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Many health IT industry groups, policy experts and other industry stakeholders continue to delve into the 1,473-page proposed rule released by the Centers for Medicare and Medicaid Services (CMS) on July 12 that provides updates to the Physician Fee Schedule and Quality Payment Program (QPP), which encapsulates the Medicare Incentive-based Payment Program (MIPS) and Advanced Payment Models.

When CMS announced the proposed rule last week for CY 2019, the agency said the changes will “fundamentally improve the nation’s healthcare system and help restore the doctor-patient relationship by empowering clinicians to use their electronic health records (EHRs) to document clinically meaningful information.”

These changes, according to CMS, would increase the amount of time that doctors and other clinicians can spend with their patients by reducing the burden of paperwork that clinicians face when billing Medicare. The proposals would also modernize Medicare payment policies to promote access to virtual care, CMS said in a July 12 announcement.

Some key changes in the proposed rule include:

  • Adjustments to the MIPS program such as the removal of 34 low-value measures, a proposal to add 10 new measures, an increase of the cost component calculation weight from 10 to 15 percent, and the doubling of the performance threshold to 30 points;
  • Major reforms to Evaluation and Management (E/M) payments including single blended payment rates for both new and established patients for office/outpatient E/M level 2 through 5 visits and a series of add-on codes to reflect resources involved in providing complex primary care and non-procedural services;
  • Streamlining documentation requirements including eliminating the requirement to justify the medical necessity of a home visit in lieu of an office visit;
  • Reduction of quality measures from 31 to 24 in the Medicare Shared Savings Program (MSSP) and additional focus on the measure set on more outcome-based measures, including patient experience of care; and
  • Expansions to telehealth and virtual care reimbursement, including payment for virtual check-ins and evaluation of patient-submitted photos or recorded video and Medicare-covered telehealth services for prolonged preventative care

Healthcare Informatics Contributing Editor David Raths interviewed telehealth advocates about expansions to telehealth and virtual care reimbursement, and his article on the telehealth provisions of the rule can be read here.

In a podcast interview with Healthcare Informatics Managing Editor Rajiv Leventhal, Jeff Smith, vice president of public policy at AMIA (the Bethesda, Md.-based American Medical Informatics Association), shared his high-level takeaways and noted that the proposed rule signals CMS’s efforts to align the MIPS Promoting Interoperability (formerly called Advancing Care Information) performance category for clinicians with the proposed new Promoting Interoperability program for hospitals, which he anticipated would be welcome news to the physician community.

According to Administration officials, the proposed changes in the PFS and QPP will streamline documentation requirements to focus on patient care and modernize payment policies, and, overall, these changes seem to be welcome news to health IT and healthcare stakeholders.

The Ann Arbor, Mich.-based College of Healthcare Information Management Executives (CHIME) expressed support for CMS’s proposed rule. In a statement, Liz Johnson, R.N., CIO, acute hospitals and applied clinical informatics at Tenet Healthcare, who serves as the CHIME Public Policy Steering Committee Chair, said, “CMS is certainly heeding calls from the provider community to reduce administrative burdens. We support efforts to reduce these burdens on clinicians, whether they were created by paper or electronic processes, and to give physicians more time to care for patients. We also applaud the discussion of expanded telehealth reimbursement, something that has been a priority for CIOs, and we commend efforts to incent use of PDMPs (prescription drug monitoring programs) as we seek ways to leverage technology in our ongoing efforts to combat the nation’s opioid crisis.”

Gerald Maccioli, M.D., chief quality officer at Envision Healthcare, a Nashville-based physician staffing company, said in a statement that CMS is moving in the right direction by focusing on measures that will enhance the delivery of patient-centered care.The streamlined measures signify that CMS is listening to clinicians and acknowledging the need to lessen their administrative burden by focusing on the measures that will make the most tangible impact on care delivery and patient outcomes. Clinicians are the voice from the front lines of patient care so it’s imperative that we involve them in quality improvement initiatives,” he said.

Don Crane, president of America’s Physician Groups (APG), said APG staff are still reviewing the proposed rules but are “cautiously optimistic that CMS has taken real action here to advance the value movement.” “Importantly, these rules include a re-affirmation of the recently announced Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) Demonstration,” he stated.

However, some industry groups voiced concerns that the CMS proposals, specifically in its proposed rule for the third year of the QPP, will undermine efforts to move Medicare provider payment to value.

