[Differences in Billing Patterns Between GPs and Pediatricians Using Early Diagnostics in Children and Adolescents as an Example: Analysis of Nationwide Data from Statutory Health Insurance Physicians]. / Kompensation von Leistungen zwischen Hausärzten und Kinder- und Jugendmedizinern am Beispiel der Früherkennungsuntersuchungen bei Kindern und Jugendlichen ­ Analyse von bundesweiten KBV-Daten.

BACKGROUND: Despite a 13.1% increase in the number of pediatricians between 2011 - 2020, the capacity of pediatric care has largely stagnated. This is due to increasing flexibility in working hours and a declining willingness of doctors to establish practices. In addition, there is an imbalance in the distribution of pediatric medical care capacities. While metropolitan areas are often characterized by oversupply, there is an increasing shortage of pediatricians, especially in rural areas. As a result, general practitioners in rural areas are increasingly taking over part of pediatric care. We quantify this compensation effect using the example of examinations of general health and normal child development (U1-U9). METHODS: Basis of the analysis was the Doctors' Fee Scale within the Statutory Health Insurance Scheme (Einheitlicher Bewertungsmaßstab, EBM) from 2015 (4th quarter). Nationwide data from the National Association of Statutory Health Insurance Physicians (KBV) for general practitioners and pediatricians from 2015 was evaluated. In the first step, the EBM was used to determine the potential overlap of services between the two groups of doctors. The actual compensation between the groups was quantified using general health and normal child development as an example. RESULTS: In section 1.7.1 (early detection of diseases in children) of the EBM, there is a list of 16 options for services that can be billed (fee schedule positions, GOP) by general practitioners and pediatricians. This particularly includes child examinations U1 to U9. The analysis of the national data of the KBV for the early detection of diseases in children showed significant differences between rural and urban regions in the billing procedure. Nationwide, general practitioners billed 6.6% of the services in the area of early detection of diseases in children in 2015. In rural regions this share was 23% compared to 3.6% in urban regions. The analysis of the nationwide data showed that the proportion of services billed by general practitioners was higher in rural regions than in urban regions. CONCLUSION: The EBM allows billing of services by both general practitioners and pediatricians, especially in the area of general GOP across all medical groups. The national billing data of the KBV shows that general practitioners in rural regions bill more services from the corresponding sections than in urban regions.

Medicare Program; Durable Medical Equipment Fee Schedule Adjustments To Resume the Transitional 50/50 Blended Rates To Provide Relief in Rural Areas and Non-Contiguous Areas. Interim final rule with comment period.

This interim final rule with comment period makes technical amendments to the regulation to reflect the extension of the transition period from June 30, 2016 to December 31, 2016 that was mandated by the 21st Century Cures Act for phasing in fee schedule adjustments for certain durable medical equipment (DME) and enteral nutrition paid in areas not subject to the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP). In addition, this interim final rule with comment period amends the regulation to resume the transition period's blended fee schedule rates for items furnished in rural areas and non-contiguous areas (Alaska, Hawaii, and United States territories) not subject to the CBP from June 1, 2018 through December 31, 2018. This interim final rule with comment period also makes technical amendments to existing regulations for DMEPOS items and services to reflect the exclusion of infusion drugs used with DME from the DMEPOS CBP.

Medicare Program; End-Stage Renal Disease Prospective Payment System, Payment for Renal Dialysis Services Furnished to Individuals With Acute Kidney Injury, End-Stage Renal Disease Quality Incentive Program, Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program (CBP) and Fee Schedule Amounts, and Technical Amendments To Correct Existing Regulations Related to the CBP for Certain DMEPOS. Final rule.

