There is an aspect of ACP advocacy that has a huge impact on the professional development and daily lives of physicians, and on the health of patients, yet does not appear to be well known by many members: the intensive work that the College does to improve the nitty-gritty details of federal regulations.
On July 12, CMS released proposed rules for the Medicare Physician Fee Schedule and the Quality Payment Program (QPP) for 2019. These two proposed rules illustrate how ACP influences federal regulatory policies, and the stakes involved, for physicians and patients.
Reducing regulatory burdens
Consistent with ACP's Patients Before Paperwork initiative, CMS agreed to many of ACP's proposals to reduce the administrative tasks imposed on physicians and patients.
Easing documentation requirements. CMS proposed to greatly reduce the burden of current documentation requirements for new and established patient office visits, specifically by allowing such documentation to focus on medical decision making, as ACP has strongly advocated for in the past. ACP also is encouraged by CMS's proposal to further reduce documentation burdens on physicians by requiring them to only document changed information for established patients and to sign off on basic information documented by practice staff. These changes were specifically sought by the College.
Changing the MIPS low-volume threshold. CMS proposed to reduce the burden of reporting on the Merit-Based Incentive Payment System (MIPS) by adding another way for clinicians to qualify for an exemption under the low-volume threshold while allowing low-volume clinicians the option to participate in MIPS, as advocated for by ACP.
Streamlining the Promoting Interoperability MIPS category. ACP is glad to see that CMS proposed to streamline the scoring methodology for the Promoting Interoperability (formally Advancing Care Information) category of MIPS.
Eliminating “low-value” measures. ACP is especially encouraged by CMS’ plan to remove a number of quality measures deemed by the agency to be of low value, a step forward in addressing the concerns raised by ACP's Performance Measurement Committee regarding the validity of many of the measures now being used by Medicare.
Influencing payment changes
CMS also proposed major changes in physician payment policies, some positive and some quite concerning.
On a positive note, CMS proposed payment for more non-face-to-face services. New reimbursable codes would be created for “virtual check-ins,” remote consults involving patient videos and photos, and interprofessional online consultations, improvements long sought by ACP that would improve care for patients and create opportunities for internists to be reimbursed for the work involved.
The proposed changes to documentation requirements, as described above, are paired with a proposal for a new, single blended payment rate for new and established patients for office/outpatient level 2 through 5 visits. For established patients, the new payment rate would be a flat $93 for level 2 through 5 visits, compared to $45, $74, $109, and $148 today. For new patients, it would be $135 compared to $76, $110, $167, and $211 under current rules.
Since internists typically take care of many elderly patients with multiple chronic conditions, ACP expressed concern from the outset that this proposed payment structure may adversely impact internal medicine specialists, subspecialists, and their patients. ACP President Ana María López, MD, MPH, FACP, observed in a press statement released the day after the proposed rules were published that “Reimbursing the most complex E/M services to such patients at the same flat level as healthier patients with less complex problems could undervalue the physician skills and training needed to care for such patients.”
CMS proposes to mitigate the potential adverse impact of instituting flat payments for most visit codes by creating new add-on “G” codes that will pay primary care and nonprocedural subspecialists an additional set dollar amount for each visit billed, $5 for primary care physicians and $9 for subspecialists. In addition, CMS proposed to add a new “G” code for prolonged face-to-face visits (visits that take more than the typical amount of time for each visit code), which, depending on the details of implementation, could allow physicians to be paid more for complex visits requiring more time.
Pluses and minuses
When the impact of the proposed payment policy changes is taken together, ACP's calculations—consistent with CMS's—show that internists who have a typical mix of office visits, levels 2 through 5, would see little change in their overall Medicare payments, when the flat fee and primary care add-on payments are included. (We were unable to calculate the impact of the prolonged service codes, because CMS has not yet issued detailed instructions on how and when they could be billed. Nor did our estimates include increased revenue from virtual visits, since Medicare has no track record of paying for such services.) And, of course, all internists would benefit from an easing of documentation and reporting requirements.
Some internal medicine subspecialists and geriatricians, though, likely would see substantial cuts because they bill more frequently for the higher-level codes. It's not just the direct impact on these physicians that raises concerns but also the direct impact on their patients: If fewer physicians enter or remain in the disciplines that take care of patients with the greatest health care needs, or if physicians react to the changes by scheduling shorter visits, patients would suffer. Complex cognitive care needs to be valued appropriately for the physician work and skill involved, and in this regard, CMS's proposal falls short.
ACP is crafting a detailed and comprehensive response to the agency's proposals, which is due to CMS on Sept. 10. Our goal will be to encourage the agency to move forward on the many changes that are aligned with ACP's advocacy agenda—easing of documentation requirements, making the MIPS program less burdensome, retiring low-value measures, and paying for virtual visits among them—while looking for alternatives that would not disadvantage physicians who take care of patients with the most complex conditions.
While we won't know the full results until the final rules are published in November, I am confident that the College's advocacy to improve the nitty-gritty details of CMS's regulations will have made a difference for the better in the daily lives of our members and in the health of their patients.