Monday, August 27, 2018

Finding a winning way forward on CMS’s proposals to restructure physician payment

Last month, I wrote about CMS’s “historic” proposals to change how physicians would be paid for their office visits and the documentation that would be required of them. 

I noted then that while ACP expressed strong support for the push to reduce the documentation burden on clinicians, we also expressed concern that flat blended fee could have an adverse impact on internal medicine physicians and subspecialists and their patients.  In an official statement of ACP’s initial reaction to the proposal, issued the day after the proposal was released, ACP President Dr. Ana María López had this to say:

“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.”

Since then, ACP has heard from many internists who are greatly concerned about the adverse impact of paying a single flat blended fee for levels 2-5 evaluation and management services.  They passionately believe that paying the same amount for the most complex office visits as less complex ones would harm their patients, and must be opposed by ACP.

We agree—CMS’s proposal for flat fee for E/M services is not acceptable.  At the same time, we believe that that the agency’s plan to reduce documentation requirements for E/M services has great value, because E/M documentation is a major contributor to physicians’ frustrations with their EHRs. In a 2015 position paper, Clinical Documentation in the 21s Century, developed by our Medical Informatics Committee, ACP observed that current E/M documentation requirements have fundamentally changed the nature of the clinical note:

 “In place of a thoughtfully written review of systems that listed pertinent positive or negative findings, clinically meaningless terms such as “ten point review of systems was negative” were introduced into the record to satisfy E&M guidelines. Instead of clinical needs determining the level of detail of the physical examination, documentation of the examination was driven by the required number of “bullets” to fulfill the requirements for a specific code.. . what is now illogically considered to be the gold standard of a good note comes not from clinical professors and mentors but from professional coders and corporate compliance training. An imbalance of values has been created, with compliance, coding, and security trumping patient care, clinical well-being, and efficiency. A harshly negative ‘gotcha’ mentality that saps the professionalism out of physicians has also appeared.”

This is still the case, and CMS’s proposals to reduce E/M documentation requirements are a good start in addressing this highly dysfunctional situation.  The problem is that CMS says it can’t reduce E/M documentation unless it goes along with paying a flat fee for E/M services. That’s not a rationale, or trade-off, that ACP can accept. We think that CMS can reduce E/M documentation while preserving the principle that more complex cognitive care should be paid more than less complex care.

ACP, through its regulatory affairs staff with oversight and direction from the physician-members on our Medical Practice and Quality Committee (whose chair and vice chair are both practicing internists in smaller independent practices), is in the process now of drafting official comments on CMS’s proposed rule, due September 10.  While not yet final, I anticipate that our comments will articulate the following key points:

  1. ACP strongly believes that cognitive care of more complex patients must be appropriately recognized with higher allowed payment rates than less complex care patients. CMS’s current proposal to pay a single flat fee for E/M levels 2-5, even when combined with proposed primary care and specialist add-on codes and payment for prolonged services, undervalues cognitive care for the more complex patients, potentially creating incentives for clinicians to spend less time with patients, to substitute more complex and time-consuming visits with lower level ones of shorter duration, schedule more shorter and lower-level visits, and potentially, avoid taking care of older, frailer, sicker and more complex patients. It could also create a disincentive for physicians to practice in specialties, like geriatrics and palliative care, that involve care of more complex patients. Accordingly, the proposal to pay a single flat fee for E/M levels 2-5 must not be implemented.

  1. ACP appreciates and supports the overall direction of CMS’s proposals to reduce the burden of documentation for E/M services, yet strongly disagrees that such improvements should be contingent on acceptance of CMS’s proposal to pay a single flat fee for E/M levels 2-5. While we understand CMS’s concerns that changes in E/M documentation requirements, without changes in the underlying payment structure for E/M services, could create program integrity challenges, we believe that CMS should consider testing of alternatives that would allow it to move forward on simplifying documentation, ensure program integrity, and preserve the overarching principle that more complex and time-consuming E/M services must be paid appropriately more than lower level and less time-intensive services.
  1. ACP urges CMS not to establish a regulatory deadline (e.g. January 1, 2019 or January 1, 2020) for finalizing and implementing its flat E/M fee proposals or possible alternatives that change how E/M services would be paid, and instead, to take the time to “get it right.” Sufficient time must be allowed to engage the physician community to develop and pilot-test alternatives that preserve the principle that more complex and time-consuming E/M services must be paid appropriately more than lower level and less time-intensive services, while allowing CMS to move forward on simplifying E/M documentation while ensuring program integrity. The stakes for patients, clinicians, and the Medicare program are too great for CMS to rush changes
Instead of just telling CMS all of the things that are wrong with their proposal for flat E/M bundled payments (and there are plenty of them, to be sure), we should point them toward a truly winning outcome for physicians, patients, and the program, one that reduces E/M documentation (that has resulted in “compliance, coding, and security trumping patient care, clinical well-being, and efficiency)” while preserving higher payment for more complex cognitive care.