The Alexandra, Va.-based trade group AMGA (formerly the American Medical Group Association) said in a statement, “In its proposed rule for the third year of the Quality Payment Program, CMS again is proposing policies that do not further the program’s intent and potential. Based on initial review of the proposal, AMGA is particularly disappointed that CMS kept a high low-volume threshold that will continue to reduce the payment adjustments for providers that are invested in value-based care.”

The proposed rule maintains the low-volume threshold at $90,000 in Part B allowed charges or less than 200 Medicare patients. In year 1 of the QPP, CMS set clinicians’ low-volume threshold at $30,000 or less in Medicare Part B allowed charges or less than 100 Medicare patients and the agency increased the threshold in year 2. For the 2018 performance year, CMS estimated that about 60 percent of otherwise eligible clinicians were excluded from MIPS, although some clinicians are not subject to MIPS requirements due to participation in advanced APMs.

“When we think about MACRA (the Medicare Access and CHIP Reauthorization Act), when it was first passed, as a statute, it essentially represented Congress’ view about moving Medicare to value, and they essentially did that by putting payments at risk. If you look at the statute in 2017, your reimbursements were at risk plus-or-minus 4 percent, depending on how you did, and it goes all the way up to plus-or-minus 9 percent by 2023,” Chet Speed, vice president of public policy, AMGA, says.

“CMS has excluded so many providers from MIPS that there are now a couple of effects: one is, the promised rewards for those who did well under MACRA are no longer occurring, and even CMS acknowledges that,” Speed says.

As authorized by MACRA, providers have the opportunity to earn an adjustment of up to 7 percent on their Medicare Part B payments in 2021 based on their 2019 performance. However, as indicated in this latest proposed rule, CMS estimates the overall payment adjustment will be 2 percent, according to AMGA.

“When you think about incentives, generally, you need both a carrot and a stick to make change. With Medicare moving to a value-based system, you need a carrot, in the form of higher payments for doing well, and you need a stick, if you don’t do well, you have less reimbursements. These exclusions get away from that. So, in essence, MIPS has gone from a significant value-based transition tool to a regulatory compliance exercise with little impact on cost or quality,” Speed says.

In fact, the House GOP Doctors Caucus, a group of 16 Republican members of Congress who are also medical providers, sent a letter to Administrator Verma on July 3 urging CMS to lower MIPS’s exclusion thresholds, so more clinicians can participate in the program. In 2020, CMS is projecting a 1.5 percent payment adjustment for high-performers, compared to a potential 5 percent adjustment level authorized under the law, the lawmakers wrote in the letter.

“This trend of continued actual adjustments that are significantly less than authorized fails to incentivize meaningful participation in MIPS,” the lawmakers wrote. “If MIPS does not provide meaningful incentive and opportunity for providers to be rewarded for the quality and cost of care provided, we are concerned MIPS will not fulfill its potential to improve quality and control cost.”

MIPS Changes and Continued Pain Points for Providers

Regarding year three of MIPS, CMS is proposing to:

  • Remove MIPS process-based quality measures that clinicians have said are low-value or low-priority, in order to focus on meaningful measures that have a greater impact on health outcomes; and
  • Overhaul the MIPS “Promoting Interoperability” (formerly called Advancing Care Information) performance category to support greater EHR interoperability and patient access to their health information, as well as to align this performance category for clinicians with the proposed new Promoting Interoperability Program for hospitals.
  • For the Promoting Interoperability performance category, CMS is requiring that MIPS-eligible clinicians to use 2015 Edition certified EHR technology beginning with the 2019 MIPS performance period.

AMIA’s Smith says he anticipates stakeholder pushback on the requirement to use 2015 CEHRT technology and the 365-day quality reporting period.

And, in fact, the Colorado-based Medical Group Management Association (MGMA), which also has offices in Washington, D.C., issued a statement voicing disappointment that CMS plans to continue its “burdensome” 365-day MIPS quality reporting policy rather than 90 consecutive days. Rather than continue with a high, low-volume threshold that exempts tens of thousands of physicians, CMS should focus on reducing the reporting burden in the MIPS program, and, therefore, “make it more accessible and less burdensome to report,” Anders Gilberg, senior vice president, government affairs, MGMA, says.

In a MGMA statement issued last week, Gilberg said, “Reducing the reporting burden would allow more physicians to participate in MIPS and focus the program on rewarding quality care rather than quality reporting. Requiring medical groups to submit excessive amounts of data to the government has little impact on the quality of care delivered to Medicare beneficiaries.”

