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CMS, GAO Respond to ADVANCE Q's About the Therapy MPPR

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It's going to be a hot, wet autumn. 

Last July CMS proposed to implement its long-delayed 21-percent-plus cutback to health care workers paid under the Physicians' Fee Schedule for 2010. Three times in the past six months Congress has had to call out the bucket brigade to stop that fire. The cuts have never gone into effect because, frankly, they would cause a disaster in health care practice, and every congressman and senator knows it.

So the health care community was about to spend the next four months trying to stamp out the embers (the cuts are under moratorium until Nov. 30).
But uh-oh. Wait a minute. No time. Now there's a hurricane coming. It's called "multiple procedure payment reduction (MPPR)."
CMS published its proposed rule for the 2011 Physicians' Fee Schedule in the Federal Register July 13. Under it, all therapy disciplines that see the same patient on any given day (not the same session, mind you) will not get their full practice-expense (PE) reimbursement. The one whose costs are highest (usually the one who goes in first) will be paid in full. The others will get 50-percent cutbacks.

In therapy, PE isn't just prepping, getting equipment ready and offering the patient post-intervention support; it can include work done by aides and OTAs ─  at least reviewing the plan of care and taking ROM and other measurements.

Many members of the health care community right now feel that CMS wants to apply the MPPR policy inappropriately and possibly with risk to rehab patients.

To add insult to injury, for many disciplines, PE component prices haven't been upgraded for at least five years or more. Meanwhile, CMS has rejected the findings of AMA's Specialty Society Relative Value Scale Update Committee (RUC) work group, with the input of many medical specialty associations, as to how PE costs really need to be calculated.

Therapy was not originally part of the MPPR package. The project focused on physicians who were seeing the same patient more than once a day for ancillary office-based imaging services. To eliminate redundancy in the charges for those visits, CMS had created the MPPR policy. Then last July, the Government Accounting Office (GAO) published a report, Medicare Physician Payments: Fees Could Better Reflect Efficiencies When Services are Provided Together. Language throughout the report suggests that MPPRs should be "expanded to non-physician services" where it is appropriate.

No one in the health provider arena suggested therapy be scrutinized. The GAO report credits third-party payer administrators who contract with Medicare as "medical directors" with saying that physical therapy was among the professions that had "the most expensive" service pairs (two codes that cover similar things), and that more than 40 percent of them could be replaced with single codes. 

The proposed rule notes that "the GAO found efficiencies when multiple physical therapy services were furnished in one session and concluded that an MPPR policy could be appropriate for these services."

But the rule does not assume various therapies will be provided in one session. Instead, it is applying the one-session model to consecutive therapy sessions, with different types of therapy, as though they are one.

CMS spokesperson Ellen Griffith said she could not say much on the record about the issue. She told ADVANCE that CMS is now "in a listening mode" through the comment period on the fee schedule that ends Aug. 24. "The important thing .to understand," she added, "is that we do take the comments very seriously. In the final rule we have to respond to the essence of all issues raised. It is often the case that a final rule is changed ─ in some cases significantly ─ in response to comments."

CMS staffers make those choices, she said. And with thousands of comments coming in, the reviewers look for the facts that back up a concern. "A well-reasoned comment about how this will hurt patient care will go a whole lot farther than 1,000 comments just saying 'don't do it,'" she noted.

But when ADVANCE asked why CMS had even established MPPRs for therapy PE costs in its 2011 Physicians' Fee Schedule, considering the disparities in information that it had, she could not answer.

"We are very concerned about beneficiary access to services," she confirmed. "We recognize the importance of these services. We are obligated by Medicare law to value services based on the resources required to furnish them. If service A costs twice as much as service B, we should pay twice as much for it."

But though Griffith emphasized that "savings" are not an issue to CMS in this because the fee schedule is supposed to be "budget neutral" (savings are re-routed to apply to other costs), the GAO report begs to differ.

As a "matter for congressional consideration," the report says, "To ensure that savings are realized from the implementation of an MPPR or other policies that reflect efficiencies occurring when services are furnished together, Congress should consider exempting these savings from budget neutrality."

This angered AMA. It took issue with that when it responded to the GAO report last year. RUC work groups and their professional affiliates have been working on an ongoing basis to reduce unnecessary medical spending by examining CPT codes. The RUC had identified 149 pairs in which overlapping code pairs could be reduced to single codes, saving about $40 million.
But RUC wasn't necessarily examining the codes that were most expensive, says GAO. Its report claims to have found far more eligible code pairs by examining CMS data that comes mostly from claims.

AMA representatives told GAO that "the RUCs work groups' efforts result in a more accurate and credible system of coding and valuation of services.than the application of 'arbitrary policies' such as an MPPR."

Never mind that. On page 15 of the report, author James C. Cosgrove, director of the health care division of GAO, writes: "The RUC's methodology is not focused on finding savings for the Medicare program. Moreover, the RUC work group's dependence on specialty societies limits its ability to make progress.

"CMS, on the other hand, has the tools in place to readily expand its MPPR policy."

 ADVANCE questioned Cosgrove, a director on GAO's health care team, aggressively on the effect of the report on CMS's decision to create the therapy MPPR. He said that his organization made no specific recommendation as to how CMS should proceed.

The request for the report came by formal letter from both majority and minority members of the House Ways and Means and Energy and Commerce committees at least two years ago, but was not associated with any bill.

"Their interest was to look and see if there was any way of encouraging greater efficiency in physician payments," he said. "We focused on looking at the fee schedule.
"AMA had voiced their views along the way that they thought things would be better handled on a service-by-service basis," Cosgrove admitted. "We decided it would still be prudent to do it the other way."

Doing it the "other way" meant listening to CMS's carrier and intermediary unit staffs, "who know what's supposed to be covered," Cosgrove said.

ADVANCE questioned how much the medical directors know about how services are actually provided in a doctor's office or clinic in real time. Cosgrove couldn't really say. But he indicated that GAO does serve beneficiary interests by helping to keep Medicare premiums down.

"Your particular concerns really have to be taken up by CMS," he said. "Our report was about CMS taking a systematic approach to paying providers twice."

To send your comments to CMS on this issue by Aug. 24, go to the Legislative Action Center on the AOTA website at www.aota.org.
And go find a rowboat and your fire extinguisher.

E.J. Brown is editor of ADVANCE.



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