Washington, DC (July 13, 2018) -- The American College of Physicians (ACP) is encouraged by provisions included in the proposed rules for the Medicare Physician Fee Schedule and the Quality Payment Program (QPP) for 2019, while recognizing several areas for improvement in the rules that were released by the Centers for Medicare and Medicaid Services (CMS) on July 12.
"Internists are excited to see that CMS is proposing long overdue improvements in the physician fee schedule and the QPP that will help physicians provide the highest quality care to patients," said Ana María López, MD, MPH, FACP, president, ACP. "This includes efforts to streamline burdensome administrative and documentation requirements -a proposal that is in line with ACP's Patients Before Paperwork initiative."
ACP welcomes improvements made in the 2019 fee schedule, including concrete steps being proposed to reduce the documentation requirements associated with evaluation and management (E/M) services, as advocated by ACP, including:
Documentation options: We strongly support the proposal to reduce the burden of current E/M documentation requirements, specifically by allowing E/M documentation to focus on medical decision making, as ACP has strongly advocated for in the past.
Add-on codes: ACP appreciates CMS's proposal to help account for cognitive services provided by internal medicine physicians that are currently not adequately supported in the traditional E/M structure, through the use of a new add-on code for primary care visit complexity. This is in line with ACP's longstanding recommendations to CMS. ACP will be examining whether the add-on payments, especially for services provided by primary care physicians, are sufficient given other changes proposed by CMS.
Redundancy in documentation: ACP is encouraged by the proposal to reduce documentation burdens on physicians by requiring them to only document changed information for established patients and to sign-off on basic information documented by practice staff. ACP strongly supports these changes, as they will reduce the documentation burden on clinicians, limit redundant information in the medical record, and cut down on duplicative time spent on re-documenting existing information.
New non-face-to-face services: CMS proposes to add new reimbursable codes for "virtual check-ins," remote consults of patient videos and photos, and interprofessional online consultations.
"We are encouraged that CMS is increasing options that would allow physicians to be reimbursed for non-face-to-face visits and services; like telehealth," said Dr. López. "This move helps enable patients and physicians to interact in the most efficient and effective way to meet each patient's unique needs."
ACP is encouraged that CMS is exploring alternatives to the current E/M payment structure, but believes that proposed changes to the E/M structure require greater examination to ensure that they do not disadvantage physicians who care for complex and frail patients.
CMS proposes a significant change to the payment structure. All level 2-5 office-based and outpatient E/M visits would be consolidated into two payment amounts; one for new patients, and one for established patients. Since internists typically take care of patients with multiple chronic conditions and the elderly, this proposed payment structure may adversely impact internal medicine specialists, subspecialists, and their patients.
"While we acknowledge the potential benefit of simplifying billing and associated documentation of E/M services by bundling levels 2-5 together, 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," Dr. López observed. "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."
ACP will also examine whether the combination of primary care and specialty add-ons to E/M services, the new codes for non-face-to-face work, and the reduced administrative costs of billing for these services, are sufficient to ensure that care of more complex patients is not undervalued.
ACP is encouraged that CMS has proposed many positive improvements to the Quality Payment Program (QPP), and that the Agency incorporated several of our past recommendations in the proposed rule, including:
Low volume threshold changes: ACP applauds CMS for proposing to increase the ways in which physicians and other clinicians can qualify for the low-volume threshold. ACP is pleased to see that eligible physicians can now opt into MIPS, even if they do not meet all three elements of low-volume threshold determination.
Streamlining the Promoting Interoperability MIPS category: ACP is glad to see the CMS proposal to remove the separate components within the Promoting Interoperability (formally Advancing Care Information) Category score to create a streamlined scoring methodology.
Facility-based scoring option: ACP strongly supports the creation of a facility-based scoring option that would leverage data already being reported by the Hospital Value-Based Purchasing program and require no additional data submission from facility-based clinicians.
Holding Advanced Alternative Payment Model (APM) risk thresholds steady: ACP supports the CMS proposal to maintain the current eight percent revenue-based nominal amount standard for Advanced APMs through 2024. Increasing the threshold would hinder development of and participation in new APMs.
ACP is especially encouraged by the proposed removal of a number of quality measures deemed by the agency to be of low-value, consistent with recommendations by ACP and its Performance Measurement Committee. We will review the specific measures proposed for removal, and remind CMS of the importance of ensuring that every specialty has a sufficient number of high quality measures.
ACP has concerns about several provisions of the rule, including:
Missed opportunities to reduce complexity, ease burden of MIPS: The College is disappointed CMS did not heed stakeholder calls to streamline MIPS requirements and scoring, reduce reporting burden by establishing a minimum 90-day reporting period for all performance categories, or reduce the total number of quality measures.
Changes to the cost category: ACP appreciates CMS developing new episode-based cost measures, but strongly opposes increasing the weight of the Cost Category to 15 percent in the same year that these eight new measures would be counted for the first time. CMS needs to evaluate the validity and reliability of the measures and allow physicians time to familiarize themselves with them before increasing the weight of the Cost Category.
Requiring use of 2015 Edition Certified EHR Technology (CEHRT) in 2019: While ACP supports CMS promoting interoperability by requiring 2015 CEHRT, we urge CMS to allow at least six months for vendors and physicians to implement system upgrades in order to ensure a smooth transition and avoid disruptions to patient care. Additionally, CMS needs to think about ways to mitigate costs associated with implementation, especially for small practices.
"ACP commends CMS for taking major steps to reduce unnecessary administrative tasks that are detracting from the patient-physician relationship," said Dr. López. "We look forward to providing CMS with detailed feedback on proposed changes in documentation and payment of evaluation and management services so that they do not undervalue the work of physicians taking care of more complex patients."
About the American College of Physicians
The American College of Physicians is the largest medical specialty organization in the United States with members in more than 145 countries worldwide. ACP membership includes 154,000 internal medicine physicians (internists), related subspecialists, and medical students. Internal medicine physicians are specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment, and compassionate care of adults across the spectrum from health to complex illness. Follow ACP on Twitter and Facebook.
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