Tuesday, July 16, 2024

Health Quality Focus as HHS and CMS Propose 2025 Medicare Fee Schedule to Enhance Equity and Care

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Health quality is the focus as the U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), proposes new policies in the calendar year (CY) 2025 Medicare Physician Fee Schedule (PFS) aimed at advancing health equity and supporting whole-person care. The proposed rule also seeks to strengthen primary care, expand access to behavioral health, oral health, and caregiver training services, maintain telehealth flexibilities, and increase access to colorectal cancer screenings and hepatitis B vaccinations. This rule reflects the Biden-Harris Administration’s commitment to providing affordable, high-quality care for all Americans while fostering innovation within the Medicare program.

HHS Secretary Xavier Becerra emphasized the administration’s dedication to enhancing the care received by Medicare beneficiaries, noting that the proposed rule aligns with HHS’s goal of creating a healthcare system that not only treats illness but also promotes wellness. He highlighted that the proposed rule continues the implementation of President Biden’s historic prescription drug law, which aims to lower costs for seniors and people with disabilities by using rebates from drug manufacturers to strengthen Medicare. Additionally, the rule seeks to increase access to behavioral and dental care, expand cancer screenings, and support caregivers.

CMS Administrator Chiquita Brooks-LaSure reiterated the Biden-Harris Administration’s commitment to expanding access to health quality. She stated that the CY 2025 Physician Fee Schedule proposed rule supports healthcare providers in delivering care that meets the needs of Medicare beneficiaries, including through telehealth flexibilities, strengthened primary, behavioral, and oral healthcare, and improved access to caregiver training services.

Proposed 2025 Medicare Fee Schedule Cuts Rates by 2.93%, Focuses on Whole-Person Care and Health Quality

Due to factors specified in law, the proposed rule includes a 2.93% reduction in average payment rates under the PFS for CY 2025 compared to CY 2024. This change incorporates the zero percent overall update required by statute, the expiration of the 2.93% increase in payment for CY 2024, and adjustments for changes in the valuation of specific services. This results in a proposed estimated CY 2025 PFS conversion factor of $32.36, a decrease of $0.93 (or 2.80%) from the current CY 2024 conversion factor of $33.29.

Dr. Meena Seshamani, Deputy CMS Administrator and Director of the Center for Medicare emphasized the importance of whole-person care, which integrates physical, behavioral, and oral health, social determinants of health, and caregiving supports, all starting with a foundation of primary care.

CMS proposes to establish a new, advanced primary care management bundle under the PFS, informed by lessons from the CMS Innovation Center’s value-based primary care models. This bundle would use coding for primary care services provided by advanced primary care teams, with adjustments for patient medical and social complexity to promote health equity. The services would be linked to primary care quality measures to improve health outcomes for Medicare beneficiaries.

CMS proposes new payment and coding for cardiovascular risk assessment and care management based on the successful outcomes of the Innovation Center’s Million Hearts® model. The proposed rule also aims to drive high-quality care through the Quality Payment Program, introducing six new MIPS Value Pathways (MVPs) for ophthalmology, dermatology, gastroenterology, pulmonology, urology, and surgical care. Updates to MIPS scoring methodologies and measure inventories are proposed to help all clinicians achieve positive scores and continuous improvement.

Health Quality

CMS Proposes Enhancements to Medicare Shared Savings Program and Health Equity Benchmarks

CMS proposes to further strengthen the Medicare Shared Savings Program by allowing eligible Accountable Care Organizations (ACOs) with a history of success to access prepaid shared savings. This would encourage investment in staffing, healthcare infrastructure, and additional services such as nutrition support, transportation, dental, vision, and hearing. The rule also proposes a health equity benchmark adjustment to incentivize ACO participation in underserved communities and aligns quality measures for providers through the Universal Foundation of Quality Measures.

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Addressing the behavioral health crisis remains a priority. CMS proposes new payments for practitioners assisting high-risk individuals, including separate payments for safety planning interventions and post-discharge follow-up. New coding and payment are also proposed for the use of digital tools in behavioral health treatment and consultations with specialists. For Opioid Treatment Programs (OTPs), the rule proposes new codes for FDA-approved medications for opioid use disorder and increased telecommunication flexibilities.

In response to public feedback, CMS is exploring payment policies for dental services critical to medical care success. This includes proposals for payment of dental services associated with dialysis for end-stage renal disease and requests for comments on dental services related to diabetes care and immunosuppressive therapies. CMS proposes to expand hepatitis B vaccination coverage for Medicare beneficiaries with no out-of-pocket cost and allow pharmacies to provide these vaccinations. Additionally, the proposed rule includes a fee schedule for drugs covered as preventive services and updates to colorectal cancer screening coverage.

CMS Proposes 2025 Medicare Rule to Maintain Telehealth Flexibilities and Advance Health Quality

CMS aims to maintain telehealth flexibilities established during the COVID-19 public health emergency. Proposals include allowing certain practitioners to provide virtual direct supervision and temporary extensions of virtual supervision for a broader range of services. However, statutory restrictions on telehealth services will be reinstated on January 1, 2025, without Congressional action.

The proposed rule continues the implementation of the Inflation Reduction Act, requiring drug manufacturers to pay rebates to Medicare for price increases that exceed inflation rates. These rebates will be deposited into the Federal Supplementary Medical Insurance Trust Fund, ensuring Medicare’s sustainability. CMS will codify and build on guidance to implement these rebates, contributing to the long-term financial health of the Medicare program.

The proposed CY 2025 Medicare Physician Fee Schedule rule by HHS and CMS aims to advance health equity, support whole-person care, and drive innovation within the Medicare program. Through these comprehensive proposals, the Biden-Harris Administration seeks to improve access to quality, affordable healthcare for all Americans, particularly Medicare beneficiaries. Public comments and engagement with healthcare providers will be crucial in refining and implementing these policies to achieve the desired outcomes in health quality and patient care.


Resource: Health and Human Services, July 10, 2024

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