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:
- 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.
- 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.
- 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?
1 comment :
I agree.
I would also note that it is getting harder for Medicare patients in particular to get the primary care they need. It is more costly to take care of older patients who, in general, have more medical problems, are often on complicated medical regimens, and often have a greater number of specialists involved in their care. They are hospitalized more often and often have significant socioeconomic barriers to care. For physicians in primary care it makes more sense from a purely economic standpoint to see younger, healthier patients with fewer chronic conditions. I believe that if the proposed changes are implemented, these problems will be further exacerbated.
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