AMIA, MGMA, AMGA Offer Comments on CMS’ Latest E&M, Quality Payment Program Proposals | Healthcare Informatics Magazine | Health IT | Information Technology Skip to content Skip to navigation

AMIA, MGMA, AMGA Offer Comments on CMS’ Latest E&M, Quality Payment Program Proposals

September 10, 2018
by Rajiv Leventhal, Managing Editor
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Leading health IT associations have varying sentiments and recommendations for the Centers for Medicare & Medicaid Services (CMS) regarding the federal agency’s Physician Fee Schedule (PFS) and the Quality Payment Program (QPP) proposed rule that was released in July.

On July 12, CMS proposed changes that the agency believes 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.”

Included in the proposal were both changes to documentation requirements for Evaluation and Management (E&M) codes; modifications to how Medicare clinicians would be paid for virtual services rendered; as well as year three proposals for MACRA’s (the Medicare Access and CHIP Reauthorization Act of 2015) Quality Payment Program, including streamlining MIPS (Merit-based Incentive Payment System) participation, which includes the newly renamed Promoting Interoperability (PI) Program.

Healthcare Informatics covered the core takeaways from these proposals, particularly for how they impact the health IT community, in a story following the rule’s release in July

Now, in a letter delivered by the AMGA (formerly American Medical Group Association), the group noted that under the proposed rule, CMS would replace the current E/M codes with a new, single blended payment rate for E/M Level 2 through 5 visits. At the same time, CMS would apply a minimum documentation standard to provide Medicare Part B physicians with a choice of time, Medical Decision Making (MDM), or the use of the current 1995 or 1997 documentation guidelines. AMGA believes CMS is conflating two distinct or separate issues: documentation requirements and the complexity of a patient’s care needs represented by a billing code.

“Providing physicians with a choice in how to document beneficiary E/M visits would be a welcome development,” said AMGA President and CEO Jerry Penso, M.D. “It indicates CMS is serious about addressing administrative burden, particularly since these billing codes represent nearly one-third of all Medicare physician visits. Unfortunately, pairing paperwork reforms with a significant change in categorizing patient complexity and reimbursement may very likely undermine care quality and coordination and cause disruption in physician workflow and referral patterns.”   

What's more, in comments submitted CMS, the American Medical Informatics Association (AMIA) applauded federal officials “for aligning physician and hospital EHR requirements and advancing policies that further incentivize the adoption of health IT for patient care.” AMIA also supported CMS efforts to reduce documentation burden through new options to use time or Medical Decision Making as a basis to determine E&M visit level.

As part of E&M guideline reforms, CMS proposed to allow physicians the option to use time or MDM as a basis to determine E&M visit level. In its comments to CMS, AMIA said it supports both the use of MDM and time as alternative means to determine appropriate level of E/M visit. “However,” the group noted, “determining levels of MDM is a convoluted and complex task under current guidelines. This complexity must be addressed with an eye towards how IT and informatics can be leveraged so the simplicity of these solutions can be realized.”

AMIA specifically recommended that CMS support their proposed E&M reforms with focused and well-resourced efforts to leverage these current functions and develop emerging functions, such as natural language processing, medical device data, voice recognition software, and the use of sensors to capture clinical activity. “Acknowledging that these and other informatics tools are still early in development,” AMIA said, “CMS should support pilots and otherwise incentivize efforts meant to use these kinds of technologies and evaluate their use for documentation purposes.”

“Our current documentation paradigm is incompatible with the digital age,” noted Joseph Kannry, chair of AMIA’s public policy committee and lead technical informaticist at Mount Sinai Health System and Professor of Medicine Icahn School of Medicine at Mount Sinai. “While imperfect, CMS must proceed with E&M documentation reforms to address growing dissatisfaction and declining wellness among clinicians. Our billing-focused health IT ecosystem must be reoriented to patient care.”

Meanwhile, the Medical Group Management Association (MGMA), in its comments, said it “urges CMS to reconsider options for reducing documentation associated with E/M office visits to avoid harming physician practices that treat the sickest patients. This proposal oversimplifies the most common yet most diverse patient interactions while doing little to reduce paperwork.” Specifically, MGMA believes that CMS should not move forward with its proposal to collapse payment rates for eight office visits for new and established patients down to two each, as there are many unanswered questions and potential unintended consequences that would result, the group stated.

QPP Recommendations

AMIA said in its comments that by mirroring proposals finalized for hospitals in 2019, CMS would require the use of 2015 Edition CEHRT (certified EHR technology) 2019 and continue a 90-day EHR reporting period through 2020. The PI Program would also include a new points system scoring methodology and fewer required measures for hospitals to report. AMIA largely supported these proposals, while recognizing that important functionalities related to retired patient engagement measures, such as secure messaging, education, and use of patient-generated health data, must remain part of CEHRT, the group stated.

