75 Ways the Big Medicare Changes Are Very Bad for Physicians and Patients
By Steve Levine


Exactly two months ago, the Centers for Medicare & Medicaid Services (CMS) unveiled a massive package of proposed new rules for the Medicare program with the promise that it 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 Texas Medical Association cried foul on that claim with a painstakingly detailed comment letter it delivered to CMS late yesterday. 

“We fear that the rule will significantly increase Medicare’s administrative burden, will reduce Medicare payments to many physician practices, will do little to improve quality of care or reduce the cost of care, and will further reduce Medicare beneficiaries’ access to care,” John G. Flores, MD, chair of TMA’s Council on Socioeconomics, and Jeffrey B. Kahn, MD, chair of the Council on Health Care Quality, wrote in their introduction to the 58-page letter.

This year, the agency combined two historically complex and controversial Medicare rule proposals into a single 1,453-page document covering the annual Physician Fee Schedule update and revisions to the Quality Payment Program (QPP). 

TMA’s analysis found extensive problems in both parts of the proposed rule. The association offered 75 distinct recommendations for improvement.

TMA welcomed CMS’ proposal to simplify the “outdated, excessive, and overwhelming” documentation requirements associated with evaluation and management (E&M) services. 

But the association rejected the agency’s plan to collapse the five levels of E&M office-visit payments to two levels, with one payment rate for level 1 visits and another covering levels 2-5. The rule projects the higher payment level to fall between the payment for levels 3 and 4 in the current structure — meaning physicians who typically handle level 4 and 5 visits for more complex patients would see their payments take a hit.

“While CMS is proposing to reduce the E&M documentation requirements, the amount of time, expertise, and skill used with the patient will not change,” Drs. Flores and Kahn wrote. “This is a significant devaluation of the physician’s work.”

Since its inception, physicians have complained that the QPP — with its multiple, rapidly changing data elements, measures, objectives, activities, thresholds, deadlines, reporting periods, and submission mechanisms — is a bureaucratic nightmare.

“As we move into the third year of the QPP, TMA continues to be concerned that the compliance, documentation, and data submission requirements required by law and regulation are costly and wasteful with no proven evidence of benefit,” Drs. Flores and Kahn wrote. 

“We remind CMS that with each measure, objective, and improvement activity it subjects physicians to under the QPP, physicians must spend more time on paperwork to document every aspect of clinical care delivery that corresponds to the data elements that support each metric.”

Failure to comply, TMA pointed out repeatedly, exposes practices to Medicare payment cuts and costly audits.

“While we acknowledge that many physician practices are in a position to engage in full participation, we continue to hear from even more physicians who are neither ready nor have the time and resources to take on and manage the additional administrative, technological, and financial challenges associated with the QPP while being subject to annual Medicare payment penalties due to nonparticipation,” the association noted.

TMA proposed delays, or major changes, to CMS’ plans to, among many other things: 


  • Pay for physician consultations with patients by telephone or telehealth;
  • Not change the payment localities used in calculating the Geographic Pricing Cost Index ;
  • Ask physicians to provide extensive price and charge data that has little or no applicability to the Medicare program; 
  • Reduce payments for E&M services provided at standalone office visits on the same day as a procedure;
  • Continue to judge physicians’ cost and quality performance without appropriately risk-adjusting their scores based on patients’ demographic or socioeconomic characteristics that have been proven to correlate with poor health outcomes;
  • Double the number of points a physician must earn to avoid a Medicare payment penalty;
  • Neither expand the number of quality measures a practice may choose from nor reduce the minimum number (six) of measures on which a practice may report — all while planning to further reduce the number of available measures over the next few years;
  • Continue to rate physicians based on costs of services that are completely unrelated to any medical care that the physician may have provided, ordered, or recommended;
  • Completely replace the terms it uses to describe its quality measures, data submission mechanisms, and submission processes; 
  • Reduce the bonus points available for small practices;
  • Refuse to hold physicians harmless for data collection and submission errors made by outside vendors; and
  • Force practices to accept more risk than they can financially manage if they wish to earn bonus payments under an Advanced Alternative Payment Model (APM). 


Finally, because of “the overall program complexity of the QPP and annual changes to data requirements, terminology, and policies that are not finalized until two months before each performance period,” TMA said CMS should simplify and improve the educational materials it provides to help physicians and groups succeed under the QPP.

“Physicians report that learning about and navigating the MIPS and APM pathways is very challenging, confusing, or simply not feasible,” Drs. Flores and Kahn wrote.

Last Updated On

September 25, 2018

Originally Published On

September 11, 2018

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