Houston neurologist Leanne Burnett, MD, knows her specialty is notorious for the amount of time spent with patients. There’s good reason for that.
“I’m a movement disorder specialist, so we have Parkinson patients that have swallowing difficulties, orthostatic hypotension, and cognitive problems,” she said. “We see stroke patients that have spasticity, hypertension, and hyperlipidemia, who also have gait problems and falls.”
Those patients usually make for a complex office visit.
“Even to decide what we’re going to order, the way we’re trained is to try to get enough history that we can ascertain the neuroanatomic location; are we talking brain, spinal cord, muscle, or nerve?” she said. “All that takes a lot of time.”
All that time and complexity means her Medicare patients usually wind up on the high end of the Centers for Medicare and Medicaid Services’ (CMS’) five levels of outpatient evaluation and management (E&M) coding. Those more complex encounters — typically billed as a level 4 or 5 office visit — naturally, earn higher payments than simpler level 1 visits, for instance.
CMS, however, has proposed a dramatic shakeup to that system, which has sounded alarm bells for Texas physicians, especially those who steward complex office visits.
In July, CMS released its draft 2019 Medicare physician fee schedule, in which it proposes collapsing outpatient coding levels 2 through 5 into one payment level, with an amount projected to sit roughly halfway between levels 3 and 4. (See “Four Levels, One Payment Rate,” page 23.)
Neurologists, rheumatologists, internal medicine physicians, and other specialists stand to lose big under CMS’ plan — as do their patients — which prompted a flood of objections ahead of the comment-period deadline on Sept. 10.
At press time, the Texas Medical Association — working to make sure physicians can stay in business and continue seeing Medicare patients — was crafting remarks of its own to persuade CMS to reconsider many of its proposals ahead of the Nov. 1 deadline to publish the final rule. TMA also took issue with CMS’ plan to reduce payments for doing office visits and procedures on the same day.
The potential changes also concern medicine because of the potential ripple effect on private insurance payments, as many commercial payers tie their rates to Medicare’s.
“This is going to be almost a death knell for some of the specialties, like maybe endocrinology, neurology, rheumatology, that spend a lot of time face to face with patients,” Dr. Burnett said. She’s also worried medical students will be discouraged from entering those specialties.
However, CMS says that on the other side of the new payment structure are reduced documentation burdens that will allow doctors to spend more time with patients, plus the potential for physicians to earn more than they do now for the most complex visits via so-called “add-on” payments.
CMS’ proposal puts forth a new structure featuring just two payment levels: Level 1 and a collapsed second category. The draft rule displays what the payment rates would have been for 2018 using the new methodology.
For example, in 2018 payment for a level 1 new-patient office visit was $45, and payment for level 5 was $211. Under the new system, a level 1 visit this year would have netted $44, and levels 2 through 5 visits would earn a physician just $135.
Another proposed change would impact office visits and procedures performed on the same day, such as when a dermatologist examines a mole and then offers to “zap” it that day. In situations where two or more procedures or office visits happen on the same day, CMS would reduce payment for all but the most expensive of those visits by 50 percent.
To read the entire proposed rule, visit tma.tips/medicarepartb19.
When it released the rule proposal, CMS said its plan would “streamline clinician billing and expand access to high-quality care.” CMS highlighted reduced documentation requirements in the proposal and said the changes 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 agency also highlighted that the rule accounts for new care-delivery methods. The proposal, CMS noted, would pay clinicians for virtual check-ins via communication technology, for evaluating patient-submitted photos, and would “expand Medicare-covered telehealth services to include prolonged preventive services.”
CMS called its proposed policy changes “the most significant reduction in provider burden ever taken by any administration” and “an example of the administration’s commitment to truly putting patients over paperwork.”
In a response to emailed questions from Texas Medicine, a CMS spokesperson said the agency had addressed the issue of more complex, time-consuming patients with new add-on payments, “which together would result in a higher payment than the current rate for a Level 5 … visit.” CMS says it held listening sessions across the country in which “thousands of providers” brought up documentation requirements that were negatively impacting care and contributing to physician burnout.
