Exploring the CMS final rule for MACRA and 2019 Physician Fee Schedule

Adding payment options for virtual services and a subset of changes to the Medicare Shared Savings Program for Accountable Care Organizations (ACOs) are two of the updates included in the final rule released by the Centers for Medicare & Medicaid Services (CMS) on November 1, 2018. The final rule includes updates to payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2019.

Many of the updates relate to communication technology, telemedicine, and virtual check-ins. One of the new payment provisions is listed under the category of “Modernizing Medicare Physician Payment by Recognizing Communication Technology-Based Services.” CMS is finalizing proposals to pay separately for two newly defined physicians’ services provided using communication technology:

  • Brief communication technology-based service, e.g. virtual check-in (HCPCS code G2012)
  • Remote evaluation of recorded video and/or images submitted by an established patient (HCPCS code G2010)

In a move toward making healthcare more efficient and more convenient, these payment provisions would mean that healthcare providers would be paid for “the brief communication technology-based service when the patient checks in with the practitioner via telephone or other telecommunications device to decide whether an office visit or other service is needed.”

Recognizing the value of telemedicine in the continuing efforts to reduce opioid addiction, CMS is also implementing a provision that removes the originating site geographic requirements from the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act, adding the home of the patient as a permissible originating site for telehealth services furnished for purposes of treatment of a substance use disorder or a co-occurring mental health disorder for services furnished on or after July 1, 2019.

In regard to ACOs, the CMS final rule addresses a number of changes, including:

  • A voluntary 6-month extension for existing ACOs whose participation agreements expire on December 31, 2018, and the methodology for determining financial and quality performance for this 6-month performance year from January 1, 2019, through June 30, 2019.
  • Allowing beneficiaries who voluntarily align to a Nurse Practitioner, Physician Assistant, Certified Nurse Specialist, or a physician with a specialty not used in assignment to be prospectively assigned to an ACO if the clinician they align with is participating in an ACO, as provided for in the Bipartisan Budget Act of 2018.
  • Revising the definition of primary care services used in beneficiary assignment.
  • Providing relief for ACOs and their clinicians impacted by extreme and uncontrollable circumstances in 2018 and subsequent years.
  • Reducing the Shared Savings Program core quality measure set by eight measures; and promoting interoperability among ACO providers and suppliers by adding a new CEHRT threshold criterion to determine ACOs’ eligibility for program participation and retiring the current Shared Savings Program quality measure on the percentage of eligible clinicians using CEHRT.

The final rule spans 2,378-pages; however, CMS has published a fact sheet on “Final Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2019,” providing a list of the updates and changes to the PFS for calendar year (CY) 2019.

Greg Miller
December 10, 2018

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How the 2018 midterm election results may impact independent physicians

In November 2018, Americans went to the polls to vote on mayors, senators, representatives, and governors, as well as local measures impacting a range of community and state concerns. One of the biggest concerns among voters was healthcare. In fact, preliminary exit polls found that 41% of voters said that healthcare was the top issue facing the country. Healthcare ranked ahead of immigration, the economy, and gun policy for midterm voters.

The results of the midterm elections included a new Democratic majority in the House of Representatives. Many experts believe that this shift in the House will ensure that the Affordable Care Act (ACA), also known as Obamacare, will remain intact for the foreseeable future. Expanded Medicaid also became a reality for many voters. Fortune reports that:

… one of Obamacare’s most popular provisions, its optional state-by-state expansion of the Medicaid program for low-income Americans, was a big winner in several traditionally conservative states. Voters in Idaho, Nebraska, and Utah overwhelmingly endorsed ballot initiatives to approve Medicaid expansion. What’s more, Kansas, Maine, and Wisconsin all elected Democratic governors who are gung-ho expansion proponents, possibly setting up a significant rise in coverage for poor, working residents.

Medicaid expansion may impact the independent physician, who will potentially see more patients seeking care under their new healthcare coverage plan.

Other healthcare initiatives that may be impacted by the midterm elections and that may affect independent physicians include potential opioids legislation and a furthering of the attempt to lower prescription drug prices. On the other hand, with a divided government, some experts think that little healthcare legislation will be passed. HealthLeaders reports that John Kelliher, Managing Director of Berkeley Research Group, believes that “divided government has historically been good for the healthcare industry, especially when Democrats gain relative power, but doubted much legislation will pass in the upcoming Congress.”

Greg Miller
December 3, 2018

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How to choose between MACRA tracks (MIPS v APMs)

As part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the Centers for Medicare & Medicaid Services (CMS) created the Quality Payment Program (QPP). The QPP rewards value and outcomes through two tracks: the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). For independent physicians, the choice of tracks is a matter of eligibility and the level of risk involved.

CMS recognizes that it may be challenging for independent physicians to participate in MIPS, so it does tailor some flexibility for groups of 15 or fewer clinicians. Independent physicians are eligible if they meet the low volume threshold, which is based on allowed charges for covered professional services under the Medicare Physician Fee Schedule (PFS) and the number of Medicare Part B patients who are furnished covered professional services under the Medicare Physician Fee Schedule. Physicians may participate as individuals or groups, including virtual groups.

Performance in the MIPS track is measured through the data clinicians report in four areas – Quality, Improvement Activities, Promoting Interoperability (formerly Advancing Care Information), and Cost. CMS designed MIPS to update and consolidate previous programs, including: Medicare Electronic Health Records (EHR) Incentive Program for Eligible Clinicians, Physician Quality Reporting System (PQRS), and the Value-Based Payment Modifier (VBM).

