Spotlight on ACOs

Specialty doctors are lobbying Congress to exclude the cost of drugs they administer from the calculation of their Medicare bonuses and penalties because the therapies are often expensive and would result in volatile swings in reimbursement.

CMS proposed Tuesday (June 20) to exempt more doctors from the performance measures of Medicare's new physician pay rule, delay measuring doctor performance on cost, allow doctors in small and rural practices to form “virtual groups,” award bonus points to the performance scores of doctors in small practice and delay a required upgrade to physicians' electronic health record systems.

CMS told doctors in alternative pay models they all should expect 5 percent bonuses in the first year of the new pay system, which a former CMS official said comes as a relief to doctors who weren't sure they qualify for the bonus and now don't have to worry about their performance in the Merit-Based Incentive Payment System.

The White House Office of Management and Budget is reviewing a CMS proposed rule that offers an opportunity for the new administration to put its mark on the physician pay system under development by CMS, called the Quality Payment Program.

CMS published Tuesday (Dec. 20) regulations on mandatory bundled pay demonstrations for cardiac and joint-replacement services, even though the incoming Republican administration opposes requiring providers to participate in demonstrations that test changes to Medicare reimbursement, and the agency finished writing policy for the accountable care organization Track 1 +, which aims to get more physicians to accept the risk of penalties for poor performance.

Republicans will likely spare accountable care organizations and other demonstrations that the Affordable Care Act created, health care lobbyists and analysts say, and the CMS innovation center that runs the demos is expected to survive as well, although possibly under a different name and with restrictions such as prohibiting mandatory demos and requiring provider involvement in demo designs.

CMS will unveil additional state Medicaid delivery and payment reforms before the Obama administration leaves office, and some of those reforms will help doctors receive Medicare bonuses in two years, CMS Deputy Administrator and Medicaid Director Victoria Wachino said Wednesday (Oct. 29).

CMS says it's unclear what effect the recently announced pilot to reduce contractor audits of doctors participating in pay models with two-sided risk will have on Medicare's improper payment rate, though the agency has also said it believes the pilot will continue to protect Medicare program integrity.

CMS says doctors participating in pay models that include penalties will be low priorities for reviews by Recovery Auditors and other contractors in a pilot scheduled to start in January.