DCMedical News: Friday, July 13, 2018
DCMedical News
Washington, D.C.
Friday, July 13, 2018
DCMedical News is published every day either the House or the Senate is in session.
THE BIG STORY TODAY IN HEALTH CARE
CMS Upends E&M Codes, Proposes to Pay Doctors for Electronic Reviews, Subtracts (and Adds) Complexity:
CMS proposed (a 1473 pg. proposal to be published in the July 27 Federal Register, here, six page summary here, 28-pg. quality fact sheet here) to revise the Evaluation and Management (E&M) codes which have been the basis of payment for much of ambulatory care since 1995. Doctors frequently complain about arbitrary third party down-coding, while electronic medical records systems nearly inevitably promote (a sales feature) upcoding. The E&M codes were originally intended to address the disparity between procedure-based work (surgeons, some other specialists) and cognitive work (which the American College of Physicians—the internists—saw as their strength). The disparity, in turn, resulted from the 1989 Health Care Financing Administration’s adoption of the California workmen’s compensation RVU (relative value unit) scheme and the Common Procedural Terminology (CPT)-based payment system. (CPT is copyrighted by the American Medical Association, and overseen by the RUC or Relative value Update Committee, a medical industry version of physician collective bargaining with the government.) CMS now proposes to allow practitioners to designate the level of a patient's care needs using their medical decision making instead of the 20+ year history of E&M documentation.
The proposed rule also provides that Medicare pay doctors for telephone or other telecommunication-based evaluation, including review of videos or imaging. CMS Administrator Verma said "This is a big issue for elderly and disabled populations for which transportation can be a barrier to care." Other changes in the proposed rule would eliminate the requirement to justify the medical necessity of a home visit, and to eliminate the prohibition against payment for same-day visits with multiple practitioners in the same specialty within a group practice. In another aspect of ambulatory care, CMS proposes to continue downgrading payment of the site-of-service differential which has fueled hospital acquisition of physician practices. Off-campus facilities built after Nov. 2, 2015, will be paid 40% of the hospital outpatient prospective payment rates.
In CMS-approved “quality” measurement, CMS is cutting 34 measures out of the Merit-based Incentive Payment System (MIPS). (See related story below, “Who Speaks for the Practicing Physician?”) However, CMS is also adding 10 new quality measures including four measures based on patient satisfaction. (Patient “satisfaction” reports for both hospitals and physicians are blamed by some for fueling the opioid prescription epidemic. Patients whose pain is controlled or who get from their doctor what they want are seen as more “satisfied.”) CMS also proposes to compel physicians to use the most recent (2015) edition of “certified” electronic medical records, contending that the requirement will save physicians money. In response, an MGMA spokesman said "Today's rule proposes to require physicians to deploy costly EHR upgrades for 2019 and takes further steps toward implementing burdensome appropriate use criteria."
DOCTORS, NURSES AND OTHER HEALTH PROFESSIONALS
Who Speaks for the Practicing Physician? The GOP Doctors Caucus has petitioned CMS Administrator Verma to limit the number of doctors who can be excused from the MIPS program. The caucus acted (according to InsideHealthPolicy) in response to concerns from the American Medical Group Association (AMGA), concerned that “the smaller number of physicians in the program limits the bonuses high performers can get.” CMS had previously raised the threshold, excluding doctors with no more than $90,000 in Part B charges per year and no more than 200 Medicare beneficiaries.
The AMA supported that previous move, as a reduction in regulatory burden on smaller practices. The result of the previous CMS action was that 60% of otherwise eligible providers were excluded from the program in 2018, most of them based on the low volume threshold. As part of its proposed payment rule for 2019 CMS issued guidelines (here) for the MA qualifying incentive to exempt physicians from other MIPS requirements. Thirteen members of Congress are physicians. Here is a list, with their specialties.
