In what has long been an annual endeavor, the AAFP once again has meticulously researched CMS' recommendations for the Medicare physician fee schedule for the coming year and sought ways to improve the proposal in family physicians' favor. The proposed 2016 schedule was published in the July 15 Federal Register.(www.gpo.gov)
In an Aug. 26 letter(28 page PDF) to CMS Acting Administrator Andy Slavitt, the Academy made suggestions in a number of areas that most affect the day-to-day work of family physicians caring for their patients.
AAFP Board Chair Reid Blackwelder, M.D., of Kingsport, Tenn., noted the AAFP's "full support" for the creation of a payment mechanism for advance care planning services and for CMS' proposal to pay for chronic care management (CCM) services in rural health clinics and federally qualified health centers.
Blackwelder then laid out in meticulous detail how CMS should rework certain segments of the fee schedule.
Evaluation and Management Codes
The AAFP expressed appreciation for CMS' interest in better understanding and valuing the cognitive work that physicians perform -- important and time-consuming work that often is not adequately reflected in the current evaluation and management (E/M) code framework.
- After scouring the proposed 2016 Medicare physician fee schedule for items that affect family physicians, the AAFP fired off a letter to CMS calling for a number of improvements.
- AAFP Board Chair Reid Blackwelder, M.D., focused on issues such as payment for advance care planning, chronic care management, and evaluation and management codes.
- The Academy also looked ahead to 2019 and commented on CMS' future implementation of the Merit-based Incentive Payment System and alternative payment models.
However, Blackwelder chided CMS for proposing add-on codes to the current E/M codes, comparing the idea to "building an addition onto a house with a very poor foundation."
He ticked off significant concerns with current E/M codes and documentation guidelines that include an overemphasis on traditional histories and physicals and do not fully recognize the complexity of patients' conditions.
The current system is bad for both physicians and CMS, said Blackwelder, because it "creates documentation and code-assignment hassles for physicians and program integrity challenges for CMS."
He urged CMS to tackle the fundamental problem: namely, that current E/M codes do not accurately describe the services physicians provide nor the resources involved with furnishing those services.
CMS needs to change tactics and turn to a research-based model, and the agency should underwrite the cost of hiring an expert contractor to do the work, said Blackwelder. That work must focus on developing a "comprehensive understanding of outpatient E/M work physicians and their clinical staff currently perform."
"We will gladly provide added support to any contractor hired to pursue this needed research," said Blackwelder, "and we will be pleased to serve as a resource for the agency in its efforts to ensure accurate service code definitions and valuations."
Chronic Care Management
The AAFP pushed hard for the development of the CCM CPT code 99490 and the transitional care management codes 99495 and 99496.
Blackwelder urged CMS to work with Congress to eliminate beneficiary cost-sharing associated with the CCM code. He pointed out that CCM services are not covered by the Medicare "preventive services umbrella," meaning that patients are responsible for coinsurance of about $8 after the annual Part B deductible has been met.
The AAFP urged CMS to drop cost-sharing for CCM services "given the immensely high value of this service," and also appealed to the agency to "reduce unneeded documentation requirements" with all three codes.
Furthermore, CMS has dropped the ball on educating patients about the CCM code. "CMS claims that it wants to be a 'partner' in the care of Medicare beneficiaries," said Blackwelder, but a partnership requires work by both parties.
"We and our members have yet to see any effort on the part of CMS or its contractors when it comes to beneficiary education related to CCM," said Blackwelder.
The AAFP also voiced significant concerns about the "disproportional burden" that primary care physicians will face in 2017 when they order certain imaging services for their patients.
"We appreciate that CMS fully recognizes that appropriate-use criteria (according to the rule) 'crosses almost every medical specialty and could have a particular impact on primary care physicians since their scope of practice can be quite vast,'" said Blackwelder.
To help ease that burden, the Academy called on CMS to use a "phase-in" approach and focus initially on a limited number of clinical conditions and related criteria.
"Many primary care physicians already find their current EHR (electronic health record) systems to be cumbersome and impeding patient care," said Blackwelder. "The AAFP is concerned that EHRs will not be able to address the workflow problems for the ordering physician when consulting and documenting that appropriate-use criteria were accessed. We have seen evidence of this obstacle in implementation of meaningful use requirements," he added.
