Physician Fee Schedule 2018 Final Rule - December 11, 2017 powered by Vizient & AAMC

 
Physician Fee Schedule 2018 Final Rule - December 11, 2017 powered by Vizient & AAMC
powered by Vizient & AAMC

          Physician Fee Schedule 2018 Final Rule

                                December 11, 2017

© 2017 Vizient, Inc. and AAMC                       Page 1
Physician Fee Schedule 2018 Final Rule - December 11, 2017 powered by Vizient & AAMC
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 © 2017 Vizient, Inc. and AAMC                                                          Page 2
Agenda
       • Payment Policies and Other Policies
              • Conversion Factors, Misvalued RVUs, RVU Targets
              • Payment Rates for Provider-Based Off Campus Hospital
                Departments
              • Payment for Telehealth
              • Other Proposals of Interest
       • Appropriate Use Criteria for Advanced Diagnostic Imaging
       • Patient Relationship Code Reporting
       • Expansion of Diabetes Prevention Program

© 2017 Vizient, Inc. and AAMC                                          Page 3
2018 Medicare Physician Fee Schedule Final Rule

   • Displayed November 2, published in Federal Register November 15
         https://www.gpo.gov/fdsys/pkg/FR-2017-11-15/pdf/2017-23953.pdf
   • Supplemental materials (including RVU data)
         https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
         Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1676-F.html

© 2017 Vizient, Inc. and AAMC                                                             Page 4
Physician Fee Schedule Final Rule

                                 Proposed
                                    Rule                   Final Rule
      Proposed Rule                           Final rule
                                 comment                   provisions
       issued: July                          published:
                                 deadline:                 effective:
         12, 2017               September    November
                                                           January 1,
                                              15, 2017
                                  11, 2017                    2018

© 2017 Vizient, Inc. and AAMC                                           Page 5
Separate Quality Programs are all Sunsetting

                                                    PQRS
                                  Meaningful
                                     Use
                                   Program
A New Consolidated
Pay-for-Performance
                                                Value
Program under                                  Modifier
                                               Program
MACRA

                                 Merit-Based Incentive
                                Payment System (MIPS)
© 2017 Vizient, Inc. and AAMC                              Page 6
Fee Schedule Remains Bedrock of Payment

                                Fee Schedule

© 2017 Vizient, Inc. and AAMC                  Page 7
Payment Policies

© 2017 Vizient, Inc. and AAMC                      Page 8
Physician Fee Schedule (PFS) Updates

 • MACRA repealed Sustainable Growth Rate
 • PFS 0.5% update CY 2016-CY 2019
 • PFS 0.0% update CY 2020-2025
 • PFS updates 2026 and beyond: 0.75% for
   APM; 0.25% for MIPS
 • Merit-Based Incentive Payment System (MIPS)
   & participation in Alternative Payment Models
   will drive payment in 2019 and beyond

© 2017 Vizient, Inc. and AAMC                               Page 9
MACRA Timeline

© 2017 Vizient, Inc. and AAMC                    Page 10
Targets for “Misvalued” Code Reductions
    ABLE Legislation
                                • 2016: 1.0% reduction
   established 3 years          • 2017: .5% reduction
   of target reductions         • 2018: .5% reduction
  for misvalued codes

                                • If reductionstarget, then no adjustment to PFS,
                                  amount over target is applied to next year’s target

     2018 reduction did         • Target recapture of -0.09 percent (CMS achieved
     not meet the 0.5%            .41% in reductions)
           target

© 2017 Vizient, Inc. and AAMC                                                           Page 11
Calculation of 2018 PFS Conversion Factor
Conversion Factor 2017                                   $35.8887
Update Factor                   0.50 percent (1.0050)

2018 RVU Budget                 -0.10 percent (0.9990)
Neutrality adjustment

2018 Target Recapture           -0.09 percent (0.9991)
Amount

2018 Conversion Factor                                   $35.9996

© 2017 Vizient, Inc. and AAMC                                       Page 12
Malpractice RVUs: No change in final rule
 • In proposed rule, CMS discussed updating malpractice
   relative units with new premium data and specialty risk
   factors. (use of new data would have negatively impacted
   many specialists).
 • Concerns raised that the proposed valuation changes were
   not indicative of what is actually occurring in professional
   liability market.
 • In final rule, CMS decides not to update malpractice data.
   They will continue to use the same data collected for the
   2015 MP RVU update.
 • The next update must occur by 2020.

