Late in the afternoon on Thursday, Nov. 1, the federal Centers for Medicare & Medicaid Services (CMS) published a final rule that provides updates to the Physician Fee Schedule and calendar-year 2019 Quality Payment Program (QPP), which encapsulates the Medicare Incentive-based Payment Program (MIPS) and Advanced Payment Models
In the proposed rule, which was released July 12, CMS recommended sweeping changes to MIPS measures, Evaluation and Management (E&M) coding and telemedicine reimbursement. At the time of the proposed rule’s release, CMS officials said the proposed changes will “fundamentally improve the nation’s healthcare system and help restore the doctor-patient relationship by empowering clinicians to use their electronic health records (EHRs) to document clinically meaningful information.”
In similar remarks about the finalized 2,378-page rule, CMS officials said changes to the Medicare Physician Fee Schedule and Quality Payment Program will shift clinicians’ time from completing unnecessary paperwork to providing innovative, high-quality patient care. The proposals in the final rule “address provider burnout and provide clinicians immediate relief from excessive paperwork tied to outdated billing practices,” CMS said in a press release.
CMS officials said the changes advance innovation, restore focus to patients and support moving the healthcare system to value-based care. A fact sheet on the final rule published Nov. 1 can be accessed here.
According to CMS officials, in Year 3 of the Quality Payment Program, CMS is continuing to use the framework established by the Patients Over Paperwork initiative, implement meaningful measures, promote interoperability, support small and rural practices, reduce clinician burden, and improve patient outcomes.
The changes in the CY 2019 PFS and QPP final rule establish Medicare payment for when beneficiaries connect with their doctor virtually using telemedicine to determine whether they need an in-person visit. Additionally, the QPP changes, set to take place in year three of the program, in 2019, would make changes to quality reporting requirements to focus on measures that most significantly impact health outcomes, CMS said.
The changes will encourage information sharing among healthcare providers electronically. And, the QPP final rule will make changes to the 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 “Promoting Interoperability” program for hospitals, which was published as a final rule in August.
“The final 2019 Physician Fee Schedule (PFS) and the Quality Payment Program (QPP) rule released today also modernizes 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.” CMS stated. “It makes changes to ease health information exchange through improved interoperability and updates QPP measures to focus on those that are most meaningful to positive outcomes. Today’s rule also updates some policies under Medicare’s accountable care organization (ACO) program that streamline quality measures to reduce burden and encourage better health outcomes, although broader reforms to Medicare’s ACO program were proposed in a separate rule.”
CMS projects that the changes will save clinicians $87 million in reduced administrative costs in 2019 and $843 million over the next decade. The changes will result in 21 million hours saved for physicians over 10 years beginning in 2021, CMS said.
During a press call late Thursday afternoon to address the final rule, CMS Administrator Seema Verma said, “During the past year and a half, we have introduced several initiatives aimed at doing the things necessary to finally achieve the long talked-about goal of value-based care. With healthcare costs skyrocketing and the demands of Americans only increasing, value-based care isn’t something that we’d like to do, it’s something that we must do,” Verma said. “To that end, our initiates serve to do the things necessary to move our healthcare system towards one that pays for the value of service rather than the mere volume.”
Verma said CMS is working to put the patient at the center of the healthcare system. “We advanced several initiatives, including Patients over Paperwork, Meaningful Measures and MyHealthEData in our rules this week.”
Verma said Thursday’s announcement was another example of CMS is “putting action behind words.” “Today’s rules represent a big win, in terms of access to care in convenient and efficient ways by offering patients new choices in how connect they with doctors and caregivers. For the first time in 2019, Medicare will pay doctors for virtual check ins with their patients, virtual consultations between physicians, evaluation of remote pre-recorded images and video and an expanded list of telehealth services,” Verma said.
“The historic reforms CMS finalized today move us closer to a healthcare system that delivers better care for Americans at lower cost,” Health and Human Services (HHS) Secretary Alex Azar, said in a statement. “Among other advances, improving how CMS pays for drugs and for physician visits will help deliver on two HHS priorities: bringing down the cost of prescription drugs and creating a value-based healthcare system that empowers patients and providers.”
“Today’s rule finalizes dramatic improvements for clinicians and patients and reflects extensive input from the medical community,” Verma said in a statement released with the final rule. “Addressing clinician burnout is critical to keeping doctors in the workforce to meet the growing needs of America’s seniors. Today’s rule offers immediate relief from onerous requirements that contribute to burnout in the medical profession and detract from patient care. It also delays even more significant changes to give clinicians the time they need for implementation and provides time for us to continue to work with the medical community on this effort.”
