New Incentives for Your Medicare Population

Written by on June 1, 2015 in Features - No comments

Are You Reaping the Benefits?

In these times of health reform, reaping added financial benefits for managing a Medicare patient are now more commonplace.  The Centers for Medicare & Medicaid Services (CMS) issued a new rule that will update payment policies and payment rates for services furnished under the Medicare Physician Fee Schedule (PFS) on or after Jan. 1, 2015.  Medicare will now pay physicians Physician Assistants (PAs) and Nurse Practitioners (NPs) for care management services as part of in person, face-to-face visits. Last year, CMS finalized a separate payment, outside of a face-to-face visit, for managing the care of Medicare patients with two or more chronic conditions beginning in 2015.

PAnNP_WEBThe payment rate for the new chronic care management (CCM) code is $41.92, billed no more frequently than once per month per qualified patient.  This could amount to more than $200,000 per year per provider in added revenue assuming a 20% Medicare population with at least 700 unique Medicare patients per year who have 2 or more chronic conditions. Chronic care management (CCM) services include development and revision of a plan of care, communication with other health professionals, and medication management.

Payment for CCM is only one part of a multi-faceted CMS initiative to improve Medicare beneficiaries’ access to primary care. PAs and NPs are estimated to do about 85% of the work a physician would otherwise provide in the primary care setting.  Nationwide, hospitals and health systems are moving toward using more PAs and NPs and there is a much greater emphasis on team based care.

Additional financial incentives for physicians and eligible providers, called the physician value based modifier (VBM) is another incentive which allows the federal government to boost or lower the amount it reimburses physicians and eligible providers including PAs and NPs based on how they score on quality measures and how much their patients cost Medicare. How providers rate this year will determine payments for more than 900,000 clinicians by 2017.  Medicare is easing providers into the program, applying it this year only to medical groups with at least 100 health professionals including physicians, Physician Assistants, Nurse Practitioners, speech-language pathologists and occupational therapists. Next year the program will expand to groups of 10 or more health professionals. In 2017, all remaining providers who take Medicare—along with about 360,000 other health professionals—will be included.

Increasing capacity of the health system to meet the growing numbers of patients seeking care is critical and necessary.  Medicare population growth is significant and leaves many patients facing access issues.  Between 2012 and 2050, the United States will experience considerable growth in its older population. In 2050, the population aged 65 and over is projected to be 83.7 million, almost double its estimated population of 43.1 million in 2012. The baby boomers are largely responsible for this increase in the older population, as they began turning 65 in 2011.

PAs and NPs are skilled medical professionals who play an integral part in health care delivery. Especially in primary care, PAs and NPs attract and manage a significant following of patients.  Redesigning teams to include increased numbers of primary care providers, not just physicians but also Physician Assistants and Nurse Practitioners, is a significant part of the solution to alleviate the well-known shortage in primary care.  Now with even greater added financial incentives for quality care delivery, improved utilization of PAs and NPs will be an integral part of the primary care delivery solution.

References: Payment/PhysicianFeedbackProgram/ValueBasedPaymentModifier.html Instruments/PQRS/Downloads/PQRS_List-of-EligibleProfessionals_022813.pdf Payment/PhysicianFeedbackProgram/Downloads/CY2015ValueModifierPolicies.pdf

By Lisa P. Shock, MHS, PA-C
President/CEO, Utilization Solutions in Healthcare, Inc.

About the Author:
Lisa P. Shock, MHS, PA-C, is a seasoned PA who has worked with clients to expand care teams in both large and small settings. She enjoys part time clinical practice and is the President and CEO of Utilization Solutions in Healthcare – a specialty consultant company for physician practices and hospitals, offering a wide range of services to help implement and improve upon the utilization of PAs and NPs in the health care system. Contact her at

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