Carter L. Alleman, J.D.
Comments to CMS’ Physician Fee Schedule and Quality Payment Model Proposed Rule
The ACOS recently submitted comments to CMS regarding Physician Fee Schedule and Quality Payment Model Proposed Rule. The comments are available below. As the ACOS continues to advocate for you, it is crucial that we hear your thoughts and concerns regarding legislation and regulation impacting your patients and practice.
Medicare Physician Fee Schedule
Evaluation and Management (E/M) Proposals
The ACOS believes that in CMS’ desire to reduce administrative burdens through the E/M proposal, CMS may have proposed a system that would be detrimental to the stability and relativity of the entire Medicare physician fee schedule and the specialty medicine physicians’ reimbursement. A single, blended payment rate for E/M services (Level 2-5) particularly undercuts and devalues specialists and subspecialists providing thorough examinations, rendering accurate diagnoses, offering a complete range of treatment options, and delivering comprehensive and effective management of complex health conditions. This is especially true for those specialists and subspecialists that provide a high volume of Level 4-5 E/M services. The lower payment rates will result in fewer resources to support providing the high-quality care these practices already struggle to provide under the current E/M payment construct.
We note that most electronic health record (EHR) vendors will not be able to update their systems in time to address this proposal, and the likely upgrades will come at a heavy cost to physicians that have purchased certified EHR technology. We also note that private payers are unlikely to be able to implement this policy in a similar timeframe or fashion, meaning physician practices will be faced with a significant administrative burden in managing two separate E/M documentation systems.
Therefore, the ACOS cannot support the E/M proposals.
The ACOS does support the reduction in repetitive documentation for office visits. We support the adoption of the proposals that would change the required documentation of the patient’s history to focus only on the interval history since the previous visit. This would eliminate the requirement for physicians to re-document information that has already been documented in the patient’s record by practice staff or the patient. We also support the removal of the need to justify a home visit instead of an office visit.
The ACOS views the administrative reduction proposals as two separate proposals and believes that one can be enacted (reduction in repetitive documentation) separately from one that is postponed (E/M documentation). The ACOS encourages CMS to take this view as well to show that it is listening to the concerns of physicians and returning doctors to their patients and not to the computer screen.
Prevention of Opioid Use Disorder
CMS seeks suggestions for regulatory and sub-regulatory changes to help prevent opioid use disorder and improve access to treatment under the Medicare program. The ACOS supports CMS’ efforts to obtain stakeholder input on how the Agency might promote the development and use of non-opioid analgesics and other pain management alternatives.
As osteopathic surgeons, the ACOS members are in a unique position to support efforts to reduce the opioid and prescription drug abuse through our training in osteopathic philosophy. The ACOS believes that a comprehensive, inclusive opioid program is necessary to decrease opioid misuse and abuse in the United States. We support and encourage its members to participate in new, effective education programs for physicians, caregivers, patients. Our Annual Clinical Assembly education opportunities include opioid prescribing best practices. The ACOS supports improvements in physician monitoring of opioid prescription use and increased access for participation. We continually encourage our members to participate in these programs and support efforts to make the programs integrate into the clinical workflow. We continue to support increases in research funding for effective alternative pain management and coping strategies and wants to participate in developing new strategies. ACOS members see the impact of the stigma around those that participate in effective opioid abuse treatment programs, we would like to see ways to reduce that stigma and encourage others to take part in those treatment programs to participate as a member of society without stigma.
Potentially Misvalued Services under the PFS
Update on Global Surgery Data Collection
The ACOS informed our members of the global codes data collection reporting requirements leading up to July 1, 2017 and afterwards. Despite our best efforts, however, it is highly unlikely that all clinicians who are required to report are doing so for every post-operative visit for every procedure. Anything short of perfect reporting will result in inaccurate data that should not be used to revalue global codes. The ACOS does not believe that the data that have been collected can be used to improve the accuracy of the existing codes, and we urge CMS not to proceed with revaluing global codes at this time. We believe that data collected for the sake of collecting data is not in the best interest of the patients that our members serve.
Teaching Physician Documentation Requirements for Evaluation and Management Services
CMS proposes to eliminate its teaching physician E/M documentation policy that currently requires a teaching physician to document the extent of their own participation in the review and direction of services furnished to each Medicare beneficiary in the medical record. The ACOS supports CMS’ proposal to eliminate potentially duplicative requirements for notations that may have previously been included in the medical records by residents or other members of the medical team.
Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging
We continue to believe the AUC reporting program, which was authorized prior to the passage of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, is inherent within the QPP, which holds clinicians accountable for the quality and cost of patient care. We would like to see CMS work with stakeholders to continue to discuss the implementation of the AUC through the MIPS program as not to continue to add administrative burdens onto physicians. The entire intent of MACRA was to streamline reporting through the consolidation of legacy quality programs. It makes little sense to continue to have a standalone program such as the AUC reporting program, when there are components within MIPS that satisfies its requirements and intents.
