CMS Proposes Physician Payment Rule to Expand Access to
High-Quality Care
On July 7, CMS issued the Calendar Year
2023 Physician Fee Schedule (PFS) proposed rule, which would
significantly expand access to behavioral health services, Accountable
Care Organizations (ACOs), cancer screening, and dental care —
particularly in rural and underserved areas. These proposed changes play
a key role in the Biden-Harris Administration’s Unity Agenda — especially
its priorities to tackle our nation’s mental health crisis, beat the
overdose and opioid epidemic, and end cancer as we know it through the
Cancer Moonshot — and ensure CMS continues to deliver on its goals of
advancing health equity, driving high-quality, whole-person care, and
ensuring the sustainability of the Medicare program for future
generations.
“At CMS, we are constantly striving to
expand access to high quality, comprehensive health care for people
served by the Medicare program,” said CMS Administrator Chiquita Brooks-LaSure.
“Today’s proposals expand access to vital medical services like
behavioral health care, dental care, and cancer treatment options, all
while promoting access, innovation, and cost savings in the Medicare
program.”
“Integrated coordinated, whole-person
care — which addresses physical health, behavioral health, and social
determinants of health — is crucial for people with Medicare, especially
those with complex needs,” said Dr. Meena Seshamani, CMS Deputy
Administrator and Director of the Center for Medicare. “If finalized, the
proposals in this rule will advance equity, lead to better care, support
healthier populations, and drive smarter spending of the Medicare dollar.
The proposed CY 2023 PFS conversion
factor is $33.08, a decrease of $1.53 to the CY 2022 PFS conversion
factor of $34.61. This conversion factor accounts for the statutorily
required update to the conversion factor for CY 2023 of 0%, the
expiration of the 3% increase in PFS payments for CY 2022 as required by
the Protecting Medicare and American Farmers From Sequester Cuts Act, and
the statutorily required budget neutrality adjustment to account for
changes in Relative Value Units.
Modernizing Coverage for Behavioral
Health Services
In the 2022 CMS Behavioral Health Strategy, CMS
set goals to remove barriers to care and improve access to, and the
quality of, mental health and substance use care. To help address the
acute shortage of behavioral health practitioners, the agency is
proposing to allow licensed professional counselors, marriage and family
therapists, and other types of behavioral health practitioners to provide
behavioral health services under general (rather than direct)
supervision. Additionally, CMS is proposing to pay for clinical
psychologists and licensed clinical social workers to provide integrated
behavioral health services as part of a patient’s primary care team.
CMS is also proposing to bundle certain
chronic pain management and treatment services into new monthly payments,
improving patient access to team-based comprehensive chronic pain
treatment. Lastly, CMS is proposing to cover opioid treatment and
recovery services from mobile units, such as vans, to increase access for
people who are homeless or live in rural areas.
Expanding Access to Accountable Care
Organizations
ACOs are groups of health care providers
who come together to give coordinated, high-quality care to their
Medicare patients. The Medicare Shared Savings Program covers more than
11 million people with Medicare and includes more than 500,000 providers.
CMS is proposing changes to the Medicare
Shared Savings Program that, if finalized, represent some of the most
significant reforms since the final rule that established the program was
finalized in November 2011 and ACOs began participating in 2012. Building
on the CMS Innovation Center’s successful ACO Investment Model, CMS is
proposing to incorporate advance shared savings payments to certain new
Medicare Shared Savings Program ACOs that could be used to address
Medicare beneficiaries’ social needs. This is one of the first times
Traditional Medicare payments would be permitted for such uses and is
expected to be an opportunity for providers in rural and other
underserved areas to make the investments needed to become an ACO and
succeed in the program. CMS is also proposing that smaller ACOs have more
time to transition to downside risk, further helping to grow
participation in rural and underserved communities. CMS is also proposing
a health equity adjustment to an ACO’s quality performance category score
to reward excellent care delivered to underserved populations. Finally,
CMS is proposing benchmark adjustments to encourage more ACOs to
participate and succeed, which would help achieve the goal of having all
people with Traditional Medicare in an accountable care relationship with
a healthcare provider by 2030.
Improving Access to Colon Cancer
Screening
Colon and rectal cancer were the
second-leading cause of cancer deaths in the United States in 2020, with
higher colorectal cancer death rates for Black Americans, American
Indians, and Alaska Natives. To reduce barriers to getting a colonoscopy,
CMS is proposing that a follow-up colonoscopy to an at-home test be
considered a preventive service, which means that cost sharing would be
waived for people with Medicare. Additionally, Medicare is proposing to
cover the service for individuals 45 years of age and above, in line with
the newly lowered age recommendation (down from 50) from the United
States Preventive Services Task Force.
Proposing Payment for Dental Services
that are Integral to Covered Medical Services
Medicare Part B currently pays for dental
services when that service is integral to medically necessary services
required to treat a beneficiary's primary medical condition. Some
examples include reconstruction of the jaw following accidental injury or
tooth extractions done in preparation for radiation treatment for jaw
cancer. CMS is proposing to pay for dental services, such as dental
examination and treatment preceding an organ transplant. In addition, CMS
is seeking comment on other medical conditions where Medicare should pay
for dental services, such as for cancer treatment or joint replacement
surgeries, as well as on a process to get public input when additional dental
services may be integral to the clinical success of other medical
services.
More Information:
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