February 2007 Practice Update (part two)

Medicare Announces Performance Measures for New Physician Quality Reporting Program
Medicare has announced preliminary information and the performance measures for the 2007 Physician Quality Reporting Initiative (PQRI). The hematology measures created by ASH have been approved and included in the program.

The Tax Relief and Health Care Act of 2006 (TRHCA) enacted this past December authorizes the establishment of a physician quality reporting system by the Centers for Medicare and Medicaid Services (CMS) known as the Physician Quality Reporting Initiative (PQRI).

PQRI establishes a financial incentive for eligible professionals to participate in a voluntary quality reporting program. Eligible professionals who successfully report a designated set of quality measures on claims for dates of service from July 1 to December 31, 2007, may earn a bonus payment, subject to a cap, of 1.5 percent of total allowed charges for covered Medicare physician fee schedule services. This initiative applies to the traditional Medicare fee-for-service program only and is not applicable to the Medicare Advantage Plans, including the private fee-for-service plans.

Last year ASH created a Pay-for-Performance Task Force to develop hematology-related performance measures that could be incorporated into a future Pay-for-Performance/Pay-for-Reporting program. The American Medical Association Physician Consortium for Performance Improvement and the AQA recently approved the ASH hematology-specific quality measures.

CMS has posted a new Web site for the Physician Quality Reporting Initiative.

Medicare to Provide Beneficiaries with Information on Physician Performance
CMS has announced that one of its quality improvement organizations has entered into subcontracts with four regional collaboratives as part of the Better Quality Information to Improve Care for Medicare Beneficiaries (BQI) Project. CMS says that the results of the BQI Project will be used for two primary purposes: first, to provide performance information to physicians that will assist them in improving the quality of care they are delivering to Medicare beneficiaries; and second, to give physician performance information to Medicare beneficiaries to help them with physician selection. More information is available at CMS.

Administration's Medicare Budget Assumes 10 Percent Physician Payment Cut; Congress Says it is Not Realistic
Designed to "strengthen the long term financial security of the program," President Bush's proposed Medicare budget, released February 5, 2007, would reduce the program's average annual growth rate from 6.5 percent to 5.6 percent over five years, cut $76 billion over five years from hospitals and other providers, and increase beneficiary cost sharing for Parts B and D by $10 billion over five years. Of the $76 billion in cuts, $42 billion would come from proposals to freeze or cut provider payment updates. The Administration's Medicare budget assumes that physicians will receive a 10 percent cut in Calendar Year 2008 and additional cuts in the out-years.

The budget also assumes $10.2 billion in savings over five years as a result of new regulatory efforts "to strengthen program integrity in Medicare payment systems, correct for inappropriate provider payments and adjust payments to encourage efficiency and productivity." No additional details were provided. The budget also proposes a "trigger" for provider cuts if the difference between total Medicare outlays and dedicated funding sources (such as premiums and payroll taxes) exceeds 45 percent of total outlays. In such cases, provider payments would be reduced by 0.4 percent until general revenue funding is brought back to the 45 percent level.

During the February 13 Senate Budget Committee hearing, lawmakers criticized the Administration budget proposal for failure to address the scheduled 10 percent reduction in Medicare physician reimbursements. Committee Chair Kent Conrad (D-ND) told HHS Secretary Mike Leavitt, "We all know that's not going to happen," adding that "it's not realistic with how we are going to treat physicians." Secretary Leavitt said that the reduction in Medicare physician reimbursements is part of current law and that a reduction will occur without a change in the law. In addition, he said that Medicare should change the formula used to calculate physician reimbursements to base payments on quality and cost, rather than the number of procedures performed.

New Medicare Coumadin Clinic Codes -- Follow-up
In the last Practice Advocacy Update, ASH shared concerns from state hematology/oncology societies about payment for the new anticoagulant management CPT codes 99363 and 99364. CMS has indicated in the 2007 final physician fee schedule that it considers payment for these codes to be bundled into the E/M code for the patient's previous office visit. According to William Rogers, MD, head of the Physician Regulatory Issues Team (PRIT) at CMS, physicians can still bill a low-level office visit such as 99211, when appropriate for a face-to-face visit. Circumstances when physicians can be paid include when the patient spoke with a doctor (or nurse) about dosage and side effects and anything that interferes with the function of coumadin. Carriers are most likely to pay when there is a change in dosage. Physicians also may be paid for the prothrombin time test, 85610, which is paid according to the lab fee schedule. The new codes are designed to be reported when adjusting the dosage or testing patients who are taking blood thinners. The CPT manual states 99363 should be reported only with a minimum of eight International Normalized Ration (INR) measurements over a period of 90 days. 99364 is to be reported for therapy provided beyond the first 90 days.

Participate in ASH Advocacy Center Campaigns
ASH has created several advocacy campaigns to strengthen communication with Congress on key legislative issues. With just a few "clicks" in ASH's e-advocacy system, hematologists and hematologist/oncologists can provide federal policy makers with information on how public policy issues affect them and the patients they treat. Please visit the ASH Advocacy Center to take action on the Society's current advocacy campaigns concerning funding for NIH, stem cell research, and passage of genetic nondiscrimination legislation.