“Meaningful Use has served as a valuable vehicle to help digitize care delivery in the United States and thereby enable informatics-driven improvements in patient safety and clinical care,” said Peter J. Embi, M.D., AMIA board chair, and president and CEO, Regenstrief Institute. “But now is the time to think differently about how this program should evolve to meet the rapidly-changing, and often challenging, environment of care delivery. These new proposals position the program to build on progress made to-date, and our recommendations provide impetus for even more innovative changes focused on the ultimate goals of improving health and healthcare.”

MGMA, meanwhile, believes that CMS ought to simplify MIPS and reduce redundancies by awarding multi-category credit. As implemented, MGMA noted, “MIPS reflects a continuation of the agency’s historically siloed approach to quality reporting, consisting of four programs under one umbrella. To reduce burden, CMS should award credit in multiple categories for overlapping efforts, such as using clinical-decision support or capturing patient-reported outcomes.”

Related to MIPS, MGMA also attested that CMS should:

•             Permanently shorten the minimum reporting period to any 90 consecutive days;

•             Provide clear and actionable feedback about MIPS performance at least every calendar quarter;

•             Increase opportunities to participate in Advanced Alternative Payment Models (A-APMs);

•             Permit MIPS and APM participants to use 2014 or 2015 CEHRT in 2019 and 2020.

What's more, CMS, via the rule, is proposing an avenue for excluded clinicians who would like to participate voluntarily to “opt in,” which AMGA sees as a positive development. In addition, this policy improvement suggests CMS recognizes—as AMGA has argued—that excluding providers from the MIPS program is counterproductive for both those excluded and those included.

“Excluding providers from MIPS has a tangible impact on those clinicians who are working to succeed in the program,” said Penso. “AMGA members will continue to deliver high-value quality care, but these exclusions prevent MIPS from recognizing and rewarding their efforts to create value for Medicare.”

Virtual Care Proposals

Beginning in January 2019, CMS proposed to reimburse physicians for engaging in “virtual care,” for “brief communications,” “remote evaluation,” and “interprofessional consultation.” AMIA applauded CMS for recognizing the increased state of digitization in healthcare delivery and thus proposing to reimburse providers accordingly.

“We view these policies as addressing long-standing Medicare reimbursement barriers to widespread adoption of virtual care tools meant to reach more patients in more places, especially those in underserved and rural areas,” AMIA said. However, AMIA noted specific concerns related to the context of these new virtual care codes and encouraged CMS to consider issues related to clinical effectiveness, patient authentication, and proliferation of data silos derived from telehealth applications.

MGMA, meanwhile, noted in its comments, “MGMA supports CMS’ efforts to increase access to care by providing reimbursement for communications-based technology and telehealth services. This is a step in the right direction toward recognizing that medical practices connect with patients using new technologies.”

MGMA added that CMS “should modernize the Medicare program by finalizing coverage for virtual care, interprofessional consultation, and remote patient monitoring services. To facilitate widespread adoption of new non-face-to-face services, CMS should permit practices the flexibility to implement any new covered codes in a manner that best fits their practice and avoid overly restrictive billing requirements.”

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Survey: Physicians Sour on Value-Based Care Metrics, EHRs

September 19, 2018
by Rajiv Leventhal, Managing Editor
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They new research has several key findings related to value-based care, health IT and burnout

More than 50 percent of U.S. physicians who receive value-based care compensation said they do not believe that the metrics the reimbursement is tied to improve the quality of care or reduce costs, according to a new survey.

The research comes from The Physicians Foundation, an organization seeking to advance the work of practicing physicians and helps them facilitate the delivery of healthcare to patients. The Foundation’s 2018 survey of U.S. physicians, administered by Merritt Hawkins and inclusive of responses from almost 9,000 physicians across the country, reveals the impact of several factors driving physicians to reassess their careers.

Specifically, the new survey underscores the overall impact of excessive regulatory/insurer requirements, loss of clinical autonomy and challenges with electronic health record (EHR) design/interoperability on physician attitudes toward their medical practice environment and overall dissatisfaction—all of which have led to professional burnout.

The research revealed several key findings, including that value-based compensation is directly connected to the overall dissatisfaction problem, which is tied to metrics such as EHR use, cost controls and readmission rates, etc. Forty-seven percent (compared to 43 percent in the 2016 survey) of physicians have their compensation tied to quality/value, but when physicians were asked if they believe that value-based payments are likely to improve quality of care and reduce costs, 57 percent either disagreed or strongly disagreed that this is the case, while only 18 percent either agreed or strongly agreed that it is.

As one responding physician put it: “We are no longer in the business of healthcare delivery, we are in the business of ‘measures’ delivery.” More than 13 percent of physicians are not sure if they are paid on value.

What’s more, the research found that 88 percent of physicians have reported that some, many or all of their patients are affected by social determinants. Conditions such as poverty, unemployment, lack of education, and addictions all pose a serious impediment to their health, well-being and eventual health outcomes. Only one percent of physicians reported that none of their patients had such conditions.