This final rule updates and makes revisions to the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) for calendar year (CY) 2019. This rule also updates the payment rate for renal dialysis services furnished by an ESRD facility to individuals with acute kidney injury (AKI). In addition, it updates and rebases the ESRD market basket for CY 2019. This rule also updates requirements for the ESRD Quality Incentive Program (QIP), and makes technical amendments to correct existing regulations related to the Competitive Bidding Program (CBP) for certain Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS). Finally, this rule finalizes changes to bidding and pricing methodologies under the DMEPOS competitive bidding program; adjustments to DMEPOS fee schedule amounts using information from competitive bidding for items furnished from January 1, 2019 through December 31, 2020; new payment classes for oxygen and oxygen equipment and a new methodology for ensuring that new payment classes for oxygen and oxygen equipment are budget neutral; payment rules for multi- function ventilators or ventilators that perform functions of other durable medical equipment (DME); and revises the payment methodology for mail order items furnished in the Northern Mariana Islands. This rule also includes a summary of the feedback received for the request for information related to establishing fee schedule amounts for new DMEPOS items and services.

Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2018; Medicare Shared Savings Program Requirements; and Medicare Diabetes Prevention Program. Final rule.

This major final rule addresses changes to the Medicare physician fee schedule (PFS) and other Medicare Part B payment policies such as changes to the Medicare Shared Savings Program, to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services, as well as changes in the statute. In addition, this final rule includes policies necessary to begin offering the expanded Medicare Diabetes Prevention Program model.

Medicare Program; Medicare Clinical Diagnostic Laboratory Tests Payment System. Final rule.

This final rule implements requirements of section 216 of the Protecting Access to Medicare Act of 2014 (PAMA), which significantly revises the Medicare payment system for clinical diagnostic laboratory tests. This final rule also announces an implementation date of January 1, 2018 for the private payor rate-based fee schedule required by PAMA.

Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models. Final rule with comment period.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) repeals the Medicare sustainable growth rate (SGR) methodology for updates to the physician fee schedule (PFS) and replaces it with a new approach to payment called the Quality Payment Program that rewards the delivery of high-quality patient care through two avenues: Advanced Alternative Payment Models (Advanced APMs) and the Merit-based Incentive Payment System (MIPS) for eligible clinicians or groups under the PFS. This final rule with comment period establishes incentives for participation in certain alternative payment models (APMs) and includes the criteria for use by the Physician-Focused Payment Model Technical Advisory Committee (PTAC) in making comments and recommendations on physician-focused payment models (PFPMs). Alternative Payment Models are payment approaches, developed in partnership with the clinician community, that provide added incentives to deliver high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population. This final rule with comment period also establishes the MIPS, a new program for certain Medicare-enrolled practitioners. MIPS will consolidate components of three existing programs, the Physician Quality Reporting System (PQRS), the Physician Value-based Payment Modifier (VM), and the Medicare Electronic Health Record (EHR) Incentive Program for Eligible Professionals (EPs), and will continue the focus on quality, cost, and use of certified EHR technology (CEHRT) in a cohesive program that avoids redundancies. In this final rule with comment period we have rebranded key terminology based on feedback from stakeholders, with the goal of selecting terms that will be more easily identified and understood by our stakeholders.

Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2017; Medicare Advantage Bid Pricing Data Release; Medicare Advantage and Part D Medical Loss Ratio Data Release; Medicare Advantage Provider Network Requirements; Expansion of Medicare Diabetes Prevention Program Model; Medicare Shared Savings Program Requirements. Final rule.

This major final rule addresses changes to the physician fee schedule and other Medicare Part B payment policies, such as changes to the Value Modifier, to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services, as well as changes in the statute. This final rule also includes changes related to the Medicare Shared Savings Program, requirements for Medicare Advantage Provider Networks, and provides for the release of certain pricing data from Medicare Advantage bids and of data from medical loss ratio reports submitted by Medicare health and drug plans. In addition, this final rule expands the Medicare Diabetes Prevention Program model.

