CMS releases proposed 2019 Medicare PFS & QPP

The Centers for Medicare & Medicaid Services (CMS) distributed the following press release on July 12…

Today, the Centers for Medicare & Medicaid Services (CMS) proposed historic changes that 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 proposed rules would fundamentally improve the nation’s health care system and help restore the doctor-patient relationship by empowering clinicians to use their electronic health records (EHR) to document clinically meaningful information, instead of information that is only for billing purposes.

“Today’s reforms proposed by CMS bring us one step closer to a modern health care system that delivers better care for Americans at a lower cost,” said HHS Secretary Alex Azar. “Such a system requires empowering American patients by giving them price and quality transparency and control over their own interoperable health records, goals supported by CMS’s proposals. These proposals will also advance the successful Medicare Advantage program and accomplish a historic regulatory rollback to help physicians put patients over paperwork. Further, today’s proposed reforms to how CMS pays for medicine demonstrate the commitment of HHS to implementing President Trump’s blueprint for lowering drug prices. The ambitious reforms proposed by CMS under Administrator Verma will help deliver on two HHS priorities: creating a value-based health care system for the 21st century and making prescription drugs more affordable.” 

“Today’s proposals deliver on the pledge to put patients over paperwork by enabling doctors to spend more time with their patients,” said CMS Administrator Seema Verma. “Physicians tell us they continue to struggle with excessive regulatory requirements and unnecessary paperwork that steal time from patient care. This Administration has listened and is taking action. The proposed changes to the Physician Fee Schedule and Quality Payment Program address those problems head-on, by streamlining documentation requirements to focus on patient care and by modernizing payment policies so seniors and others covered by Medicare can take advantage of the latest technologies to get the quality care they need.”

The proposals, part of the Physician Fee Schedule (PFS) and the Quality Payment Program (QPP), would also modernize Medicare payment policies to promote access to virtual care, saving Medicare beneficiaries time and money while improving their access to high-quality services no matter where they live. Such changes would establish Medicare payment for when beneficiaries connect with their doctor virtually using telecommunications technology (e.g., audio or video applications) to determine whether they need an in-person visit. Additionally, the QPP proposal would make changes to quality reporting requirements to focus on measures that most significantly impact health outcomes. The proposed changes would also encourage information sharing among health care providers electronically, so patients can see various medical professionals according to their needs while knowing that their updated medical records will follow them through the healthcare system. The QPP proposal would make important changes to the Merit-based Incentive Payment System (MIPS) “Promoting Interoperability” performance category to support greater EHR interoperability and patient access to their health information, as well as to align this clinician program with the proposed new “Promoting Interoperability” program for hospitals.

If today’s proposals were finalized, clinicians would see a significant increase in productivity – leading to substantially more and better care provided to their patients. Removing unnecessary paperwork requirements through the PFS proposal would save individual clinicians an estimated 51 hours per year if 40 percent of their patients are in Medicare. Changes in the QPP proposal would collectively save clinicians an estimated 29,305 hours and approximately $2.6 million in reduced administrative costs in CY 2019.

Key CY 2019 Physician Fee Schedule Changes 

The Physician Fee Schedule establishes payment for physicians and medical professionals treating Medicare patients. It is updated annually to make changes to payment policies, payment rates and quality-related provisions. Extensive public feedback the agency has received has highlighted a need to streamline documentation requirements for physician services known as “evaluation and management” (E&M) visits, as well as a need to support greater access to care using telecommunications technology.

The proposed changes to the Physician Fee Schedule would reinforce CMS’ Patients Over Paperwork initiative focused on reducing administrative burden while improving care coordination, health outcomes, and patients’ ability to make decisions about their own care.

Streamlining E&M Payment and Reducing Clinician Burden

CMS and the Office of the National Coordinator for Health Information Technology (ONC) have heard from stakeholders that CMS’s extensive documentation requirements for Evaluation and Management 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.

Responding to stakeholder concerns, several provisions in the proposed CY 2019 Physician Fee Schedule would help to free EHR to be powerful tools that would actually support efficient care while giving physicians more time to spend with their patients, especially those with complex needs, rather than on paperwork. Specifically, this proposal would…

– Simplify, streamline and offer flexibility in documentation requirements for Evaluation and Management office visits — which make up about 20 percent of allowed charges under the Physician Fee Schedule and consume much of clinicians’ time.

– Reduce unnecessary physician supervision of radiologist assistants for diagnostic tests.

– Remove burdensome and overly complex functional status reporting requirements for outpatient therapy.

Advancing Virtual Care

“CMS is committed to modernizing the Medicare program by leveraging technologies, such as audio/video applications or patient-facing health portals, that will help beneficiaries access high-quality services in a convenient manner,” said Administrator Verma.

Getting to the doctor can be a challenge for some beneficiaries, whether they live in rural or urban areas. Innovative technology that enables remote services can expand access to care and create more opportunities for patients to access personalized care management as well as connect with their physicians quickly.

Provisions in the proposed CY 2019 Physician Fee Schedule would support access to care using telecommunications technology by…

– Paying clinicians for virtual check-ins – brief, non-face-to-face appointments via communications technology.

– Paying clinicians for evaluation of patient-submitted photos.

– Expanding Medicare-covered telehealth services to include prolonged preventive services.

Lowering Drug Costs

President Trump is putting American patients first and lowering prescription drug costs, and CMS is committed to advancing this effort. CMS is today proposing changes as part of the continued rollout of the Administration’s blueprint to lower drug prices and reduce out-of-pocket costs.