© 2017 Vizient, Inc. and AAMC                                     Page 13
CMS Analysis of Specialty Impact

                Social Worker (+ 3%)       Diagnostic Testing Facility
                Clinical Psychologist (+2%) (-4%)
                Psychiatry (+1%)           PT/OT (-2%)
                Infectious disease (+1%)   Independent labs (-1%)
                Cardiology (+1%)           Allergy/Immunology (-3%)
                                           Vascular Surgery (-1%)

© 2017 Vizient, Inc. and AAMC                                            Page 14
Overview
 • Coding changes (additions/deletions)
        –   Diagnostic radiology
        –   Artificial heart procedures and other Cardiology services
        –   Esophagectomy additions
        –   Collaborative care management

 • Specialty impact
        –   Cardiology: Electrophysiology
        –   Cardiology: Noninvasive
        –   Pediatric Cardiology: Noninvasive
        –   Pediatric Cardiology
        –   Thoracic Surgery

 • GPCI gains and losses

© 2017 Vizient, Inc. and AAMC                                           Page 15
New Radiology Chest and Abdominal
                        X-Ray Codes
. Chest x-ray CPT codes 71010-71035 (described as      Abdominal x-ray CPT codes 74000-74020 deleted
  ‘stereo’) deleted                                    Abdominal x-ray CPT codes added based on number
  Chest x-ray CPT codes added based on number of       of views
  views, simplifying code selection.

                   Deleted CPT Codes                                   New CPT Codes
   CPT                                                     CPT
                    CPT Description        2017 wRVU                   CPT Description        2018 wRVU
   Code                                                    Code
  71010    Chest x-ray 1 view frontal         0.18        71045   X-ray exam chest 1 view       0.18
  71015    Chest x-ray stereo frontal         0.21        71046   X-ray exam chest 2 views      0.22
  71020    Chest x-ray 2vw frontal&latl       0.22        71047   X-ray exam chest 3 views      0.27
  71021    Chest x-ray frnt lat lordotc       0.27        71048   X-ray exam chest 4+ views     0.31
  71022    Chest x-ray frnt lat oblique       0.31
  71023    Chest x-ray and fluoroscopy        0.38              X-ray exam abdomen 1
                                                          74018                                 0.18
  71030    Chest x-ray 4/> views              0.31              view
  71034    Chest x-ray&fluoro 4/> views       0.46              X-ray exam abdomen 2
                                                          74019                                 0.23
  71035    Chest x-ray special views          0.18              views
                                                                X-ray exam abdomen 3+
                                                          74021                                 0.27
  74000 X-ray exam of abdomen                 0.18              views
  74010 X-ray exam of abdomen                 0.23
  74020 X-ray exam of abdomen                 0.27

 © 2017 Vizient, Inc. and AAMC                                                                           Page 16
Total Heart Replacement System Codes
       Move from Category III to Category I
        •     CPTs 33927-33929 replace 0051T-0053T Category III codes (emerging
              technologies, services and procedures.
        •     33927 will no longer be gap-filled and may receive fewer Work RVUs than in
              2017
        •     33928 and 33929 will be subject to FPSC gap-filling methodology

                                                                         2018               2017
              CPT Code                 CPT Description
                                                                         wRVU              wRVU*
                 33927          Impltj tot rplcmt hrt sys                 49.00             53.26

                 33928          Rmvl & rplcmt tot hrt sys                    0                 0

                 33929          Rmvl rplcmt hrt sys f/trnspl                 0                 0

            * wRVUs calculated using the FPSC gap-filling methodology
                 •   Gap-filling is applied to codes with zero work, practice expense, and malpractice RVUs
                 •   Locally weight ratio of charges to RVUs

© 2017 Vizient, Inc. and AAMC                                                                                 Page 17
Esophagectomy

 CPT codes 43286, 43287 and 43288 created to report
 esophagectomy via laparoscopic and thoracoscopic approaches.
                                                                      2018
                          CPT Code           CPT Description
                                                                      wRVU
                                43286   Esphg tot w/laps moblj        55.00
                                43287   Esphg dstl 2/3 w/laps moblj   63.00
                                43288   Esphg thrsc moblj             66.42

