Late in December, the Academy fired off a letter(8 page PDF) to CMS Acting Administrator Andy Slavitt with the sole purpose of reminding CMS of all the unfinished business that was not addressed in the final 2017 Medicare physician fee schedule.
When the final rule(www.federalregister.gov) was released on Nov. 2 and published in the Nov. 15 Federal Register, it reflected input from the AAFP and many other stakeholders from around the country.
The Dec. 22 letter, signed by AAFP Board Chair Wanda Filer, M.D., M.B.A., of York, Pa., was quick to point out that "the complexity of care provided by family physicians is unparalleled in medicine" and that family physicians "address more diagnoses and treatment plans per visit than any other medical specialty."
The Academy's letter noted that "the number and complexity of conditions, complaints and diseases seen in primary care visits is far greater than those seen by any other physician specialty."
- In a yearend letter to CMS, the AAFP highlighted unfinished business the agency failed to address in its final 2017 Medicare physician fee schedule.
- The AAFP called out the number and complexity of conditions, complaints and diseases seen in primary care compared with those seen in other medical specialties.
- The letter addressed many other topics, including issues with evaluation and management codes, interoperable electronic health records, appropriate use criteria requirements for advanced diagnostic imaging requests, and payment for translation services.
Furthermore, the AAFP referenced the Medicare Payment Advisory Commission's March 2016 report,(www.medpac.gov) which said primary care physicians are paid significantly less than their subspecialty colleagues.
"CMS currently undervalues evaluation and management (E/M) codes and other primary care services. Without remedying this flaw, payments under MIPS (the Merit-based Incentive Payment System) and future actuarial calculations for APMs (alternative payment models) will not adequately compensate primary care for the complexity of care provided," said the AAFP.
The Academy called on CMS to make an immediate upward adjustment to relative value units (RVUs) for common primary care services "in order to pay appropriately for those services now and in these new payment programs and models."
Currently, said the AAFP, primary care services represent no more than 6 percent of Medicare Part B physician spending; the Academy urged CMS to "use its authority" to increase that spending to no less than 15 percent.
The AAFP pointed out that increases in payments for primary care services would be especially critical to the success of the Medicare Access and CHIP Reauthorization Act (MACRA).
Recommendations for Future Rulemaking
The AAFP outlined a number of recommendations CMS should address in future rulemaking. For instance, the Academy pushed CMS to achieve the target recapture amount of 0.5 percent in net expenditure reductions in 2017 to ensure physicians receive a 0.5 percent positive update in 2018.
"The AAFP remains deeply disappointed that CMS only finalized misvalued code changes that achieve 0.32 percent in net expenditure reductions and that the 2017 Medicare Physician Fee Schedule conversion factor will be $35.89," said the letter. This represents an increase of only 9 cents from 2016 and, more importantly, means that physicians will not get the 0.5 percent raise in 2017 that was promised under MACRA.
"Since the agency did not reduce overvalued RVUs to the levels required by law, CMS should have taken steps to reduce the impact on primary care services that are known to be undervalued until the agency could meet its statutory requirement," continued the AAFP.
The letter reminded Slavitt that family medicine has been a leader in practice transformation, delivery system reform and adoption of electronic health records (EHRs). However, "physicians need the national health IT ecosystem to undergo more rapid transformation than has been the case to date," especially with regard to the provision of broad interoperability between systems, said the AAFP.
"We call on ONC (Office of the National Coordinator for Health IT) and CMS to place the burden of compliance on the vendors and not on physicians. EHR vendors must be held accountable for the inadequate design and poor usability of their products, not the physicians who struggle to use these products in their practices," said the Academy.
The AAFP also urged CMS to "explore the structure of E/M services to better distinguish primary care services from the E/M services provided by nonprimary care physicians." Furthermore, the letter suggested the agency consider existing research(www.sciencedirect.com) that indicates E/M services vary greatly among medical specialties as CMS works to "correctly assess the value of global surgical services and to appropriately value the complexity of primary care services."
The Academy's letter also suggested that documentation guidelines for E/M services need a revision. "The current guidelines were written almost 20 years ago and do not reflect the current use and further potential of EHRs to support clinical decision-making and patient-centeredness," said the AAFP.
Specifically, the Academy asked that all documentation guidelines for E/M codes 99211-99215 and 99201-99205 be eliminated for primary care physicians.
Another area of great concern to the AAFP is the increasing amount of regulatory burden handed off to primary care physicians. Case in point: requiring physicians to consult appropriate use criteria (AUC) before requesting advanced diagnostic imaging for a patient.
"This troubling program will divert resources from patient care and is unproven in efficacy," said the letter, which went on to point out that these requirements represent a "significant and new regulatory burden," particularly for primary care physicians. "We therefore urge CMS to compensate physicians for the additional time spent navigating these requirements," said the AAFP.
Furthermore, CMS must align the AUC program with MIPS, according to the letter, because one component impacting MIPS payment is a cost category.
Overall, the Academy strongly urged CMS to delay implementation of the AUC provision in the law until certain conditions were met -- including "evidence to demonstrate that AUC improves quality of care."
The AAFP also took up an issue of increasing importance to family physicians: the cost of translator services.
On Oct. 17, "new and costly limited English proficiency policies went into effect," the AAFP pointed out, and although the Academy supports efforts to ensure successful physician-patient communication, "neither Medicare nor Medicaid consistently compensates physicians for providing these services."
Furthermore, "The AAFP strongly believes that CMS should permit interpreters to bill Medicare and Medicaid for their services and, if applicable, treat this as a change in law and regulation for purposes of the physician payment update formula."
Additional Issues Needing Solutions
The AAFP highlighted a number of other topics that it has repeatedly addressed and that still need solutions. The Academy asked CMS to
- seek authority to waive the applicable Medicare Part B coinsurance and deductibles for patients seeking primary care services related to the management of chronic care conditions;
- improve policy language related to the Medicare Annual Wellness Visit so that beneficiaries are encouraged to engage with their primary care physicians or other usual source of care rather than commercial entities that are subverting this benefit and misleading patients;
- enhance EHRs and health information exchanges -- including reducing interoperability barriers -- to ease the uptake of transitional care management services;
- harmonize and align quality measures by utilizing the core measure sets developed by the Core Quality Measures Collaborative;
- simplify documentation and certification related to Medicare and Medicaid billing and develop policies that first target individual providers who have repeatedly attempted to fraudulently bill the system; and
- streamline and coordinate claims reviews currently conducted by multiple CMS contractors, because "redundant and inconsistent audits place an enormous administrative burden on practicing physicians."
The AAFP also asked CMS to enforce regulations pertaining to health plan enumeration and use of the health plan identifier, re-evaluate Medicare signature requirements, and review current provider portals before making beneficiaries solely responsible for sharing newly issued Medicare Beneficiary Identifier numbers with their physicians and other medical professionals providing care.
Related AAFP News Coverage
2017 Final Medicare Physician Fee Schedule
AAFP Summary Identifies Key Elements for Family Physicians