How industry groups say Medicare payment rule proposals will hurt practices already besieged by COVID-19

Proposed policy changes for Medicare payments for 2021 could hurt physician practices already experiencing severe reductions in revenue during the COVID-19 pandemic, industry groups say.

The American Medical Association (AMA) urged the Centers for Medicare & Medicaid Services (CMS) prevent the steep budget neutrality cuts pending in the proposed annual Physician Fee Schedule and Quality Payment Program rule (PDF). Federal health officials released the proposed rule in August setting 2021 Medicare payment rates for physicians and included changes to the Merit-based Incentive Payment System (MIPS).

There are certain proposals in the rule that AMA strongly supports, including the implementation of a new office visit policy on Jan. 1 that will significantly reduce administrative burdens and better describe and recognize the resources involved in office visits.

But, officials said, they are deeply concerned about the corresponding budget neutrality cuts.

Among them:

Physician fee schedule cuts

The proposal, drafted before the pandemic, would result in a 5.5% cut to physician payment, and additional CMS proposals would lead to an escalation of this cut to almost 11%, according to the AMA in a statement.

The AMA pushed for CMS to use its authority to waive budget neutrality and avert the cuts.

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“Physicians have made unique sacrifices during the pandemic. They have faced personal dangers often without enough personal protective equipment. CMS has given physicians flexibility so they can continue seeing patients. We need to keep these changes in place as COVID is still presenting challenges every day,” said AMA President Susan Bailey, M.D.

AMGA also is concerned that the proposed 2021 Physician Fee Schedule rule would inadvertently exacerbate the financial situation facing practices.

"While appreciative of the effort to increase support for primary care services, the Physician Fee Schedule’s budget neutrality requirements effectively shift funds from one specialty to another, potentially undermining the team-based approach to care that is the hallmark of the group practice model," the organization said in a letter to CMS.

“More than anything right now, our members need certainty,” said AMGA president and CEO Jerry Penso, M.D. in a statement. "CMS’ plan unfortunately would add yet another change into a system that is dealing with an upheaval in how care is provided."

Changes to E/M visits and MSSP

In their comments to CMS, AMGA specifically recommends that the agency not move forward with its proposal to revalue a number of office and outpatient evaluation and management (E/M) visits. The reduction in the conversion factor needed to maintain budget neutrality represents a significant decrease in support for Medicare providers and would decrease payments for a number of providers, the organization said.

"From canceled elective procedures to a rapid shift to telehealth, group practices are working to not only get their bearings and recognize what care delivery models are most effective for treating patients during this pandemic, but also to understand what practice patterns will be like after COVID-19," Penso said. "Changes to code values just add more uncertainty.”

AMGA also is opposed to CMS’ proposals for the Medicare Shared Savings Program (MSSP), such as a proposed reduction in the number of quality measures that accountable care organizations (ACOs) will report and the elimination of the pay-for-reporting year for ACOs in their initial contract.

CMS also would revise the quality performance standard so it creates an “all-or-nothing” ability for an ACO to earn shared savings. AMGA opposes these changes, which increase the influence of any one measure on an ACO’s ability to earn shared savings. These significant proposals come shortly after CMS finalized a new structure to the ACO program in 2018.

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“Our members understand that CMS is going to make technical adjustments to the ACO program during a contract period,” Penso said. “This rule goes beyond that and would significantly alter the program not even two years after CMS finalized a major overhaul of the MSSP.”  

Privia Health, an independent physician organization with more than 2,600 providers, also criticized some of the proposed changes that could have extensive negative impacts on MSSP, especially for ACOs that have taken on higher levels of risks in the program.

The organization particularly took issue with CMS' “all-or-nothing” proposed revisions to establishing the final shared savings rate.

"Entering into the MSSP program already involves a significant amount of uncertainty and risk. There is downside risk associated with certain ACO Tracks, and also the risk of not achieving any shared savings. This is a critical issue for ACOs who incur up-front, and ongoing, infrastructure costs to successfully care for their communities with no direct reimbursement from CMS to cover those investments. Earned shared savings is the only financial source ACOs rely on to fund those resources," Privia Health said in a letter to CMS.

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Make permanent telehealth changes

In the proposed rule, CMS also will expand the list of telehealth services covered by Medicare. Services added include more complex visits that allow offices to bill for more advanced office/outpatient evaluation and management codes. prolonged services, group psychotherapy, neurobehavioral status exam, care planning for patients with cognitive impairment and home visits.

The AMA urges CMS to make permanent several telehealth services, to remove geographic and site-of-service barriers, and to continue covering services through the end of the year following the year in which the pandemic ends. These services should include audio only visits, the organization said.

America’s Physician Groups said it supports CMS' efforts to expand access to telehealth but wants the agency to resolve outstanding issues and barriers still in place for providers and their patients.

"Expanding access to smartphone and internet technologies, expanding the ability of providers and/or payors to provide patients with the components for audio/visual technology, or extending eligibility for risk adjustment payment to telehealth services conducted solely through audio only technology such as landlines are all viable options in strengthening access for patients and ensuring that they receive all necessary care," the organization said in its letter to CMS.

"We understand that CMS is limited in expanding telehealth beyond the public health emergency due to their limited authority, however we appreciate their commitment to explore other avenues," APG said.