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In comments on Medicare fee schedule proposal, AGS calls for putting older people first

American Geriatrics Society

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IMAGE: E/M services for outpatient office visits include diagnosing and managing chronic conditions, treating acute illness, developing care plans, coordinating care across providers and settings, and discussing an older person's preferences... view more 

Credit: (C) 2018, American Geriatrics Society

In a letter sent to the Centers for Medicare & Medicaid Services (CMS) and described today in an extensive editorial published in the Journal of the American Geriatrics Society (JAGS; DOI: 10.1111/jgs.15651), the American Geriatrics Society (AGS) voiced strong opposition to a proposal that would significantly change the way physicians and other qualified health care professionals are paid for Evaluation and Management (E/M) services under Medicare. According to AGS experts, the proposal presents a high risk for significant unintended consequences and could negatively impact patient care, especially for people with complex care needs. Outside the payment proposal, the AGS did commended CMS efforts to reduce the administrative burden associated with documentation requirements for E/M services, but continued to note that these positive steps forward could be overshadowed by changes to E/M payment, if finalized as written. The comments were submitted in response to the Medicare Physician Fee Schedule Proposed Rule for 2019 (released in July 2018), a regulatory document which outlines proposed Medicare payment rates and other payment policies for the upcoming calendar year.

The proposed rule addressed a variety of policies for 2019, including proposed updates to the Medicare Physician Fee Schedule and the Quality Payment Program--a component of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 for reforming reimbursement under Medicare. The AGS provided extensive comments on many of the proposals, but spent significant time reviewing and addressing changes to E/M services, which form the foundation for geriatrics' hallmark approach to high-quality, person-centered, and team-based care for older people. E/M services for outpatient office visits include diagnosing and managing chronic conditions, treating acute illness, developing care plans, coordinating care across providers and settings, and discussing an older person's preferences for care.

The CMS proposal would alter the present system by creating a single-rate payment for almost all E/M outpatient office visits irrespective of the visit's length or complexity. In effect, such a change would slash reimbursement for providers who care for older people, offering the same pay for all patients, even those who may need more time and attention from their health professionals because of complex care concerns. Among several concerns, AGS experts worry the proposed changes could lead to shorter patient visits and visits on separate days, neither of which support coordinated care for people who benefit from time-intensive services and support.

"In our AGS letter to CMS, we noted our strong support for efforts to reduce administrative burden, and recommended finalizing a number of proposed changes to documentation requirements beginning in 2019," Nancy E. Lundebjerg, MPA, Chief Executive Officer of the AGS observed. "But we strongly urged CMS to withdraw all of its proposals related to payment for E/M services and recommended that CMS engage with stakeholders to develop a refined approach that would achieve the best possible outcome for patients."

In addition to drafting its own letter to CMS, the AGS led a multispecialty coalition of like-minded medical societies. Together, coalition members developed two letters. The first was a joint letter to CMS signed by 41 organizations detailing concerns with the proposed changes to E/M payment and reiterating recommendations that CMS withdraw its payment proposal and work with stakeholders on more effective solutions. The second letter, signed by 40 organizations, urged House and Senate Committees to reach out to CMS directly to reinforce the concerns voiced by coalition members. Separately, the AGS and other stakeholders also met with members of Congress to educate them on what the proposed changes could mean for Medicare beneficiaries.

"Our understanding from various stakeholder meetings is that CMS recognizes our significant concerns and is reflecting on potential ways to work collaboratively on a solution as a result of our collective efforts," Lundebjerg summarized. "We are hopeful this means CMS will not move forward with its proposed changes to E/M payment in 2019."

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The AGS comment letters are available at https://www.americangeriatrics.org/where-we-stand/payment-services-older-adult-care; the related article describing the AGS process for assessing the fee schedule and providing AGS commentary is available for free from JAGS at https://onlinelibrary.wiley.com/doi/abs/10.1111/jgs.15651.

About the American Geriatrics Society

Founded in 1942, the American Geriatrics Society (AGS) is a nationwide, not-for-profit society of geriatrics healthcare professionals that has--for more than 75 years--worked to improve the health, independence, and quality of life of older people. Its nearly 6,000 members include geriatricians, geriatric nurses, social workers, family practitioners, physician assistants, pharmacists, and internists. The Society provides leadership to healthcare professionals, policymakers, and the public by implementing and advocating for programs in patient care, research, professional and public education, and public policy. For more information, visit AmericanGeriatrics.org.

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