Friday, September 7, 2018

Tell CMS the Payment Proposals Will Hurt Patients with Serious Illness

by Phil Rodgers (@PhilRodgersMD)


Submit comments this weekend! Deadline: Monday, Sep 10, 11:59 PM ET

Regular Pallimed readers will remember Amy Davis’ excellent post regarding CMS’ recent proposed rule updating the Medicare Physician Fee Schedule and Quality Payment Program for 2019. (See this CMS Fact Sheet to learn more). In this rule, the agency proposes historically bold changes to outpatient evaluation and management (E/M) documentation requirements and payments, among many other substantial changes in the fee-for-service Medicare program. CMS says these proposed changes are designed to "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,” and they align with CMS’ Patients Over Paperwork initiative.

One of the provisions most concerning to the hospice and palliative care community is the proposal to create a single ‘blended’ payment for level 2 through 5 outpatient E/M visits (both new and established) that is lower than the current payment for level 4 visits. (See a CMS slide deck for more detail). Since many outpatient palliative care providers bill almost exclusively level 4 and 5 visits, this proposal is particularly damaging to our field. In fact, an American Medical Association (AMA) impact analysis showed that hospice and palliative care providers will be the hardest hit of all specialties, with an expected 20% reduction in outpatient E/M revenue. CMS also proposes new complexity and prolonged services payments, but they will not be sufficient to offset the cut in E/M payments.

On the positive side, the rule also includes proposals to reduce physician burden, like significantly decreasing documentation requirements (or 'note bloat'), and providing options to bill based primarily on ‘medical decision making’ or even face-to-face time. CMS also proposes new payments for technology-based services (both patient interactions and interprofessional consultation), new payments for E/M services provided on the same day by different providers in the same specialty or practice, and eliminating the requirement to justify a home visit instead of an office visit.

The reaction from the medical community to this proposed rule has been swift and significant. The AMA gathered 170 state and specialty medical societies and other health professional organizations to sign on to a letter that encourages CMS to move ahead with the positive changes in the proposed rule, but not to finalize the ‘code collapse’ proposals as written. Instead, the signatories request that CMS work with the medical community to develop payment reforms that ‘get it right’ for patients and providers, for implementation as soon as 2020.

The American Academy of Hospice and Palliative Medicine (AAHPM) has been actively engaged since the release of the proposed rule in mid-July. In addition to signing on to the AMA letter, AAHPM has worked with the National Coalition for Hospice and Palliative Care, the Patient Quality of Life Coalition, and a multi-specialty coalition led by the American Geriatrics Society, as well as participated in meetings with CMS leadership and a high-profile E/M workgroup convened by the AMA Current Procedural Terminology (CPT) Editorial Panel and RVS Update Committee (RUC). AAHPM has stressed throughout that many outpatient palliative care providers will be severely affected by the E/M payment reductions to the point of being forced to close, and that the proposed changes will likely reduce access to care for many Medicare beneficiaries with serious illness. AAHPM has also has pledged to continue very active engagement to help develop more patient-centered payment proposals.

Now it’s your turn! Public comments are being accepted through midnight (Eastern time) Monday September 10, and I strongly urge you to weigh in. It’s easier than you may think: AAHPM has provided a short and readable guide that provides suggested Talking Points and details how to submit comments online. Do check it out. You can also review these tips for effective comments from Regulations.Gov.

In addition to those resources, I’d offer the following thoughts on comment writing:

1. CMS really does read every comment received on proposed rules, and sometimes cites specific comments as leading to changes in the final regulations — so your input counts!

2. Write in your own voice, and speak to the impact the proposals will have on your practice and your patients. If you happen to have specific knowledge about regulations (say, from a leadership or administrative role) don’t be afraid to share it; however, you don’t need to be an ‘expert’ (or try to write like one) to weigh-in effectively.

3. Don’t feel like you have to comment on every issue in the proposed rule (it’s massive). Focus on those that you feel most strongly about. Sometimes a shorter, well-reasoned and well-supported comment packs a bigger punch.

4. Remember the ‘feedback sandwich’: start with something positive, then provide specific criticisms (as constructively as possible), then finish up with a positive comment. You can be a little more ‘on the nose’ in a comment letter than you would when evaluating a learner or colleague, but double down on specificity in your concerns, not vitriol or outrage. (Hint: the AAHPM Talking Points are structured in ‘sandwich’ format, and meant to strike a concerned but constructive tone.)

Bottom line: Submit comments soon! You can comment online here (https://www.regulations.gov/comment?D=CMS-2018-0076-0621) and either add text directly to a comment box, or prepare a letter and upload the file.)

Deadline is Monday, September 10, at 11:59 PM ET!

Phil Rodgers practices and teaches Palliative Medicine and Family Medicine at the University of Michigan, and directs UM Adult Palliative Medicine clinical programs. He also represents the American Academy of Hospice and Palliative Medicine (AAHPM) in multiple national advocacy efforts related to payment and policy, and is leading the Academy team developing strategy, comments and collaboration in response the 2019 MPFS proposed rule.

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