President's Message

Fighting for a Fee Schedule That Works for You, Your Patients

August 21, 2018 09:00 am Michael Munger, M.D.

CMS released the 2019 Medicare physician fee schedule and Quality Payment Program proposed rule(s3.amazonaws.com) on July 12. Given the potential impact this proposed rule would have on family physicians and our patients, as AAFP president, I felt it important to provide an update on both the proposal and the AAFP's related advocacy work. I understand there are concerns about this proposal. The AAFP shares these concerns and is expressing its misgivings to HHS and CMS as we simultaneously prepare our comprehensive response to the proposed rule.

Michael Munger, M.D.

I would urge each of you to access the resources made available by the AAFP to assist you in learning more about the proposed rule and its potential impact on your practice. We have produced a summary on the subject(2 page PDF) and published some initial analysis in the Fighting for Family Medicine newsletter via the In the Trenches blog. In addition, earlier this month, the AAFP hosted a webinar outlining the proposed rule and its content, featuring staff from CMS. An archived version of the webinar and the accompanying slide deck are available to all AAFP members.

The 2019 proposed rule contains several provisions that will impact each of us and our practices. Over the past few weeks, the AAFP has carefully analyzed the 1,400-plus pages of the proposed rule, taking extra care to model the payment impact of the various provisions, independently and collectively, on family physicians. Although the proposed changes to evaluation and management (E&M) codes are top of mind for most family physicians, there are other important adjustments that will have short- and long-term impacts on our specialty and our patients. I assure you we are carefully analyzing all these issues to best represent our interests and those of our patients.

Your AAFP leadership and professional staff have been actively engaged in analyzing the rule, evaluating its impact and preparing the AAFP's response. In addition, over the past month, we have directly engaged with senior leadership at HHS and CMS, including Administrator Seema Verma, M.P.H., regarding the proposed rule on several occasions. These conversations provide the AAFP an opportunity to learn more detail from CMS and provide directed feedback on behalf of each of you. We've also shared our initial views with key congressional committees and are prepared to initiate a full lobbying campaign should it become appropriate and necessary.

In short, be assured we've heard you and have your back. We are fighting every day to promote the interests of our members and protect the foundations of family medicine. Based on our analysis, we've identified several provisions that raise concerns, some that are in need of greater clarity, and others that are positive. Allow me to outline a few items:

The goals: We view the goals CMS is attempting to accomplish -- coding simplification and a potential reduction in documentation -- as positive and consistent with AAFP policy, but we have significant concerns regarding how CMS proposes to accomplish these goals. We applaud CMS for bringing these issues to the forefront and proposing some initial solutions, and it is now our responsibility to evaluate those solutions and respond appropriately on behalf of our members and for our specialty.

Documentation guidelines: The AAFP strongly challenges CMS' assertion that the documentation, coding and payment provisions must be combined to be implemented. It is our opinion CMS can and should initiate reductions in documentation and administrative burden regardless of any changes in coding standards and payment options. We are developing a recommendation that will allow CMS to reduce the documentation requirements independent of the coding and payment decisions.

E&M codes: The proposal to simplify the E&M codes for both new and existing patient visit codes is conceptually consistent with the AAFP's position that coding for services needs to be easier and less burdensome. However, we strongly believe that any new or revised codes must reflect the complexity of family medicine and support comprehensiveness and continuity. The current proposal -- to collapse payment into a single amount for levels 2-5 for new and established patients -- will not achieve this intent and is fundamentally flawed. Our data show that, over the past few years, family physicians have more accurately coded for complexity and services. As a result, we've seen a significant decrease in the number of 99213 codes and an increase in 99214 codes billed by family physicians. Based on our modeling, in 2021, 99214 codes will account for more than 60 percent of all visits to a family physician. Overall, we cannot support the proposed changes to E&M coding and payment in its current form.

Primary care add-on payment code: Although the AAFP strongly supports increasing the overall spend on family medicine and primary care, the proposed primary care "bonus" payment of $5 as outlined in the CMS rule is woefully insufficient. This will not achieve the desired outcome of reflecting the complexity and comprehensiveness of the care we deliver daily.

Multiple procedure payment reduction: The proposed rule would require a 50 percent reduction in payment of procedures provided at the time of an E&M visit via a -25 modifier. The AAFP strongly opposes this policy. We have forcefully opposed this when recommended by commercial insurers and we will continue to oppose its implementation in the Medicare program.

Patient-centered primary care: The proposed rule undercuts advances we have made to provide comprehensive primary care in every visit. This proposal incentivizes physicians to perform fewer services per visit and to conduct more physician visits per patient. This is not patient-centered, and it is not how you and I want to practice medicine. Medicare should pay family physicians for the comprehensive care we provide instead of forcing us to churn our patients to remain economically viable.

Advanced primary care: The AAFP is most disappointed that CMS continues to attempt unrealistic reforms of the broken fee-for-service system. Our proposal to CMS for an Advanced Primary Care Alternative Payment Model (APC-APM)(38 page PDF) for family medicine and primary care would allow CMS to accomplish its three goals of reducing the burden of documentation, simplifying coding and increasing the overall spend on primary care in a seamless manner. We continue to strongly advocate to CMS that the path to achieving their goal is directly in front of them. The agency should act immediately to implement the APC-APM proposal.

Please be assured that the AAFP will respond to this proposed rule prior to the Sept. 10 deadline. Our response will be available at the Fighting for Family Medicine hub, and we will publish a summary of our response letter in AAFP News. If you have comments on our approach, or if you wish to share recommendations on how the AAFP should respond to the proposed rule, please email AAFP Senior Vice President of Advocacy, Practice Advancement and Policy Shawn Martin at smartin@aafp.org with the subject line "MPFS2019."

These are the times when the AAFP serves as a bold champion on your behalf to achieve what is best for us and our patients. Thank you for your membership and support of the AAFP and all that you do every day for your patients, your communities and our specialty. If you have any other concerns or comments, as always, please let me know.