AAFP Guides CMS on Administrative Simplification Efforts

August 13, 2019 03:24 pm News Staff

The AAFP recently responded to a CMS request for information on how the agency should proceed in its efforts to reduce the crushing administrative burden that continues to overwhelm physicians in practice.

[Close-up of stethoscope on desk and stressed doctor with head in hands in the background]

Specifically, the agency singled out its Patients Over Paperwork(www.cms.gov) initiative in a request for public comment that was published in the June 11 Federal Register.(www.govinfo.gov)  

In an Aug. 7 letter(6 page PDF) addressed to CMS Administrator Seema Verma, M.P.H, and signed by AAFP Board Chair Michael Munger, M.D., of Overland Park, Kan., the Academy noted that reducing administrative and regulatory tasks for family physicians is a top priority and referenced results of the 2019 AAFP Member Satisfaction Survey.

"Fully 74% of respondents said the time spent on administrative tasks has increased in the past year," said the letter. Work associated with EHR documentation, prior authorizations for prescription drugs and quality measure reporting cause physicians the most consternation.

Story Highlights
  • The AAFP has offered recommendations to CMS on how the agency can improve its efforts to reduce physicians' administrative tasks that take time away from direct patient care.
  • According to the AAFP, 74% of family physicians surveyed indicated their time spent on administrative tasks had increased in the past year.
  • In a letter to CMS, the Academy advised the agency to focus its efforts on simplifying reporting, coding and documentation requirements; eliminating prior authorization procedures; and helping rural physicians overcome barriers to participating in the Merit-based Incentive Payment System.  

The letter signaled the Academy's strong support for the initiative but added that more needs to be done so physicians "can devote more time to patient care." To that end, the AAFP urged CMS to "consult, adopt and adhere to" a list of joint principles(2 page PDF) on reducing administrative burden developed by the AAFP and five other medical organizations in 2018.

The AAFP offered feedback to CMS on a variety of topics, including the following.

Reporting, Coding, Documentation Requirements

Regarding reporting and documentation requirements, the AAFP called on CMS to work with specialty societies, physicians, patients and health IT vendors on the development of performance measures, and urged the agency to implement registry and EHR-based clinical quality measures that were developed by the Core Quality Measures Collaborative.

The letter also requested transparency of methodology, simpler and standardized quality measure feedback reports, and quick delivery of feedback to physicians to they can "make changes to their practice and improve clinical care."

Lastly, "CMS should prioritize development of measures that matter to patients," said the letter.

The AAFP also made recommendations on requirements for coding and documentation related to Medicare and Medicaid payment, and specifically asked CMS to "ensure that current clinical documentation requirements are revised or simplified" to capture essential elements of the patient encounter; furthermore, those elements should be "automatically captured" by the EHR "without the need for unnecessary and irrelevant documentation."

Prior Authorization Hassles Rankle AMA Delegates

Few issues raise practicing family physicians' hackles as swiftly and surely as prior authorizations. For years, they've topped the list of onerous tasks named on the AAFP Member Satisfaction Survey as sucking the joy out of medical practice, and they're a perennial topic at the AAFP Congress of Delegates.

And it's not just FPs; other physicians loathe these requirements, as well. That fact was clear at this year's annual meeting of the AMA House of Delegates June 8-12, during which physicians of all specialties gathered to debate and create new policy. As always, the Academy's AMA delegation was on site representing family medicine's interests.

Citing results of a 2018 AMA survey, a resolution on the topic highlighted the fact that 91% of physician respondents said jumping through prior authorization hoops "delays patient access to necessary care," and 28 percent said satisfying PA requirements "has led to serious or life-threatening events for their patients."

The resolution asked the AMA to "explore emerging technologies to automate the prior authorization process … and evaluate their efficiency and scalability," as well as advocate cutting back on the total volume of PA requirements.

AAFP delegate Romero Santiago, M.D., M.P.H., of Sacramento, Calif., stated the Academy's unequivocal support during a June 9 reference committee hearing. "Anything we can utilize to bring technology to streamline this process so that we can best preserve the patient-physician relationship as much as possible would be absolutely appreciated," he said.

