Tweet

by Amy Davis (@MaximizeQOL)

(CMS open to comments until Sep 10, 2018. See end of post for details. - Ed.)

Centers for Medicare and Medicaid Services (CMS) has proposed sweeping reforms to documentation requirements, clinician reimbursement, and the Quality Payment Program (QPP), to begin in 2019. (1)  If approved in their current form, the changes are likely to have dramatic net negative effects on outpatient palliative care reimbursement. A detailed review and analysis of all 1,473 pages of the Proposed Rule, plus its addenda, would not be practical here. The reader is referred to the complete text (1) and others’ assessments (2) reviewing its discussions of specific codes, telemedicine, unrelated Relative Value Units (RVUs), the QPP (3), and other issues less directly related to general specialty outpatient palliative care. The sections involving the new documentation and reimbursement paradigm seem poised to have the biggest impacts.

Numerous professional organizations have been persistently calling for CMS and other similar stakeholders to eliminate the ever-growing administrative tasks burdening clinicians today that are not meaningfully helping patients. For example, the American College of Physicians’ initiative (4) has avidly encouraged, among other things, the elimination of duplicative and clinically irrelevant documentation and a focus on those administrative elements demonstrated to have clinically meaningful impact.

CMS has listened to this universal outcry and is making strong efforts to adjust requirements accordingly through its Patients Over Paperwork campaign. The 2019 Proposed Rule would consolidate the complicated 1995/1997 Evaluation and Management documentation guidelines currently used to support billing for the various levels of outpatient care provided in medical offices (CPT codes 99201-99205 and 99211-99215 for new and established patient visits, respectively). Clinicians would continue to bill for the appropriate level of care provided (levels 1 through 5; see also below). However, levels 2 through 5 would only require documentation corresponding to a level 2 visit; that required for 99201 and 99211 visits would remain unchanged.

The Proposed Rule further suggests documentation of straightforward medical decision-making (5) would alternatively be acceptable, as long as medical necessity was established. Clinicians would still retain the options of adhering to current documentation guidelines or to bill based on time. Further, billing for a home visit (CPT codes 99341-99350) would no longer require explaining the medical reason the person could not be seen in the office. CMS indicates reforms pertaining to additional sites of care will be proposed in future years using a step-wise transformation model. The Proposed Rule also suggests ways to eliminate the unnecessary duplication of documentation, such as an unchanged family history, between visits and among clinicians using a shared electronic medical record. While of course other insurers and third-party companies managing the prior authorization system are not obligated to follow CMS’s lead in changing documentation requirements, CMS encourages other stakeholders to similarly reform.

CMS’s corollary to these meaningful and appreciated improvements involves uncoupling reimbursement from documentation, providing a single payment amount for level 2 through 5 visits. The Proposed Rule suggests a new, single RVU for the different levels of outpatient care provided during new and established patient visits done in medical offices, regardless of the visit level submitted. The payment amount was determined based on the weighted general frequencies visit levels 2 through 5 were submitted on all 2012 through 2017 claims. CMS accordingly proposes a RVU of 1.90 and 1.22 for new and established visits, respectively. Direct practice expense inputs were similarly established ($24.98 and $20.70). CMS applied these calculations to the available 2018 claims data and suggest the corresponding reimbursement would have been $135 for new and $93 for established level 2 through 5 visits, respectively. The complex data and calculations provided in the Proposed Rule and its Addenda suggest these amounts would generally be similar in 20196 if instituted unchanged in the Final Rule.