A timely article: in this month’s Health Affairs (here) a majority of physicians in a survey are concerned that MIPS could harm patient care. "We found a significant number of physicians believed that there could be unintended consequences under these pay-for-performance incentives," according to author Joshua Liao, MD. Doctors score MIPS points based on reporting and performing on CMS-approved “clinical quality measures,” “controlling” how patients use resources, level of participation in CMS-authorized “clinical practice improvements” and of course using electronic medical records. Almost 70% of the physicians surveyed were concerned that MIPS would "focus on aspects of care being measured to the detriment of other unmeasured aspects of care." Sixty per cent said physicians might "avoid sicker or more medically complex patients to improve performance on quality or utilization measures."
MEDICARE, MEDICAID, COMMERCIAL HEALTH INSURANCE
Conservative Groups Favor HSA Legislation: The Ways & Means Committee (here) heard from a coalition of conservative groups concerning HSA legislation. A summary of the bills being marked up is here. Testimony was offered at the most recent hearing. The Committee subsequently promoted the testimony of three of the four witnesses, those three commercially connected to the HSA industry. The fourth, Wagner Dean Sherry Glied, Ph.D., was the only one whose testimony did not favor the growth of HSAs. (See DCMN 6-7-2018 here and Dean Glied’s testimony here.)
EVENTS & MEETINGS
July 13
9:00 a.m.-Noon, “Strategies for stabilizing the individual market,” USC-Brookings, 1775 Massachusetts Avenue, N.W., Paul Ginsburg, academics.
July 13
9:00 a.m-Noon, Brookings, PPACA repair by the states, study of four states, discussion, (202) 797-6105, events@brookings.edu.
July 17
9:00 a.m. – 5:00 p.m., National Committee on Vital and Health Statistics (NCVHS), Standards (patient medical record information, electronic exchange of such information, health terminology and vocabulary). Federal Register notice here. Continued on the 18th, 8:30 a.m. – 3:00 p.m.
10:00 a.m., House Ways and Means Oversight Subcommittee hearing “Combating Fraud in Medicare,”
1100 Longworth HOB.
10:15 a.m., House Energy & Commerce Subcommittee on Oversight and Investigation will explore state efforts to improve transparency in health care pricing. National Conference of State Legislatures report here. 2322 Rayburn HOB.
2:00 p.m., House Ways and Means Subcommittee on Health, Hearing “Modernizing Stark Law to Ensure the Successful Transition from Volume to Value in the Medicare Program.”
July 20
12:00 p.m. – 1:30 p.m., “State Responses to the Evolving Individual Health Insurance Market,” Commonwealth and Alliance for health Policy, Dirksen SD-106, lunch!
July 25
7:30 a.m. – 4:30 p.m., Medicare Evidence Development and Coverage Advisory Committee (MEDCAC), volume requirements for aortic valve replacements and percutaneous coronary interventions.
Maria Ellis, MEDCAC, (410) 786-0309, maria.ellis@cms.hhs.gov. Federal Register notice of meeting here, National Coverage Determination request for comment (6-28-2018) here.
Aug. 20
Meeting of Medicare Advisory Panel on Hospital Outpatient Program (through August 21), APCs, OPPS, the works. Evaluation of Advanced Primary Care (APC) groups; packaging of Outpatient Prospective Payment System (OPPS). Federal Register notice (5-3-2018), here.
Aug. 22
7:30 a.m. – 4:30 p.m., Medicare Evidence Development and Coverage Advisory Committee (MEDCAC), CAR-T cell therapies, collection of patient reported outcomes in cancer clinical studies.
Maria Ellis, MEDCAC, (410) 786-0309, maria.ellis@cms.hhs.gov. Federal Register notice (6-15-2018) here.
FOR REFERENCE
Members of the Senate (here) and Members of Senate Committees (here), Senate Calendar (here).
Members of the House with their House Committees (here), House Calendar (here).
PUBLICATION SCHEDULE FOR DCMEDICAL NEWS
DCMedical News is published every day that either the House of Representatives or the Senate is in session.
Trial subscriptions may end without notice, and all will end July 31.
July publication dates: 16, 17, 18, 19, 20, 23, 24, 25, 26, 27, 30, 31.
August publication dates: prn, Senate may be in session.
September publication dates: 4, 5, 6, 7, 12, 13, 14, 17, 18, 20, 21, 24, 25, 26, 27, 28.
Notes to: Fred Hyde, MD, JD, MBA; fredhyde@aol.com