Medicare Program; End-Stage Renal Disease Prospective Payment System, Coverage and Payment for Renal Dialysis Services Furnished to Individuals With Acute Kidney Injury, End-Stage Renal Disease Quality Incentive Program, Durable Medical Equipment, Prosthetics, Orthotics and Supplies Competitive Bidding Program Bid Surety Bonds, State Licensure and Appeals Process for Breach of Contract Actions, Durable Medical Equipment, Prosthetics, Orthotics and Supplies Competitive Bidding Program and Fee Schedule Adjustments, Access to Care Issues for Durable Medical Equipment; and the Comprehensive End-Stage Renal Disease Care Model. Final rule.

This rule updates and makes revisions to the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) for calendar year 2017. It also finalizes policies for coverage and payment for renal dialysis services furnished by an ESRD facility to individuals with acute kidney injury. This rule also sets forth requirements for the ESRD Quality Incentive Program, including the inclusion of new quality measures beginning with payment year (PY) 2020 and provides updates to programmatic policies for the PY 2018 and PY 2019 ESRD QIP. This rule also implements statutory requirements for bid surety bonds and state licensure for the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP). This rule also expands suppliers' appeal rights in the event of a breach of contract action taken by CMS, by revising the appeals regulation to extend the appeals process to all types of actions taken by CMS for a supplier's breach of contract, rather than limit an appeal for the termination of a competitive bidding contract. The rule also finalizes changes to the methodologies for adjusting fee schedule amounts for DMEPOS using information from CBPs and for submitting bids and establishing single payment amounts under the CBPs for certain groupings of similar items with different features to address price inversions. Final changes also are made to the method for establishing bid limits for items under the DMEPOS CBPs. In addition, this rule summarizes comments on the impacts of coordinating Medicare and Medicaid Durable Medical Equipment for dually eligible beneficiaries. Finally, this rule also summarizes comments received in response to a request for information related to the Comprehensive ESRD Care Model and future payment models affecting renal care.

The Components of the Merit-Based Incentive Payment System.

The passage of the Medicare Access and CHIP Reauthorization Act in Apri 2015 set the stage for the Part B reimbursement changes set to take place in 2019 based on the 2017 reporting period in relation to performance within core Medicare initiatives through the Merit-Based Incentive Payment System (MIPS) These changes will reflect the new "fee-for-performance" approach to reimbursements through individualized changes to an individual or practice group's conversion factor used in the RVU reimbursement calculation. The metrics being used as a basis for eligible provider competitive ranking for either positive or negative reimbursement changes are in proportion to performance on chosen Physician Quality Reporting System measures, value-based payment modifier calculations, compliance with Modified Stage 2 or Stage 3 Meaningful Use as part of the Electronic Health Record Incentive Program, and ongoing participation in clinical practice improvement activities. This article describes the core elements that make up MIPS and discusses the likely criteria that will be used as the core elements necessary for competitive reimbursement rankinq.

How Medicare preventive services can bolster the hospital-physician enterprise.

Medicare preventive services offer hospital-owned physician practices an opportunity to increase revenue.

State Variation in Medical Imaging: Despite Great Variation, the Medicare Spending Decline Continues.

OBJECTIVE: The purpose of this study was to assess state-level trends in per beneficiary Medicare spending on medical imaging. MATERIALS AND METHODS: Medicare part B 5% research identifiable files from 2004 through 2012 were used to compute national and state-by-state annual average per beneficiary spending on imaging. State-to-state geographic variation and temporal trends were analyzed. RESULTS: National average per beneficiary Medicare part B spending on imaging increased 7.8% annually between 2004 ($350.54) and its peak in 2006 ($405.41) then decreased 4.4% annually between 2006 and 2012 ($298.63). In 2012, annual per beneficiary spending was highest in Florida ($367.25) and New York ($355.67) and lowest in Ohio ($67.08) and Vermont ($72.78). Maximum state-to-state geographic variation increased over time, with the ratio of highest-spending state to lowest-spending state increasing from 4.0 in 2004 to 5.5 in 2012. Spending in nearly all states decreased since peaks in 2005 (six states) or 2006 (43 states). The average annual decrease among states was 5.1% ± 1.8% (range, 1.2-12.2%) The largest decrease was in Ohio. In only two states did per beneficiary spending increase (Maryland, 12.5% average annual increase since 2005; Oregon, 4.8% average annual increase since 2008). CONCLUSION: Medicare part B average per beneficiary spending on medical imaging declined in nearly every state since 2005 and 2006 peaks, abruptly reversing previously reported trends. Spending continued to increase, however, in Maryland and Oregon. Identification of state-level variation may facilitate future investigation of the potential effect of specific and regional changes in spending on patient access and outcomes.

