Proposed Changes to Medicare Regulations Met With Mixed Reviews

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Aug. 10, 2018 (ACP) – Drafts of two key Medicare policies for 2019 – the Medicare Physician Fee Schedule and the Quality Payment Program – reflect progress, but still need more work to fully meet the needs of physicians and patients, according to the American College of Physicians.

“We appreciate the fact that Centers for Medicare and Medicaid Services (CMS) is working to lessen the burdens of administrative requirements, such as documentation associated with evaluation-and-management (E/M) services,” said Brian Outland, ACP's director of regulatory affairs. “But we want to make sure the policies for 2019 don't adversely impact physicians who care for chronically ill and sick patients.”

The two policies are updated each year, and the review process for ACP and other organizations begins in the summer when CMS distributes draft regulations. The policies are expected to be finalized by November.

On the positive side, ACP is pleased with certain fee schedule proposals, including the following:

  • Documentation options that allow physicians to focus on medical decision-making.
  • Add-on codes that allow support for internal medicine physicians who provide cognitive services. These codes reflect the complexity of primary care visits and fit in with ACP's long-standing recommendations.
  • An effort to reduce redundancy in documentation that allows physicians to only document patient information that has changed. It also allows doctors to sign off on basic information documented by practice staff.
  • New reimbursable codes for “virtual check-ins” to evaluate if an office visit or other services is needed, remote consults of patient videos and photos, and interprofessional online consultations.

However, ACP is concerned about the proposed establishment of a single base payment level that could adversely affect internal medicine specialists and subspecialists who see chronically ill patients and must spend extra amounts of time with them.

Under the proposal, all level 2 to 5 office-based and outpatient E/M visits would be consolidated into base payment levels – one for new patients, and one for established patients.

According to Outland, the established patient rate would be $93 under the proposal, plus an add-on that would bring the total to about $98 and $107 respectively for primary care physicians or specialists. CMS will add $5 to each office visit performed for primary care purposes and proposes to add $14 to each office visits performed by the specialties. That's in contrast to the current system, in which payments range from $48 to $148, depending on the complexity of the patient visit.

As Dr. Ana María López, ACP's president, explained: “We acknowledge the potential benefit of simplifying billing and the associated documentation of E/M services. ACP will be assessing whether this change will have the unintended impact of undervaluing the work associated with caring for more complex and frail patients.”

“Reimbursing the most complex E/M services to such patients at the same flat level as healthier patients with less complex problems could undervalue the physician skills and training needed to care for such patients,” she said.

Outland put it this way: “They're offering to reduce administrative burden, but it's coupled with lower payment. We're trying to uncouple this and get it to work.”

As for the Quality Payment Program, ACP is pleased that CMS wants to change aspects of the program in line with what the College has recommended. For instance:

  • Proposed changes in low-volume threshold will reduce burden and expand participation in the Merit-based Incentive Payment System (MIPS).
  • Streamlining the Promoting Interoperability MIPS category is expected to improve the scoring methodology.
  • By holding Advanced Alternative Payment Model (APM) risk thresholds steady, CMS will avoid hindering development of and participation in new APMs.

ACP is also pleased that CMS wants to remove low-value quality measures, a move that reflects recommendations by ACP and its Performance Measurement Committee.

However, ACP also believes that CMS can do more to reduce the burdens and complexities of MIPS. It would like CMS to streamline MIPS requirements and scoring and reduce the reporting burden by establishing a minimum 90-day reporting period for all performance categories, and potentially reduce the total number of quality measures required to be reported.

ACP also opposes increasing the weight of the Cost Category to 15 percent in the same year that eight new measures would be counted for the first time.

Finally, ACP is concerned about the proposal to require use of 2015 Edition Certified EHR Technology in 2019.

The College urges CMS to allow at least six months for vendors and physicians to implement system upgrades in order to meet this requirement if implemented. In addition, ACP wants CMS to focus on mitigating the costs of this process, especially for small practices.

“While both the proposed fee schedule and the proposed QPP rules have changes that we like, there are some big areas for improvement,” said Outland. “ACP is working on a more detailed analysis of both rules and will provide our feedback to CMS by the beginning of September.”

More Information

More detail on the draft proposals is available from fact sheets prepared by CMS – one on the Physician Fee Schedule and one on the Quality Payment Program.

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