Friday, July 13, 2018

FOUR things you should know about Medicare’s “historic” changes to physician payments

The word “historic” is often used by PR professionals to hype something that is, well, pretty run-of-the-mill.  They figure that no one is going to read a news release that announces “[Name of organization] proposes small change that really won’t make much of a difference.”  The problem is that when something is done that really measures up to being historic, the recipient is less likely to believe it, kind of like the constant Breaking News chyrons loved by cable news shows. 

Yesterday, CMS—the agency that runs Medicare—issued a press release announcing “Historic Changes to Modernize Medicare and Restore the Doctor-Patient Relationship.”  You know what? This one may actually live up to the billing!

CMS is proposing to radically overhaul how it pays physicians for office visits and other evaluation and management (E/M) services; to lift restrictions on payment for telehealth consults and other physician services that are not part of the office visit itself; and to ease the myriad of crushing administrative tasks imposed on physicians to document their services or to get credit for participating in Medicare’s Quality Payment Program.

Both of CMS’s proposed rules are thousands of pages long, so few readers of this blog will be up to reading them. (Never mind trying to decipher the technical and legalistic language used for federal rulemaking!)  Fortunately, ACP’s crackerjack regulatory affairs staff was at it late last night and early this morning (when do they sleep???), to go through it and find out what is to like, and not like, about it.

They found that there is much to like.  Based on their review, ACP released a statement just a short while ago that expressed optimism that many of the proposed changes will “streamline burdensome administrative and documentation requirements –a proposal that is in line with ACP’s Patients Before Paperwork initiative” as Ana María López, MD, MPH, FACP, president, ACP, put it.  ACP also cautioned, though, that one of the biggest changes proposed by CMS—paying a flat fee for most office visits, regardless of their complexity—needed greater examination because of its potential to undervalue the skill and training required of physicians to take care of patients with more complex medical conditions.

There are 4 BIG changes proposed by CMS that are noteworthy:

1.  CMS proposes to make it less burdensome for physicians to participate in its Quality Payment Program, including streamlining the Promoting Interoperability MIPS category by removing the separate components within the Promoting Interoperability (formally Advancing Care Information) Category score to create a streamlined scoring methodology, increasing the ways in which physicians and other clinicians can qualify for the low-volume threshold  and removing a number of quality measures deemed by the agency to be of low-value, consistent with recommendations by ACP and its Performance Measurement Committee.

2.  CMS proposes to pay for more physician services that are not part of a face-to-face office visit. CMS proposes to add new reimbursable codes for “virtual check-ins,” remote consults of patient videos and photos, and interprofessional online consultations.

3.  CMS proposes to take major steps to reduce the documentation requirements associated with evaluation and management (E/M) services, by allowing medical decision making to be the basis for documentation, requiring physicians 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.  CMS also proposes to create add-on codes for primary care visit complexity.

4.  CMS proposes to create a flat, single blended payment for most office visits, regardless of their complexity.  ACP expressed concern that this proposed payment structure potentially could have an adverse impact on internal medicine physicians and subspecialists and their patients, since internists typically take care of elderly patients with multiple chronic conditions.  “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.”

There is much more to the proposed rules, including several areas where it fell short in ACP’s opinion.

Still, the overall direction of easing the burdens of participating in Medicare’s QPP, simplifying requirements to document office visits, paying for telehealth consultations and other work that falls outside of an office visit, and yes, the proposal to pay a flat fee for office visits of varying levels of complexity (whether this turns out to be a good idea or not after further examination of its impact), might just live up to being “historic.” 

Today’s question: what do you think of CMS’s “historic” proposals to change Medicare payments to doctors and its Quality Payment Program?


Angus Worthing, MD said...

Internists and especially internal medicine sub-specialists can expect cuts in reimbursement for taking care of complex/ sick patients. This could worsen the doctor shortage & prolong wait times to see a doc.

Note that reimbursement changes are multiplied by 3 in order to calculate true pay cuts. For example 3% cut (expected for rheumatologists) becomes ~10% cut after paying ~70% business overhead costs.

Med students who are paying attention will be turned off from cognitive or complex specialties.

Unknown said...

If the problem is over burdensome documentation, then fix that. The E/M tables are not intuitive and could easily be simplified. But to pay the same for a 5-10 minute visit compared to a 20-30 minute visit is crazy. Perhaps have "unintended consequences"? In a time were it is already hard to find physicians willing to grapple with the growing number and degree of complex patients, the Retail Clinics will profit more and the ACP's support of this may just be the nail in the coffin for Internal Medicine.

Unknown said...

