CMS Leveraging PFS Proposal to Address Health Inequity

 Data collection and expansion of access are two critical elements of the plan.

If soaring levels of income and wealth inequality building up for decades didn’t make it plain enough, the global COVID-19 pandemic that killed more than half a million people in the U.S. in less than 18 months illustrated beyond the shadow of a doubt that health inequity has become a critical issue.

It hasn’t gone unnoticed by federal officials who manage the nation’s largest coverage programs.

The Centers for Medicare & Medicaid Services (CMS) this week proposed changes to address the problem and expand patient access to comprehensive care, especially in underserved populations, via its annual Physician Fee Schedule (PFS) proposed rule.

“Over the past year, the public health emergency has highlighted the disparities in the U.S. healthcare system, while at the same time demonstrating the positive impact of innovative policies to reduce these disparities,” CMS Administrator Chiquita Brooks-LaSure said in a statement, just weeks after the U.S. Senate voted to confirm her as the first Black person to serve as head of the entity that employs roughly 6,300 workers and provides healthcare coverage to about 1 in 3 Americans. “CMS aims to take the lessons learned during this time and move forward toward a system where no patient is left out and everyone has access to comprehensive quality health services.”

CMS said in a press release issued Tuesday that the pledge begins with improving data collection to better measure and analyze disparities across programs and policies. As such, in the newly proposed PFS rule, CMS is soliciting feedback on the collection of data and on how the agency can advance health equity for people with Medicare (while protecting individual privacy), potentially through the creation of confidential reports that allow providers to look at patient impact through a variety of data points, including but not limited to LGBTQ+ status, race and ethnicity, dual-eligible status, disability status, and rural populations.

“Access to these data may enable a more comprehensive assessment of health equity and support initiatives to close the equity gap,” CMS said in its press release. “In addition, hospitals and healthcare providers may be able to use the results from the disparity analyses to identify and develop strategies to promote health equity.

Another aspect of the proposed PFS rule involves what CMS described as reinforcing a commitment to expanding access to behavioral healthcare and reducing barriers to treatment – specifically, by implementing recently enacted legislation removing certain statutory restrictions to allow patients in any geographic location, and in their homes, access to telehealth services for diagnosis, evaluation, and treatment of mental health disorders.

“Along with this change, CMS is proposing to expand access to mental health services for rural and vulnerable populations by allowing, for the first time, Medicare to pay for mental health visits when they are provided by Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs), to include visits furnished through interactive telecommunications technology,” officials said. “This proposal would expand access to Medicare beneficiaries, especially those living in rural and other underserved areas.”

CMS also announced plans to allow payment to eligible practitioners when they provide certain mental and behavioral health services to patients via audio-only telephone calls from their homes when certain conditions are met, including counseling and therapy services provided through opioid treatment programs. The underserved population expected to benefit from such a change would include those in areas with poor broadband infrastructure, as well as Medicare beneficiaries who are not capable of (or do not consent to the use of) devices that permit a two-way, audio/video interaction for their visits.

“The COVID-19 pandemic has put enormous strain on families and individuals, making access to behavioral health services more crucial than ever,” Brooks-LaSure said. “The changes we are proposing will enhance the availability of telehealth and similar options for behavioral health care to those in need, especially in traditionally underserved communities.”

CMS also announced plans to expand the Medicare Diabetes Prevention Program (MDPP), developed to help people with Medicare with prediabetes from developing type 2 diabetes. The expanded model is being implemented at the local level by MDPP suppliers: organizations that provide structured, coach-led sessions in community and healthcare settings using a Centers for Disease Control and Prevention (CDC)-approved curriculum to provide training in dietary change, increased physical activity, and weight loss strategies.

Additionally, CMS said it is proposing to require clinicians to meet a higher performance threshold to be eligible for incentives, with the new threshold tied to requirements established for the Merit-based Incentive Payment System (MIPS), and also seeking to change how providers are reimbursed for administering preventive vaccines.  

“Medicare payments to physicians and mass immunizers for administering flu, pneumonia, and hepatitis B vaccines have decreased by around 30 percent over the last seven years,” CMS noted. “In the PFS proposed rule, CMS is requesting feedback to help update payment rates for administration of preventive vaccines covered under Part B. In addition to seeking information on the types of healthcare providers who furnish vaccines and their associated costs, CMS is looking for feedback on its recently adopted payment add-on of $35 for immunizers who vaccinate certain underserved patients in the patient’s home.”

CMS is also seeking comments on the treatment of COVID-19 monoclonal antibody products as vaccines, and whether those products should be treated like other monoclonal antibody products after the PHE.

Lastly, to “ensure more meaningful participation for clinicians and improved outcomes for patients,” CMS said it is moving forward with the next evolution of QPP and proposing its first seven MIPS Value Pathways (MVPs)  ̶  subsets of connected and complementary measures and activities, established through rulemaking, used to meet MIPS reporting requirements.

“The initial set of proposed MVP clinical areas include rheumatology, stroke care and prevention, heart disease, chronic disease management, lower extremity joint repair (e.g., knee replacement), emergency medicine, and anesthesia,” the CMS press release read. “MVPs will more effectively measure and compare performance across clinician types and provide clinicians more meaningful feedback. CMS is also proposing to revise the current eligible clinician definition to include clinical social workers and certified nurse-midwives, as these professionals are often on the front lines serving communities with acute healthcare needs.”

For a fact sheet on the CY 2022 Physician Fee Schedule proposed rule, go online to:  https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2022-medicare-physician-fee-schedule-proposed-rule

For a fact sheet on the CY 2022 Quality Payment Program proposed changes, go to: https://qpp-cm-prod-content.s3.amazonaws.com/uploads/1517/2022%20QPP%20Proposed%20Rule%20Overview%20Fact%20Sheet.pdf

To view the CY 2022 Physician Fee Schedule and Quality Payment Program proposed rule in its entirety, go to: https://www.federalregister.gov/public-inspection/current