The final CY 2019 PFS and QPP rule retains many of the dramatic changes to MIPS measures, E&M coding and telemedicine reimbursement contained in the proposed rule, but CMS officials did make some changes in the final rule in response to stakeholder concerns, Verma stated in the press release.
Speaking to Managing Editor Rajiv Leventhal at the CHIME Fall Forum in San Diego, Mari Savickis, vice president, federal affairs at the Ann Arbor, Mich.-based College of Healthcare Information Management Executives (CHIME), said in response to the final rule's release: "The biggest takeaway for us, and we’re still combing through the rule, is the telehealth part. [CMS] has done so many positive things here, that it's no longer one toe in the water; it’s definitely now one foot in the water. This is a great start for 2019, and it’s exceptionally promising that they are following through on many things we have seen from Congress.”
“And they appear to largely have aligned physicians [in this rule] with hospitals in the Promoting Interoperability rule. That is a huge burden reduction for our members. We also strongly support fewer measures and objectives. We have been advocating for that for years," Savickis said.
E&M Documentation Reforms
During the press call, Verma said coding requirements for physician services known as “evaluation and management” (E&M) visits have not been updated in 20 years. Verma said the final rule simplifies documentation so doctors can spend more time with patients. The final rule addresses longstanding issues and also responds to concerns raised by stakeholders when commenting on the proposed rule, Verma said.
Initially, in the proposed rule, CMS proposed major reforms to E&M payments including single blended payment rates for both new and established patients for office/outpatient E&M level 2 through 5 visits, essentially proposing to collapse the number of codes from five levels to two.
After listening to concerns from the provider community, CMS modified its proposals and will maintain a separate level of payment for the most complex patient care, or level 5 visits, Verma said.
The agency also is delaying implementation of E&M coding reforms until 2021, which will enable continued stakeholder engagement. “Physicians will see some immediate changes in 2019 that reduce burden and even more significant burden reduction in 2021, when broader changes to the E&M framework take effect,” Verma said. A CMS chart on E&M payment amounts can be found here.
Reimbursing for Virtual Care
As it relates to virtual care, CMS officials said that provisions in the CY 2019 Physician Fee Schedule would support access to care using telecommunications technology. Under the final rule, Medicare will pay providers for new communication technology-based services, such as brief check-ins between patients and practitioners, and pay separately for evaluation of remote pre-recorded images and/or video. CMS is also expanding the list of Medicare-covered telehealth services.
“This provides opportunities for patients around communicating with providers remotely. We’ve never had this in the program at large. There has been a telehealth benefit mostly for rural providers, but access to care is not just a rural issue, it’s something that patients struggle with across the country,” Verma said. “This is an historic change in terms of increasing access and it’s also a great example of some of the efforts that we’re trying to make around supporting innovation. This has been happening in the private market and I think the opportunities and the impact could be tremendous. We’re excited to be able to harness this innovation for Medicare beneficiaries.”
Changes to MIPS
Finally, regarding year three of MIPS, CMS made changes to remove 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, agency officials said.
The rule also will overhaul the MIPS “Promoting Interoperability” (formerly called Advancing Care Information) 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 new Promoting Interoperability Program for hospitals. For the Promoting Interoperability performance category, CMS is requiring that MIPS-eligible clinicians to use 2015 Edition certified EHR technology beginning with the 2019 MIPS performance period.
“This means that physician incentives are now directly tied to doctors updating their systems so that they are interoperable,” Verma said during the press call. “Today is an important milestone toward increasing the interoperability of electronic health records, which is critical to patient empowerment and driving toward a value-based healthcare system. We firmly believe health records belong to patients, and patients should control them and be able to share them with providers, researchers, caregivers, or whomever they want.”
CMS also introduced an opt-in policy so that certain clinicians who see a low volume of Medicare patients can still participate in MIPS, if they choose to do so, according to CMS. In addition, CMS is providing the option for clinicians who are based at a healthcare facility to use facility-based scoring to reduce the burden of having to report separately from their facility.
In addition, the rule continues CMS’s work to deliver on President Trump’s commitment to lowering prescription drug costs. Effective January 1, 2019, payment amounts for new drugs under Part B will be reduced, decreasing the amount seniors have to pay out-of-pocket, especially for drugs with high launch prices, CMS stated.
During the press call, Verma said the CMS initiatives announced in the past year and a half are a reflection of the agency’s “serious commitment to patient-centered care.” And, Verma noted that some industry stakeholders will have complaints about the changes to PFS and QPP programs. “This does not deter us. The status quo, where nearly one in five dollars will be spent on healthcare, is unacceptable. If we’re going to move our system to a patient-centered, value-based system, change is inevitable, and change is always hard for those whose livelihood is dependent on the status quo.”