The AAFP is confident that if the Medicare Access and CHIP Reauthorization Act (MACRA) is implemented properly, the law can change the U.S. health care system in a positive fashion. However, the details that fill in the framework of this groundbreaking law must be created with wisdom, foresight and a deep understanding that what the nation needs above all else is a health care system built on primary care.
With that goal in mind, AAFP Board Chair Robert Wergin, M.D., of Milford, Neb., recently conveyed to CMS key recommendations that, if adopted by the agency, will help ensure MACRA's success.
"I write to articulate our vision of how MACRA can fundamentally change our health care delivery system to achieve the goals of improving the patient experience of care, improving the health of populations and reducing the cost of health care," said Wergin in the April 11 letter(8 page PDF) to CMS Acting Administrator Andy Slavitt.
"A review of the law clearly demonstrates that Congress wanted a greater priority placed on comprehensive, continuous, coordinated, first contact and connected primary care," wrote Wergin. The AAFP's recommendations aim to facilitate the law's implementation and "fully optimize delivery and payment reforms" that emphasize the value of primary care, he added.
- The AAFP recently sent a letter to CMS to convey the Academy's key recommendations for implementing the Medicare Access and CHIP Reauthorization Act (MACRA).
- The Academy strongly urged CMS to adopt the recommendations and help ensure MACRA's success.
- According to AAFP Board Chair Robert Wergin, M.D., MACRA could fundamentally change the U.S. health care delivery system, improve health care and reduce the cost of care.
Valuing Primary Care Services
At the top of the AAFP's list of recommendations is addressing flaws in the current payment rates in the Medicare physician fee schedule.
"Primary care is particularly affected by longstanding inequities in payment that must be corrected if primary care is to be the foundation of new payment and delivery models," noted Wergin.
Correcting existing flaws is especially critical since the Merit-based Incentive Payment System (MIPS) and alternative payment models (APMs) will evolve from the existing fee-for-service system. Wergin agreed with nationally recognized payment experts who argue that CMS should not create value-based payment models based on a flawed physician fee schedule.
Specifically, the AAFP urged CMS to
- make immediate upward adjustments to the relative value units for common primary care services,
- study the structure and documentation guidelines of evaluation and management (E/M) services to distinguish primary care services from those E/M services provided by non-primary care physicians,
- incorporate published research(www.sciencedirect.com) by David Katerndahl, M.D., in order to correctly assess the value of global surgical services and appropriately value the complexity of primary care services,
- conduct a study on the impact of the E/M documentation guidelines and
- determine if the current E/M coding structure should be revised to support implementation of MACRA.
Wergin pointed out that current E/M documentation guidelines do not support team-based care -- a necessary component for physicians' successful participation in MIPS and APMs.
"All the elements of team-based care that are part of the patient office visit, if reviewed and finalized by a physician or other qualified health care professional, should be considered part of the E/M service and should be considered supporting documentation for the coding that follows the information entered," said Wergin.
Defining the Medical Home
The question of whether a practice is a patient-centered medical home (PCMH) should be answered based on the work the practice performs, not on third-party recognition, Wergin told CMS.
He encouraged CMS to review the Joint Principles of the Patient-Centered Medical Home(3 page PDF) -- a document created by the AAFP and three other physician organizations in 2007 -- as well as elements of CMS' own Comprehensive Primary Care (CPC) initiative(innovation.cms.gov) to help determine PCMH criteria.
Wergin urged the agency to embrace the AAFP's firm stance that no physician "should be required to pay a third party to secure the recognition necessary to participate in a Medicare program."
Establishing Performance Years
Regarding timelines, Wergin acknowledged CMS' need for speed in developing and implementing MACRA regulation, but reminded the agency that meaningful primary care transformation "is a complex and long-term endeavor" that can take a practice three years or longer to accomplish.
"That is why we urge CMS to provide flexibility in establishing the performance and payment years," he said. He called on CMS to exercise its authority with regard to implementing MACRA.
He also insisted that CMS provide actionable feedback in "near-real time" to allow primary care physicians to make informed decisions about quality improvement and patient care.
He noted that physicians struggle to make sense of the two-year lag between when performance data is collected and reported, and the CMS payment year.
"The AAFP continues to believe that two-year old data is not clinically actionable or meaningful, and we implore CMS to explore ways to realistically provide actionable feedback within one year or less," said Wergin.
Ensuring Useful Electronic Health Records
Wergin pointed out that CMS publicly stated not so long ago that its meaningful use (MU) program should be "replaced with something better." A good first step would be to adopt an "any-90-day reporting period" for physicians participating in MU, said Wergin. Taking this action would help physicians make an easier transition from the existing MU program to MIPS and APM programs.
He described electronic health records (EHRs) as "the chassis upon which the new delivery and payment models established under MACRA must be built," but noted that physician attitudes toward their EHRs and the MU program were at "historic negative levels."
Indeed, "most family physicians describe the MU program as one that has stopped progress versus a program that has facilitated it," said Wergin.
Therefore, as CMS moves forward with implementation of MACRA it must speed up EHR interoperability to support continuity of patient care and care coordination, discard requirements that burden practices and siphon resources away from patient care, and combine numerous other duplicative government initiatives and regulations.
Covering all the Bases
Wergin touched on a number of other topics in the eight-page letter to CMS. For instance, he urged CMS to
- recognize the cost savings potential that primary care physicians provide,
- offer a per-patient-per-month care management fee in addition to fee-for-service to help control the total cost of care as per the CPC initiative model,
- implement the core measure sets agreed to by the Core Quality Measures Collaborative for inclusion in MIPS and APM,
- use the prospective patient attribution methodology employed in the CPC initiative for MACRA programs,
- include a reconciliation process to allow family physicians to review and dispute patient lists and
- offer physicians multiple options for completing clinical practice improvement activities.
Finally, Wergin requested that CMS give the AAFP's recommendations the attention they deserve and respond to the Academy in a timely manner.
CMS' attention to primary care policies is "critical to the successful implementation of MACRA," he concluded.
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