CMS further proposes the creation of HCPCS G-code “add-ons.” One is designed to account for the increased overall care complexity tackled by clinicians practicing certain areas of medicine, such as oncology, endocrinology, and interventional pain management, reflected in higher frequencies of level 4 and 5 visits in their claim submissions (GCG0X). Another is an attempt to counterbalance the increased practice expenditures primary care clinicians face “…coordinating patient care, collaborating with other physicians, and communicating with patients” more than other clinicians, as described on page 355 (GPC1X). Most clinicians providing outpatient palliative care appropriately almost exclusively submit visit levels 4 and 5 due to the high medical complexity of the patients involved. Further, they are generally highly involved with the same costly services also provided by primary care specialists. While the chronic care management, advanced care planning, and prolonged face-to-face service codes will remain available to all clinicians, palliative care specialists ironically do not seem to be eligible for either of these add-on G-codes. However, the overall financial impact of these G-codes is expected to be small. The proposed significantly decreased reimbursement, coupled with the G-code inclusion oversight, is likely to result in a major, if not prohibitive, deficit in our ability to provide much-needed outpatient subspecialty palliative care services. Worse, it may result in palliative medicine specialists intentionally re-classifying themselves as primary care or other alternate covered specialties in order to try to mitigate this potentially devastating financial loss.

Many in palliative care more often code visits based solely on the time spent with the patient than those practicing other specialties, primarily due to the nature of our role in helping patients and teams match provided care to the patient’s goals. CMS proposes eliminating the current policy that requires more than 50% of the time-based visit involve counseling and/or care coordination, suggesting the time spent is often a valid surrogate to the visit’s complexity. The face-to-face requirement remains unchanged. CMS also proposes to eliminate the current policy preventing two clinicians with the same Medicare enrollment specialty from receiving reimbursement for care provided on the same day. This will hopefully eliminate patients having to return to the office on a subsequent day or clinicians foregoing reimbursement for the care they provide. CMS’s formal recognition that a clinician enrolled with Medicare as an internist, for example, may also have additional training in another specialty, such as palliative care or geriatrics, is appreciated but will likely benefit a rather limited number of patients and clinicians.

The CMS paradigm transformation proposed for 2019 implementation offers a number of very positive reforms. CMS is clearly listening to the global outcry from clinician stakeholders across the healthcare spectrum, and their efforts are sincerely appreciated. However, taken in its entirety, the proposed changes as they stand are likely to result in potentially profound net negative consequences on the provision of outpatient palliative care. It is imperative that palliative care organizations, clinicians, and other stakeholders offer comments (7) to CMS before the comment period ends on September 10th to sustain and support outpatient palliative care.

(Primer on how to make comments to CMS here by lawyer Matthew Cortland (@mattbc). CMS open to comments until Sep 10, 2018.- Ed.)

Amy Davis (@MaximizeQOL) is a private palliative care physician in the Philly area. She sometimes thinks about overlapping serious illness & SUD and about quality improvement while gardening and enjoying her turtle

References and Resources
1 - Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2019; Medicare Shared Savings Program Requirements; Quality Payment Program; and Medicaid Promoting Interoperability Program. (Prepared by the Center for Medicare and Medicaid Services, 42 CFR Parts 405, 410, 411, 414, 415, and 495 [CMS-1693-P]) Baltimore, MD: Department of Health and Human Services; July, 2018. Accessed 07/17/2018.

2 - Pear, Robert. “Sniffles? Cancer? Under Medicare plan, payments for office visits would be same for both.” NY Times 2018 July 22. Accessed 07/23/2018. Doherty, Bob. ACP Advocate Blog 2018 July 13. Accessed 07/13/2018. Young, Kerry Dooley. Medscape: Medical News 2018 July 18. Accessed 07/22/2018. CMS, Fact Sheet: Proposed policy, payment, and quality provisions changes to the medicare physician fee schedule for calendar year 2019. 2018 July 12. Accessed 07/22/2018. Patients Over Paperwork: CMS.gov

3 - Fact sheet: Proposed rule for the Quality Payment Program year 3. (Prepared by the Center for Medicare and Medicaid Services, 42 CFR Parts 405, 410, 411, 414, 415, and 495 [CMS-1693-P]) Baltimore, MD: Department of Health and Human Services; July, 2018. Accessed 07/17/2018.

4 - Erickson SM, Rockwern B, Koltov M, McLean RM, for the Medical Practice and Quality Committee of the American College of Physicians. Putting Patients First by Reducing Administrative Tasks in Health Care: A Position Paper of the American College of Physicians. Ann Intern Med. 2017; 166: 659–661.