AAFP member and Alabama delegate George "Buddy" Smith Jr., M.D., of Lineville, echoed that sentiment. "Speaking for myself as a rural family physician, anything that can be done to keep us from drowning in PAs would be welcome," he said.

Radiation oncologist Sheila Rege, M.D., a Washington delegate and member of the AMA Council on Medical Service, testified that the council "recognizes the importance of evaluating efficacy and appropriateness of emerging technology to automate the prior authorization process while continuing to seek an overall reduction in these burdensome policies."

"Wouldn't it be nice if you write a prescription, and … as part of that, it doesn't just drag on? Why can't that happen?"

General surgeon and California alternate delegate Scott Karlan, M.D., bemoaned the diverse PA processes required by different insurers and suggested expanding the measure to state that "where the federal government has passed laws mandating specific steps physicians have to take before any test, that private insurance companies be required to accept the same processes."

In the face of unanimously supportive testimony, the HOD adopted the measure on June 11.

The letter asked CMS to seek technical solutions to address the frustration physicians face with annual recoding of permanent patient conditions such as a limb amputation. And the AAFP suggested CMS upgrade its infrastructure to support permanent patient conditions using EHR technology to summarize and aggregate such conditions.

Prior Authorization Procedures

The biggest portion of the letter was devoted to prior authorization procedures -- particularly those related to prescription drugs. The AAFP noted that this particular area "is consistently listed as a leading burdensome administrative task," and urged CMS to consult and abide by the AAFP's recommendations(2 page PDF) related to prior authorizations and step therapy.

The letter pointed out that the manual and time-consuming processes currently in use "burden family physicians, divert valuable resources from direct patient care and can inadvertently lead to negative patient outcomes" by delaying treatment.

"Family physicians using appropriate clinical knowledge, training and experience should be able to prescribe medications and order medical equipment without being subjected to prior authorizations" said the AAFP.

"Generic medications should not require prior authorization," continued the letter. The AAFP also noted its displeasure with step therapy protocols and maintained that these should not be considered mandatory for patients who already are doing well on a course of treatment.

"Ongoing care should be continued while prior authorization approvals or step therapy overrides are obtained," said the letter. Furthermore, "patients should not be required to repeat or retry step therapy protocols failed under previous benefit plans."

The AAFP also tackled prior authorization hassles frequently encountered by family physicians when requesting durable medical equipment for patients, in particular when prescribing diabetic supplies for Medicare patients.

The AAFP argued that it should be acceptable for a physician to write a prescription for diabetic supplies to encompass syringes, needles, test strips, lancets, glucose testing machines and such, with the physician needing only to provide a diagnosis and an indication that the prescription is "good for the patient's lifetime."

Rural Challenges

The AAFP also made a passionate appeal on behalf of rural family physicians and their patients, particularly related to CMS' Merit-based Incentive Payment System reporting requirements.

The letter noted that many small rural practices have indicated to the Academy that they face significant barriers to implementing value-based care, including lack of staff time and insufficient financial resources to invest in health IT.

"Rural practices do not have the resources to dedicate staff solely to MIPS reporting, as their staff is primarily involved in patient care," said the AAFP.

Furthermore, "one of the more concerning portions of MIPS is the promoting interoperability category," said the AAFP. The letter called on Congress and CMS to work together to remove legislative barriers that "restrain and complicate" the PI category.

"Congress should encourage CMS to simplify the scoring, remove health IT utilization measures and the 'all or nothing' requirement, and hold health IT vendors accountable for interoperability before measuring physicians on EHR use," said the letter.

The AAFP also asked CMS to "pursue thoughtful and appropriate e-prescribing flexibility that balances the need for security and efficacy with the challenges inherent in the practice of rural medicine." Such barriers can be exacerbated by limited or inconsistent health IT capabilities, continued the letter.

Additionally, "there should be safe harbors for those prescribers who incur significant administrative burden and/or access issues to prescribing software," said the AAFP.

Related AAFP News Coverage
AAFP Outlines Steps to Reduce Administrative Burden
Letter Offers Solutions in Advance of 'Patients Over Paperwork' Meeting

(2/9/2018)

Leader Voices Blog: Real Action on Administrative Burden Is Long Overdue
(2/27/2018)