Additional notable findings from the research included:

  • 18.5 percent of physicians now practice some form of telemedicine
  • 80 percent of physicians report being at full capacity or being overextended
  • 40 percent of physicians plan to either retire in the next one to three years or cut back on hours—up from 36 percent in 2016
  • 32 percent of physicians do not see Medicaid patients or limit the number they see, while 22 percent of physicians do not see Medicare patients or limit the number they see
  • 46 percent of physicians indicate relations between physicians and hospitals are somewhat or mostly negative

Coupled altogether, 78 percent of physicians said they have experienced burnout in their medical practices, according to the survey’s findings. And the results show that one of the chief culprits contributing to physician burnout is indeed the frustration physicians feel with the inefficiency of EHRs.

“The perceptions of thousands of physicians in The Physicians Foundation’s latest survey reflect front-line observations of our healthcare system and its impact on all of us, and it’s sobering,” Gary Price, M.D., president of the Foundation, said in a statement. “Their responses provide important insights into many critical issues. The career plans and practice pattern trends revealed in this survey—some of which are a result of burnoutwill likely have a significant effect on our physician workforce, and ultimately, everyone’s access to care.”

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Brigham Health’s 3-Pronged Approach to Reducing EHR’s Contribution to Burnout

September 18, 2018
by David Raths, Contributing Editor
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Focus is on individualized training, reducing unnecessary clicks, voice recognition tools

Research studies have found that “burnout” is nearly twice as prevalent among physicians as among people in other professions.  Physician surveys have found that 30 to 60 percent report symptoms of burnout, which can threaten patient safety and physician health. With EHR documentation ranked high among aspects of their work physicians are dissatisfied with, Brigham Health in Boston has taken a three-pronged approach to reducing the pain.

Brigham Health, which is the parent organization that includes Brigham and Women’s Hospital, Brigham and Women’s Faulkner Hospital and the Brigham and Women’s Physicians Organization, rolled out its implementation of Epic in 2015. In a Sept. 18 presentation that was part of the Harvard Clinical Informatics Lecture Series, Brigham Chief Information Officer Adam Landman, M.D., said the organization’s initial EHR physician training was eight hours of classroom training on where to find things in the EHR instead of focusing on workflows and how to use the EHR to support it.  “Our experience was not the best,” Landman admitted.  They followed up with tip sheets, a help desk and a swat team to do service calls, but providers only rated those interventions as somewhat helpful, so Brigham informaticists re-doubled their efforts to:

• Improve the EHR;

• Provide one-on-one training in the clinical setting; and

• Offer voice recognition software and training.


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Landman said IT teams at Brigham feel a sense of urgency about reducing the burden of EHR documentation. “Burnout is an epidemic, and the EHR is a component of this,” he said, adding that the changes are not just a one-year cycle but must involve continual iterative improvements. “We need to be more aggressive about making changes,” he said.

He described some efforts to reduce notifications and remove clicks from the medication refill process. They also removed a hard stop when discontinuing a medication. Those three changes alone reduced the number of clicks per month by 950,000 across the health system.

They also worked to reduce clinical decision support alerts with very low acceptance rates by turning them off. Three alerts with very low acceptance rates were turned off. “If we thought they were important, we would fine tune them to increase the acceptance rate,” Landman stressed. “That is part of clinical decision support lifecycle management. But we will continue to iterate to reduce the number of unnecessary clicks.”

A year and a half ago, Brigham also created a one-to-one support program, in which an expert trainer would meet the physicians in their practice and help them with their work flow. A pilot project involved four specialties, including general surgery. Each session was 90 minutes to two hours long, and providers were offered one or more follow-up sessions, as well as optional training on speech recognition. After seeing some negative feedback on their initial classroom training, the one-to-one sessions were met with a very positive response. Almost 95 percent said it was valuable, and 95 percent said they thought their efficiency with the EHR would improve following the training. Based on that early success, the training effort is now being rolled out to much larger groups of physicians at Brigham and across the Partners HealthCare network.

In another attempt to improve documentation turnaround time, Brigham has made voice recognition tools and training available to physicians. They made two-hour training sessions mandatory for those interested in adoption, with additional personalization sessions also available. Informaticists partnered with departments to build department-specific order sets. (Brigham also started offering 15-minute e-learning sessions for residents.) More than 90 percent of surveyed physicians said the training met expectations, and 70 percent said they would be willing to have additional training, Landman said. Currently 5,000 physicians across Partners are trained to use voice recognition tools with the EHR.

Landman also cited a study that compared U.S. and international use of Epic that saw a huge disparity in length of documentation notes. The U.S.-based users’ notes were nearly four times longer on average than those of their international counterparts. Epic users overseas tend not to complain about the burden of documentation, he noted. This has to do with how the provider notes are used in billing, he said, adding that CMS is working on proposals to change billing requirements that may alleviate some of the documentation burden for physicians.

In closing, Landman urged informatics colleagues to think about working on EHR optimization research and studying the impact of policy and technology changes. “New technology tools can seem fun and exciting, but for physicians who see up to 100 patients per day, they can be quite overwhelming,” he said. “We don’t want physicians spending half their time doing administrative work.”






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