Societies encouraged by spirit of CMS' proposed changes, question efficacy

CMS’s suggestions to modernize Medicare with the intention of restoring the doctor-patient relationship — a broad, wide-reaching initiative the agency stated was historic and has dubbed “Patients Over Paperwork” — were met with general optimism from several medical societies, who also noted further steps that should be taken.

According to a press release, CMS’ proposal calls for:

Initiating payment for physicians and medical professionals treating Medicare patients that is updated yearly to make changes to quality-related provisions, payment rates and payment policies;
Simplifying, streamlining and offering flexibility in documentation requirements for Evaluation and Management office visits;
Decreasing physician supervision of radiologist assistants for diagnostic tests;
Eliminating outpatient therapy functional status reporting requirements;
Reimbursing clinicians for evaluating patient-submitted photos as well as virtual check-ins;
Including prolonged preventive services in Medicare-covered telehealth services;
Changing the payment amount for new drugs under Part B to more closely align with the drug’s actual cost;
Eliminating the Merit-Based Incentive Payment System’s (MIPS) process-based quality measures that clinicians have said are low-priority or low-value and putting stronger emphasis on measures that have greater impact on health outcomes;
Changing MIPS’ “Promoting Interoperability” performance category to support greater electronic health record interoperability and patient access to their health information, and make this category resemble the new “Promoting Interoperability Program” for hospitals;
Testing a “Medicare Advantage Qualifying Payment Arrangement Incentive,” which waives MIPS’ reporting requirements and payment adjustments for clinicians who participate in Medicare Advantage arrangements that closely resemble the Advanced Alternative Payment Models; and
Soliciting feedback as to whether providers and suppliers can and should be mandated to let patients know about charge and payment information for health care services and out-of-pocket costs, what data elements would be most helpful to encourage price shopping, and what other changes are needed to empower health care consumers.

“[These] reforms proposed by CMS bring us one step closer to a modern health care system that delivers better care for Americans at a lower cost,” Alex Azar, HHS Secretary, said in a press release.

“[The reforms] enable doctors to spend more time with their patients,” Seema Verna, CMS administrator, added. “Physicians tell us they continue to struggle with excessive regulatory requirements and unnecessary paperwork that steal time from patient care. This administration has listened and is taking action.”

Medical societies share more details, response

The American Academy of Family Physicians indicated their complete review of the “Patients over Paperwork” proposal was still underway at the time of this story’s posting, but was willing to offer preliminary insight on what it might mean to their members.

Ease evaluation/management coding by blending CPT codes 99202 to 99205 into a single payment of $135;
Blend established patient office visits levels two through five that currently are covered by CPT codes 99212 to 99215 into a single payment of $93;
Lower documentation requirements for patient exam and history by concentrating on interval history since the last patient exam;
Allow them to review and verify certain information entered by ancillary staff or beneficiaries, rather than re-enter this information;
Begin a payment reduction of 50% applied to the lower paid of two services, when physicians report an evaluation/management service and a procedure on a single day;
Determine misvalued services, implement payment for care management services and communication technology-based services provided in federally qualified health centers and rural health clinics;
Enhance existing appropriate use criteria for advanced diagnostic imaging policy;
Require physicians in MIPS to use 2015-edition certified electronic health record technology;
Change the low-volume threshold, so that eligible clinicians can opt in if they meet only one or two of the low-volume threshold criteria; and
Create new category weighting for the 2019 performance year that would set quality at 45%, promoting interoperability at 25%, and cost and improvement activities at 15% each.

“Our initial assessment indicates CMS continues progress to simplify and modernize in documentation requirements for Evaluation and Management office visits,” AAFP president Michael Munger, MD, said in a separate statement.

Other medical societies had a point-of-view that suggested there are both good and bad points to CMS’ initiative.

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The ACP noted that the proposal also helps account for cognitive services provided by internal medicine physicians that are presently not sufficiently supported in the traditional evaluation/management structure by using a new add-on code for primary care visit complexity and cuts down on the surplus in documentation, according to a release.

The College added that CMS’ proposal includes several ACP recommendations, including: holding advanced Alternative Payment Model risk thresholds steady, creating a facility-based scoring option, streamlining the Promoting Interoperability category within MIPS and low volume threshold changes.

“ACP welcomes improvements made in the 2019 fee schedule, including concrete steps being proposed to reduce the documentation requirements associated with evaluation and management services,” the ACP said in a release.

However, ACP also expressed concerns about missed opportunities to reduce complexity, ease the MIPS burden, changes to the cost category and requiring use of 2015 Edition Certified EHR Technology in 2019, the College added.

Other societies also welcomed the broad strokes of the CMS plan, but noted significant limitations toward achieving its stated objectives.

“We applaud CMS for taking action to reduce the regulatory burden hospitals and health systems face, including advancing their ‘Meaningful Measures’ initiative. We also are pleased to see CMS taking some steps to expand the ability of physicians to serve patients through telehealth and virtual connections,” Tom Nickels, executive vice president of the American Hospital Association said in a statement.

“On the other hand, we remain disappointed that CMS continues its short-sighted policies on the relocation of existing off-campus hospital outpatient departments,” he continued. “We also continue to urge CMS to improve its payment methodology to better account for the fact that the outpatient payment system includes many more services in its payment rates. … We are also concerned about reductions in payments for certain new drugs and providing substantially less ability to distinguish evaluation and management codes for different levels of resource use and intensity of services.”

The Community Oncology Alliance said in a statement that CMS’ plan drops the reimbursement for new cancer medications and other specialty therapies to the rate of list price plus 1.35% and factors in a sequester cut for a drug’s first 6 months on the market. The group also expressed concern at the idea of looping all clinicians in the same category.

Ted Okon, executive director of the alliance, also said parts of CMS’ proposal seem to contradict ideas the Trump administration has put forth to lower drug prices.

“No words can adequately describe how puzzling the CMS proposals are,” Okon said.

“At a time when the Trump administration is floating its blueprint to bring down drug prices, they are proposing a move that will actually fuel list prices of chemotherapy and other life-saving drugs. And their scheme to pay a physician the same amount for evaluating a case of sniffles and a complex brain cancer simply defies all logic. It is the antithesis of value-based healthcare and cheapens the medical care seniors are entitled to under Medicare.”

CMS will accept comment on its Patients Over Paperwork proposal until Sept. 10, 2018. – by Janel Miller

Disclosures: Healio Family Medicine was unable to determine relevant financial disclosures prior to publication.