CMS proposes slight doc pay cut in 2023 and several reforms to ACOs, dental service coverage

Doctors could get a small decline in their Medicare payments next year under a new rule proposed by the Centers for Medicare & Medicaid Services (CMS), which is also proposing new options to cover dental services and boost accountable care participation.

The agency released Thursday the proposed 2023 Physician Fee Schedule rule. In addition to revenue adjustments, the rule includes major reforms to the accountable care organization program such as a new equity adjustment and upfront investments to lower-revenue organizations and changes to coverage for certain behavioral health services.

CMS proposed a 2023 fee schedule conversion factor of $33.08 for each relative unit, which determines how Medicare payments to doctors are calculated. That factor is a slight decline of the 2022 factor of $34.61. 

The factor considers a statutory requirement that the conversion factor for 2023 remains flat and the expiration of a 3% bump in fee schedule payments that went away in 2022. The slight bump was installed to help physicians weather the revenue impact from the COVID-19 pandemic. 

The fee schedule must also be budget neutral under federal law.

Physician groups blasted the decision, saying that it hurts providers especially as another 4% cut is expected under Congress' PAYGO law, which calls for mandatory cuts if federal spending reaches a certain threshold. 

"These proposed cuts, coupled with the 4% PAYGO sequestration scheduled to take effect on Jan. 1, 2023, will have a detrimental impact on group practices, with 58% of recently surveyed groups indicating they are considering limiting the number of new Medicare beneficiaries served," said Anders Gilberg, the senior vice president of government affairs for the Medical Group Management Association.

The Surgical Care Coalition, which represents a collection of surgery provider groups, also blasted the cuts. 

"The current Medicare Physician Fee Schedule is broken. It fails to incentivize collaboration and pits doctor against doctor every year,” said Joseph C. Cleveland Jr., MD, chairman of The Society of Thoracic Surgeons Council on Health Policy and Relationships, and a member of the coalition.

In addition to the payment changes, CMS is proposing to expand the dental services that would get coverage from Medicare. Currently, Medicare only pays for certain treatments such as reconstruction of a jaw after an injury or tooth extraction following cancer care. 

Now, CMS proposed to also pay for a dental exam and treatment preceding an organ transplant as well as several other services. The agency also wants comments on what else Medicare should reimburse for dental services.

The proposal comes as more than 100 House Democrats called on CMS to expand its dental coverage as federal efforts for such expansion have fallen through.

The agency is also proposing several provisions aimed at expanding behavioral health services, including covering opioid treatments and services from mobile units like vans and paying clinical psychologists and licensed social workers as part of a primary care team.

Boosting value-based care participation

CMS also proposed several major changes to the Medicare Shared Savings Program (MSSP) that oversees ACOs. Chief among them is a proposal to install a health equity adjustment of up to 10 bonus points to the ACO’s Merit-based Incentive Payment System (MIPS) quality performance score. The equity adjustment would only positively impact an ACO but not penalize them, CMS said in a release.

“The proposal would add bonus points to the ACO’s MIPS quality performance category score if the ACO scores in the top third or middle third of performance for each quality measure,” the agency said. 

It is also hoping to entice more physicians into value-based care, a key request from ACO stakeholders that say that initial costs of investment in becoming an ACO are too high and burdensome.

CMS is proposing that an organization new to MSSP which is not renewing or reentering as an ACO and qualifies as low revenue can get a one-time payment of $250,000 and quarterly payments for the first two years of a five-year period. 

The advance payments would be recouped once an ACO starts to generate shared savings in their current and next agreement periods. However, if an ACO does not generate savings, CMS will not move to recoup the money, but the ACO must stay in the program for the full five years.

The proposal comes as participation in MSSP has been sliding amid concerns from stakeholders about high upfront costs and unreachable benchmarks that represent savings and quality targets an ACO must reach to qualify for savings.

CMS is hoping to address the issues surrounding benchmarks in part by using a sliding scale for determining shared savings losses. The agency is proposing a sliding scale to prevent a small difference in a quality score from “elimination of all shared savings,” the fact sheet said.

CMS also wants to get rid of several requirements to help ease the administrative burden. For example, CMS wants to do away with a requirement ACOs submit marketing materials to the agency before use starting in 2023.

The National Association of ACOs lauded the proposed changes.

"While we are still studying the major changes, policies in today’s proposed Physician Fee Schedule will help grow participation in ACOs," said Clif Gaus, president and CEO of NAACOS.