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.
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.”