 CPT codes 43107, 43112, and 43117 were also reviewed as part of
 the family with the three new codes. CPT code 43112 was revised
 to clarify the nature of the service being performed.
        – Additional specialty impact information detailed in following slide

© 2017 Vizient, Inc. and AAMC                                                   Page 18
Collaborative Care Management

 Three new, time based codes for psychiatric collaborative care
 management (CoCM):

                                                                                    2018
                CPT Code                      CPT Description
                                                                                    wRVU
                   99492        1st psyc collab care mgmt; 70 min                   1.70

                   99493        Sbsq psyc collab care mgmt; 60 min                  1.53

                   99494        1st/sbsq psyc collab care; each additional 30 min   0.82

© 2017 Vizient, Inc. and AAMC                                                              Page 19
Specialty Impacts

© 2017 Vizient, Inc. and AAMC                       Page 20
Cardiology: Electrophysiology Observed
                       Overall Loss
                                     % Variance (2018 vs. 2017)
                                    Negative figures = reduction
                    Work RVU       Non Facility Total RVU         Facility Total RVU
                   per 1.0 cFTE        per 1.0 cFTE                 per 1.0 cFTE
                        -3.1%              -1.7%                        -1.8%

                                                                                  Mean Impact
CPT                                   2018     2017       wRVU          %
               CPT Description                                                  wRVU per 1.0 cFTE
Code                                  wRVU     wRVU      Change       Change
                                                                                    per MD
         Dev interrog remote
93295                                  0.74     1.29      -0.55        -43%            -169
         1/2/mlt
         Electrophys map 3d add-
93613                                  5.23     6.99      -1.76        -25%            -132
         on

  © 2017 Vizient, Inc. and AAMC                                                               Page 21
Adult and Pediatric Cardiology Echo
          w/Doppler Accounts for Overall Increase
                                              % Variance (2018 vs. 2017)
                                             Negative figures = reduction
                                                                                                   Mean Impact
                                                          Non Facility
                                          Work RVU                            Facility Total RVU    wRVU per
             Specialty                                     Total RVU
                                         per 1.0 cFTE                           per 1.0 cFTE        1.0 cFTE
                                                          per 1.0 cFTE
                                                                                                     per MD
Cardiology: Noninvasive                     +2.3%            +2.0%                 +2.1%              +174

Pediatric Cardiology: Noninvasive           +2.0%            +1.7%                 +1.8%              +102

Pediatric Cardiology                        +1.3%            +1.2%                 +1.2%              +60

              CPT                                          2018       2017        wRVU         %
                                   CPT Description
              Code                                         wRVU       wRVU       Change      Change
              93306       Tte w/doppler complete            1.50       1.30       +0.20       +15%

   © 2017 Vizient, Inc. and AAMC                                                                             Page 22
Surgery Thoracic Displays Increase Due
             to Esophagectomy wRVU Change
                                      % Variance (2018 vs. 2017)
                                     Negative figures = reduction
                    Work RVU      Non Facility Total RVU            Facility Total RVU
                   per 1.0 cFTE       per 1.0 cFTE                    per 1.0 cFTE
                       +1.0%              +0.6%                          +0.7%

                                                                                    Mean Impact
CPT                                  2018      2017        wRVU          %
               CPT Description                                                    wRVU per 1.0 cFTE
Code                                 wRVU      wRVU       Change       Change
                                                                                      per MD
        Partial removal of
43117                                57.50     43.65       +13.9         +32%            +43
        esophagus
43112 Removal of esophagus           62.00     47.48       +14.5         +31%            +29
43107 Removal of esophagus           52.05     44.18        +7.9         +18%            +16

  © 2017 Vizient, Inc. and AAMC                                                                Page 23
Geographic Pricing Cost Index (GPCI)
                         Gains and Losses
•     Based on an average mix of Work, Practice Expense and Malpractice RVUs, we found
•
      the following year-over-year changes from 2017 to 2018.
      a

•     The 1.0 Work GPCI floor required by Section 201 of the MACRA of 2015 expires on
      December 31, 2017, therefore the Work GPCIs for 2018 do not reflect a 1.0 floor.

