Healthcare
groups
are
reacting
to
CMS’
proposed
2026
Physician
Fee
Schedule
mainly
with
concern,
arguing
that
it
needs
significant
revisions
in
order
to
avoid
destabilizing
providers
and
undermining
value-based
care
momentum.
The
proposal,
issued
in
July,
seeks
to
establish
two
new
conversion
factors
—
one
for
physicians
in
advanced
alternative
payment
models
(APMs)
and
another
for
those
who
aren’t.
CMS
plans
to
increase
the
APM
rate
by
3.83%
in
2026,
while
the
non-APM
rate
would
go
up
by
3.62%.
These
increases
reflect
several
factors
—
a
small
statutory
bump
(0.75%
for
APM
participants
and
0.25%
for
others),
an
across-the-board
2.5%
increase
required
by
recent
legislation,
and
an
additional
0.55%
adjustment
tied
to
CMS’
proposed
changes
in
physician
work
relative
value
units
(wRVUs).
For
2026,
CMS
is
also
proposing
to
trim
payments
by
applying
a
2.5%
“efficiency
adjustment”
to
certain
wRVUs.
Essentially,
CMS
believes
some
services
can
be
delivered
more
efficiently,
so
it
is
lowering
the
amount
of
physician
work
credited
for
those
services
—
wRVUs
are
central
to
how
Medicare
sets
payment
rates,
so
this
adjustment
would
effectively
reduce
reimbursement
for
many
affected
codes.
In
addition,
the
agency’s
plan
seeks
to
lower
the
indirect
practice
expense
payments
for
services
performed
in
hospital
facilities,
arguing
that
providers
in
those
settings
face
lower
overhead
costs
than
office-based
practices.
This
change
would
reduce
reimbursement
for
many
facility-based
services
while
slightly
boosting
payments
for
care
delivered
in
physician
offices.
CMS’
deadline
for
healthcare
organizations
to
submit
their
comments
was
September
12.
In
its
letter,
the
Medical
Group
Management
Association
(MGMA)
voiced
strong
opposition
to
the
payment
rates
included
in
the
proposal.
While
the
organization
appreciates
that
CMS
is
proposing
to
increase
the
two
newly
introduced
conversion
factors,
“this
does
not
remedy
previous
cuts
that
physician
groups
have
had
to
absorb
due
to
flawed
policy,
nor
does
it
address
potential
future
cuts
due
to
budget
neutrality,”
MGMA
wrote.
The
group
also
pushed
back
on
the
efficiency
adjustment
to
wRVUs
and
the
cuts
to
indirect
practice
expenses,
saying
both
changes
would
unfairly
penalize
providers
and
accelerate
consolidation.
Another
industry
group
—
the
National
Association
of
ACOs
(NAACOS)
—
criticized
CMS’
plan
to
mandate
participation
in
its
ambulatory
specialty
model,
which
is
a
value-based
care
program
aimed
at
integrating
specialists
into
Medicare
payment
models
for
conditions
like
heart
failure
and
back
pain.
In
its
proposal,
CMS
said
participation
would
be
mandatory,
with
specialists’
payments
tied
to
performance
and
patient
outcomes,
overlapping
with
other
programs
like
the
Medicare
Shared
Savings
Program
(MSSP).
“Requiring
specialists
in
an
ACO
to
participate
will
exponentially
increase
administrative
burden,
create
duplicative
reporting
requirements,
and
more
importantly,
unintentionally
discourage
specialists
from
remaining
in
and
joining
advanced
APM
arrangements.
At
a
minimum,
providers
that
have
qualified
provider/partial
qualified
provider
status
should
be
excluded
from
the
model
or
allowed
to
voluntarily
opt-in
to
[the
ambulatory
specialty
model],”
NAACOS
wrote
in
its
letter.
In
addition
to
structural
and
payment
concerns,
healthcare
groups
are
pressing
CMS
to
make
better
use
of
data.
Premier
called
on
the
agency
to
utilize
data
from
performance-based
contracting
arrangements
to
better
inform
coverage
and
reimbursement
decisions
for
new
digital
health
tools.
“Premier
encourages
CMS
to
engage
with
SaaS
vendors
and
provider
end
users
who
are
already
collecting
and
evaluating
evidence
of
the
tool’s
impact
on
quality
improvement
and
cost
effectiveness,”
the
company
wrote.
Healthcare
stakeholders
will
now
wait
to
see
how
the
agency
responds
to
these
comments
and
whether
the
final
rule
will
address
the
concerns
they
raised.
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