MedPAC June report focuses on site of service

In some good news for radiology, the Medicare Payment Advisory Commission (MedPAC) June report to the U.S. Congress does not propose any cuts in physician payments beyond statutory updates mandated by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

"Over the last several years when the updates to physician fee schedule have been similar to the updates prescribed by MACRA -- in the order of zero to 1% over most years -- those updates have been sufficient to ensure adequate access to care for Medicare beneficiaries," MedPAC Executive Director Jim Mathews, PhD, said in a press conference on June 14. "We have refrained from commenting on whether that level of update will continue to be sufficient, in the future, since we believe more solid approach is to stick with the year-by-year assessment that we do in our March report each year."

But the commission is concerned with how site of service affects fee schedule imaging procedure volume, although the report does not offer specific ways to address this concern.

"Shifts over time from the physician office to the hospital outpatient department make it appear that volume growth is generally smaller than it would be if the services remained in the same setting over time," MedPAC wrote in its report. "The effects of adjusting for shifts in site of service is even more significant for particular [imaging] services."

Site of service

The report outlines the commission's concern about the effect of site-of-service changes on fee schedule volume and scheduling. Overall, service volume per Medicare beneficiary grew 1% per year between 2012 and 2016, with growth accelerating to 1.6% between 2016 and 2017, the commission wrote. But because of how MedPAC measures volume -- by both the units and intensity of service -- these figures are sensitive to shifts in sites of service.

For example, when services such as CT imaging shift from physician offices to the hospital, Medicare Physician Fee Schedule (MPFS) volume and spending decline, but total Medicare spending goes up.

"Shifts over time from the physician office to the hospital outpatient department make it appear that volume growth is generally smaller than it would be if the services remained in the same setting over time," MedPAC wrote. "The effects of adjusting for shifts in site of service is even more significant for particular [imaging] services."

MedPAC hinted that there may be other feasible approaches for setting payment rates for services provided in multiple settings.

"For example, some of the services that show the greatest shift in setting over the past five years are imaging and tests," MedPACS wrote. "Certain imaging services, in particular, do not involve substantial clinician work but do constitute substantial practice expense costs for the equipment and so may lend themselves to a different price-setting and updating mechanism from other fee schedule services."

The report also addressed increased spending in emergency departments (ED) over recent years, which it suggested may be due to providers coding patient visits at "higher acuity levels in response to payment incentives."

"The commission recommends that the secretary create and implement national ED coding guidelines for hospitals that would result in more accurate payments for patients in the ED setting," it wrote.

Access to primary care

Finally, the commission reiterated its concern that Medicare beneficiaries must have sufficient access to primary care and offered a few ideas as to how to ensure this.

"We discuss whether or not there could be benefit to Medicare-specific scholarship programs or loan repayment programs that could be available to physicians who opt for careers in primary care or geriatrics given that existing programs ... are not specifically focused on the Medicare program," Mathews said.

The report also examines the role of nurse practitioners and physician assistants in providing primary care for Medicare patients.

"Over the last several years, we have noted that there has been robust growth in the participation of these types of clinicians in Medicare, but their true level of effort is obscured by a phenomenon called 'incident to billing' where the nurse practitioner or physician assistant bills for their services incident to services provided by a supervising physician ... so their actions are hidden from the Medicare program," MedPAC noted in the report. "To more precisely and accurately track their activity, we're recommending that [this type of] billing be eliminated."