      Decreases due to potential GPCI floor expiration
                       2018      2018    2018      Work                             2018    2018    2018      Work
     Locality Name     Work       PE      MP       GPCI      Locality Name          Work     PE      MP       GPCI
                       GPCI      GPCI    GPCI    % Change                           GPCI    GPCI    GPCI    % Change
    Oklahoma           0.961     0.891   0.954     -4%      Metro Boston            1.033   1.179   1.061     1%
    Rest of Missouri   0.961     0.863   0.993     -4%
                                                            San Francisco
    Mississippi        0.961     0.870   0.370     -4%                              1.075   1.325   0.421     1%
                                                            (Alameda/Contra Costa
    West Virginia      0.966     0.857   1.296     -3%      Cnty)
    Kansas             0.966     0.911   0.615     -3%      Los Angeles (Orange
    Iowa               0.969     0.907   0.423     -3%                              1.046   1.177   0.694     0.5%
                                                            County)
    Indiana            0.969     0.919   0.379     -3%
    Nebraska           0.970     0.910   0.318     -3%
    Arkansas           0.971     0.872   0.576     -3%
    Kentucky           0.974     0.880   0.819     -3%

      © 2017 Vizient, Inc. and AAMC                                                                                  Page 24
Background: Payment for Off-Campus
       Provider-Based Hospital Departments

  Section 603 of Bipartisan Budget Act of 2015 requires
  payment for services furnished by off-campus provider
  based departments under Part B system other than
  Hospital Outpatient Prospective Payment System (OPPS).

  The new payment rate policy does not apply to hospitals
  that were furnishing covered OPD services before
  November 2, 2015.

© 2017 Vizient, Inc. and AAMC                               Page 25
2017 Payment Rates for “Nonexcepted” Off
       Campus Outpatient Hospital Departments
                                For 2017, CMS made the Physician Fee Schedule the
                                 payment system and set payment rates based on a
                                  50-percent reduction to the OPPS payment rates
                                              (inclusive of packaging).

                                 The adjustment is referred to as the “PFS Relativity
                                                     Adjuster”

                                Must report a modifier “PN” on each UB 04 claim line
                                     to indicated nonexcepted items or service

© 2017 Vizient, Inc. and AAMC                                                           Page 26
2018 Payment Rates for Off-Campus Provider-
                 Based Hospital Departments

         CMS proposed 75 percent reduction in
         payment for nonexcepted services at off
         campus OPDs (current reduction is 50 percent)

         In response to comments, CMS finalizes a 60
         percent reduction instead of 75 percent
         proposed.

© 2017 Vizient, Inc. and AAMC                            Page 27
Other Off Campus Hospital Provisions
 • CMS specifies that all beneficiary cost-sharing
   rules that apply under the PFS will continue to
   apply to all nonexcepted items and services
   furnished by off-campus OPDs
 • The supervision rules continue to apply to off
   campus departments that furnish
   nonexcepted services

© 2017 Vizient, Inc. and AAMC                        Page 28
Evaluation and Management (E/M)
              Documentation Guidelines
                                CMS invited comments on:

 • Approaches to guideline revision that reduce burden and
   leverage electronic health technology
 • Revisions that deemphasize history and physician exam
   performance
 • Consideration of reducing or evening eliminating the history and
   physical exam components at all E/M code levels.
 • Extension of practitioner autonomy to determine volume of
   documentation
 • Guidelines structured to match documentation to patient
   complexity (particularly medical decision-making)

© 2017 Vizient, Inc. and AAMC                                         Page 29
Evaluation & Management
                       Documentation Guidelines
            AAMC Comments                       CMS Final Rule
 • With increased use of EHR, and      • CMS will consider these issues
   movement to team-based care,          for future rulemaking, but the
   E&M guidelines impose a               immediate focus will be on
   significant administrative burden     revision of current E&M
   and are an impediment to good         guidelines in an effort to reduce
   patient care.                         unnecessary administrative
 • For surgical/subspecialties, a        burden.
   comprehensive exam is not
   always relevant.
 • Determination of the level of
   service should be based on
   medical decision-making, not
   time alone.