In a letter to CMS Administrator Seema Verma back in April, MGMA, along with the American Medical Association (AMA) and the American Academy of Family Physicians (AAFP), urged CMS to shorten the data reporting period for the “Quality” component of MIPS from 365 to 90 days, saying the reduction was necessary “due to the lack of timely and direct notification by CMS on whether a physician is considered MIPS eligible, as well as a severe delay by CMS in updating the Quality Payment Program interactive website with 2018 information.”

“The final rule for these programs is often not out until early November, so there’s very little turnaround time,” Gilberg says. “You need to decide things like, what kind of quality measures report are we going to report and are we going to report through a registry or some another means to report? We think it would be more administratively simple to have the quality reporting period be at 90 days and that would allow the government to get the data they need on quality, but it reduces the burden for physician practices and gives them some flexibility throughout the year to submit the data that they need to.”

Gilberg said in the MGMA statement that the CMS rule proposes requiring physicians to deploy “costly EHR upgrades for 2019 and takes further steps toward implementing burdensome appropriate use criteria.”

“At first glance, the rule doesn’t meet MGMA’s definition of administrative simplification,” Gilberg said in the statement.

E&M Documentation Reforms

In the announcement about the proposed rule, officials from CMS and the Office of the National Coordinator for Health Information Technology (ONC) said they have heard from stakeholders that CMS’ extensive documentation requirements for Evaluation and Management (E&M) codes have resulted in unintended consequences.

To meet these documentation requirements, providers have to create medical records that are a collection of predefined templates and boilerplate text for billing purposes, in many cases reflecting very little about the patients’ actual medical care or story, according to federal officials.

Christopher Longhurst, M.D., CIO at UC San Diego Health, says, “The evidence is clear that extensive billing requirements contributes substantially to physician frustration with the EHR. I applaud administrator Seema Verma and the CMS proposal to ‘put patients ahead of paperwork’ and both patients and providers will benefit if these E&M changes come to pass.”

Gilberg notes that the proposed E&M documentation changes, specifically the proposal of a single blended payment rates for both new and established patients for office/outpatient E/M level 2 through 5 visits, was a “bombshell.” “We expected CMS to address E&M documentation guidelines, but we didn’t think they would eliminate four levels of billing,” he says. He also notes that whether these documentation changes are beneficial to physicians will be largely dependent on medical specialty.

AMGA’s Speed says, “At first blush, I can only assume that most physicians will welcome eliminating these documentation guidelines. It’s not clear what the blended rate would mean to our members. Some of our groups are taking care of very sick, chronically ill patients, so how does the blended rate work for them? We’re still reviewing that.”

Gilberg agrees that a single blended payment rate raises issues with regards to physicians who treat complex patients. “Medicare patients seeing certain types of specialists often have multiple chronic conditions. So, you have a specialist who is billing a lot of level 5 or level 4 visits, who sees patients with three or four chronic conditions and has to spend a lot of time with that patient, and now you’re reducing the payment to the same payment a physician who did a very brief level 2 visit would receive; I think there is going to be some concern expressed about that. There are some issues that are going to have to be addressed, such as whether that creates a disincentive for physicians to see these highly complex patients,” he says.

He adds, “It remains to be seen whether it’s received by the physician community in the same way that it’s being conveyed by the Administration. The Administration says they are simplifying the coding requirements and therefore, the payment will pay for itself, because it’ll be so much easier, but we’re not sure yet.”

These concerns about potential lower reimbursement were addressed during a CMS media call with reporters July 18, featuring a panel discussion with Verma and other CMS and ONC leaders. During that call, Anand Shah, M.D., CMMI Chief Medical Officer, said, “This [the lowered reimbursement] is a question we are exquisitely mindful of. In cardiology and oncology, for instance, providers spend a lot of time billing for level 4 and 5 visits. But we estimate that the decrease in reimbursement will only be in the 1-2 percent range.”

National Coordinator for Health IT Don Rucker, M.D., also said, “And that will be offset because we think the gains in time [saved] by documenting less will be very large. You will save time in almost every single note.”

AMIA’s Smith also notes that time will tell if changes to E&M coding and billing and documentation requirements will improve the usability of EHRs, as many contend. “It will take some time for the policies to matriculate into the technology and then for the technology to be in a state where you can say definitively that fixing E&M coding definitely helped EHRs be more usable and effective,” he says.

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