4 changes physician groups don’t like in proposed MACRA, physician fee schedule rule

Doctors' groups are still digesting the 1,473-page proposed federal rule updating the Medicare physician fee schedule and outlining changes for year three of the physician payment program implemented under MACRA.

But in their preliminary review of the proposal released by the Centers for Medicare & Medicaid Services last Thursday, they've already found plenty to fault, including changes that would slow the move of physician practices to value-based payment and a failure to lower drug costs.

That, even as CMS Administrator Seema Verma sent out a “Dear Doctor” letter on Monday to various clinician groups saying the proposed final rule is aimed at restoring the doctor-patient relationship and reducing “burdensome and often mindless administrative tasks.”

“CMS’s focus is on putting patients first, and that means protecting the doctor-patient relationship. We believe that you should be able to focus on delivering care to patients, not sitting in front of a computer screen,” Verma wrote in the letter that describes changes CMS is proposing.

What exactly do these groups representing physicians find problematic? Here are some of the changes the groups pointed out:

It could slow the move to value-based payment. The AMGA, a trade association that is pushing for the transformation of healthcare, said in a statement that the agency “missed the opportunity” to move Medicare provider payments to a value-based system.

The group said it was disappointing that CMS kept a high low-volume threshold for providers to participate in MIPS, one of two payment tracks under the Medicare Access and CHIP Reauthorization Act (MACRA). That will continue to reduce the payment adjustments for providers that are invested in value-based care, the AMGA said.

As authorized by MACRA, providers can earn an adjustment of up to 7% on their Medicare Part B payments in 2021 based on their 2019 performance. However, as indicated in the proposed rule, CMS estimates the overall payment adjustment will be 2%. “We are concerned that CMS has again opted not to recognize the efforts of high-performing AMGA members. As we enter the program’s third year, it is time for CMS to honor congressional intent and use MIPS to create value for Medicare,” said Jerry Penso, M.D., AMGA president and CEO.

Not everyone held that viewpoint. America’s Physician Groups President and CEO Donald Crane said the group is cautiously optimistic that CMS has taken real action to advance the value movement. In particular, he cited the reaffirmation of the recently announced Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) demonstration. 

It could raise, not lower, drug prices. The Community Oncology Alliance, a nonprofit association of independent oncology centers, said CMS’ proposal to cut a 6% fee doctors get for drugs dispensed in their offices to 3%, which would apply to new drugs during their introductory period, will not lower drug prices as the government indicated. The proposal was likely to trigger pushback, and it did.

“COA believes that this payment cut for new cancer therapies will result in drug manufacturers actually increasing WAC [wholesale acquisition cost] list prices so that their new products will not be at a competitive disadvantage to existing products which are reimbursed at average sales price (ASP) plus 6%,” the group said in a statement.

“No words can adequately describe how puzzling the CMS proposals are,” said Ted Okon, executive director of COA. “At a time when the Trump administration is floating its blueprint to bring down drug prices, they are proposing a move that will actually fuel list prices of chemotherapy and other lifesaving drugs.”

The American Society of Clinical Oncology said the move to cut physician reimbursement for Part B drugs would make the cancer care delivery system more unstable. “Additionally, the cuts could hinder patient access to newer, innovative therapies—potentially stalling progress against cancer and almost certainly making it more difficult for oncologists to provide essential services to patients with cancer,” said Monica M. Bertagnolli, M.D., the group’s president, in a statement.  

It could cut payments for evaluating complex cases. While CMS is proposing to overhaul the Evaluation and Management (E&M) documentation and coding system to dramatically reduce the amount of time doctors must spend on documentation, the COA was worried about the impact.

Under the proposal, CMS would drastically cut payment for the critical evaluation and management of more complex cancer cases from $172 to $135 (a 22% payment cut) for a new patient and from $148 to $93 (a 37% payment cut) for an existing patient, the group said. While the intent is to streamline reporting, it will severely undervalue the thorough and critical evaluation and management of seniors with cancer, especially life-threatening complex cases, the group said.

“Their scheme to pay a physician the same amount for evaluating a case of sniffles and a complex brain cancer simply defies all logic. It is the antithesis of value-based healthcare and cheapens the medical care seniors are entitled to under Medicare,” said Okon.

In her letter to doctors, Verma said most specialties will see changes in their overall Medicare payments in the range of 1% to 2% up or down from the new E&M policy, but she said any small negative payment adjustments would be outweighed by the significant reduction in documentation burden.

It could increase costs, keep reporting burden. The Medical Group Management Association (MGMA) said it was disappointed that CMS decided to continue its policy requiring physicians to document a full 365 days of quality measures rather than 90 consecutive days.

The proposed rule would also require physicians to upgrade to 2015 Edition Certified Electronic Health Record Technology beginning in 2019. The MGMA was also unhappy that the rule would require physicians to make costly upgrades to their electronic health records for 2019 and take further steps toward implementing burdensome appropriate use criteria.

“At first glance, the rule doesn’t meet MGMA’s definition of administrative simplification,” said Anders Gilberg, senior vice president of government affairs.