Proposed changes to rules governing how Medicare pays physicians in 2019 were released by the Centers for Medicare & Medicaid Services (CMS) last month in a 1,472-page proposed rule known as CMS-1693-P.
CMS says the proposal puts “Patients Over Paperwork” by ending the notorious AMA-designed Evaluation & Management (E&M) documentation “guidelines” that meld physicians to computer screens while decreasing face-time with patients and bloating the medical record with data that does not benefit, and too often detracts, from patient care.
Because the existing paperwork burden is required to document justifications for higher-level payments, CMS is also proposing to “blend” reimbursements for level 2 through 5 Evaluation & Management visits. Current Medicare-allowed fees for an established patient range from $45 to $148, and for a new patient from $76 to $211. The new schedule would pay $93 for an established or $135 for a new patient, regardless of the complexity of the service. Documentation need only be sufficient to justify a level 2 visit.
“Specialists who provide many level 4 and 5 visits to complicated patients would see a large decrease in revenue based on this blending,” notes AAPS executive director Jane M. Orient, M.D.
Bottom line? Cutting bureaucratic red tape is welcome relief; however, doubling down on Medicare price controls will only serve to further impede competition and limit access to care.
Buried in the proposed rule alongside the fee schedule modifications are planned changes to the MACRA “Quality Payment Program” aka MIPS and APMs for 2019. The program is largely unchanged from previous years except for marginal changes that don’t meaningfully fix the inherent flaws in MACRA’s top-down design.
Yet, there is one change CMS proposes that is especially welcome. On page 801, CMS writes, “Beginning with the 2019 MIPS payment year, we are proposing that the MIPS payment adjustment does not apply for non-assigned claims for non-participating clinicians.” We agree. Patients who directly pay “non-Par” physicians for care, and are reimbursed by Medicare, should not be subject to MIPS penalties. However, there will likely be push back to this good change from those who seek increased MIPS bonuses by subjecting more small and independent practices to MIPS adjustments.
CMS needs to hear from YOU as it considers finalizing the rule changes for 2019. To be assured consideration, comments must be received no later than 5 p.m. Eastern on September 10, 2018.
Here’s how you can speak out:
1) Copy our suggested comments:
Dear Administrator Verma,
I appreciate this opportunity to comment on the Medicare physician payment rules for 2019 as proposed in CMS-1693-P.
Reducing paperwork burden is greatly needed, but this relief should not be tied to more stringent price controls that further impede competition and will serve to ration care. I ask that CMS rethink the implementation of blended rates that flatten payments and threaten to degrade patient access to physician services.
Alternatives CMS should explore include giving patients greater flexibility to determine the value of services to them apart from the Medicare-set fee.
In fact, CMS should be applauded for a step in this direction by proposing to exempt reimbursement to patients of non-participating physicians from MIPS penalties. It is improper to impose penalties on patients who choose non-Par physicians for their care. More, not fewer, exemptions to MIPS like this are needed, despite the claims from entities who seek additional bonuses at the expense of small and independent practices.
Additionally, to further the goal of putting patients over paperwork, CMS should use the final rule to revoke 42 C.F.R. § 405.415(o). This regulation mandates patients periodically re-sign private contracts with physicians who have opted-out of Medicare. It does not align with statutory changes made by Section 106 of MACRA (Public Law 114-10) to “reduce administrative burden” for Medicare private contracting and should be rescinded.
In conclusion, I appreciate CMS efforts to make changes to free patients and their physicians from bureaucratic red tape. Meaningful change, however, must include abating price controls and discriminatory payment practices, not calcifying them. As Secretary Azar recently stated, “value is best determined by markets and consumers, not arbitrary rules and central planners.”
2) Visit the comment submission page and paste in the comments. Feel free to customize the comments to your liking before submitting. The form for submitting comments is at: https://www.regulations.gov/comment?D=CMS-2018-0076-0621
Thank you for speaking out! ~AAPS.