Regional variation in Medicare payments for medical imaging: radiologists versus nonradiologists.

OBJECTIVE: The purpose of this article was to study regional variation in Medicare Physician Fee Schedule (MPFS) payments for medical imaging to radiologists compared with nonradiologists. MATERIALS AND METHODS: Using a 5% random sample of all Medicare enrollees, which covered approximately 2.5 million Part B beneficiaries in 2011, total professional-only, technical-only, and global MPFS spending was calculated on a state-by-state and United States Census Bureau regional basis for all Medicare Berenson-Eggers Type of Service-defined medical imaging services. Payments to radiologists versus nonradiologists were identified and variation was analyzed. RESULTS: Nationally, mean MPFS medical imaging spending per Medicare beneficiary was $207.17 ($95.71 [46.2%] to radiologists vs $111.46 [53.8%] to nonradiologists). Of professional-only (typically interpretation) payments, 20.6% went to nonradiologists. Of technical-only (typically owned equipment) payments, 84.9% went to nonradiologists. Of global (both professional and technical) payments, 70.1% went to nonradiologists. The percentage of MPFS medical imaging spending on nonradiologists ranged from 32% (Minnesota) to 69.5% (South Carolina). The percentage of MPFS payments for medical imaging to nonradiologists exceeded those to radiologists in 58.8% of states. The relative percentage of MPFS payments to nonradiologists was highest in the South (58.5%) and lowest in the Northeast (48.0%). CONCLUSION: Nationally, 53.8% of MPFS payments for medical imaging services are made to nonradiologists, who claim a majority of MPFS payments in most states dominated by noninterpretive payments. This majority spending on nonradiologists may have implications in bundled and capitated payment models for radiology services. Medical imaging payment policy initiatives must consider the roles of all provider groups and associated regional variation.

Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2016. Final rule with comment period.

This major final rule with comment period addresses changes to the physician fee schedule, and other Medicare Part B payment policies to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services, as well as changes in the statute.

FEE-SCHEDULE INCREASES IN CANADA: IMPLICATION FOR SERVICE VOLUMES AMONG FAMILY AND SPECIALIST PHYSICIANS.

Physician spending has substantially increased over the last few years in Canada to reach $27.4 billion in 2010. Total clinical payment to physicians has grown at an average annual rate of 7.6% from 2004 to 2010. The key policy question is whether or not this additional money has bought more physician services. So, the purpose of this study is to understand if we are paying more for the same amount of medical services in Canada or we are getting more bangs for our buck. At the same time, the paper attempts to find out whether or not there is a productivity difference between family physician services and surgical procedures. Using the Baumol theory and data from the National Physician Database for the period 2004-2010, the paper breaks down growth in physician remuneration into growth in unit cost and number of services, both from the physician and the payer perspectives. After removing general inflation and population growth from the 7.6% growth in total clinical payment, we found that real payment per service and volume of services per capita grew at an average annual rate of 3.2% and 1.4% respectively, suggesting that payment per service was the main cost driver of physician remuneration at the national level. Taking the payer perspective, it was found that, for the fee-for-service (FFS) scheme, volume of services per physician decreased at an average annual rate of -0.6%, which is a crude indicator that labour productivity of physicians on FFS has fallen during the period. However, the situation differs for the surgical procedures. Results also vary by province. Overall, our finding is consistent with the Baumol theory, which hypothesizes higher productivity growth in technology-driven sectors.

Getting the balance right between generalism and specialisation - does remuneration matter?

