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ACP Objects to CMS Plan to Flatten Pay for Patient Evaluation and Management Services

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Proposal to reduce documentation should move forward without payment changes, College maintains

Sept. 21, 2018 (ACP) – Responding to members' concerns, the American College of Physicians is sounding an alarm about a proposed Medicare agency rule that would overhaul the reimbursement of physicians for the care of challenging, time-consuming patients.

The Centers for Medicare and Medicaid Services has proposed a single base payment level for levels 2 to 5 of evaluation and management (E/M) services. ACP fears this move would adversely affect internal medicine specialists and subspecialists who see chronically ill patients and must spend extra amounts of time with them.

“The proposal should not be implemented,” ACP has told CMS.

“The proposal to pay the same for complex cognitive care as more basic care will undermine patients who need our help the most,” said Dr. Ana María López, ACP's president. “A considerable number of physicians would be disadvantaged if they treat patients who are frail, sick or more complex and would be discouraged from spending time with them.”

The payment change is part of the proposed rule for Medicare Physician Fee Schedule and Quality Payment Program for 2019.

Currently, payments range from $48 to $148, depending on the complexity of patient visits. Under the new plan, primary care physicians would receive about $98 for established patients and specialists would receive about $107. (These amounts include patient rates of $93 and add-ons of approximately $5 and $14, respectively.)

“ACP has heard from many internists who are greatly concerned about the adverse impact of paying a single flat blended fee for levels 2-5 evaluation and management services,” said Bob Doherty, ACP's senior vice president for governmental affairs and public policy. “They passionately believe that paying the same amount for the most complex office visits as less complex ones would harm their patients, and must be opposed by ACP. We agree. CMS's proposal for flat fee for E/M services is not acceptable.”

On the other hand, ACP supports the agency's plan to reduce the required E/M documentation in a way that would reduce the burden on physicians, which aligns with ACP's “Patients Before Paperwork” initiative.

“The problem is that CMS says it can't reduce E/M documentation unless it goes along with paying a flat fee for E/M services,” Doherty said. “That's not a rationale, or trade-off, that ACP can accept. We think that CMS can reduce E/M documentation while preserving the principle that more complex cognitive care should be paid more than less complex care.”

ACP explained its stance on aspects of the proposed fee schedule in a 127-page letter submitted to CMS by its Sept. 10 deadline for comments. Key positions taken by ACP include:

  • Care of more complex patients must be reimbursed at a higher level than care of less complex patients.
    “CMS's current proposal undervalues cognitive care for the more complex patients, potentially creating incentives for clinicians to spend less time with patients, to substitute more complex and time-consuming visits with lower level ones of shorter duration, schedule more shorter and lower-level visits and, potentially, avoid taking care of older, frailer, sicker and more complex patients,” Doherty said. “It could also create a disincentive for physicians to practice in specialties, like geriatrics and palliative care, that involve care of more complex patients.”
  • Improvements in the documentation burden should not be linked to the single flat fee for E/M levels 2-5.
    “While we understand CMS's concerns that changes in E/M documentation requirements, without changes in the underlying payment structure for E/M services, could create program integrity challenges,” Doherty said, “we believe that CMS should consider testing of alternatives that would allow it to move forward on simplifying documentation, ensure program integrity and preserve the overarching principle that more complex and time-consuming E/M services must be paid appropriately more than lower level and less time-intensive services.”
  • CMS should not set a regulatory deadline for finalizing and implementing its flat E/M fee proposals or possible alternatives.
    “Sufficient time must be allowed to engage the physician community to develop and pilot-test alternatives that preserve the principle that more complex and time-consuming E/M services must be paid appropriately more than lower level and less time-intensive services, while allowing CMS to move forward on simplifying E/M documentation while ensuring program integrity,” Doherty said. “The stakes for patients, clinicians and the Medicare program are too great for CMS to rush changes.”
  • CMS should move forward with simplified E/M documentation requirements as of Jan. 1, 2019.
    As López said, “We want to work with CMS toward a plan that would reduce E/M documentation burdens while preserving appropriate payment levels for more complex cognitive care.”

In addition, ACP in its letter urged CMS to implement proposals to pay for virtual check-ins, other telehealth and technology-based services and prolonged face-to-face visits because these services help address long-recognized needs and challenges with the current payment system.

More Information

ACP's letter to CMS detailing changes it would like the agency to make in its proposed payment policies is available on the College's website.

Information about ACP's Patients Before Paperwork initiative is available on the College's website.

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Back to the September 21, 2018 issue of ACP Advocate