Medicare Compliance & Reimbursement

Plus:  Concerns intensify regarding PCP shortage.

Watch out: The quality data you provide to the Centers for Medicare & Medicaid Services (CMS) for the Physician Quality Reporting Initiative (PQRI) could soon end up in the hands of beneficiaries.

Medicare patients could soon be using PQRI data to comparison-shop for doctors' offices based on quality, according to Michael Beebe, director of CPT editorial services for the American Medical Association. "Down the line, there's going to be interest on the part of CMS in providing this data to beneficiaries, as they did with hospitals," Beebe told the American Association for Professional Coders conference April 17.

Starting next year, CMS plans to make the PQRI a normal part of the physician fee schedule. CMS will issue a 2008 PQRI proposed rule by August 15, 2007, with a final rule by Nov. 15, 2007.

By law, CMS is required to include "structural measures," such as electronic health records and e-prescriptions, in 2008. Also, next year, reporting will be "registry-based and electronic record-based," Beebe warned.

The AMA is preparing its own user-friendly version of the PQRI measure specifications, which should be on the AMA web site by June, Beebe promised.

Medicare Could Split Updates Between Procedures And E/M Visits

As the nation's over-65 population doubles between 2000 and 2030, patients will be demanding more physician services from Medicare, according to Ed Salsburg, associate vice president of the American Association of Medical Colleges. In particular, oncologists will be in short supply, Salsburg told the Medicare Payments Advisory Commission's April meeting.

The real problem isn't a shortage of doctors, but a shortage of primary care doctors, argued Kevin Grumbach, chair of the UCSF Center for California Health Workforce Studies. Medicare still pays more for a doctor's time if he or she is doing a procedure (like a colonoscopy) than if he or she is just talking to the patient, Grumbach pointed out. So Medicare may be encouraging more doctors to become specialists and creating a shortage of primary care docs.

Grumbach suggested dividing Medicare's physician payment update formula into two systems: one for evaluation & management visits, and one for procedures. Because the increase in costs all comes from surgical procedures, Medicare could target that spending growth without hurting primary care doctors.

Another possibility: Medicare could do more with nurse practitioners and other physician extenders, which would put doctors in more of a supervisory role, panelists said.

New Bill Would Cut Health-Care Costs With E-Records

The "Medicare for All" bill would help the some 46 million Americans currently without health insurance and at the same time provide incentives to providers for nationwide adoption of e-health records, reports Government Health IT.

Sen. Edward Kennedy (D-MA) and Rep. John Dingell (D-MI), leaders of the Senate and House health committees, proposed the bill on April 25. The bill calls for universal coverage of all Americans through Medicare and the Federal Employees Health Benefits program, reports Government Health IT.  Increased payroll taxes will fund the public or private plans chosen by the uninsured, and according to Kennedy spokeswoman Laura Capps, coverage would be phased in over five years.

In addition to the proposed universal coverage, the Kennedy-Dingell bill would give incentives to health care providers who use electronic health records, although no one has yet identified those incentives. The nationwide adoption of EHRs would drastically cut health-care costs by reducing administrative expenses, increasing preventive care and disease management and extending pay-for-performance programs, reports Business Health IT.

Medicare Should Put High-Cost Doctors Under Lens, GAO Says

Doctors with the highest number of expensive patients were also the ones most likely to practice medicine inefficiently, the Government Accountability Office (GAO) said in a new report (GAO-07-307). Medicare should single out these big-spending docs for education or audits, the GAO urged.

In Other News...

· Only about 2,200 physicians have joined the Competitive Acquisition Project (CAP) for Part B drugs, according to testimony at the April meeting of the Medicare Payments Advisory Commission (MedPAC). That number represents a huge increase from the 300 doctors who originally signed up for the CAP (who were mostly ophthalmologists and allergists).

But it's still just a tiny fraction of the number of doctors who provide Part B drugs in their offices, MedPAC noted.