After many weeks of preparation, the AAFP has finalized and sent to CMS a 92-page letter, including an addendum, that outlines the Academy's concerns with the agency's proposed 2019 Medicare physician fee schedule as published in the July 27 Federal Register.(federalregister.gov)
In the Sept. 5 letter(92 page PDF) to CMS Administrator Seema Verma, M.P.H., that was signed by AAFP Board Chair John Meigs, M.D., of Centreville, Ala., the AAFP pledged its commitment to helping CMS remake Medicare into a program that "prioritizes the delivery of high-quality, patient-centered and efficient care." That said, those efforts will require an increased investment in primary care.
"Our comments are comprehensive and intended to provide constructive recommendations so CMS can implement policies that will be meaningful for beneficiaries, supportive of their family physicians, and improve the financial security of the program," said the AAFP.
The letter noted that CMS' 2019 proposed fee schedule would make four significant alterations to the Medicare Part B fee-for-service program, modifications that would have "an immediate and measurable impact on family medicine."
In short, it said, CMS would like to implement a single payment rate for E/M codes for new patients and a single one for existing patients; reduce physicians' documentation load by requiring documentation at only the 99202 and 99212 levels; establish a new G-code, valued at about $5 per visit, to be added to the proposed new value for existing patient E/M services; and execute a 50 percent payment reduction for certain services provided in conjunction with an E/M code using CPT modifier 25.
- The AAFP has sent CMS a 92-page letter detailing concerns and suggesting improvements to the proposed 2019 Medicare physician fee schedule.
- The Academy's letter highlighted five recommendations that would greatly improve Medicare by, among other things, boosting payment for primary care physicians while easing the documentation burdens they face each day.
- The AAFP's proposed Advanced Primary Care Alternative Payment Model, the letter noted, would help remake Medicare into a program that prioritizes high-quality, patient-centered and efficient health care.
The AAFP called out and commented at length on these specific proposed changes because of how they would, if adopted, affect many of the family physicians who care for millions of patients across the country.
Before getting into the fine details, the Academy in its letter highlighted five major changes that would strengthen the proposed fee schedule, with additional comments provided later in the letter. Specifically, the AAFP recommended that CMS
- immediately implement proposed changes in documentation, but delay collapsing payment for CPT codes 99202-99205 and 99212-99215 into a single payment;
- delay implementation of any changes to evaluation and management (E/M) policies or codes and their descriptions until the AAFP and others can help CMS create new ones with values that spur comprehensive, continuous and coordinated primary care;
- replace the primary care add-on code with a 15 percent pay increase for E/M services provided by physicians who list their primary practice designation as family medicine, internal medicine, pediatrics or geriatrics;
- discard the proposed 50 percent multiple procedure payment reduction for the primary care physicians listed above; and
- work with Congress to eliminate deductible and co-insurance requirements for chronic care management codes to foster greater utilization of the codes and improve care coordination for high-need patients; the AAFP also urged a reduction in documentation requirements for these codes.
Readers willing to invest the time in a deeper dive into the letter will find suggestions and comments on many other issues of interest to family physicians.
What follows is an overview of the AAFP's comments to CMS.
E/M Payment Levels
The AAFP noted its strong support for CMS efforts to re-examine payment levels for undervalued services provided by primary care physicians, as well as the agency's pledge to reduce physicians' documentation burdens.
That said, "Although further simplification is critical, we are concerned with and cannot support the structure of CMS' proposal to collapse the payment for levels two through five office/outpatient E/M codes to a single set of relative value units (RVUs) for new patients and a single set for established patients," said the AAFP.
The letter noted that even though CMS is attempting to alleviate administrative burden by allowing just two levels of payment and documentation when compared to the current five levels, "the cost of that burden relief is, in our opinion at the present time, too great."
Furthermore, the proposed payment levels could create negative consequences for patients by increasing out-of-pocket expenses for levels two and three visits. Additionally, the proposed payment structure could penalize those physicians who undoubtedly would continue to address multiple concerns at a single visit rather than inconvenience their patients.
Medical Groups Press CMS to Implement Documentation Changes
In addition to providing CMS with its own suggestions for improving the proposed 2019 Medicare physician fee schedule, the AAFP joined more than 160 other professional medical organizations in asking CMS Administrator Seema Verma, M.P.H., to implement three documentation policy changes immediately.
As outlined in their Aug. 27 letter(6 page PDF), the groups encouraged prompt action on proposals that would
- change the required documentation of a patient's history to focus only on the interval history since the previous visit,
- eliminate the requirement for physicians to redocument information that has already been documented in the patient's record by practice staff or by the patient, and
- remove the obligation to justify a patient's need for a home visit versus an office visit.
"Implementation of these polices will streamline documentation requirements, reduce 'note bloat,' improve workflow and contribute to a better environment for health care professionals and their Medicare patients," said the letter, as well as signify "significant progress" in meeting goals associated with CMS' Patients Over Paperwork initiative.
The medical organizations also showed solidarity in opposing CMS' proposal to collapse payment rates for certain evaluation and management codes.
"Family physicians and others who care for patients with multiple problems and the frail elderly will likely be disadvantaged the most by the current proposal because they will simply not be able to spend the time needed to care for those patients properly -- and keep their practices financially solvent," wrote the AAFP.