© 2017 Vizient, Inc. and AAMC                                                Page 30
Expansion of Telehealth Services

      CMS finalized the addition of the following codes:
       • HCPCS code G0296: Counseling visit to discuss
         the need for lung cancer screening using LDCT
       • CPT codes 90839 and 90840: Psychotherapy for
         crisis; first 60 minutes

© 2017 Vizient, Inc. and AAMC                              Page 31
Expansion of Telehealth Services
      CMS finalized the addition of the following codes:
       • CPT code 90785: Interactive complexity
       • CPT codes 96160 and 96161: Administration of
         patient-focused health risk assessment
         instrument and Administration of caregiver-
         focused health risk assessment instrument
       • HCPCS code G0506: Comprehensive assessment
         or/and care planning for patients requiring
         chronic care management services

© 2017 Vizient, Inc. and AAMC                              Page 32
Telehealth: Elimination of GT modifier
 • Effective January 1, 2017 Place of Service
   (POS) code 02 Telehealth is required on
   professional claims
 • CMS finalized the proposal to eliminate
   required use of the GT modifier on
   professional claims
 • Institutional claims, and federal telemedicine
   programs in AK and HI will need to continue
   using the GT modifier
© 2017 Vizient, Inc. and AAMC                       Page 33
Telehealth: Remote Patient Monitoring
 • CMS activated separate payment for CPT code
   99091, changing status from bundled
 • 99091: Collection and interpretation of
   physiological data digitally stored and/or
   transmitted by the patient and/or caregiver
 • Medicare allowed payment: $58.68

© 2017 Vizient, Inc. and AAMC                    Page 34
Appropriate Use Criteria (AUC) for Advanced
                  Diagnostic Services
  Established by Protecting Access to Medicare Act of 2014

  Criteria for physicians to better identify the appropriate advanced
  diagnostic imaging service:
    • Appropriate Use Criteria (AUC) must be developed by qualified provider-led
      entities (list published in June 2016).
    • Clinical decision support mechanism (CDSMs) are electronic tools physicians
      will use to access the AUC to determine appropriateness of advanced diagnostic
      imaging test.
    • Requirement that in future ordering physicians must begin consulting CDSMs
      and furnishing professionals must append AUC information about ordering
      physician’s consultation to Medicare claim.
    • Identification of Outlier physicians in the future.

© 2017 Vizient, Inc. and AAMC                                                          Page 35
AUC Implementation
 CMS makes the AUC consultation and reporting requirements effective for
 an educational and operational testing period beginning on January 1, 2020.
 From mid-2018 through 2019, a voluntary physician participation period will
 run.

 In future, payment may only be made if the claim includes the proposed
 information required by furnishing professionals.

 It applies across the following payment systems (PFS, hospital outpatient,
 ASC)

© 2017 Vizient, Inc. and AAMC                                                  Page 36
AUC Implementation: What is Required?
                                                   Furnishing Professional: Must
          Ordering Professional
                                                        report the following
 • Must consult AUC through                       • Must report:
   qualified CDSMs for tests                        • Which qualified CDSM was
   ordered on or after January                        consulted by ordering
   1, 2020.                                           professional
 • (delayed from statutory                          • Whether service ordered
   requirement of 2017).                              would adhere to AUC or
                                                      not, or whether AUC not
                                                      applicable; and
                                                    • NPI of ordering
                                                      professional
 CMS will continue to pay claims whether or not they correctly include appropriate
 information.

© 2017 Vizient, Inc. and AAMC                                                        Page 37
New Coding Systems: MACRA
 • Statute required claims submitted after Jan. 1, 2018
   must include:
        – Patient Condition Groups: Based on a patient’s chronic
          conditions, current health status, and recent significant
          history (e.g. hospitalization or surgery) (better risk
          adjustment)
        – Care Episode Groups: Create to define the types of
          procedures or services furnished for particular clinical
          conditions or diagnoses
        – Patient Relationship categories: Distinguish the
          relationship and responsibility of a physician with a patient
          at the time of furnishing the item/service. (accountability)

© 2017 Vizient, Inc. and AAMC                                             Page 38
Patient Relationship Modifiers
 • Beginning January 1, 2018 claims for services
   provider may voluntarily submit claims with
   modifiers.
 • Duration of voluntary modifier reporting
   period is not specified.

