Medicare’s physician fee schedule for 2013 contains both a 26.5% pay cut based on the Sustainable Growth Rate formula and an additional 7% reduction for radiation oncology services.
Under current law, the SGR formula will kick in Jan. 1 and lop one-fourth off doctors’ pay under Medicare, unless Congress steps in to halt the cut.
In issuing the fee schedule final regulation on Nov. 1, the Obama administration noted that Congress has reversed the mandated cut every year since 2003.
The administration "is committed to fixing the SGR update methodology and ensuring these payment cuts do not take effect," according to a statement. "Predictable, fiscally responsible physician payments are essential for Medicare to sustain quality and lower health care costs over the long term."
Courtesy AMA
Dr. Ardis D. Hoven
The American Medical Association decried the SGR cut.
"Eliminating this failed formula will allow us to enter a period when physicians can begin transitioning to new payment and delivery models to help meet the overall goal of improving patient care and moving to a higher-performing Medicare program," Dr. Ardis D. Hoven, AMA president-elect, said in a statement.
The fee schedule final rule also includes cuts to payments for intensity-modulated radiation treatment (IMRT) and stereotactic body radiation treatment (SBRT), although the reductions are not as steep as originally proposed back in July. Instead of an approximately 15% drop in payments for radiation oncology services, Medicare officials limited the cuts to 7%.
Part of the reason that the payment reduction was not as deep as expected is that officials at the Centers for Medicare and Medicaid Services (CMS) added a second therapist for the delivery of IMRT. They also added seven pieces of equipment that were inadvertently deleted from the IMRT delivery in the 2012 fee schedule.
ASTRO (American Society for Radiation Oncology), which represents radiation oncologists, praised the changes, which avoided about half of the proposed cut.
"Nearly 65% of all cancer patients receive radiation treatment as part of their care," Dr. Michael L. Steinberg, chairman of ASTRO’s board of directors, said in a statement. "Reducing the original proposed cuts will preserve access to lifesaving cancer treatment for Medicare patients nationwide. While we remain concerned about the overall level of the cuts to radiation oncology, we appreciate that CMS heard our concerns, and we look forward to working with CMS and Congress to achieve meaningful payment reforms that place incentives on value rather than volume."
The remaining cuts are largely due to CMS’s plans to change the way it calculates the time involved to perform IMRT and SBRT. Using patient education materials published by leading medical societies, Medicare officials determined that IMRT and SBRT services don’t take as long to perform as had previously been calculated. The CMS reviewed the procedure time assumptions associated with IMRT and SBRT as part of an overall review of potentially "misvalued" codes.
For example, the current CPT code for IMRT delivery (77418) is based on an assumption that the procedure will take 60 minutes to perform. However, information from patient fact sheets showed a significantly shorter procedure time. As a result, the CMS will base payment on a procedure time of 30 minutes starting on Jan. 1. Similarly, the procedure time assumption for SBRT delivery (CPT code 77373), has been lowered from 90 minutes to 60 minutes.
The fee schedule final rule also includes changes to the value-based modifier program, designed to pay physicians based on the quality of care they deliver.
In a proposed rule issued earlier this year, physicians in groups of 25 or larger would have been subject to the new pay plan in 2015. The final rule increases the size of the group to 100 initially.
In addition, the final rule creates a new set of codes to pay physicians for care coordination in the 30 days after a patient is discharged from a hospital or nursing home. Those codes were initially proposed as G codes, but now they will be full-fledged codes in the AMA Current Procedural Terminology (CPT). Physicians will be rewarded for patient interactions that are not face to face, such as phone consults, chart reviews, and e-mail communications.
The fee schedule rule will be published in the Federal Register on Nov. 16, and comments will close on Dec. 31. The rule takes effect Jan. 1, 2013.