Key Takeaways from the CY2025 Physician Fee Schedule Proposed Rule
The last proposed Medicare Physician Fee Schedule rule under the Biden Administration is out now and physicians, trade groups, and those engaged in the Medicare Shared Savings Program and subject to the Quality Payment Program are taking note of the many proposed changes. This year’s proposed rule covers a lot of ground—pressing full steam ahead on eCQMs for ACOs, introducing new payment codes for advanced primary care, and seeking more open-ended comment on a higher risk track of MSSP. Moreso than any one theme (such as advancing accountability for downside risk or health equity) —the rule has the look and feel of the last chance effort for the current Administration to advance policies they’ve previously set in motion.
For quick overviews of the proposed changes, we recommend:
Around policies related to the Medicare Shared Savings Program, the greatest disappointment for many ACOs was seeing no delays to the requirement that ACOs report quality measures through eCQMs or Medicare CQMs starting in PY2025. Given the challenges, expense, and policy considerations raised by participating ACOs and their providers and their related advocacy we anticipated a possible extension of the Web Interface reporting option. While true that a few organizations have begun eCQM reporting, the vast majority are still wrestling with the implications of electronically reporting measures across all patient populations and a variety of EHRs and all while contending with continued workforce shortages, burnout, and post-pandemic rebuilding. Given the tremendous surge over the last six years of ACOs who reconstitute each performance year under different configurations of participating providers and thus different EHRs or at least instances of EHRs—the operational complexity is real. In addition to maintaining the eCQM/Medicare CQM reporting requirement, CMS preposes removing the MIPS CQM reporting option for MSSP ACOs, and would, if finalized, phase in five new measures over the next four years, aligning the measure set with the Universal Foundation. The expansion of the measure set – referred to as the Alternative Payment Model (APM) Performance Pathway Plus or “APP Plus” has pros and cons for ACOs: reporting additional measures via eCQM or Medicare CQM almost certainly increases the cost of an already expensive transition. On the other hand, expanding the measure set helps mitigate the potential for a single measure to make or break an ACO’s performance.
In the Quality Payment Program (QPP) portion of the rule, we didn’t see many major changes. Despite advocacy efforts to delay the requirement that models must require 100% Certified EHR Technology (CEHRT) from participants to qualify as Advanced APMs, no changes were proposed and the policy will go forward as finalized in last year’s rule. Another policy we were on the lookout for in this year’s rule was whether CMS would resurrect a prior proposal to assess QP status at the individual rather than APM entity level. No such proposal was made, which will likely be a relief to ACOs and other Advanced APM participants for whom such a policy could have introduced significant new complexity to an already complicated set of calculations. Although we didn’t see many changes to QPP in this year’s rule, a restructuring of the MACRA law may be on the horizon for Congress in the coming year.
One additional area that stood out was robust support for primary care. By all indications this Administration heard the battle cry that post pandemic and economic pressures were putting primary care at risk. The result is less a big, shiny one-size fits all solution, and more an array of funding and support dispersed not only through this rule—with the addition of three new Advanced Primary Care Management codes and an expanded opportunity for advance payment of shared savings—but also through models like Making Care Primary and the Primary Care Flex add-on to the Medicare Shared Savings Program. While each program seeks in its own way to support primary care through additional or upfront funds and to direct funding, as much as possible, to primary care, it’s hard to size the impact overall. It’s been confusing for the industry to absorb so many opportunities aimed at similar but perhaps distinct segments of the primary care landscape. While specific proposals were not made, CMS also included a Request for Information (RFI) on a potential hybrid payment model for primary care that could potentially incorporate payment for Evaluation & Management services into the advanced primary care management codes being proposed – an indication that CMS recognizes that more robust change in physician payment may be needed to sustain and improve access to high quality primary care.
CMS is seeking comment on the RFI and these and other proposals now through September 9, 2024.