News | Radiation Oncology | July 14, 2023

CMS Physician Payment Rule Advances Health Equity

Proposed policies will expand behavioral health services, support the President’s Cancer Moonshot, promote innovation, and grow value-based care

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July 14, 2023 — The Centers for Medicare & Medicaid Services (CMS) issued the calendar year (CY) 2024 Medicare Physician Fee Schedule (PFS) proposed rule to announce rate updates, advance health equity, and expand access to critical medical services — including behavioral health care and certain oral health services. Notably, the proposed rule supports the Biden-Harris Administration’s Cancer Moonshot mission to accelerate the fight against cancer.

“At CMS, our mission is to expand access to health care and ensure that health coverage is meaningful to the people we serve,” said CMS Administrator Chiquita Brooks-LaSure. “CMS’ proposals in the proposed physician payment rule would help people with Medicare navigate cancer treatment and have access to more types of behavioral health providers, strengthen primary care, and for the first time, allow Medicare payment for services performed by community health workers.”

“CMS continues to demonstrate commitment to advancing health equity and building a stronger Medicare program,” said Meena Seshamani, MD, CMS Deputy Administrator and Director of the Center for Medicare. “If finalized, the proposals in this rule ensure the people we serve experience coordinated care focused on treating the whole person, considering each person’s unique story and individualized needs — physical health, behavioral health, oral health, social determinants of health, and are inclusive of caregivers, which are all so important to providing the care that people with Medicare deserve.”

Proposed Payment Rate

The CY 2024 PFS proposed rule includes updates to PFS payments for clinicians as required by law. Overall proposed payment amounts under the PFS would be reduced by 1.25% compared to CY 2023, in accordance with factors specified by law. CMS is also proposing increases in payment for many visit services, such as primary care, and these proposed increases require offsetting and budget neutrality adjustments to all other services paid under the PFS, by law. The proposed CY 2024 PFS conversion factor is $32.75, a decrease of $1.14, or 3.34%, from CY 2023.

Advancing Health Equity and Caregiver Support

Building on the agency’s commitment to health equity, and the Biden-Harris Administration’s Executive Order to support caregivers, CMS is proposing coding and payment for several new services to help underserved populations, including addressing unmet health related social needs that can potentially interfere with the diagnosis and treatment of medical problems. First, CMS is proposing to pay for certain caregiver training services in specified circumstances, so that practitioners are appropriately paid for engaging with caregivers to support people with Medicare in carrying out their treatment plans.

CMS is also proposing separate coding and payment for community health integration services, which would include person-centered planning, health system coordination, promoting patient self-advocacy, and facilitating access to community-based resources to address unmet social needs that interfere with the practitioner’s diagnosis and treatment of the patient. These are the first Physician Fee Schedule services designed to include care involving community health workers, who link underserved communities with critical health care and social services in the community and expand equitable access to care, improving outcomes for the Medicare population.

In alignment with the goal of the Biden-Harris Administration’s Cancer Moonshot for everyone with cancer to have access to covered patient navigation services, CMS is proposing payment for Principal Illness Navigation services to help patients navigate cancer treatment and treatment for other serious illnesses. These services are also designed to include care involving other peer support specialists, such as peer recovery coaches for individuals with substance use disorder.

This rule also proposes coding and payment for social determinants of health risk assessments, which could be furnished as an add-on to an annual wellness visit or in conjunction with an evaluation and management visit.

Payment for Dental Services prior to Certain Cancer Treatments

Access to oral and dental health services that promote health and wellness allows people with Medicare to achieve the best health possible. In this proposed rule, CMS is supporting the Biden-Harris Administration’s Cancer Moonshot initiative by proposing that payment can be made for certain dental services prior to and during several different cancer treatments, including, but not limited to, chemotherapy.

Supporting Whole-Person Care

The CMS Behavioral Health Strategy strives to support a person’s emotional and mental well-being through their behavioral health care. This rule contains some of the most important changes to improve access to behavioral health in Medicare in the program’s history. The rule proposes to allow marriage and family therapists and mental health counselors, including addiction counselors, to enroll in Medicare and bill for their services for the first time. The rule also proposes increased payment for crisis care, substance use disorder treatment, and psychotherapy.

Primary care is instrumental in the delivery of high-quality, whole-person care. CMS is recognizing the value and inherent complexity in primary and longitudinal care by proposing to implement new payment and coding to accurately and appropriately pay for these services, which aligns with the goals articulated in the HHS Initiative to Strengthen Primary Care.

CMS is also continuing to promote whole-person care in the Medicare Shared Savings Program, the largest Accountable Care Organization (ACO) program in the country. CMS is proposing changes to the assignment methodology that would better promote access to accountable care for individuals who see nurse practitioners, physician assistants, and clinical nurse specialists for their primary care services. CMS is also proposing changes to the financial benchmarking methodology to better encourage participation by ACOs serving complex populations. In total, these proposals are expected to increase participation in the Shared Savings Program by roughly 10% to 20%, which will provide additional opportunities for beneficiaries to receive coordinated care from ACOs.

CMS is further driving quality care by proposing to increase the performance threshold in the Quality Payment Program from 75 to 82 points for the CY 2024 Merit-Based Incentive Payment System (MIPS) performance period/2026 MIPS payment year. This statutorily required increase aligns with our goal to provide practices with a greater return on their investment in MIPS participation by giving an opportunity to achieve a higher positive payment adjustment while also encouraging participation in Advanced Alternative Payment Models. CMS is also proposing changes to align the Quality Payment Program with the Universal Foundation, a core set of quality metrics across CMS programs to more effectively drive change.

There are also proposed changes to promote care for individuals with diabetes, by enhancing the Medicare Diabetes Prevention Program (MDPP) Expanded Model to further increase participation and access in underserved communities. This rule proposes to extend the MDPP Expanded Model’s Public Health Emergency Flexibilities for four years, which would allow all MDPP suppliers to continue to offer MDPP services virtually using distance learning delivery through December 31, 2027, as long as they maintain an in-person Centers for Disease Control and Prevention organization code.