WASHINGTON -- What's the best way to narrow the payment gap between primary care physicians and specialists? The Medicare Payment Advisory Commission (MedPAC) mulled over that question at a public meeting on Friday.
The panel, which advises Congress on Medicare payment policy, also examined "distortions in practice patterns" and strategies for limiting the overuse of more lucrative services.
The commission zeroed in on potential adjustments to the Medicare Physician Fee Schedule as a means of correcting these imbalances. Members discussed previous recommendations and some new ideas, including combining current procedural terminology (CPT) codes into families and taking a partial capitation approach to primary care payment.
Even with the repeal of the widely maligned sustainable growth rate formula under the Medicare Access and CHIP Reauthorization Act and the move toward paying based on the value of services rather than their volume, the fee schedule is still the core basis by which physicians payments are set, explained the analysts.
With over 7,000 possible codes, there is significant opportunity for clinicians to upcode, explained MedPAC analyst . For example, there are multiple codes for excising a skin lesion depending on its size in millimeters, which means there is always an incentive to remove just a bit more and get a higher payment, he said.
So might there be a benefit to aggregating clinically similar codes in the fee schedule, Winter and fellow MedPAC analyst , asked the commissioners.
Commissioner , of Arlington, Va. noted that it could be possible to group fecal blood tests and colonoscopies, for example, under one code paid according to a weighted average. However she stressed that she was "not a fan of reference pricing."
While it might make sense to group codes for skin lesions, paying for angioplasty and bypass surgery at a similar rate would be considered by many to be "extreme," she said.
"I think if the problem we are trying to solve is really paying primary care more appropriately and then going after those overvalued procedures. I think that's doable," Buto said; however, grouping codes without careful thought could "potentially open up a can of worms."
In addition to mispriced primary care services, Winter and Hayes also noted two other problems: the valuation process -- in which each service or procedure is assigned a "relative value" -- is overly complex; and the Department of Health and Human Services (HHS) lacks the objective data needed to ensure that relative values are accurate.
And the Relative Value Scale Update Committee (RUC), which is charged with helping set Medicare payment rates, is heavily dependent on specialty groups who have their own financial interests at stake, they pointed out.
Winter and Hayes offered several possible solutions, including:
- adding a per-beneficiary payment for primary care services that could be billed under the fee schedule (replacing the Primary Care Incentive Payment program which ended Jan. 1, 2016.
- developing a panel of experts to help the Centers for Medicare and Medicaid Services find "mispriced" services
- expanding the Multiple Procedure Payment Reduction (MPPR), which applies to certain services conducted by the same doctor on the same day.
- having the HHS secretary collect data from a "cohort of selected practices," which might be paid for participating, in order to establish more accurate payment rates.
Most commissioners agreed that previous recommendations could be re-framed with greater specificity and resubmitted. However, there was significant debate around whether the commission should endorse some of the MedPAC's staff's other potential recommendations.
One commissioner, , of the University of California San Francisco, used the example of colorectal cancer screening. She noted that while fecal occult blood testing has been shown in randomized control trials to reduce colorectal cancer mortality, most patients aren't offered that option and instead undergo colonoscopies, which are more expensive.
Similarly, she noted that studies have shown patients with stable coronary disease are usually steered towards cardiac catheterization instead of medical management because they mistakenly believe the stent will prevent a heart attack and that management won't, she said.
"I think we have to address the fact that when two methods are equally effective for treatment, when you have this big payment disparity, we are unintentionally driving a lot more procedure-oriented care that's not necessarily in our beneficiaries' interest, and just revaluing the codes is not going to address that."