The proposed add-on codes: a $5 additional payment for more complex primary care visits; a $14 additional payment for more complex visits in certain specialty care; and a $67 additional payment for a prolonged 30-minute visit.
“Under the current system, the differences between levels 2-5 are difficult to discern and time-consuming to document,” CMS told Texas Medicine in the email. “Under our proposal, clinicians would only need to meet the documentation requirements currently associated with a level 2 visit. These proposed changes would allow clinicians to spend more time with patients and less time on electronic paperwork at home and on the weekends, as well as less time combing through lengthy or bloated notes to find important clinical information.”
But TMA is worried those concessions hardly balance out the toll the payment changes could take on physician practices and patient care, not the least of which is discouraging doctors from taking Medicare patients at a time when 10,000 baby boomers are turning 65 years old each day, according to Pew Research.
In late August, TMA was drafting comments on the rule proposal, expressing deep concern CMS’ payment cuts would cause significant harm to both doctors and patients, namely that they would make treating Medicare patients even more challenging, and make the program more unattractive to physicians.
“[CMS] just basically … said, ‘Oh, this looks like a great idea. [Doctors are] always griping about too much documentation, and here we go; we can save some money and save the doctors time.’ But it’s not going to do that,” said Little Elm internist John Flores, MD, chair of TMA’s Council on Socioeconomics.
“It’s really going to end up costing primary care in the independent realm a loss of a lot of income, and probably some more practices are going to close. The hospitals can do this. … But independent practice docs like me and a lot of my colleagues, we’re going to take a hit.”
Dr. Flores says internists like him typically see patients with “two to three problems,” which is usually a level 4 visit and carries a $109 payment for an established patient. Even tacking on a $5 add-on for a complex primary care visit, he would receive just $98 for those visits under the new proposal, a 10-percent cut.
“Who knows what the documentation is going to be like to get that extra $5? But even then, in this system, I’m still losing  percent, because most internists aren’t seeing [level 2 and 3 patients]. Those aren’t a big-ticket item,” he said. “If you look at my codes, 80 percent of my codes are [level 4], and I’m about to take a  percent cut. Even just to get that  percent cut, I’m going to document probably extra, because knowing CMS, they’re going to have us push a bunch of other buttons.”
Dr. Flores says the CMS proposal would “devalue that higher-level work. And that’s what concerns me and a lot of my colleagues around the country.” He says it would result in widespread down-coding, and he’s concerned Medicare will become the domain of mid-level practitioners, rather than physicians.
San Antonio rheumatologist Chelsea Clinton, MD, says the changes to in-office procedure payments create a disincentive for physicians to perform same-day procedures. Someone in her specialty who performs a knee injection on a patient, for example, would be inclined to have the patient come back on a different day.
“It’s inconvenient for the patient to return for another visit,” said Dr. Clinton, a member of Texas Medicine’s editorial board. “Physicians want to provide the best and most timely care for their patients. However, I strongly suspect a rule like this would lead to physicians performing non-urgent procedures on a different day.”
For the most part, Dr. Clinton hasn’t taken new Medicare patients for the past two years, although she has kept her existing patients who age into Medicare.
The proposed payment rate for a new-patient visit is unlikely to change that. Most of her Medicare patients take a lot of time for the initial visit, with Dr. Clinton collecting an extensive history.
“Well-established patients are often stable on a good medication regimen. I know their medical history well, need to obtain less information about them, and usually have to make fewer decisions about their care. Generally, the initial visits take much more time,” she said. “I can better understand lowering rates for follow-up visits in exchange for dramatically less documentation requirements. I definitely don’t feel it is a good idea to lower the rate so much for an initial visit.”
Even after opting out of Medicare, Lubbock geriatrician Shannon Tapia, MD, felt compelled to submit a comment objecting to CMS’ proposed payment structure. She considers opting out of Medicare an “insane” thing for a geriatrician to do; all her patients are Medicare enrollees. They pay her directly but can submit to Medicare any lab tests she orders or prescriptions she writes.