5 - The current guidelines for a 99202 visit include an expanded problem-focused history (chief complaint and one history of present illness element), an examination with at least two (1995) or six (1997) elements, and straightforward medical decision-making (minimal diagnosis and minimal risk, with or without data). The current guidelines for a 99212 visit include two of the three: a history containing the chief complaint and one history of present illness element, one examination element, and/or straightforward medical decision-making (minimal diagnosis, one stable problem, and minimal risk, with or without data).

6 - The lack of specificity in the Proposed Rule, and anticipated changes when finalized, make conclusive detailed amount determinations impossible. Sincerest thanks to Dr. Christopher Jones and to those who wish to remain anonymous for discussing this complex topic with me.

7 - All comments received through Sept. 10 will be reviewed. Send comments via: (1) http://www.regulations.gov and follow the “submit a comment” instructions, (2) (regular mail) Centers for Medicare and Medicaid Services, Department of Health and Human Services, Attention: CMS-1693-P, P.O. Box 8016, Baltimore, MD 21244-8016, or (3) (express mail only) Centers for Medicare and Medicaid Services, Department of Health and Human Services, Attention: CMS-1693-P, Mail Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.

Tweet

This week the New York Times talks about the rising costs of providing hospice care in America with a particularly juicy hook about a nearly $25 million whistle-blower settlement against an Alabama hospice.  From there it talks about the focus of some hospices to seek patients who are likely to have longer lengths of stay, like dementia and stroke.  One research analyst even goes as far to say "It's a lucrative business, at least under the current reimbursement system."  They also feature an inspector general report that documentation for hospice patients in nursing homes was lacking. 

Not a good start from a newspaper that has actually been quite kind to hospice in the past.  The rest of the article goes on to discuss the various fixes including every hospice medical director's new task: the face to face certification visit.  (We have not yet dedicated a blog post to face-to-face home visits for certification, but one is in the works so we can has that out at a later date.)

But the article leaves out a lot and I feel it is pretty one-sided.  Apparently Don Schumacher, head of the NHPCO, has found some flaws in the article too as he is communicating with the NYT editorial board.  There is relatively little about potential changes to the payment structure to focus greater reimbursement during the first 7 and last 7 days of service when need is thought to be the greatest.  The article does not talk about or reference the article by another NYT reporter from 2007 with the title "In Hospice Care, Longer Lives Mean Money Lost" about the aggregate cap. Nor did it quote the Duke Study that found hospice care saved Medicare an average of $2,300 per beneficiary (OPEN ACCESS PDF), calling hospice “a rare situation whereby something that improves quality of life also appears to reduce costs.”  Yeah, they missed some stuff.

Which is not to say we need to look closely at fraud issues.  Good oversight is important for a multi-billion part of the health care system, but we have to realize that every problem started out as the solution to another problem.  The system is perfectly designed for the outcomes it gets.  So let your legislators know about what hospice means to you.  Talk to your organizations and actually answer the advocacy emails that moment instead of promising to get back to them later.

As the NYT usually does there is no ability to comment on the article but there is a linked blog post at "The New Old Age" which allows for comments.  As of this writing there are 64 comments.  Here are a few I thought stood out:

It is amusing and annoying to be complaining about the costs of hospice care, when in fact hospice patients are forgoing the ER visits, hospitalizations, specialists' visits, procedures, and many medications that Medicare would instead be covering if not for the patient making a decision to pursue comfort care only. So, what was the cost SAVINGS to Medicare by having these people on hospice, even though they stayed on longer than usual? Alot.- ras

I don't even believe desperate old people are gaming the system via hospice. But if they are, it's because this country has utterly failed them, taken payroll deductions for a lifetime in exchange for medical care in old age, and then only given the kind of medical care 70-year-olds need, not 90-year-olds. Shame on us. - jane gross

Hospice is a critical service that is offered to all. It is necessary, compassionate, and well run. So, if we discontinue it or cut services, we are a nation without merit and compassion. We will not only be third world, we should not be in this world. - Julie

