Medicare Hospital Outpatient Prospective Payment System

AAFP Urges Review, Rewrite of Portions of Proposed Rule

August 31, 2016 03:22 pm News Staff

The AAFP never passes up an opportunity to provide feedback to CMS on proposed rules and regulations that impact family physicians and their patients.

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Such was the case recently when AAFP Board Chair Robert Wergin, M.D., of Milford, Neb., responded to a proposed rule that would, among other things, modify Medicare's 2017 hospital outpatient prospective payment system, as well as the ambulatory surgical center payment system.

The proposal,(www.gpo.gov) published in the July 14 Federal Register, also would implement rules relating to payment for some items and services provided by certain off-campus outpatient departments, revise the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs, and eliminate the pain management element from the Hospital Value-Based Purchasing Program.

In an Aug. 24 letter(8 page PDF) to CMS Acting Administrator Andy Slavitt, Wergin expressed support for proposals that would be helpful to busy family physicians -- and posed thoughtful objections to those that would be burdensome or even harmful.

Story Highlights
  • The AAFP has responded to a CMS proposed rule that would, among other things, modify Medicare's 2017 hospital outpatient prospective payment system.
  • AAFP Board Chair Robert Wergin, M.D., pressed CMS to create incentives for services to be performed in the most cost-effective location -- usually, a physician's office.
  • He pressed CMS to make other changes to the proposal, including eliminating meaningful use stage three entirely.

Off-Campus Providers

Wergin noted that increasingly, hospitals are purchasing physician practices and integrating them into a hospital department. This trend increases the delivery of physician services in a hospital setting, often at a higher cost to the Medicare program and its beneficiaries.

"When a Medicare beneficiary receives services in an off-campus department of a hospital, the total payment amount for the services made by Medicare is generally higher than the total payment amount made by Medicare when the beneficiary receives those same services in a physician's office," said Wergin.

He noted that Medicare pays a higher amount in these situations because it pays two separate claims for the services -- one for the institutional services and one for the physician services offered in the off-campus department. This often results in "significantly higher" patient cost-sharing than if the service had been furnished in a physician's office.

Wergin expressed strong support for CMS' proposal to implement changes that would better align payment policies for physicians in independent practices with those for practices owned by hospitals. He also urged CMS to "create incentives for services to be performed in the most cost-effective location" -- namely, a physician's office.

Wergin was "troubled by CMS' admission" that it could not automate a process to link hospital enrollment information to claims processing information that would clearly identify items and services provided in an off-campus department and thus ensure that off-campus provider-based departments are billing under the proper billing system.

Consequently, Wergin supported CMS' "inclination" to require hospitals to self-report certain information even though doing so would add to their administrative burden.

"Those hospitals already benefit from the additional Medicare payments attributed to excepted items and services, so they are, in some sense, compensated for this reporting burden, a luxury not enjoyed by physician practices that often have to report things to CMS without any financial incentive," said Wergin.

EHR Reporting Period, Meaningful Use

The AAFP threw its support behind a CMS proposal that the Academy has suggested multiple times -- that is, to change 2016 EHR reporting periods for returning participants from the full calendar year to any continuous 90-day period within 2016.

Regarding CMS's proposal to modify meaningful use stage two for new participants in 2017, Wergin suggested an easier fix.

"For purposes of clarity, simplicity and as an expressly obvious indicator to physicians that their feedback is being heard, the AAFP urges CMS to simply propose to eliminate stage three," he said.

Regarding physicians' ability to apply for an EHR incentive program "significant" hardship exception -- a new category of hardship exception proposed in the rule -- Wergin noted that the proposed rule would only allow significant hardship exceptions to new eligible provider (EP) attesters.

"The AAFP rejects that as inadequate and recommends CMS make this new category of significant hardship exception available to all EPs so that existing/returning and new meaningful users may apply for it," said Wergin.

He further detailed the AAFP's concerns and noted that meaningful use attesters needed "flexibility and additional time to enable them to implement updates of 2015 CEHRT (certified EHR technology) and put into place functionality increasingly required to succeed within MIPS (Merit-based Incentive Payment System) and APMs (Advanced Payment Models) reimbursement models."

Wergin pointed out that physicians can experience hardships whether they are new attesters or experienced and successful meaningful use performers. For instance, it's not unusual for physicians to

  • suffer failure of EHR systems that no longer meet user needs or
  • encounter complications when selecting and implementing new systems.

"The time and resource investments involved when changing EHR systems cannot be overstated," and that includes integrating new workflows into already busy medical practices, said Wergin.

Therefore, the AAFP urged CMS to "also extend eligibility for a hardship exception or significant hardship exception not only to new attesters but to all EPs who encounter challenges with compliance and reporting due to valid issues," he added.

Pain Management Element

Lastly, Wergin said the AAFP was encouraged by CMS' acknowledgment that some physicians feel pressured to prescribe opioids for patient pain relief because of the linking of scores on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey to Medicare payments to hospitals.

"To mitigate the perception that there is financial pressure to overprescribe opioids, we fully support the proposal to remove the HCAHPS survey pain management questions from the hospital payment scoring calculation," said Wergin.

"The AAFP believes this is laudable policy that should be extended to all patient experience measures."

Related AAFP News Coverage
AAFP Calls for Revisions in Proposed 2017 Physician Fee Schedule
CMS Proposal Signals Significant Boost in Primary Care Payment

(8/24/2016)