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.

2. 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.

2. 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?