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Medicare finalizes substantial improvements that focus on primary care, mental health, and diabetes prevention

Medicare finalizes substantial improvements that focus on primary care, mental health, and diabetes prevention
Medicare finalizes policies to expand the Diabetes Prevention Program Model

Today, the Centers for Medicare & Medicaid Services (CMS) finalized the 2017 Physician Fee Schedule final rule that recognizes the importance of primary care by improving payment for chronic care management and behavioral health. The rule also finalizes many of the policies to expand the Diabetes Prevention Program model test to eligible Medicare beneficiaries, the Medicare Diabetes Prevention Program (MDPP) expanded model, starting January 1, 2018. This is the first time a prevention model from the CMS Innovation Center will be adopted under the CMS authority to expand successful payment and service delivery models to reach all eligible beneficiaries.

The 2017 Physician Fee Schedule final rule is one of several rules that reflect a broader Administration-wide strategy to create a health care system that results in better care, smarter spending, and healthier people.

The rule’s finalized primary care policies improve how Medicare pays for services provided by primary care physicians and other practitioners for patients with multiple chronic conditions and mental and behavioral health issues, as well as cognitive impairment. These changes will improve payment for clinicians who are making investments of time and resources to provide more coordinated and patient-centered care. 

These coding and payment changes will better reflect the resources involved in furnishing comprehensive primary care, care coordination and planning, mental health care, and care for cognitive impairment, such as Alzheimer’s disease. In addition, these changes further reinforce Medicare’s transformation to better align priorities and reward physicians for quality care through the Quality Payment Program.

“These policies will give significant support to the practice of primary care and boost the time a physician can spend with his or her patients listening, advising and coordinating their care,” said CMS Acting Administrator Slavitt. “By better valuing primary care, behavioral health, and prevention models like the Medicare Diabetes Prevention Program expanded model, we help beneficiaries access the services they need to stay well and live long, healthy lives.”

In March 2016, CMS announced that the Diabetes Prevention Program model test met the statutory criteria for expansion under CMS’s authority to expand successful payment and service delivery models. Today, CMS is finalizing its proposal to implement the Medicare Diabetes Prevention Program expanded model beginning January 1, 2018. CMS’ finalized proposal would allow suppliers that have Centers for Disease Control and Prevention recognition to prepare to enroll in Medicare, and submit claims for furnish these services. CMS intends to finalize a process as soon as possible for these organizations to enroll in Medicare so they can furnish services and begin billing by the time the expanded model becomes effective.  

“Through the Medicare Diabetes Prevention Program expanded model, eligible beneficiaries will be able to access a community-based intervention that prevents diabetes and keeps people healthy,” said Patrick Conway, Acting Principal Deputy Administrator and CMS Chief Medical Officer. “Preventing the onset of diabetes through proven measures not only keeps people living healthier lives, but also helps to preserve Medicare. This is an exciting milestone for prevention and population health.” 

Data released today shows the importance of preventing diabetes: In total, we estimate that Medicare will spend $42 billion more in the single year of 2016 on fee-for-service, non-dual eligible, over age 65 beneficiaries with diabetes than it would spend if those beneficiaries did not have diabetes -- $20 billion more for Part A, $17 billion more for Part B, and $5 billion more for Part D. On a per-beneficiary basis, this disparity is just as clear. In 2016 alone, Medicare will spend an estimated $1,500 more on Part D prescription drugs, $3,100 more for hospital and facility services, and $2,700 more in physician and other clinical services for those with diabetes than those without diabetes.

CMS hopes that the expanded model will encourage employers and insurers to initiate diabetes prevention programs in their populations as well. To learn more about the Medicare Diabetes Prevention Program expanded model and the importance of primary care, please visit the CMS Blog at http://blog.cms.gov/2016/11/02/a-healthier-medicare-focusing-on-primary-care-mental-health-and-diabetes-prevention and Medicare Diabetes Prevention Program expanded model fact sheet: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-11-02-2.html

The annual Physician Fee Schedule updates payment policies, payment rates, and quality provisions for services provided in calendar year 2017. These services include, but are not limited to, visits, surgical procedures, diagnostic tests, therapy services, and specified preventive services. In addition to physicians, a variety of practitioners and entities, including nurse practitioners, physician assistants, and physical therapists, as well as radiation therapy centers and independent diagnostic testing facilities are paid under the physician fee schedule. Additional policies finalized in the 2017 payment rule include:

• Primary Care and Care Coordination: The rule finalizes revisions to payment for chronic care management, including payment for new codes for complex chronic care management and for extra care management furnished by a physician or practitioner following the initiating visit for patients with multiple chronic conditions. This finalized change is a significant update to the Physician Fee Schedule and will support primary care when and where patients need it most.
  
  
• Mental and Behavioral Health: CMS is finalizing payments for codes that describe specific behavioral health services furnished using the psychiatric Collaborative
  Care Model, which has demonstrated benefits in a variety of settings. In this model, patients are cared for through a team approach, involving a primary care practitioner, behavioral health care manager, and psychiatric consultant. CMS is also finalizing payment for a new code that broadly describes behavioral health integration services, including payments for other approaches and for practices that are not yet prepared to implement the Collaborative Care Model.
  
  
• Cognitive Impairment Care Assessment and Planning: CMS finalizes payment to physicians to perform cognitive and functional assessment and care planning for patients with cognitive impairment (e.g., for patients with Alzheimer’s). This is a major step forward for care planning for these populations.

The 2017 payment rule also finalizes a data collection strategy for global services with significantly reduced burden for practitioners compared to the proposal. Required reporting will be limited to a sample of practitioners for selected services, and those practitioners who do report will report less information.  

In addition, CMS is finalizing a change that will more accurately reflect local costs and significantly increase payments to practitioners in Puerto Rico. Other changes in the final regulation will enhance program integrity and data transparency in the Medicare Advantage program.

For more information, please visit: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-11-02.html

To learn more about the Medicare Diabetes Prevention Program expanded model, visit: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-11-02-2.html

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