© 2017 Vizient, Inc. and AAMC                        Page 39
Patient Relationship HCPCS Modifiers and
                        Categories
 Number                         Proposed HCPCS Modifier   Patient Relationship
                                                          Categories

 1x                             X1                        Continuous/Broad Services

 2x                             X2                        Continuous/Focused
                                                          Services

 3x                             X3                        Episodic/Broad Services

 4x                             X4                        Episodic/Focused Services

 5X                             X5                        Only as Ordered by
                                                          Another Clinician

© 2017 Vizient, Inc. and AAMC                                                         Page 40
Patient Relationship Modifiers
     Relationship Category      Description                     Example
     Continuous/Broad           Clinicians who provide the      Primary care, specialists
                                principal care for a patient,   providing comprehensive
                                where there is no planned       care to patients in addition
                                endpoint of the relationship    to specialty care, etc
     Continuous/Focused         Could include a specialist      Rheumatologist taking care
                                whose expertise is needed       of a patient’s rheumatoid
                                for the ongoing                 arthritis longitudinally but
                                management of a chronic         not providing general
                                disease or a condition that     primary care services
                                needs to be managed and
                                followed for a long time.
     Episodic/Broad             Clinicians that have broad      Hospitalist providing
                                responsibility for the          comprehensive and general
                                comprehensive needs of the      care to a patient while
                                patients, but only during a     admitted to the hospital.
                                defined period and
                                circumstance, such as a
                                hospitalization.

© 2017 Vizient, Inc. and AAMC                                                                  Page 41
Patient Relationship Modifiers
 Relationship Category          Description                   Example
 Episodic/Focused               A specialist focused on       An orthopedic surgeon
                                particular types of time-     performing a knee
                                limited treatment.            replacement and seeing
                                                              the patient through the
                                                              postoperative period.
 Only As Ordered By             A clinician who furnishes     A radiologist interpreting
 Another Clinician              care to the patient only as   an imaging study ordered
                                ordered by another            by another clinician
                                clinician.

© 2017 Vizient, Inc. and AAMC                                                              Page 42
2018 PQRS Payment Adjustment:
                   Finalized Modifications
 • Reduced the number of required measures
   from 9 measures across 3 domains to 6
   measures with no domain requirement (does
   not apply to Web Interface)
 • Eliminated requirement to report cross-
   cutting measure
 • Eliminated requirement that group practices
   of 100 or more EPS that use GPRO must
   administer to CAHPS for PQRS patient survey.
© 2017 Vizient, Inc. and AAMC                     Page 43
2018 Value Modifier Program: Finalized
                 Modifications
 Finalized modifications to VM policies for 2018 payment adjustment; would result in
 fewer EPs and groups receiving negative VM adjustment & size of positive
 adjustments would be reduced.

 All groups and practitioners that avoid the PQRS payment reduction will be held
 harmless from downward adjustments in quality tiering for 2018.

 Adjustment for those who fail to report PQRS are reduced from -4% to -2% for groups
 with 10 or more EPs and at least one physician. Reduced from -2% to -1% for groups
 with between 2 and 9 Eps, physician solo practitioners, non-physician EP groups.

 For groups with 10 or more EPs, maximum upward adjustment reduced from +4x to
 +2x and average quality would reduce from 2.0x to 1.0x.

© 2017 Vizient, Inc. and AAMC                                                          Page 44
Expansion of Medicare’s Diabetes
                     Prevention Program

© 2017 Vizient, Inc. and AAMC                     Page 45
Medicare Diabetes Prevention Program (MDPP)
     What: Structured health behavior change program delivered in community and health care settings
     by training community health workers or health professionals, administered by Centers for Disease
     Control (CDC)

     Why: Diabetes affects more than 25% of Americans aged 65 or older and accounts for $104 billion
     annually which are anticipated to grow by 2050

     Who: Targets individuals with prediabetes (individuals who have blood sugar higher than normal but
     not yet in the diabetes range)

     Program Structure: Consists of 16 intensive “core sessions” of a CDC-approved curriculum in a group-
     based setting that provides practical training in long-term dietary change, increased physical activity,
     and problem solving strategies for overcoming challenges to sustaining weight loss and a healthy
     lifestyle. Access to ongoing maintenance sessions after core benefit
     Goal: Reduce incidence of Type 2 diabetes by achieving at least 5 percent average weight loss among
     participants