BACKGROUND: Remuneration has been cited as a factor influencing the distribution of doctors between generalist and specialist roles. OBJECTIVE: To review the evidence on earnings differentials between specialists and GPs, and suggest possible policy responses. DISCUSSION: Specialists earn almost twice as much as GPs but only half of this difference can be explained by differences in their characteristics. Evidence suggests that expected future earnings, together with a range of other factors, influence specialty choice. Directly altering relative earnings may be difficult, but greater targeted investment in primary care is more achievable to help shift the balance.

The Road To Value Can't Be Paved With A Broken Medicare Physician Fee Schedule.

Value-based payment has been promoted for increasing quality, controlling spending, and improving patient and practitioner experience. Meanwhile, needed reforms to fee-for-service payment (the Medicare Physician Fee Schedule) have been ignored as policy makers seek to move payment toward alternatives, even though the fee schedule is an intrinsic part of Alternative Payment Models. In this article, we show how value-based payment and the fee schedule should be viewed as complementary, rather than as separate silos. We trace the origins of embedded flaws in the fee schedule that must be fixed if value-based payment is to succeed. These include payment distortions that directly compromise value by overpaying for certain procedures and imaging services while underpaying for services that add value for beneficiaries. We also show how the fee schedule can accommodate bundled payments and population-based payments that are central to Alternative Payment Models. We draw two conclusions. First, the Centers for Medicare and Medicaid Services should correct misvalued services and establish a hybrid payment for primary care that blends fee-for-service and population-based payment. Second, Congress should alter the thirty-five-year-old statutory basis for setting Medicare fees to allow CMS to explicitly consider policy priorities such as workforce shortages in refining fee levels.

Relative billing complexity of in-person versus telehealth outpatient encounters.

RATIONALE: Video visits became more widely available during the coronavirus disease (COVID-19) pandemic. However, the ongoing role and value of video visits in care delivery and how these may have changed over time are not well understood. AIMS AND OBJECTIVES: Compare the relative complexity of in-person versus video visits during the COVID-19 pandemic and describe the complexity of video visits over time. METHODS: We used billing data for in-person and video revisits from non-behavioural health specialities with the most video visit utilisation (≥50th percentile) at a large, urban, public healthcare system from 1 January 2021 to 31 March 2022. We used current procedural terminology (CPT) codes as a proxy for information gathering and decision-making complexity and time spent on an encounter. We compared the distribution of CPT codes 99211-99215 between in-person and video visits using Fisher's exact tests. We used Spearman correlation to test for trends between proportions of CPT codes over time for video visits. RESULTS: Ten specialities (adult primary care, paediatrics, adult dermatology, bariatric surgery, paediatric endocrinology, obstetrics and gynaecologist, adult haematology/oncology, paediatric allergy/immunology, paediatric gastroenterology, and paediatric pulmonology) met inclusion criteria. For each speciality, proportions of each CPT code for in-person visits and for video visits varied significantly, and patterns of variation differed by speciality. For example, in adult primary care, video visits had smaller proportions of moderate/high complexity visits (99214 and 99215) and greater proportions of lower complexity visits (99211-99213) compared with in-person visits (p < 0.001), but in paediatric endocrinology, the opposite was seen (p < 0.001). Trends in CPT codes over time for video visits in each speciality were also mixed. CONCLUSION: In-person and video visits had differing proportions of complexity codes (typically skewing towards lower complexity for video visits). The complexity of video visits changed over time in many specialities. Observed patterns for both phenomena varied by speciality.

The Final Rule for 2022: What's New and How Changes in the Medicare Physician Fee Schedule and Quality Payment Program Affect Dermatologists.

The Centers for Medicare & Medicaid Services (CMS) 2022 final rule, which went into effect on January 1, 2022, contains updates affecting the practice of dermatology. This article reviews many of the changes to the Medicare Physician Fee Schedule (PFS) and Quality Payment Program (QPP) and their impact on clinical practice.