CMS promises to ‘restore the doctor-patient relationship’ with 2019 proposed rule

Telemedicine doctor
A proposed physician payment rule includes telehealth reimbursement and requires physicians to upgrade EHR systems. (shironosov/Getty)

The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule on Thursday making what officials called “historic changes” to the Medicare program aimed at restoring the doctor-patient relationship.

The federal agency issued the 1,473 page proposed rule (PDF) to update the Medicare physician fee schedule and outline changes for year three of the physician payment program implemented under MACRA.

In a press call, CMS Administrator Seema Verma said officials had listened to physicians and made changes to give them more time with patients.

“Today’s proposals deliver on the pledge to put patients over paperwork by enabling doctors to spend more time with their patients. Physicians tell us they continue to struggle with excessive regulatory requirements and unnecessary paperwork that steal time from patient care,” she said in an announcement.

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The major changes of the proposed rule include streamlining documentation requirements for so-called evaluation and management office visits to save doctors time; paying clinicians for more virtual care provided via technology; lowering costs for new drugs that come on the market; and giving doctors in small practices who don’t meet existing thresholds for participation in MIPS the choice to opt into the program.

The changes would take effect in 2019, but Verma noted that the proposals are subject to change based on public comments, which are due by September 10.

Removing paperwork requirements through the physician fee schedule would save individual clinicians an estimated 51 hours per year if 40% of their patients are in Medicare, according to CMS. Changes to the MACRA program would collectively save clinicians an estimated 29,305 hours and approximately $2.6 million in reduced administrative costs in 2019. 

In the press call, Verma described the following changes:

Streamlining documentation: The agency would reduce documentation requirements for physician services known as “evaluation and management” or E&M office visits, that make up about 20% of allowed charges under the physician fee schedule and consume much of clinicians’ time. The requirements were put in place in 1997 and have not changed in 21 years, Verma said. They require doctors to put information into the patient record strictly for Medicare billing purposes, reflecting little about the patient’s actual medical care. The plan is to cut four different sets of documentation down to just one.

Leveraging technology: Changes in the fee schedule would pay clinicians for virtual check-ins, or brief, non-face-to-face appointments using telecommunications technology (e.g., audio or video applications); pay for the evaluation of patient-submitted photos such as a skin condition; and expand Medicare-covered telehealth services to include prolonged preventive services.

While not meant to replace regular office visits, the change will allow patients, particularly the elderly and disabled who may struggle to get to the doctor’s office, the ability to check in with a clinician, Verma said.

However, the proposed rule would also require physicians to upgrade to 2015 Edition Certified Electronic Health Record Technology beginning in 2019. The rule said the 2014 edition certification criteria—currently allowed for 2018—is out of date and insufficient to meet clinician needs in the evolving health IT industry.

Changing the MIPS program, one of two payment tracks under MACRA: CMS proposed eliminating MIPS process-based quality measures that clinicians said are low value or low priority. The agency will also overhaul the MIPS “Promoting Interoperability” performance category to support greater EHR interoperability and patient access to their health information, and align the program with the proposed new program for hospitals.

In addition, doctors in small practices who don’t meet the existing threshold to participate in MIPS can do so, allowing them to be eligible for bonus incentives. The 2018 threshold will remain in place for 2019. The agency also plans to move forward with its Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) demonstration. Under the project, CMS will move ahead with intent to test whether certain Medicare Advantage plans should qualify as an advanced alternative payment model and exempt doctors from MIPS.

Lowering prescription drug costs: The changes would affect payment under Medicare Part B, which covers medicines that patients receive in a doctor’s office, such as infusions. CMS is proposing a change in the payment amount for new drugs under Part B, so that the payment amount would more closely match the actual cost of the drug.

This change would be effective January 1, 2019, and would reduce the amount that seniors would have to pay out-of-pocket, especially for drugs with high launch prices, Verma said. CMS proposes reducing the add-on for these Part B drugs that are new to the market from 6% to 3% beyond the wholesale acquisition cost (WAC), an estimate of the manufacturer's list price for the drug.

Currently, Medicare pays the physicians that WAC plus the add-on to cover office overhead and the cost of administration. Under the proposal, for the first two quarters that a new drug is on the market, Medicare would pay the reduced 3%. Thereafter, reimbursement would revert to the current system, which pays doctors the average sales price of the drug plus an additional 6%.

The proposed rule already drew reaction from both supporters and critics. In a blog post, Don Rucker, M.D., of the Office of the National Coordinator for Health Information Technology supported what it called a “historic shift” in the documentation requirements for E/M visits.

“This effort, if finalized, will help shift the nation’s electronic documentation away from overly long, form-driven, hard-to-read documents written primarily to satisfy billing requirements to what it was originally intended for—providing high-quality care to patients,” he wrote.

But in a statement, the Medical Group Management Association (MGMA) said it was disappointed that CMS decided to continue its policy requiring physicians document a full 365-days of quality measures, rather than 90 consecutive days.

“Reducing the reporting burden would allow more physicians to participate in MIPS and focus the program on rewarding quality care rather than quality reporting,” said Anders Gilberg, senior vice president of government affairs.

Forty-nine physician groups sent a letter to CMS earlier this year asking the government to reduce the reporting period for MIPS this year.

The MGMA was also unhappy 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,” Gilberg said.

In an emailed statement, the AMGA said it was disappointed CMS maintained a high MIPS exclusion threshold and said the agency missed the opportunity to move Medicare provider payments forward to value-based care. 

To help physicians understand all the changes, CMS released a series of fact sheets on the physician fee schedule proposed rule regarding the changes to the quality payment program under MACRA and for the MAQI demonstration.