After a thorough review of CMS' proposed 2018 Medicare physician fee schedule,(www.gpo.gov) the AAFP has responded with detailed comments about what the Academy likes in the proposal as well as suggestions for changing the proposed rule for the good of family physicians and their patients.
The Academy's Aug. 30 letter(40 page PDF) to CMS Administrator Seema Verma, M.P.H., was signed by AAFP Board Chair Wanda Filer, M.D., M.B.A., of York, Pa.
On page one of the 40-page letter, the AAFP blasted CMS for its proposed 2018 Medicare conversion factor of $35.99 -- an increase of just 10 cents from the 2017 conversion factor.
"For the third year in a row, the AAFP is very disappointed and cannot understand why CMS has failed to achieve the required minimum net expenditure reduction through identifying misvalued codes.
"Since these changes do not fully meet the misvalued code target required by law, physicians will not receive the full positive 0.5 percent update in 2018 called for in the Medicare Access and CHIP Reauthorization Act (MACRA)," the AAFP wrote.
Furthermore, since CMS did not reduce overvalued relative value units to the levels required by law, the agency "should have taken steps to reduce the impact on primary care services -- which are known to be undervalued -- until the agency could meet its statutory requirement," said the letter.
- The AAFP has informed CMS what it likes about the 2018 Medicare physician fee schedule and what areas need to be revised for the benefit of family physicians and their patients.
- The 40-page comment letter covers vast territory, including evaluation and management documentation guidelines and code sets, appropriate use criteria for advanced diagnostic imaging services, and expansion of the Medicare diabetes prevention program.
- CMS also asked for suggestions on how to simplify the agency's regulations, and the AAFP responded by tackling items such as translation services, electronic health record interoperability and documentation requirements for chronic care management.
Unfortunately, the ongoing undervaluation of primary care services in the fee schedule "will be perpetuated in the new MACRA quality payment programs if the agency does not urgently act to mitigate and correct these longstanding imbalances," said the AAFP.
The letter reminded CMS of the AAFP's submission of its Advanced Primary Care Alternative Payment Model (APM) to the Physician-Focused Payment Model Technical Advisory Committee. The model, if adopted, could migrate family physicians away from the current "inequitable" fee-for-service payment system.
What follows is a sampling of the AAFP's comments and recommendations to Verma on ways to improve the 2018 fee schedule.
Evaluation and Management Documentation Guidelines
The AAFP had much to say on the topic of evaluation and management (E/M) documentation guidelines and applauded CMS for seeing the need to review and revise guidelines, which were created in the mid-1990s.
"Family physicians rely on the E/M code set to capture the essence of their work," said the AAFP, despite the fact that the guidelines place a huge burden on family physicians and lack "an offsetting benefit to clinical care."
The guidelines are merely a coding tool used to justify payment," the AAFP noted; they distract physicians from their work and even create a barrier between physicians and their patients. Moreover, the guidelines consume an inordinate amount of physician time, fail to support the workflow of family physicians and chain physicians to a system that can "displace critical thinking."
The E/M guidelines are outdated and costly, the letter continued.
"As noted, we ideally believe that the documentation guidelines should be eliminated for primary care physicians for all three domains: history, physical exam and medical decision-making," said the AAFP.
"CMS currently undervalues E/M codes and other primary care services," said the letter. "Without remedying this flaw, payments under MIPS (the Merit-based Incentive Payment System) and future actuarial calculations for APMs will not adequately compensate primary care for the complexity of care provided -- and could undermine broader goals to improve care, improve health and reduce costs."
The Academy called for swift action, including the appropriation of adequate resources to accomplish comprehensive reform of E/M documentation and the E/M code set. And in the short term, CMS could easily make the guidelines "more consistent with team-based primary care as practiced today," the AAFP noted.
Alignment of Payment Policies
The Academy continues to look out for the interests of family physicians in independent practice and noted this fact in its strong support of CMS' efforts to align payment policies for independent practices with those for practices owned by hospitals.
"The AAFP continues to encourage CMS to also consider site-of-service payment parity polices from a broader perspective," said the letter. "Namely, CMS should not pay more for the same services in the inpatient, outpatient, or ambulatory surgical center setting than in the physician office setting."
Furthermore, the AAFP continues to encourage CMS to "create incentives for services to be performed in the most cost-effective location," which in many instances is a physician's office.
Unfortunately, the letter observed, CMS has proposed to continue paying certain off-campus provider-based departments under the hospital outpatient prospective payment system for 2018 rather than the Medicare physician fee schedule.
Appropriate Use Criteria
The subject of appropriate use criteria (AUC) for advanced diagnostic imaging services has long been a hot-button issue for the AAFP. In its remarks to CMS, the Academy noted that it had "unending, substantial concerns about the disproportional burden primary care physicians will face when trying to comply with AUC requirements."
Furthermore, said the AAFP, "AUC requirements will place more burden on primary care physicians than on other providers," a point on which CMS agrees.
The AAFP urged CMS to fully align the AUC with MIPS cost or quality performance categories, or better still, discontinue the AUC program completely.
"We will work with Congress to achieve this (discontinuation) goal legislatively and would hope that CMS would do likewise," said the AAFP. "With the passage and implementation of MACRA, which begins to align payment with value, the need for AUC requirements has been supplanted, and those requirements will now likely divert resources from patient care in the interest of unproven efficacy."
Medicare Diabetes Prevention Program Expanded Model
The AAFP has been fully supportive of the the expansion of the diabetes prevention program and noted that "addressing prediabetes in patients is important to family physicians."
Therefore, the AAFP took issue with CMS' proposed new start date of the expanded program, saying that CMS and suppliers have had "ample time to plan, enroll and prepare to operationalize this program."
The letter pointed out that obesity and diabetes are rampant in the United States. "Thus, we urge CMS to not finalize April 1, 2018, as a start date, and instead work with speed and efficiency to make these services available on Jan. 1, 2018, as the agency had previously finalized."
Request for Recommendations
Notably, CMS invited commenters to submit recommendations detailing how the agency could simplify its regulations and policies.
The AAFP took advantage of that opportunity, noting that it is "continuously working to alleviate demands placed on family physicians through entangling paperwork and needless regulatory complexities." The Academy made a number of suggestions including
- eliminating Medicare's requirement for prior authorizations for generic drugs and durable medical equipment,
- doing away with documentation guidelines for E/M codes 99211-99215 and 99201-99205 for primary care physicians,
- placing the burden of electronic health record (EHR) interoperability on vendors rather than physicians,
- procuring funding from Congress and HHS to offset the financial burden practices face when complying with interpretation service costs,
- aligning quality and performance measures by using the core measures sets developed by the multistakeholder Core Quality Measures Collaborative,
- streamlining claims review programs by using a universal set of criteria,
- reducing documentation requirements for chronic care management, and
- enhancing EHR and health information exchange in the provision of transitional care management services.
The letter also provided CMS with recommendations on how to address opioid abuse disorder and referred to the AAFP's position paper on this topic, titled "Chronic Pain Management and Opioid Misuse: A Public Health Concern."
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