Society Comments on 2019 Physician Fee Schedule and QPP Proposed Rule

September 13, 2018
Policy Snapshot

This week the Society submitted comments to the Centers for Medicare & Medicaid Services (CMS) on the CY 2019 Physician Fee Schedule (PFS) and Quality Payment Program (QPP) proposed rule. The Society noted that they were appreciative of CMS’ focus to reduce burden in both evaluation and management (E&M) documentation requirements and reporting into the Quality Payment Program (QPP): “We agree that clinicians need administrative burden relief so that they focus more on patient care. While we support these general efforts, we feel CMS must work in a collaborative and open manner with the stakeholder community to achieve the desired outcomes.”

The Society, like many national physician specialty societies, opposed CMS’ proposal to collapse the payment structure of E&M visits: “We believe this proposal has not been well vetted and has not been tested to assess the true impact on patient access for the most chronically ill population. CMS may not have given sufficient attention to specialties that treat the frailest older adults to ensure that these proposals will not hurt patient access to these uniquely skilled clinicians.” The Society noted that, “If this proposal were finalized, clinicians who treat patients in the office and in the nursing home setting (or hospitals, residential/domiciliary locations, and other non-office settings) would now have to abide by two different sets of rules. Their electronic health records will have to keep track of two different sets of documentation requirements. This amounts to more administrative complexity, not less.”

Here are some of the highlights from the Society’s comments:

Telehealth Services

In CMS’ proposed rule they also noted the Society’s previous concerns with limiting telehealth services to once every 30 days for subsequent nursing facility care visits; however they decided not to remove the frequency limitations. The Society noted its disappointment in their decision and voiced their concerns that this “limitation really stifles innovation and use of telehealth in the PALTC setting, which is vital to the continuum of care and where a large number of seriously and chronically ill Medicare and Medicaid beneficiaries receive care.”

Cost Performance

CMS proposed to increase the cost category of Merit-based Incentive Programs (MIPS) to 15 percent of the total score for the 2019 performance period. The Society noted that, “based on previous data from a number of QRUR reports, we know that clinicians practicing in the PALTC environment score poorly in the cost category because the risk stratification included in the two measures used for that category does not adequately account for the complexity of the patients these clinicians take care of.” The Society urged CMS to not finalize the proposal until such time that the risk adjustment and proper comparison among PALTC base physicians is adopted in the MIPS program.

Promoting Interoperability (PI)

The Society requested that CMS consider an automatic hardship exemption for PI for PALTC clinicians, much like the exemptions granted to hospitalists and ambulatory surgical center-based clinicians. Currently, clinicians practicing in PALTC have to fill out a hardship exemption for each year of the program. This amounts to additional paperwork and administrative burden that could simply be eliminated from the program. In addition, the Society asked for flexibility for those who are trying to meet the PI category requirements. The comments stated, “in the legacy e-prescribing incentive program, PALTC clinicians had an exemption for this requirement, but this exemption has not carried over into PI. Exempting prescriptions by prescribers in the SNF/NF setting from all denominators for ‘prescribing’ would eliminate a significant barrier to meeting the PI category for those that elect to do so.”

Expanding Facility-Based Measurement for Post-Acute Care Settings

The Society was appreciative of CMS’ inclusion of a request for information (RFI) to expand facility-based scoring from hospital and ambulatory surgical centers (ASC) to post-acute settings: “We agree that this has the potential to significantly reduce administrative burden and align clinician and facility incentive programs. Overall, we believe that CMS should adopt a voluntary and flexible approach for facility-based scoring. We agree with the language in the hospital-based proposal that allows CMS to pick the best score between facility-based and MIPS score. This option will not work for all clinicians but it will be a great way to reduce their reporting requirements for many.” The Society urged CMS to develop a technical expert panel on facility-based scoring as the agency reviews comments received on this RFI and starts to develop a proposal for next year’s rule.

Skilled Nursing Facility Specialty Measure Set

The Society was pleased to see the new proposed Skilled Nursing Facility Measure Set in the proposed rule. The Society noted that this “is the first step to delineating the SNF/NF setting as an integral but different area of practice of medicine that deserves its own consideration within MIPS and APM programs. While there are many ‘reportable’ measures included in the MIPS program, some measures are counter to recommendations for the SNF/NF population.” The Society noted that finalizing the measure set would allow those practicing in the SNF/NF setting to identify such measures directly from CMS.

Advanced Alternative Payment Models (APMs)

The Society urged CMS to expand the numbers of Advanced APMs by providing more flexibility on what it defines as an Advanced APM: “Currently, there are no APMs in the Advanced APM category that would allow clinicians who practice in PALTC settings to qualify. The Bundled Payment for Care Initiative and the Initiative to Reduce Hospitalizations Among Nursing Facility residents are APMs, but they do not qualify as an Advanced APM in their current form. Both programs have shown significant quality improvement and cost savings primarily driven by incentives in PALTC practice changes. Given that these are the only two APMs focused on the PALTC population, we strongly urge CMS to work to establish a process to allow these models to be modified so that they can qualify and allow flexibility to allow participants to qualify in the first year of the program. Other programs, such as CPC+, should be considered for their application the PALTC population. Current quality measures used in the program do map to SNF residents and yet they are not included in the model.”

Click here to read the Society’s comments.