Proposed CMS Primary Care Payment Hike Rewards Post-Discharge Care Coordination

Webinar Replay: Improving Transitions of Care Between Hospital and SNF


Family and primary care physicians could receive as much as 7 percent increases in payments under a proposed ruling from the CMS that includes separate payments for care coordination in the 30 days following hospital discharge.

The ruling would update payment policies and rates under the Medicare Physician Fee Schedule (MPFS) for 2013. If passed, family practitioners would receive up to 7 percent, and PCP’s between 3 and 5 percent for care provided in the 30 days following patient discharges from a hospital or skilled nursing facility.

Intended to help primary care doctors improve patient care and lower healthcare costs long term by helping to transition patients back into the community following a hospitalization or SNF stay, CMS will make separate payments to a patient’s community physician or practitioner to coordinate the patient’s care after they are discharged.

Other key points of the ruling include the following:

The proposed increases in fees to PCPs and family practitioners are based on the projected reduction in MPFS payment rates under the Sustainable Growth Rate (SGR) formula, which has been used to adjust Medicare physician payment rates every year since 2003. It is anticipated to be 27 percent in 2013; but it is a formula that has been bypassed by Congress every year since 2003.

Physicians will be able to choose their level of participation. Payments will be made based on the value modifier, which assesses the quality of care furnished to Medicare beneficiaries compared to costs and could be applied over three years from 2015 to 2017 to all groups of physicians with 25 or more eligible professionals. Physician groups will have the option of choosing how the value modifier would be calculated based on whether they participate in the Physician Quality Reporting System (PQRS). For those that do not participate in the PQRS, CMS could set their value modifier at a 1 percent payment reduction. Groups that wish to have their payment adjusted according to their performance on the value modifier could be paid more based on their quality of care compared to costs.

Intended to align quality reporting across programs to reduce burden and complexity and increase transparency, the proposal proposes changes to two quality reporting programs that are associated with the MPFS: the PQRS and the Electronic Prescribing (eRx) Incentive Program – as well as the Medicare Electronic Health Records (EHR) Incentive Pilot Program, which promotes the use of health information technology. The PQRS proposal includes simplified, lower burden options for reporting and the proposed rule aligns quality reporting across the various programs in support of the National Quality Strategy. The ruling also includes plans to enhance the Physician Compare Website to provide beneficiaries with more information when choosing physicians.

CMS will accept comments on the proposed rule until September 4th, and issue its final rule by November 1st.

Source: CMS, July 6, 2012

Guide to Physician Performance-Based Reimbursement: Payoffs from Incentives, Data Sharing and Clinical Integration

In Guide to Physician Performance-Based Reimbursement: Payoffs from Incentives, Data Sharing and Clinical Integration, newly minted reimbursement formulas at two health plans and two independent practice associations (IPAs) are explored, providing payor and provider perspectives on the formula development process; clinical, quality and efficiency measures in use; physician incentive payments and program outcomes.

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