The article disingenuously ignores this broader care issue while it exploits an example of an Alzheimer's patient. Please, NY Times, get perspective on the bigger picture. Help the US face its fear of dementia that keeps us in denial and prevents us from preparing to fight a huge healthcare tidal wave. Take more leadership and make a difference. - Suzanne

So it's too expensive to have an MD check on hospice patients once every six months? The health care industry has become even more shamelessly and barbaricly greedy than I thought. - Cowboy Marine

TAYLOR JR, D., OSTERMANN, J., VANHOUTVEN, C., TULSKY, J., & STEINHAUSER, K. (2007). What length of hospice use maximizes reduction in medical expenditures near death in the US Medicare program? Social Science and Medicine, 65 (7), 1466-1478 DOI: 10.1016/j.socscimed.2007.05.028

Photo credit: Flickr user:  castle79

Tweet

Joanne Kenen of the New America Foundation posted an excellent analysis of the importance of advance care planning language that was supported and kept in the house bill despite the emotional ruckus about straw man arguments this summer.

I love her introduction and wish I could come up with something like this when I am writing posts:

After all the sound and fury of last August, we're pleasantly surprised that the right hasn't risen again with all sorts of horror stories about the resurrection, so to speak, of the "death panels." Maybe because all that fear-mongering was finally discredited. Maybe we are finally getting just a little bit smarter.

She makes a lot of good points:

Right now, there are all sorts of built-in disincentives -- cultural, emotional, legal and yes financial -- against having that conversation. The incentives lie in the other direction: Doctors, and ERS and ICUs are all reimbursed for giving you the aggressive care, and aggressive care is often the default form of care. Maybe our system should make sure you want it.

Although I can't agree with her on all points but the only disagreement I have is more of a technical quibble about DNR vs. AND, which I blogged about earlier this year.

(And we do so wish that the move to change the terminology eventually catches on, so that instead of Do Not Resuscitate, or DNR, we talk about Allow a Natural Death, or AND).

She does add some info I was not aware of:

The Finance bill sets up a 26-site hospice concurrent care demonstration project in Medicare, so adults too in these test programs can have both curative and hospice care.

And the New America Foundation also marks the blogging debut of Dr. Ira Byock in his own accompanying editorial post (actually his second since his first was in August, but still the blog is his debut!)

Tweet

With a tagline like: "What exactly is a death panel?" PBS is starting to sound like an afternoon tabloid show, but they end up covering the topic very well in the 25 minute clip now available online.  I am sure many palliative care people are familiar with the Gundersen Lutheran "Respecting Choices" project to increase the communication and recognition of advanced care planning through living wills, health care power of attorney's, POLST's and consultation with medical staff.  If you are not familiar with it here is a brief background:

The program started in the early 90's with an oncologist, nurse practioner, and a clinical ethicist, who is also featured in the video clip (Bud Hammes, Ph.D.).  And within two years they had a 85% penetration of advanced directives and a shocking 95% were found in the chart.  I say shocking because if you have ever spent more than a week on a palliative care team you realize you may be the first one to ask more than one question about advanced directives and your team is the one who actually gets the information in the chart.  There are similar projects based off of "Respecting Choices" sprouting up around the US and also internationally.

The clip also featured a palliative care doctor making home visits!  Awesome!

The only slight but important error in the clip mentioned by the reporter and Hammes was that Medicare does not reimburse for having these conversations.  That is actually not true.  Medicare does reimburse for these conversations indirectly via physicians billing for time spent with patient and family.  A longer conversation means a physician could bill using a prolonged service code.  Billing by complexity will always bring in more revenues compared to billing by time so it basically undermines good communication by nudging a medical system towards seeing more patients in shorter amounts of time and then billing for the higher complexity.  So the bill tried to set up a unique reimbursement structure which the details of relative compensation compared to complexity or time based billing were still unclear.  Regardless that section of the bill is not in the Senate version and is still (I think) in the House version and is now political poison given the hyperbole.