Why doesn't the author be realistic about this new 'historic ' MCR change in reducing E&M visit reimbursement ,as a "reduction in payment", plain and simple! Knowing that any rationale, and well trained physician will look at a problem, and develop a plan to maximize his work effort for max payment, is exactly what many of us have done, while taking care of complex medical problems first and foremost. Now that we have 'figured it out' , MCR has found that we are paid too much for the service performed. You can't have it both ways, ...good care requires investigating and knowing the med. record to make complex decisions, and deserves the max. reimbursement allowed. Making a reduction in payment, while "simplifying" the med. record, does not mean the physician needing to still know this info , won't actually still make efforts to get it(whether documented or not, which is what we did long before the E&M coding guidelines came out), so as to ensure he is making the right types of complex decision making...but now will find himself being paid less for the same work done, which will actually cause more harm in that these physicians will have another reason to leave medicine due to financial hardship in addition to the 'burnout'(while trying to find other financial resources and time to 'make ends meet') caused by MCR, due its insidious way to cheapen the services that are deserving for care of this ill pt population, which are ultimately the group of individuals that will in the end be hurt the most. Wise up MCR and pay people fairly for the work effort, and stop being so sneaky!!!!
JJ SmithMD

Unknown said...

We are a 60 physician practice in the lower Hudson Valley in New York, representing internal medicine, urology, gastroenterology, rheumatology, dermatology, podiatry, endocrinology, nephrology and pulmonary medicine specialties. We are writing to make you aware of the recent CMS proposal having to do with changing documentation and payment for E&M coding which is part of the initiative, “Patients over Paperwork“. In brief, CMS proposes simplifying documentation guidelines and collapsing E&M codes higher than 99211 and 99201 into one code with a blended rate of reimbursement. For a more complete but brief outline of this proposal, going to Patients over Paperwork and scrolling down to click on “Sharing our 2019 Medicare physician fee schedule proposed rule presentation” will inform the interested reader. The goal of allowing doctors to spend more time with patients and less with documentation is the spoken outcome, but this proposal will result in anything but that achieving that goal.
The documentation which has been chosen for elimination/simplification is the easiest and least time consuming for physician to perform with the electronic measures we have been encouraged to adopt. Having adjusted our EMR’s to accomplish the E&M requirements in place for the past 20 years, we are copying information and opening fields of previous data with a few clicks. In other words, physicians have gotten good at this. Calculating about 15 seconds per patient, changing this documentation would save about 10 physician hours a year.

Unknown said...

The ever-increasing stress of our electronic time comes from listening to webinars, spending time working with our EMR venders to create and click new, and recognizable fields and performing other IT gymnastics to meet CMS MIPS requirements. We have been called upon to learn, implement and pay for these with our time and resources, and we are doing our best to comply.
Perhaps because of the extra time CMS says will be generated by this proposal, or because they will no longer be able to track how much work we are doing for our patients, CMS has proposed a blended rate of reimbursement for all but nurse visits, which will greatly disadvantage providers who spend time caring for patients requiring complex care. We serve a large Medicare population with problems which are increasingly time consuming and very often qualify for 99204 and 99214 levels of care. The proposed new blended payment would result in at least a 10-15% cut in reimbursement. CMS proposes an additional code that physicians can use to add to the blended rate which would result in 5 more dollars for primary care providers and 15 more dollars for specialty providers. According to the Federal document which explains CMS reasoning for the additional primary care code, it was created to cover “additional resource costs and maintain the work as budget neutral” for “visit complexity inherent to the evaluation and management associated with primary medical care services that serve as the continuing focal point for all needed health care services”. It is both frightening and demeaning to discover that CMS believes the aforementioned care to be worth less for primary care providers than for specialists, and less than cost of a Starbucks coffee.
CMS’s goal is to promote better, less expensive care for patients and to encourage providers to take on risk for patient care. This care must take place in some form of a primary care office setting as opposed to the overuse of specialty, emergency room and hospital care.
A 10-15% decrease in Medicare reimbursement will result in less time available for each patient because there will need to be more patients seen every day to offset the financial loss. Visits will need to be shorter and will cover fewer concerns with patients returning more frequently. More patients will end up in emergency rooms and hospitals.
There will be less money available for support staff and for new staff such as chronic care managers and mental health providers whom we are being encouraged to hire to improve the quality and broaden the level of our care.
There will be an increase in referrals to specialists to handle more complicated problems. With this increase in the use of referrals and hospitals, providers who were working to decrease resource utilization will be reluctant to assume financial risk for their patients’ care.
Office physicians who depend on reimbursement from E&M codes will be disproportionately affected in comparison to specialists who are paid higher rates to perform procedures.
For all the above reasons, we do not favor the adoption of this policy. If it is adopted in some form, the blended reimbursement rates should be within $1-$2 of the current rates for 99204 and 99214 without the add-on 5 and $15 codes. We will already be giving up the higher reimbursement rates for 99205 and 99215.
As discussed, expenses for physicians in terms of time and resources is increasing. If CMS is to be the agent for beneficial change for Medicare patients and desires respect and cooperation from the practicing physician community, its proposals must be at least cost neutral.
We asked that your organization do everything possible to make physicians across the country aware of this proposal and to fight its adoption. We are told that feedback must be received by September 10

Bob Doherty said...

No where in this post did I say that ACP was supporting the flat blended payment rate for evaluation and management services. We are not. At the same time, the reduction in documentation requirements, payment for prolonged services, and payment for virtual visits are positive aspects of the proposed rule. ACP will be urging CMS not to proceed with the current proposal as is, to take at least the next year to work with us and others on an alternative approach that would reimburse more for complex visits while still advancing the goals of simplying documentation and paying for virtual visits.