The changes would affect payment under Medicare Part B. Part B covers medicines that patients receive in a doctor’s office, such as infusions. CMS is proposing a change in the payment amount for new drugs under Part B, so that the payment amount would more closely match the actual cost of the drug. This change would be effective January 1, 2019, and would reduce the amount that seniors would have to pay out-of-pocket, especially for drugs with high launch prices. This is one of many steps that CMS is taking to ensure that seniors have access to the drugs they need.

Proposed Key CY 2019 QPP Changes

To implement the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), CMS established the Quality Payment Program (QPP), which consists of two participation pathways for doctors and other clinicians – the Merit-based Incentive Payment System (MIPS), which measures performance in four categories to determine an adjustment to Medicare payment, and Advanced Alternative Payment Models (Advanced APM), in which clinicians may earn an incentive payment through sufficient participation in risk-based payment models.

The proposed changes to QPP aim to reduce clinician burden, focus on outcomes, and promote interoperability of electronic health records (EHRs), including by…

– Removing 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.

– Overhauling the MIPS “Promoting Interoperability” 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.

Under the requirements of the Bipartisan Budget Act of 2018, CMS is continuing the gradual implementation of certain MIPS requirements to ease administrative burden on clinicians. The proposed changes to the Quality Payment Program reflect feedback and input from clinicians and stakeholders, and we will continue to offer free and customized support from CMS’s technical assistance networks.

MAQI Demonstration

Aligning with the agency’s goals of improving quality of care and responding to the feedback we have received from clinicians, CMS also proposes waivers of MIPS requirements as part of testing a demonstration called the Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) demonstration. The MAQI demonstration would test waiving MIPS reporting requirements and payment adjustments for clinicians who participate sufficiently in Medicare Advantage (MA) arrangements that are similar to Advanced APM.

Some Medicare Advantage plans are developing innovative arrangements that resemble Advanced APMs. However, without this demonstration, physicians are still subject to MIPS even if they participate extensively in Advanced APM-like arrangements under Medicare Advantage. The demonstration will look at whether waiving MIPS requirements would increase levels of participation in such MA payment arrangements and whether it would change how clinicians deliver care.

Price Transparency

Finally, as part of its commitment to price transparency, CMS is seeking comment through a Request for Information asking whether providers and suppliers can and should be required to inform patients about charge and payment information for healthcare services and out-of-pocket costs, what data elements would be most useful to promote price shopping, and what other changes are needed to empower health care consumers.

Public comments on the proposed rules are due by September 10, 2018.

AMA’s Assessment

In assessing the Medicare Fee Schedule proposals, the American Medical Association (AMA) points out that…

– With the budget neutrality adjustment to account for relative value changes, as required by law, the proposed 2019 PFS conversion factor is $36.05, a slight increase above the 2018 PFS conversion factor of $35.99.

– CMS has proposed to collapse payment for office and outpatient visits. New patient office visit (99202-99205) payments would be blended to be $135. Established office visits (99212-99215) would be blended to be paid at $93. New codes would be created to provide add-on payments to office visits for specific specialties ($9) and primary care physicians ($5). 

– To replace existing documentation guidelines, CMS proposes to allow the use of 1) 1995 or 1997 documentation guidelines or 2) medical decision-making or 3) time. Documentation for history and exam will focus on interval history since last visit. Physicians will be allowed to review and verify certain information in the medical record entered by ancillary staff or the beneficiary, rather than re-entering the information.

– When physicians report an E/M service and a procedure on the same date, CMS proposes to implement a 50 percent multiple procedure reduction to the lower paid of the two services.

– CMS will implement new CPT codes and payment for remote monitoring and interprofessional consultations.

– CMS updated supplies and equipment pricing. The re-pricing of antigens has a significant impact on allergy and immunology payments, with an estimated six percent reduction for the specialty.

AMA also notes that key Merit-based Incentive Payment System (MIPS) proposals would…

Retain the low-volume threshold but add a third criterion of providing fewer than 200 covered professional services to Part B patients.  

Retain bonus points for 1) care of complex patients and 2) end-to-end reporting and 3) small practices.

Allow eligible clinicians to opt-in if they meet one or two, but not all, of the low volume threshold criterion.

Consolidate the low-volume threshold determination periods with the determination period for identifying a small practice.

Eliminate the base and performance categories and reduced the number of measures in the Promoting Interoperability category.

Require eligible clinicians to move to 2015 CEHRT.

Provide an option to use facility-based scoring for facility-based clinicians.

AMA says that the 2019 performance year weights proposals include quality at 45 percent, cost at 15 percent, promoting interoperability at 25 percent, and improvement activities at 15 percent.

Finally, AMA points out that the Bipartisan Budget Act of 2018 provided additional flexibility for CMS on several MIPS issues, including…

Excluding Medicare Part B drug costs from MIPS payment adjustments and from the low-volume threshold determination.

Allowing CMS to reweight the cost performance category to not less than 10 percent and not more than 30 percent for 2019-2021 performance years.

Allowing CMS flexibility in setting the performance threshold for performance years 2019-2021 to provide a gradual and incremental transition for physicians.

Click for CY 2019 Physician Fee Schedule proposed rule fact sheet

Click for CY 2019 Physician Fee Schedule proposed rule

Click for CY 2019 Quality Payment Program proposed rule fact sheet

Click for CY 2019 Quality Payment Program proposed rule

Click for MAQI Demonstration fact sheet