© 2017 Vizient, Inc. and AAMC                                                                               Page 46
MDPP’s Finalized Requirements
   CMS Finalized Requirements                                    Beneficiaries Eligibility
      Effective date beginning April 1, 2018 (instead of           Pre-diabetic patient having a body mass index (BMI) of
       January 1, 2018)                                              25 or greater (BMI of 23 for Asian beneficiaries)
           Services begin April 1, 2018                            Following blood levels:
           Providers can begin enrolling January 1, 2018                Hemoglobin A1c test with a value of 5.7-6.4
      12-month program using the CDC-approved DPP                           percent or;
       curriculum                                                        a fasting plasma glucose of 110-125 mg/dL
      Beneficiaries can only enroll in MDPP once                            within last 12 months or;
      Beneficiaries who complete the 12 month program who                   2-hour plasma glucose of 140-199 mg/dL after
       achieve and maintain required weight loss can be                      the 75 gram oral glucose tolerance test
       eligible for up to one year of monthly maintenance           No previous diagnosis of diabetes (applies only at time
       sessions as long as weight loss is maintained                 of the first core session)
      Ongoing maintenance sessions adhere to the same
       curriculum requirements as the course
      Each MDPP session be at least an hour in duration
      Existing Medicare providers and suppliers must submit a
       separate enrollment application for MPDD services and
       with national provider identification (NPI) required

© 2017 Vizient, Inc. and AAMC                                                                                                  Page 47
MDPP Reimbursement

                                    • Number of
                      Two             Sessions Attended

                     Factors        • Achievement and
                                      Maintenance of
                                      Min. Weight Loss

© 2017 Vizient, Inc. and AAMC                             Page 48
MDPP Reimbursement
             Performance Goal              Payment Per Beneficiary     Payment Per Beneficiary
                                           (with min. weight loss)     (without min. weight
                                                                       loss)
             1 session attended                                      $25

             4 sessions attended                                     $50

             9 sessions attended                                     $90

             2 sessions attended in 1 st   $60                         $15
             core maintenance session
             interval (months 7-9)
             Weight loss of 5%             $160                        $0
             achieved

             Advanced weight loss of       $25                         $0
             9% achieved

             Max Total Performance         $670                        $195
             payment

© 2017 Vizient, Inc. and AAMC                                                                    Page 49
Diabetes Prevention Program: Social Risk
                   Factors
 • CMS requested comments about social risk
   factors in the context of the set of MDPP
   services for future consideration.
 • CMS will be reviewing comments made as
   they consider additional policies surrounding
   social risk factors in the future.

© 2017 Vizient, Inc. and AAMC                      Page 50
Medicare Shared Savings Program Changes

                                   Revises assignment
                                    methodology for
                                                             Adds 3 new chronic care
                                 assigning Medicare FFS
                                                              management codes and
                                 beneficiaries to an ACO
                                                                 behavioral health
                                 based on utilization of
                                                               integration codes to
                                  services furnished by
                                                             definition of primary care
                                 rural health clinics and
                                                                      services
                                federally qualified health
                                      care centers.

                                   Reduces burden for
                                   submitting an initial       Makes changes for
                                 Shared Savings Program       consistency with the
                                     application and         MIPS program reporting
                                application for use of SNF       under MACRA
                                       3 day waiver

© 2017 Vizient, Inc. and AAMC                                                             Page 51
Resource links
  Medicare Physician Fee Schedule Final Rule
       https://www.gpo.gov/fdsys/pkg/FR-2017-11-15/pdf/2017-23953.pdf

  CMS Fact Sheet on Medicare Physician Fee Schedule
       https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-
       items/2017-11-02.html

  AAMC Webpage: Physician Payment and Quality
       https://www.aamc.org/initiatives/patientcare/patientcarequality/311244/physicianpayment
       andquality.html

© 2017 Vizient, Inc. and AAMC                                                                    Page 52
Questions and Feedback
          Questions and Feedback about PFS Final Rule
          Gayle Lee, galee@aamc.org
          Kate Ogden, kogden@aamc.org

          FPSC Projects Related to PFS and Q&E
          Dave Troland, David.Troland@vizientinc.com
          Jake Langley, Jake.Langley@vizientinc.com

© 2017 Vizient, Inc. and AAMC                           Page 53
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