Proposed Rule: 2018 Hospital Inpatient Prospective Payment

AAFP Pushes for Revisions, Easing of Regulatory Burden

June 16, 2017 04:00 pm News Staff

The AAFP takes very seriously its mission to serve family physicians and advocate on their behalf for a health care system where they can take care of patients with the least interference from regulatory rules.

[Suggestions - written on marbled wall with wooden floor]

And so it comes as no surprise that the AAFP has weighed in on a CMS proposed rule regarding inpatient payments.

In a June 8 letter(8 page PDF) to CMS Administrator Seema Verma, M.P.H., the AAFP provided CMS with its response to a proposed rule regarding the 2018 Hospital Inpatient Prospective Payment as published in the April 28 Federal Register.(

The letter, signed by AAFP Board Chair Wanda Filer, M.D., M.B.A., of York, Pa., began by reminding CMS of the critical role family physicians play in the U.S. health care system.

"Today, family physicians provide more care for America's underserved and rural populations than any other medical specialty," said the letter, and patients see a family physician for about 20 percent of all office visits.

Story Highlights
  • The AAFP's response to CMS' 2018 inpatient payment proposal covered various topics important to family physicians.
  • The June 8 comment letter addressed electronic health records, accounting for social risk factors in hospital readmissions, focusing on patient-centered care and reducing administrative burden.
  • The AAFP took advantage of the opportunity to highlight outstanding issues with prior authorizations, quality measure harmonization, chronic care management documentation, transition care management services and more.

Therefore, said the AAFP, the comments in the letter go to the heart of sections of the proposed rule that directly affect family physicians.

Electronic Health Records

The first issue addressed in the AAFP's comments dealt with the Medicaid Electronic Health Record (EHR) Incentive Program, particularly the alignment of the program's reporting requirements and reporting period with the Merit-based Incentive Payment System (MIPS).

The letter commended CMS' proposal to allow those reporting electronically to move to "any 90 continuous days during the 2017 performance year." However, a full-year reporting requirement remains for Medicaid-eligible professionals who report via attestation, a situation that likely will cause confusion among all participants and challenges for those who have to follow this requirement.

Furthermore, the AAFP said it "does not share CMS' optimism" about the level of readiness of 2015 edition certified EHR technology for the 2018 reporting period.

"The meaningful use program is littered with instances of last-minute changes to meet the reality of slower than projected progress," said the AAFP. The letter asked for flexibility in 2018 by allowing eligible providers to use 2014 technology, if necessary.

Social Risk Factors

CMS requested help identifying methods to account for social risk factors in the Hospital Readmissions Reduction Program,( and the AAFP complied by pointing to recommendations( previously made by researchers who called for a combined ranking method that considers both quality and disparities.

The AAFP called this method "a potential solution to mitigate unintended consequences of pay-for-performance programs while helping to reduce national disparities within a framework that still focuses on improving quality."

Regarding which social risk factors to consider, the AAFP said the use of a single determinant such as race, gender or geography was not enough and recommended CMS "begin a stepwise strategy where, eventually, multiple social determinants of health will be integrated into health care processes and payment methodologies."

Taking it one step further, the Academy suggested CMS begin by leveraging existing demographic data available in certified EHRs to add two determinants: poverty status and educational level.

Focusing on Patient-centered Care, Administrative Burden

In response to a request for ideas on how to put additional focus on patient-centered care while reducing administrative burden, the AAFP noted that the Medicare Access and CHIP Reauthorization Act (MACRA) was intended to simplify Medicare payment, quality improvement and performance measurement programs.

Instead, CMS introduced "new complexities that do not improve care for beneficiaries," said the letter, including cumbersome administrative requirements for physicians.

The AAFP encouraged CMS to take several steps to begin simplifying the design of the Quality Payment Program (QPP) by

  • removing financial risk from regulatory definitions of the medical home model,
  • eliminating arbitrary size restrictions limiting advanced alternative payment model (APM) participation in medical home models,
  • dropping all documentation guidelines for evaluation and management (E/M) codes for primary care physicians who participate in the MIPS and advanced APM pathways,
  • withdrawing the MIPS APM category, and
  • deleting administrative claims population health measures.

The AAFP also urged CMS to use consistent language to avoid confusion among those trying to interpret the rules.

Numerous other recommendations on how to improve and simplify the transition to the QPP were outlined in a numbered list in the AAFP's letter.

For instance, the Academy made recommendations related to the MIPS transition period, virtual group provisions, quality measures, CME improvement activities and coding.

Highlighting Additional Problem Areas

The AAFP took advantage of its letter to the CMS administrator to reiterate the enormous administrative burden that Medicare-participating physicians face every day.

For instance, acquiring prior authorization for a patient's treatment is an aggravation physicians face almost daily -- a situation that sparked the recent creation of an AAFP policy on the topic.

The AAFP's letter pointed out that most family physicians have contractual relationships with seven or more payers, meaning "they must often navigate seven or more different prior authorization rules and forms."

The Academy urged CMS to, among other things, eliminate the use of prior authorizations for generic drugs in the Medicare program, create a single prior authorization form required for use by all Medicare Part D plans and continue to reduce the number of products and services that require such a form.

Regarding E/M services, the letter pointed out that current guidelines were written 20 years ago and "do not reflect the current use and further potential of EHRs and team-based care to support clinical decision making" and patient-centered care.

Those outdated guidelines have led to "clunky" EHR systems that were designed to document billing in a fee-for-service payment system, said the AAFP.

Among other changes, the AAFP strongly recommended that all documentation guidelines for E/M codes 99211-99215 and 99201-99205 be eliminated for primary care physicians.

The letter also called on CMS to correct ongoing problems with

  • quality measure harmonization and alignment,
  • chronic care management documentation,
  • inconsistent claims review, and
  • transitional care management services.

Regarding that last bullet point, the AAFP pointed out that improving EHRs and health information exchanges would reduce the burden on physicians and hospitals, and reduce patient readmissions.

"These activities would in turn result in reduced cost for physicians, hospitals, health plans and government payers," said the AAFP.

Related AAFP News Coverage
New AAFP Policy Takes Aim at Prior Authorizations

Medical Organization Coalition Calls for Prior Authorization Reform
AAFP Also Drafts Policy on Requirements


AAFP Leads Move to Consistent, Meaningful Quality Measurement
Core Quality Measures Collaborative Announces New Core Measures Sets