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July 12, 2022

Inside the proposed MPFS 2023

Daily Briefing

    CMS last week issued a proposed rule to update the Medicare Physician Fee Schedule (MPFS) for calendar year (CY) 2023, which proposes updates to physician payments and the Medicare Shared Savings Program (MSSP), as well as new policies to expand patient access to behavioral health care, cancer screenings, and more.

    The 10 biggest health policy topics—including physician pay—to watch in 2022

    Proposed payment updates

    For CY 2023, CMS is proposing to reduce the conversion factor used to calculate physician reimbursement for Medicare fee-for-service payments to $33.08, a decrease of $1.53 from CY 2022's $34.61 conversion factor.

    According to the agency, this reduction reflects several factors, including the expiration of a 3% increase in payments required by Congress, a 0% conversion factor update, and a budget neutrality adjustment.

    In addition, CMS proposed to delay the implementation of its split (or shared) visits policy that was finalized in CY 2022 for the definition of substantive portion.

    Other proposed changes

    In addition to the physician payment updates, CMS also proposed several policy changes that would expand access to several areas of care, including:

    Accountable care organizations (ACOs)

    CMS proposed several changes to the MSSP, which assists providers and hospitals that want to create an ACO.

    If the new policies are enacted, CMS would offer advanced shared savings payments to low-revenue ACOs. The agency would also provide increased flexibility to ACOs that assume performance-based risk and add a health equity adjustment to ACOs' quality performance category to reward organizations for excellent care in underserved communities.

    In addition, CMS wants to adjust ACO benchmarks to correct glitches that make it more difficult for organizations to earn shared savings. According to CMS projections, these proposed changes could result in $650 million in higher shared savings payments to ACOs.

    Behavioral health

    To address the shortage of behavioral health providers, CMS proposed that different mental health practitioners, including licensed professional counselors, marriage and family therapists, and others, provide behavioral health care under general instead of direct supervision.

    In addition, CMS proposed that clinical psychologists and licensed clinical social workers be integrated behavioral health services as part of patients' primary care teams.

    The agency also proposed that certain chronic pain management and treatment services be bundled into monthly payments, which could improve patient access to comprehensive chronic pain treatment. Finally, CMS proposed covering opioid treatment and recovery services administered from mobile units, including vans, to increase access for individuals living in rural areas or who are homeless.

    Colon cancer screenings

    To reduce barriers to colonoscopy, CMS proposed that follow-up colonoscopies after an at-home test be covered as a preventive instead of a diagnostic service. Doing so would waive the service's cost-sharing for Medicare patients.

    In addition, CMS proposed the colonoscopies be covered for patients ages 45 and older, in line with recommendations form the U.S. Preventive Services Task Force.

    Dental services

    Currently, CMS covers dental services that are integral to medically necessary services, such as jaw reconstruction surgery after an injury. Now, the agency is proposing to cover dental services, including exams and treatments, before an organ transplant.

    CMS is seeking comment on what other medical conditions Medicare should cover dental services for, such as cancer treatments or joint replacement surgeries. In addition, the agency is asking for comments on a process to receive public input on when additional dental services could be necessary to the clinical success of other medical procedures.

    Drug-related provisions

    CMS is proposing to implement policies from the Infrastructure Investment and Jobs Act that require manufacturers of certain single-dose or single-use packaged drugs administered by physicians in outpatient settings to reimburse CMS for discarded drugs.


    So far, medical groups, including the American Medical Association (AMA) and the Medical Group Management Association (MGMA), have expressed concerns about how CMS' proposed payment updates will impact physicians, MedPage Today reports.

    AMA president Jack Resneck Jr. said the organization is still reviewing the proposed payment updates, but noted that "it is immediately apparent that the rule not only fails to account for inflation in practice costs and COVID-related challenges to practice sustainability, but also includes a significant and damaging across-the-board reduction in payment rates."

    "Such a move would create long-term financial instability in the Medicare physician payment system and threaten patient access to Medicare-participating physicians," he added.

    Separately, MGMA said it "is incredibly concerned about the likely impact of the proposed 4.42% reduction to the conversion factor, especially in light of the financial uncertainty which medical groups have faced over the past two years stemming from the COVID-19 pandemic, inflation, and the staffing crisis."

    However, CMS' other proposals to expand access to behavioral health care, colonoscopies, dental services, and ACOs are likely to be more welcomed by both physicians and patients, according to MedPage Today.

    "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 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." (CMS press release, 7/7; CMS fact sheet, 7/7; D'Ambrosio, MedPage Today, 7/8; Beerman, HealthLeaders Media, 7/8; AHA News, 7/7; Lagasse, Healthcare Finance News, 7/8; Goldman, Modern Healthcare, 7/7; Herman, STAT+, 7/7)

    Health policy topics to watch in 2022

    The legislative, regulatory, and judicial outlook for health policy in 2022


    The Biden administration's first year in office was unsurprisingly dominated by the Covid-19 pandemic. While Democrats in Congress were able to pass part one of President Biden’s infrastructure package, other health care priorities were largely sidelined. As we look to 2022, there are 10 key health care topics that are ripe for congressional or regulatory action. If and how Congress and the Biden administration move on those actions will have strategic implications for industry executives across the health care ecosystem.

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