How would the AAFP improve CMS' proposed 2012 Medicare physician fee schedule(www.gpo.gov)? It took AAFP Board Chair Lori Heim, M.D., of Vass, N.C., 26 pages to detail all of the Academy's recommendations.
In her Aug. 29 letter(26 page PDF) to CMS Administrator Donald Berwick, M.D., Heim urged CMS to make multiple revisions to the schedule -- from how the agency measures the value of primary care to its plan to include a mandatory health risk assessment in Medicare's annual wellness visit.
Heim hit the issue of potentially misvalued services early and hard. She pointed out the well-documented and widening income gap between cognitive and procedural physician specialties, and the resulting downstream effect that is dramatically reshaping the physician workforce.
"Effectively revaluing primary care and other cognitive codes will be essential to ensuring that there are a sufficient number of primary care physicians in the future," said Heim.
"The critical shortage of primary care physicians, who best manage the complexities of chronic care, results from the current flawed payment structure," said Heim. She urged CMS to improve the existing payment disparity by
- paying for services that currently are not covered, such as telephone calls and online medical evaluations;
- revisiting and adopting the median relative value units for outpatient evaluation and management codes that were originally submitted to the AMA/Specialty Society Relative Value Scale Update Committee, or the RUC, in 2007 (those values were substantially reduced by the RUC prior to adoption); and
- reimbursing certain "G" codes that relate to care provided in practices that offer patients a "certified" patient-centered medical home.
- In feedback on CMS' proposed 2012 Medicare physician fee schedule, AAFP Board Chair Lori Heim, M.D., focused attention on the need for CMS to more fairly appraise the value of the services primary care physicians provide to patients.
- Heim objected to CMS' proposal to require a health risk assessment as part of the annual wellness visit in 2012.
- The AAFP urged CMS to ensure proper metrics have been identified and vetted before launching the next phase of its physician performance reporting program.
Heim pointed out that tools that didn't exist 20 years ago are available today to assess work intensity, practice expense and the cost of training, and she urged CMS to "establish a more rapid review of misvalued services."
Given the usual RUC process, potentially misvalued services remain that way for a full two years after they are identified, said Heim. "If CMS and the RUC are unable to develop a more timely process, then CMS should proceed to identify and adjust misvalued codes independently of the RUC."
The Academy asked CMS to continue its involvement as an observer to the Academy's newly created Primary Care Valuation Task Force, which is charged with finding ways to more fairly appraise the value of evaluation and management services. That task force of health care policy experts held its initial meeting on Aug. 22 in Washington.
The Academy also objected to CMS' proposal to require a health risk assessment, or HRA, as part of Medicare beneficiaries' annual wellness visits, or AWV, in 2012.
Heim made it clear that although the AAFP supports the concept of the HRA as an evaluation tool that helps gather accurate information about a patient's health status, injury risks, modifiable risk factors and urgent health needs, CMS has yet to provide guidance to FPs on how to do this.
The HRA model, which was mandated by the Patient Protection and Affordable Care Act, has yet to be formulated. Development and availability to the public of an HRA model was supposed to be completed no later than 18 months after the Affordable Care Act was passed, but HHS Secretary Kathleen Sebelius has yet to meet this requirement.
Heim pushed the point: "While we understand CMS' desire to comply with the inclusion of the HRA into the AWV, it is unfair to hold physicians accountable for this portion of the Affordable Care Act when the Secretary has not yet fulfilled the crucial step of providing an HRA model.
"How can physicians successfully implement an HRA in January of 2012 when no model and no guidance are available?"
Furthermore, said Heim, the majority of HRAs in the current Medicare population will be handled by phone or during the patient's AWV and "will add a significant burden of time and expense for the practice."
CMS also underestimated the complexity of the documentation needed for each HRA completed, said Heim. The AAFP expanded the two-page form used to capture the elements of Medicare's initial preventive physical exam into a six-page form just to capture the additional elements of the AWV. The inclusion of an HRA "will reach another level of complexity," said Heim.
Heim also ticked off a number of necessary improvements to the agency's Physician Quality Reporting System, or PQRS, a program aimed at delivering payment incentives to physicians who successfully report data on quality measures during a specific reporting period.
Heim suggested that CMS
- continue to offer as many PQRS reporting options and timeframes as possible to facilitate successful participation by small to medium-sized groups,
- allow physicians to form "virtual" groups for PQRS reporting proposes,
- accelerate the requirement definition and the review process for qualifying PQRS registries,
- hold vendors accountable for successful data submission, and
- minimize administrative burdens if physicians are required to report on PQRS core measures that focus on cardiovascular conditions and only use measures endorsed by the National Quality Forum.
The Academy also urged CMS to refrain from basing the 2015 PQRS penalty on 2013 performance, and provide physicians with more timely access to PQRS feedback reports.
"The current 18-24 month lag time between the point of care and access to a feedback report is fundamentally not helpful from a quality improvement perspective," said Heim. "If the PQRS program is truly intended to improve the quality of physician services, the AAFP believes CMS must begin offering timelier (monthly or quarterly) interim feedback reports to PQRS participants."
Additionally, the Academy noted that, in some instances, CMS must not move ahead with a program before the necessary infrastructure is in place. For example, Heim urged CMS to refrain from prematurely posting information on physician performance on its "Physician Compare" website -- as required by the Affordable Care Act -- before standardized metrics for assessment of safety, effectiveness and timeliness of care and assessment of continuity and coordination of care are created.
"The AAFP reminds CMS that the Affordable Care Act stipulates that public reporting should only occur to the extent that scientifically sound measures are developed and available," said Heim. "The AAFP urges CMS to be aware of the possibility of penalizing physicians who see patients who are less willing or able to adhere to recommended care," she added.
Heim also advised CMS to avoid rushing the implementation of the next phase of improvements to the physician feedback program and the establishment of a new value-based payment modifier scheduled for implementation in 2015.
According to the law, CMS is to establish quality measures for the value-based modifier by 2012.
"CMS should not rush implementation of the value-based payment modifier and hastily adjust physicians' Medicare payments" before CMS' payment policies are clear, said Heim. "CMS must publicly develop further specifications surrounding this program while significantly improving the agency's capability of processing Medicare claims and performance data in a more meaningful and real-time manner," she added.
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