"This disruption in continuity and comprehensiveness is the foundation of our concerns," the letter continued. "In short, we worry that CMS' proposal could place an even greater emphasis on episodic care of discrete conditions that creates pressure to stint on care at an office/outpatient visit and churn patients."
As noted above, the AAFP encouraged CMS to proceed with its proposal to require documentation at only the 99202 and 99212 levels.
In addition, the AAFP was pleased to see that CMS recognized the need to review and revise decades-old documentation guidelines for E/M services. "We appreciate that CMS proposes to offer physicians flexibility and choices in how to document E/M services," such as allowing the use of either medical decision-making or time as a basis for determining the level of E/M visit.
Lastly, the AAFP asked CMS to "use its unique position to drive changes in documentation not only in Medicare, but through all public and private health plans" and to forestall making any changes to E/M policies or codes until the AAFP and others can work with the agency to come up with office visit codes, descriptors and values that better support good primary care.
Primary Care Add-on Code
Regarding CMS' proposal to create a G-code that would be billed in addition to the E/M visit code when the visit involved primary care-focused services, the AAFP said it could not support the move for several reasons.
At the top of the list was the AAFP's concern as to whether the add-on code was valued appropriately by CMS. "We are unclear how CMS arrived at its proposed RVUs for the add-on code," said the AAFP. "We are unclear how less than two minutes of physician time and $5.40 … 'accounts for the additional resource costs associated with furnishing primary care that distinguishes E/M primary care visits from other types of E/M visits,'" said the letter.
And CMS further complicated the issue by proposing higher values for add-on codes for complex visits provided by subspecialists, the AAFP pointed out, even though primary care physicians address many of the same conditions, such as diabetes, arthritis, neuropathy, allergies and heart disease.
Patients often see endocrinologists, cardiologists, rheumatologists, neurologist and allergists many times for these problems. However, "Primary care physicians typically address various combinations of these multiple issues at a single visit," noted the AAFP, and "family medicine and internal medicine encounters are the most complex overall, especially when duration of visit is considered."
"Accordingly, we cannot support any proposal that values primary care physicians at a lesser value than other (sub)specialties with a supposedly high complexity of patients visits," said the letter.
Furthermore, said the AAFP, "CMS has shown a real commitment to supporting primary care in recent years. The difference in payment levels of the two add-on codes flies in the face of that commitment."
The AAFP called on CMS to eliminate the proposed primary care add-on code and instead implement a 15 percent increase in payment for E/M services provided by family physicians, internists, pediatricians or geriatricians.
Multiple Procedure Payment Reduction
The AAFP shot down another CMS policy outlined in the proposed fee schedule that calls for a 50 percent reduction in payment "for the least expensive procedure or visit that the same physician (or a physician in the same group practice) furnishes on the same day as a separately identifiable E/M visit."
Such an item is currently identified on a claim by an appended modifier 25.
The AAFP noted its strong stance against such a policy and urged CMS to remove it. "This policy is inconsistent with our vision of advanced primary care, and it places unnecessary strains on patients," said the letter.
In further outlining its objections, the AAFP noted that the proposal "does not account for the fact that CMS has already set the relative values of the procedures in question. The Relative Value Scale Update Committee already accounts for overlap in procedures typically done on the same day as an E/M in its recommendations to CMS."
The AAFP also expressed concern that the policy does not support patient-centered care and could encourage practices to deny patients same-day procedures, instead having them make another appointment.
"This potential consequence is especially problematic for rural patients and patients of limited means and/or limited mobility (i.e., the complex and high-needs patients about whom CMS is most concerned)," said the AAFP.
If implemented, the proposed policy could have additional negative impacts by
- hampering progress toward value-based payment models by some physicians operating on razor-thin margins, and
- costing Medicare more than it saves by delaying patient care or driving patients to higher-cost subspecialists for procedures that could be provided in primary care offices.
The AAFP suggested that CMS talk to private payers who have tested similar policies but, in the end, backed down and withdrew those changes.
Alternative Payment Models
In addition to addressing specific issues in the proposed fee schedule, the AAFP noted that "the pathway to true reform of the Medicare program, especially for primary care, lies in the broader proliferation of alternative payment models (APMs) versus efforts to tweak the legacy fee-for-service system."
The AAFP took advantage of the opportunity to draw CMS' attention to the Academy's Advanced Primary Care Alternative Payment Model, which was "considered and positively advanced by the (Physician-Focused Payment Model Technical Advisory Committee) in December 2017."
"The implementation of this primary care APM would drive Medicare toward the proven values of primary care -- first contact, comprehensive, continuous and coordinated care," said the AAFP.
It would also be an important step toward remaking Medicare into a program that prioritizes high-quality, patient-centered and efficient health care.
Solo and Small Practices
The AAFP also expressed concern that some of the changes in the proposed rule could harm the quality of care Medicare beneficiaries receive and hike the price they pay for that care.
In addition, said the AAFP, the proposed rule could have negative impacts on solo and small physician practices -- the very practices that represent the foundation of the U.S. health care system.
Family medicine practices have already alerted the AAFP that implementation of some of the proposed policies could force physicians to reduce the number of Medicare beneficiaries they care for or, in some cases, result in the loss of their independent practices.
"The further elimination of independent practices through consolidation is not positive for American communities, Medicare beneficiaries or the financial sustainability of the Medicare program," the AAFP cautioned.
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