Skip to main content

Advanced Search

Advanced Search

Current Filters

Filter your query

Publication Types



Newsletter Article


Medicare Eyes Doctor Pay Rule to Move Broader Policy Changes

By Kerry Young, CQ Roll Call

July 18, 2016 -- The Obama administration is working to take advantage of one of its final opportunities to put its stamp on the nation's health care. Officials are seeking to use the annual update of Medicare’s physician payment rule to make significant changes that would affect diabetes treatment, other chronic care, and information about insurer-run Advantage plans.

"It’s a last chance to put different sorts of policies in place that would support primary care," said Adam Borden, a vice president at the consulting firm Avalere Health, about the draft 2017 payment rule released July 7.

Health care has been a marquee issue for the Obama administration, even beyond the implementation of the 2010 overhaul. Medicare officials in March announced that they had reached a goal ahead of schedule of tying 30 percent of its payments to newer models of care that link reimbursement to judgments about the quality of the service provided. Unlike the health overhaul, which remains a highly divisive topic, attempts to shift away from the fee-for-service payment model for Medicare have enjoyed strong bipartisan support from Congress.

Several of the proposed initiatives in the physician fee rule mirror ideas being considered by the Senate Finance Committee’s chronic care working group, led by Sen. Mark Warner, D-Va., and Sen. Johnny Isakson, R-Ga. In a December white paper, the Senate Finance group called for new payments specifically for the management for patients with a greater complexity of chronic conditions and for comprehensive assessment and care planning for patients with Alzheimer’s disease or dementia. The physician fee rules include proposals for both.

The rule also proposes the release of more Medicare Advantage pricing data and information about how much insurers spend on health care claims from Medicare health and Part D drug plans.

Perhaps the most popular provision tucked into the physician fee rule is an expansion of diabetes prevention efforts, another aim shared with Senate Finance’s working group. In the draft payment rule, CMS says that diabetes "is at epidemic levels in the Medicare population." More than 25 percent of senior citizens may have diabetes.

CMS is considering a program that would start with 16 counseling sessions on topics such as nutrition and exercise. People would attend these sessions in groups that may meet in classrooms. There then would be monthly follow-up meetings to help people maintain healthier lifestyles. The primary goal of the program is at least 5 percent average weight loss among participants, the agency said.

Diabetes occurs when the body doesn't produce enough insulin, which helps with transport sugar into cells for use as energy. The condition can cause heart and kidney disease and blindness and lead to the amputation of feet and legs.

CMS aims to kick off the diabetes prevention effort in January 2018. The agency said it hasn’t yet decided whether to make this a national program in its first year or phase it in more slowly. Consumers would qualify for the program if they had a body mass index of 25 or greater. Asian beneficiaries would be eligible if they have a BMI of 23 or more. People in Medicare also would have to have blood sugar test readings indicating a potential risk for diabetes in order to qualify.

CMS will accept comments on the proposed physician fee rule until Sept. 6. The American Diabetes Association expressed quick support for Medicare's proposal for teaching people how to avoid the disease through changes in diet and exercise habits.

"Providing people with prediabetes with effective tools to prevent diabetes is a win for all of us," said Robert E. Ratner, the chief scientific and medical officer for the American Diabetes Association, in a July 8 statement.

Publication Details