CMS Proposed Changes to the Medicare Physician Fee Schedule and Quality Payment Program

This week the Centers for Medicare & Medicaid Services (CMS) proposed changes that would increase the amount of time that doctors and other clinicians can spend with their patients by reducing the burden of paperwork that clinicians face when billing Medicare. The proposed rules would fundamentally improve the nation’s healthcare system and help restore the doctor-patient relationship by empowering clinicians to use their electronic health records (EHRs) to document clinically meaningful information, instead of information that is only for billing purposes.

The proposals, part of the Physician Fee Schedule (PFS) and the Quality Payment Program (QPP), would also modernize Medicare payment policies to promote access to virtual care, saving Medicare beneficiaries time and money while improving their access to high-quality services no matter where they live. Such changes would establish Medicare payment for when beneficiaries connect with their doctor virtually using telecommunications technology (e.g., audio or video applications) to determine whether they need an in-person visit. Additionally, the QPP proposal would make changes to quality reporting requirements to focus on measures that most significantly impact health outcomes.

The proposed changes would also encourage information sharing among healthcare providers electronically, so patients can see various medical professionals according to their needs while knowing that their updated medical records will follow them through the healthcare system. The QPP proposal would make important changes to the Merit-based Incentive Payment System (MIPS) “Promoting Interoperability” performance category to support greater EHR interoperability and patient access to their health information, as well as to align this clinician program with the proposed new “Promoting Interoperability” program for hospitals.

Proposed CY 2019 Physician Fee Schedule Key Changes

The Physician Fee Schedule (PFS) establishes payment for physicians and medical professionals treating Medicare patients. It is updated annually to make changes to payment policies, payment rates, and quality-related provisions. Extensive public feedback has highlighted a need to streamline documentation requirements for physician services known as “evaluation and management” (E&M) visits, as well as a need to support greater access to care using telecommunications technology.

The proposed changes to the PFS would reinforce CMS’ Patients Over Paperwork initiative focused on reducing administrative burdens while improving care coordination, health outcomes, and patients’ ability to make decisions about their own care.

Streamlining Evaluation and Management Payment and Reducing Clinician Burden

CMS and the Office of the National Coordinator for Health Information Technology (ONC) have heard from stakeholders that CMS’ extensive documentation requirements for Evaluation and Management (E&M) codes have resulted in unintended consequences. To meet these documentation requirements, providers must create medical records that are a collection of predefined templates and boilerplate text for billing purposes, in many cases reflecting very little about the patients’ actual medical care or story.

Responding to stakeholder concerns, several provisions in the proposed CY 2019 Physician Fee Schedule would help to free EHRs to be powerful tools that would actually support efficient care while giving physicians more time to spend with their patients—especially those with complex needs—rather than on paperwork. Specifically, this proposal would:

• Simplify, E&M office visits—which make up about 20 percent of allowed charges under the PFS and consume much of clinicians’ time
• Reduce unnecessary physician supervision of radiologist assistants for diagnostic tests
• Remove burdensome and overly complex functional status reporting requirements for outpatient therapy

Advancing Virtual Care

Provisions in the proposed CY 2019 PFS would support access to care using telecommunications technology by:

• Paying clinicians for virtual check-ins—brief, non-face-to-face appointments using communications technology
• Paying clinicians for evaluation of patient-submitted photos
• Expanding Medicare-covered telehealth services to include prolonged preventive services

Lowering Drug Costs

CMS is proposing changes as part of the continued rollout of the administration’s blueprint to lower drug prices and reduce out-of-pocket costs.

The changes would affect payment under Medicare Part B, which covers medicines that patients receive in a doctor’s office such as infusions. CMS is proposing a change in the payment amount for new drugs under Part B, so that the payment amount would more closely match the actual cost of the drug. This change would be effective January 1, 2019, and would reduce the amount that seniors would have to pay out-of-pocket, especially for drugs with high launch prices. This is one of many steps CMS is taking to ensure that seniors have access to the drugs they need.

Proposed CY 2019 Quality Payment Program Key Changes

To implement the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), CMS established the Quality Payment Program (QPP), which consists of two participation pathways for doctors and other clinicians: the Merit-based Incentive Payment System (MIPS), which measures performance in four categories to determine an adjustment to Medicare payment, and Advanced Alternative Payment Models (APMs), in which clinicians may earn an incentive payment through sufficient participation in risk-based payment models.

The proposed changes to the QPP aim to reduce clinician burden, focus on outcomes, and promote interoperability of electronic health records (EHRs), including by:

• Removing MIPS process-based quality measures that clinicians have said are low-value or low-priority, in order to focus on meaningful measures that have a greater impact on health outcomes
• Overhauling the MIPS “Promoting Interoperability” performance category to support greater EHR interoperability and patient access to their health information, as well as to align this performance category for clinicians with the proposed new Promoting Interoperability Program for hospitals.

Under the requirements of the Bipartisan Budget Act of 2018, CMS is continuing the gradual implementation of certain MIPS requirements to ease administrative burden on clinicians. The proposed changes to the QPP reflect feedback and input from clinicians and stakeholders, and CMS will continue to offer free and customized support from CMS’ technical assistance networks.

Medicare Advantage Qualifying Payment Arrangement Incentive Demonstration

Aligning with CMS’ goals of improving quality of care and responding to the feedback it has received from clinicians, the agency also proposes waivers of MIPS requirements as part of testing the Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) demonstration. The MAQI demonstration would test waiving MIPS reporting requirements and payment adjustments for clinicians who participate sufficiently in Medicare Advantage (MA) arrangements that are similar to Advanced APMs.

Some Medicare Advantage plans are developing innovative arrangements that resemble Advanced APMs. However, without this demonstration, physicians are still subject to MIPS even if they participate extensively in Advanced APM-like arrangements under MA. The demonstration will look at whether waiving MIPS requirements would increase levels of participation in such MA payment arrangements and whether it would change how clinicians deliver care.

Price Transparency: Request for Information

Finally, as part of its commitment to price transparency, CMS is seeking comment through a Request for Information asking whether providers and suppliers can and should be required to inform patients about charge and payment information for healthcare services and out-of-pocket costs, what data elements would be most useful to promote price shopping, and what other changes are needed to empower healthcare consumers.

Public comments on the proposed rules are due by September 10, 2018.