In addition, the AAFP pushed to have primary care physicians "involved in all aspects of developing appropriate-use criteria."
Merit-based Incentive Payment
Regarding low-volume thresholds and clinical practice improvement activities related to the Merit-based Incentive Payment System (MIPS) that CMS must implement in 2019, the AAFP urged CMS -- after seeking further input from stakeholders -- to set a total minimum number of patients enrolled under Medicare Part B rather than impose a percentage of a physician's total patient panel.
"The AAFP is inclined to believe that 'percentage of patient volume attributable to Medicare' is not the best marker of patient volume; an absolute number of Medicare patients treated is clearer," said Blackwelder.
Furthermore, the AAFP appealed to CMS to examine minimum thresholds in other programs to gauge the effectiveness of those existing thresholds, particularly the Comprehensive Primary Care initiative threshold of 150 patients versus the Physician Quality Reporting System (PQRS) threshold of 20 patients per measure.
"In this context, the AAFP notes that many eligible professionals do not participate in PQRS," said Blackwelder. It would behoove the agency to examine barriers to PQRS participation and apply what it learns to MIPS and alternative payment models (APMs), another aspect of Medicare that CMS must implement in 2019.
As far as clinical practice improvement activities associated with those payment models, CMS should consider a "wide range of services," said Blackwelder, including implementation of
- open-access scheduling,
- 24/7 patient access to the care team,
- CCM services
- electronic visits or other forms of telehealth services,
- group visits,
- health coaching, and
- shared decision-making.
"We do not expect that a practice would or should need to do all of these things," said Blackwelder. He called the list of services a "menu of possibilities."
Alternative Payment Models
Blackwelder noted that the Medicare Access and CHIP (Children's Health Insurance Plan) Reauthorization Act of 2015 (MACRA) introduced a framework for promoting and developing APMs and for providing incentive payments to participating physicians beginning in 2019.
Family physicians stand to benefit from these programs, said Blackwelder. However, "Many primary care practices will not be able to participate effectively in an APM unless resources are provided to the practice to overcome significant cost and workflow barriers" associated with practice transformation, he added.
Barriers to practice participation include lack of contract negotiation experience, limited capital for health IT and insufficient access to price information for certain medical services.
"If payers want primary care physicians to accept responsibility for the total cost of care, they must provide the primary care physicians with timely and accurate data on the cost and quality of all physicians, hospitals and outpatient care facilities in their community or service area," said Blackwelder.
Physicians also must see "harmonization of quality and other measures across all payers," added Blackwelder. "Otherwise, primary care practices participating in APMs could experience an increase in administrative burdens."
Practices already are overburdened with such work, said the AAFP. "Unless CMS facilitates the transition to APMs by easing physician burdens in other areas, many practices will not be able to make the transition.
"Providing clear operational details and performance goals of APMs, along with an easy-to-use mechanism to collect, use and share data, is the only way to improve patients' experience of care and the health of populations while reducing the per-capita cost of health care."
Value-based Payment Modifier
The value-based payment modifier calls for differential pay for physicians based on the quality and cost of care they furnish to Medicare patients.
Patient experience is one measurement, and CMS has proposed adoption of a single instrument dubbed the Clinician-Group-CAHPS (Consumer Assessment of Health Providers & Systems) -- a proposal the AAFP opposes.
However, if adopted, the AAFP urged CMS to "bear the cost" for small practices. Furthermore, said the AAFP, "practices should not be penalized for factors outside of their control such as lack of patient engagement for completing the survey."
The best-case scenario would be to offer the CAHPS survey free to physicians and their patients via an online process, concluded the AAFP.
Related AAFP News Coverage
2016 Proposed Medicare Physician Fee Schedule
AAFP Lauds Payment Stability, Action on Advance Care Planning Codes
More From AAFP
Press Statement: This is What Stability Looks Like: Proposed 2016 Medicare Physician Fee Schedule
CMS Fact Sheet(www.cms.gov)