Dr. Tapia says her work in a direct primary care practice mostly consists of home visits. Those are the equivalent of a level 5 office visit almost every time. “They take a ton of time, and a lot of mine live in assisted living facilities that you have to reconcile med lists, you have to get collaborative history. A lot of my patients have dementia,” she said.
The CMS proposal, Dr. Tapia says, incentivizes high-volume, low-quality care. Geriatricians are already underpaid as it is, and if the CMS proposal goes through unchanged, she says it would “100 percent” create an environment with fewer geriatric primary care physicians.
“It’s already hard enough to go into geriatrics. A lot of people will do a fellowship in geriatrics as a filler year, but finding people who will actually do the fellowship, get board-certified, do the training it takes, and then also just do geriatrics is really hard — because it really does not pay back student loans, or at least in a timely manner,” Dr. Tapia said.
“This is not going to help it at all. Those that do have the heart for geriatrics, they’re kind of like me: They’re not going to give crappy care. They’re not going to put themselves in a situation where they’re being forced to do things that they know are not right. So they’re either going to burn out, or they’re just not going to go into it.”
The proposed 2019 Medicare physician fee schedule rule also includes potential changes to the Quality Payment Program (QPP), many of which the Texas Medical Association believes result in more program complexity than the previous CMS legacy programs it replaced. TMA supports maintaining and expanding the low-volume threshold for participating in QPP’s Merit-Based Incentive Payment System (MIPS), as CMS proposes, but is concerned the QPP, as designed, will continue to harm small and solo practices in Texas.
TMA believes the overall documentation required for each performance measure and activity contradicts the agency’s new priority of creating a health care system that increases the amount of time that physicians spend with their patients while reducing the burden of paperwork.
Jeffrey Kahn, MD, chair of TMA’s Council on Health Care Quality, says the 665-page proposed rule in the Federal Register is daunting for physicians to read, and he suspects most won’t even try. One aspect of the rule he’s concerned about is CMS’ plan to remove a slew of quality measures. In the rule, CMS proposes to add 10 new measures, remove 34 immediately, and gradually remove others, with few new ones under development.
“There’s just a general concern that removing a large number of measures without reducing quality reporting requirements may make it harder to score high on QPP/MIPS, especially in certain specialties with limited measures from which to choose,” Dr. Kahn said. “Not to mention that many physicians view the existing measures as failing to really capture the quality of their practice and specialty as a whole.”
At right is a snapshot of key parts of the proposal for MIPS. In September, TMA was continuing to analyze the proposal and draft a formal response to CMS’ plan. Read the full proposed rule at tma.tips/medicarepartb19.
Low volume threshold:
Physicians who bill $90,000 or less in Medicare covered professional service charges in 2018, or treat 200 or fewer Medicare patients, would be exempt from required MIPS reporting. But the 2019 proposal adds a third possible criteria for exemption: Providing 200 or fewer covered services.
Eligible clinicians who meet one or two, but not all three, of the low-volume threshold criteria would be able to opt in to MIPS reporting.
Those who see 75 percent of their Medicare patients through a facility, such as a hospital, would be able to use the facility’s scoring.
Increase in performance thresholds:
The performance threshold to avoid payment penalties would be doubled from 15 points to 30 points, and the threshold to earn an additional bonus for exceptional performance would be increased from 70 points to 80.
One of the four weighted categories determining a clinician’s score, the cost category would account for 15 percent of their total MIPS score in 2019, up from 10 percent in 2018. The other categories and their proposed weights for 2019: Quality, 45 percent (down from 50 percent in 2018); Promoting Interoperability, 25 percent; and Improvement Activities, 15 percent.
Physicians who participate would be required to use an electronic health records system certified under the 2015 Certified EHR Technology standards.
Tex Med. 2018;114(10):20-25
October 2018 Texas Medicine Contents
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