adoption of Certified EHR Technology.

AMBULATORY SURGICAL CENTER (ASC) PAYMENT UPDATE

For 2013, the payment update for ASCs will be 0.6%. CMS has chosen once again to update ASC payments using the Consumer Price Index for all Urban Consumers (CPI-U) despite repeated requests by ASGE and other stakeholders to use an inflation index (such as the hospital market basket) that more appropriately reflects ASC costs. CMS projects the CPI-U to be 1.4%, which is adjusted downward, as required by law, by a multi-factor productivity adjustment of 0.8%. By comparison, the ASC update for 2012 was 1.6 percent.

ASC Quality Reporting Program
In the final rule, CMS does not make changes to the ASC Quality Reporting Program for the 2014 and 2015 payment determinations. The reporting period for the 2014 payment determination is October 1, 2012-December 31, 2012. ASCs must report on five claims-based quality measures to avoid a -2.0% payment adjustment.

To apply the payment penalty, CMS will calculate two ASC conversion factors: 1) a full update conversion factor for ASCs that meet quality reporting requirements; and 2) a conversion factor that accounts for a 2% reduction for ASCs that do not meet quality reporting requirements.

The performance period for the 2015 payment determination begins January 1, 2014.

Additional information on the proposed rule will be posted on ASGE’s website. In the meantime, questions should be directed to Lakitia Mayo, Assistant Director of Health Policy and Quality at lmayo@asge.org.