Today’s question: what would you like to hear ACP say in its response to CMS’s proposals?

Friday, August 3, 2018

An Immigrant's Tale

There are many things that make me proud of the American College of Physicians. 

ACP’s courageous leadership in standing up for those seeking to immigrate to the United States is one of them.  Over the past 18 months, ACP has issued a comprehensive statement on immigration policy affirming its opposition “to discrimination based on religion, race, gender or gender identity, or sexual orientation in decisions on who shall be legally admitted to the United States as a gross violation of human rights,” opposed the President’s original Executive Order barring immigrants from six majority Muslim countries because it was discriminatory, and would adversely affect non-U.S. born IMGs seeking to study, train, or provide medical care in the United States; joined in an amicus brief to the U.S. Supreme Court urging that the court overturn a modified version of the ban for the same reasons; issued a statement expressing concern that the Supreme Court upheld the ban; advocated for legislation to provide permanent legal status, and eventually citizenship, for persons enrolled in DACA (Dreamers); successfully advocated to end delays in processing H-1B visa applications from IMGs that were stalled or denied due to increased scrutiny regarding prevailing wage data; objected to the administration’s “zero tolerance” policy of separating immigrant children from parents, or detaining parents and children together in detention facilities, because of the harm to the health of children and their families.

Many other medical organizations have shied away from immigration policy, maybe because it is considered to be too controversial, too complicated, too political, and too divisive, among their own members and the public.  Some may feel that immigration policy is not their area of expertise.
For sure, there are reasons to be cautious about entering the fray: immigration is controversial, complicated, political, and divisive, and physicians are not experts on how to enforce U.S. immigration laws or control access to our borders.

But physicians are experts on how public and social policy affects the health of the public and their patients.  While immigration policy is complicated and controversial, so are many other issues, from gun violence, to high prescription drug prices, to what happens if people are denied access to affordable coverage. Yet, many physician professional societies have tackled those issues, because of their abiding concern for patients. 

While my own family experience has no bearing on ACP policy, it is one of the reasons why I am especially proud of ACP’s willingness to speak out on the impact of immigration policies as a public health and human rights issue.

My father, Jack Doherty, was born poor in Ireland, in a thatched cottage with no plumbing or electricity.  He originally emigrated with my grandmother and grandfather to New York City as an infant. For reasons unknown to me, my dad at age two returned to Ireland with my grandmother, without my grandfather. My grandmother raised my dad as single mother in Ireland on a subsistence farm for eight years, during which they had no contact with my grandfather. When my father was 10, they got a letter from my grandfather asking them to return to NYC to be with him.  They sailed in steerage once again to NYC and were reunited with my grandfather.

My grandfather, Thomas, was a bar-owner and bartender at Doherty’s Bar in Woodside, Queens, NYC.  My father told me he had a very difficult relationship with his father, given that my grandfather had abandoned him and my grandmother for so many years, and my father had grown up without knowing his dad.

Thomas died when my father was only 16. My widowed grandmother took over and ran Doherty’s Bar until my father was 18, and then my father ran it—not as an absent owner, but an owner-bartender who worked six days a week, 10 hour shifts behind the bar, serving shots and beer to blue collar workers.  He married my mother, Marilyn, a few years later, a U.S. born and college-educated woman who  came from a working class Irish-German background.

The bar ended up being successful enough for my mom, three sisters, and I to enjoy a middle-class lifestyle, enabling my siblings and I to go to good schools and colleges and have just about everything we wanted and needed. 

When I was in college, I was the third generation of Doherty men to work behind the bar while  on summer break from college.

Fast forward: my dad decided that being a bartender/bar-owner with only a high school diploma was not giving enough back the country (the U.S, not Ireland) that he so loved. While still tending bar 10 hours a day, six days per week, he went to college at night to get his B.A. in history, and then, a Masters in secondary education. He sold the bar in the late 1970s and became a NYC public school teacher, in a high school that taught mostly underprivileged minority students. He said he wanted to teach disadvantaged minority kids who faced discrimination and hardship because he had been a poor child himself, facing discrimination (the Irish at that time were not welcome by many Americans) and hardship.

Because my grandmother, grandfather, and father came to America to escape dire poverty, my sisters and I had great schooling and a college education. One of my sisters is a U.S. diplomat, one’s an award- winning theater costumer designer; one is a social worker who has spent most of her professional life counseling poor and emotionally troubled teenagers. I, of course, have spent my career advocating for internal medicine physicians.  The advantages we have had have been passed on to our children.

My dad passed away 11 years ago.  His immigrant story, like millions of others, is what truly makes America great: unskilled, poor people coming to America to improve their lives, and by doing so, improving America. 

So, when ACP speaks out for the unskilled, poor people coming to America today to improve their lives, it resonates with me. And makes me so proud. 

Today’s questions:  What is your view on ACP taking on immigration policy?  And do you have a family immigration story you want to share?