Key Takeaways from the CY2025 Physician Fee Schedule Final Rule
The last Medicare Physician Fee Schedule final 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 finalized changes. This year’s final rule covers a lot of ground including phasing in additional quality measures for ACOs and introducing new payment codes for advanced primary care. 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:
Medicare Shared Savings Program (MSSP)
Regarding policies related to the Medicare Shared Savings Program, one of the key updates from proposed to final rule was the decision by CMS to delay the removal of MIPS CQMs as a reporting option. Initially proposed for removal starting in PY2025, CMS finalized a decision allowing MIPS CQMs as a reporting option for PY2025 and PY2026. ACOs will have the flexibility to choose between eCQMs, MIPS CQMs, or Medicare CQMs for reporting during these years. However, starting in PY2027, MIPS CQMs will no longer be a reporting option for ACOs. This delay provides ACOs more time to adjust to the evolving reporting requirements, given the challenges, expenses, and policy considerations raised by participating ACOs, providers, and their advocates. Additionally, CMS finalized a proposal to use flat benchmarks for Medicare CQMs, which may make that option more appealing to ACOs that are not yet in a position to report eCQMs. Under the prior policy, Medicare CQM benchmarks would have been set using performance year data, which would have been limited to those MSSP ACOs that reported via that method. Under the finalized policy, CMS will use flat benchmarks for the first two years in which a measure is in use, giving ACOs more information with which to make reporting decisions. While some 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, 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.
CMS also finalized phasing in five new measures over the next four years, aligning the measure set with the Adult 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, MIPS CQM, 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 and creates increased opportunities for multi-payer alignment.
Quality Payment Program (QPP)
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 nor finalized, 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.
Primary Care
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 finalization of three new Advanced Primary Care Management codes and an expanded opportunity for advance payment of shared savings to MSSP ACOs—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 directed to primary care as much as possible, 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) in the proposed rule on a future hybrid payment model for primary care that would incorporate payment for Evaluation & Management services into the advanced primary care management codes. The final rule acknowledged the feedback received indicating that a more robust change in physician payment may be needed to sustain and improve access to high quality primary care.