Quality Payment Program
The ACOS appreciates the considerable flexibility and incentives for small practices CMS incorporated into its proposed policies for Year 3 of the QPP, many of which will benefit specialty physicians. Nevertheless, we continue to believe specialists will struggle with the reporting and performance requirements, primarily under the MIPS, and that patient health and outcomes will not significantly improve commensurate with the time and effort they will expend to engage.
The fragmented nature of the MIPS performance categories, each with different reporting requirements and complex scoring mechanisms, are also a constant challenge for providers to understand. Despite our best efforts to simplify and distill the information, many are still confused about how to participate. CMS’ QPP website is filled with a plethora of information, yet many practices are unable to apply it practically. CMS must work to streamline the MIPS, integrating the performance categories into a more cohesive program, and simplify the scoring, so it is well understood by participants. More training, educational tools, and technical assistance are also needed, particularly for specialty physicians.
We are frustrated by CMS’ continued desire to promote participation and provide low-volume thresholds, but disadvantage those that do participate. Several proposals including removal of “topped out” measures, complexity of scoring, reporting measures that are outside of the physicians control, such as patient portal participation, continue to show that CMS is not quite sure of what it wants the final QPP to look like. We would ask that CMS develops some sort of roadmap that would allow stakeholders and CMS to understand where the QPP is going and what is going to be expected before the annual thousand-page proposed rule is released. CMS has said that it wants to listen to physicians and wants to promote value-based care, however when a program is created to have winners and losers, no one wins and that harms the patient. CMS should work to develop measures that can be reported for outcomes, that track improvements based on those outcomes, and that are meaningful for a physician’s practice. CMS should also allow and promote more innovation in specialty focused Advanced Alternative Payment Models. Specialists are hindered from participating in this part of the QPP because few AAPMs exist that they can actively participate.
Low-Volume Threshold and “Opt-In” Policy
The ACOS supports CMS’ proposal to add a third criterion for the determination of low-volume status. We support CMS’ proposal to allow eligible clinicians and groups the option to “opt-in” to MIPS and receive either a positive or neutral payment adjustment based on their performance. We do not want to see “opt-in” be viewed as a detriment to those who voluntarily chose to participate when they are not required. Again, the MIPS program is about flexibility by participants reporting measures to show that they are providing quality and value-based care.
Quality Performance Category
We continue to oppose the elimination of “topped out” measures. CMS is aware that many specialties already lack a sufficient number of measures in the MIPS program. By topping out more measures, this would leave some specialties with few quality measures on which to report, if any. At that point, some physicians will be forced to report measures that have little, if any, relevance to their clinical practice. Moreover, CMS is not taking into consideration that removing so-called “topped out” measures could lead to a performance gap in areas that were showing improvement. Measures may appear “topped out” in the context of the MIPS program, but CMS cannot determine whether performance is really at its peak when, so few physicians are participating in the program.
The ACOS urges CMS to reduce the number of quality measures a physician must report under this category. We feel that maintaining the current number further hinders any reduction in red tape and administrative burdens.
We continued to be disappointed that CMS is maintaining yearlong reporting despite the promise of reduced administrative burden and our long-standing request for 90-day reporting, consistent with the reporting timeframes for the PI and IA performance categories. Physicians should spend more time delivering quality care, rather than focusing on reporting measures of quality. We urge CMS to adopt 90-day reporting for the Quality performance category.
The overall MIPS scoring methodology remains complex and cumbersome for clinicians to understand. The scoring section of the proposed rule was just over 100 pages long, evidence that the policies are needlessly complicated. We urge CMS to simplify scoring so that clinicians can better understand their performance and needed achievement/improvement to be successful year over year.
We oppose CMS’ proposal that reporting via Medicare Part B claims would only be available to MIPS eligible clinicians in small practices beginning in 2019. We still believe the claims-based option is necessary for those who are unable to use or afford other reporting options. CMS should be encouraging reporting in any method available.
Advanced Alternative Payment Models (AAPMs)
We continue to be frustrated by a lack of AAPM participation options available to specialty physicians, given the intent of MACRA to move physicians away from traditional fee-for-service and into payment models that better focus on cost and quality. We urge CMS to rectify this issue with due haste and not ignore the issue any longer.
Specialty Impact Tables
We are disappointed that CMS has eliminated specialty impact tables from the QPP section of the proposed rule. We urge CMS to provide the same data it provides in the inaugural QPP proposal and final regulations, in addition to other data, to show how participation has changed year-over-year since the inception of the program. CMS continually calls upon medical societies to assist it in education of their members on CMS programs, however CMS fails to provide adequate information and data that would be helpful in these efforts. If the ACOS and other medical associations do not know the level of participation, it is extremely difficult to provide resources to educate and promote the QPP beyond what is assumed. We strongly urge that CMS makes the specialty impact tables available as a course of regular business on its QPP website as well as provide periodic updates throughout the QPP reporting cycle to better inform the physician community and the public on participation in the QPP.