I 112th CONGRESS 1st Session H. R. 1256 IN THE HOUSE OF REPRESENTATIVES March 30, 2011 Mr. McDermott introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned A BILL To amend title XVIII of the Social Security Act to require the use of analytic contractors in identifying and analyzing misvalued physician services under the Medicare physician fee schedule and an annual review of potentially misvalued codes under that fee schedule.

1.

Short title; findings

(a)

Short title

This Act may be cited as the Medicare Physician Payment Transparency and Assessment Act of 2011. (b)

Findings

Congress finds the following: (1)The Centers for Medicare & Medicaid Services (CMS) has not had sufficient resources or commitment to undertake the needed surveys and analytic research needed to keep the Medicare resource-based relative value scale (RBRVS) current with changes in medical, surgical, consultative, procedural, and diagnostic practices. For the last 20 years, the American Medical Association has sponsored the Specialty Society Relative Value Scale Update Committee (RUC) as a good faith effort to support CMS in the task of developing the physician fee schedule but a more robust process is needed. (2)CMS has depended on the AMA's RUC for recommendations as to the values assigned to Medicare service codes for over 90 percent of all code changes over the last 19 years. (3)Although primary care physicians provide about 44 percent of Medicare physician visits, they constitute only 1/6 to 1/13 of the membership of the RUC. (4)The RUC lacks voting transparency and relies on self-reported and unrepresentative survey data that present serious conflict-of-interest concerns. (5)The Medicare Payment Advisory Commission has found that while the RUC tends to identify and correct undervalued codes, it does not have the same incentives to find and correct overvalued codes. Specialists, especially those who derive the majority of their income through procedural codes, have no incentive to reduce the value of potentially overvalued codes, even though the requirements for physician work in many procedures should generally reduce as time passes and proficiency increases. (6)The assignment of relative values to the evaluation and management (E/M) codes was the most unsubstantiated component of the original RBRVS and has not been systematically and scientifically studied since the institutionalizing of RBRVS. (7)The advent of electronic health records will require new methods to assess the intensity and work effort of the E/M codes. (c)

Purpose

It is the purpose of this Act to require the Secretary of Health and Human Services to consider the recommendations of independent, analytic contractors that are responsible for initially identifying and analyzing misvalued Medicare physician services and to require an annual review of potentially misvalued codes under the Medicare fee schedule.

2.

Requiring use of analytic contractors in identifying and analyzing misvalued Medicare physician services and annual review of potentially misvalued codes under Medicare fee schedule

Section 1848(c)(2)(K) of the Social Security Act (42 U.S.C. 1395w–4(c)(2)(K)), as amended by section 3134(a) of the Patient Protection and Affordable Care Act (Public Law 111–148), is amended— (1)in clause (i), by striking periodically and inserting annually; and (2)in clause (iii)— (A)subclause (I), by inserting before the period at the end the following: , but only to the extent consistent with the use of analytic contractors under subclause (III); and (B)in subclause (III)— (i)by striking may use and inserting shall use; and (ii)by adding at the end the following: This subclause shall not be construed as prohibiting the Secretary from making modifications to one or more codes under the fee schedule without use of the analytic contractors..