The APM track involves taking on more risk but offers additional incentive payments. There are two types of APMs:

Advanced APMs – In the Advanced APM track of the Quality Payment Program, physicians may earn a 5 percent incentive for achieving threshold levels of payments or patients through Advanced APMs. Independent physicians who achieve these thresholds are excluded from the MIPS reporting requirements and payment adjustment. There are a number of APM models available to the independent physician.

MIPS APMs – Most Advanced APMs are also MIPS APMs so that if an eligible provider participating in the Advanced APM does not meet the threshold for sufficient payments or patients through an Advanced APM in order to become a Qualifying APM Participant (QP), thereby being excluded from MIPS, the MIPS eligible clinician will be scored under MIPS according to the APM scoring standard.

Through the QPP tracks of MIPS and APMS, the CMS focus is for independent physicians to be rewarded for providing value-based healthcare that improves patient outcomes.

Greg Miller
November 29, 2018

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Report says physicians seek clarity on alternative payment models

An update to a 2014 report examining alternative payment models (APMs) and their effects on physicians has just been released. The study, “Effects of Health Care Payment Models on Physician Practice in the United States,” was sponsored by the American Medical Association (AMA).

The comprehensive study includes a range of payment models, including:

  • Core payment (fee for service, capitation, episode-based and bundled)
  • Supplementary payment (shared savings, pay for performance, retainer-based)
  • Combined payment (medical homes and accountable care organizations).

Key findings of the study reveal that many physicians and other healthcare providers find it difficult to keep up with the changing payment models. The models are increasingly complex and physician practices are increasingly risk-averse. Specifically, the study’s key findings are:

  • Payment models are changing at an accelerating pace: Physician practices, health systems, and consultants find it difficult to keep up with the proliferation of new models, with some calling for a “time out” to allow them to better adapt to current APMs.
  • Payment models are increasing in complexity: Alternative payment models have become increasingly complex since 2014. Practices that have invested in understanding complex APMs have found opportunities to earn financial awards for their preexisting quality — without materially changing patient care.
  • Risk aversion is more prominent among physician practices: Risk aversion among physician practices was more prominent. Risk-averse practices sought to avoid downside risk or to off-load downside risk to partners (e.g., hospitals and device manufacturers) when possible.

The new study recommends that payment models be simplified for better understanding and for improved patient care. Value-based programs that focus on the quality of healthcare have become too complex and change too often for many independent physicians to be able to realize true and timely financial rewards.

The study also recommends incorporating physician feedback into the APM process. APMs should be designed according to what those physicians see as valuable, including positive financial incentives rather than those designed around risk. In addition, the report recommends that the pace of any changes should be slowed to allow independent physicians to gain a clearer understanding and participate.

Greg Miller
November 12, 2018

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NAM emphasizes the importance of interoperability during EHR selection

Electronic health records (EHRs) enable independent physicians to seamlessly and efficiently record visit notes, monitor their patients’ progress, and track outcomes for improved population health. EHR interoperability enables physicians, laboratories, and other healthcare providers to electronically communicate in real-time, reducing the potential for errors and increasing their ability to work together for positive patient outcomes.

A recently released National Academy of Medicine (NAM) special publication outlines the need for EHR interoperability between healthcare providers, stating that “several common causes of medical errors, including drug errors, diagnostic errors, and failure to prevent injury, can partially be addressed by better data exchange among patients, medical devices, EHRs, and other health technologies.”

While the majority of hospital and independent physicians’ practices do use EHRs, the lack of EHR interoperability between them means that “information from multiple sources, devices, and organizations across the care continuum are unable to flow at the right time, to the right party, and for the right patient,” according to the NAM report. The publication cites 2016 statistics which indicate that 96 percent of hospitals and 78 percent of physicians’ offices were using EHRs.

The key to EHR interoperability is in the selection of the EHR system itself for the independent physician’s practice. As the NAM publication indicates, “most health care providers spend time and money setting up each technology in a different way, instead of being able to rely on a consistent means of connectivity.”

Victor J. Dzau, NAM’s president says, “To ensure that health care dollars are spent in pursuit of health care delivery systems reaching desired levels of care quality, safety, and efficiency, interoperability must be a top priority.”

Solutions such as Elation Health’s Collaborative Health Record enable the independent physician to automatically share updates directly from their Clinical EHR. Other providers are immediately notified so they can take action based on the most up-to-date clinical information. Collaborating with other providers is done with the click of a button, so the independent physician always has the most current and accurate patient information.

Sam Peirce
November 5, 2018

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Researchers recommend EHR certification for pediatric care

Just as women and men are different, physically, so are adults and children. Many researchers have found that those differences also require differences in the electronic health record (EHR) capabilities for each patient age group.

The 21st Century Cures Act for States includes a section for “Assisting doctors and hospitals in improving quality of care for patients.” In regard to EHRs and pediatric care, section 4001(b) specifically states that the Office of the National Coordinator for Health Information Technology (ONC) “must encourage, keep, or recognize the certification of health IT for use in medical specialties” and that Health and Human Services (HHS) “must adopt certification criteria to support health IT for pediatrics, and begin certification soon after.”

Pew researchers have urged the ONC to institute a voluntary certification program for EHRs related to pediatric care, stating that is a “a golden opportunity to make digital records more effective for the youngest and often most vulnerable patients.” Pew emphasizes the positive effects of using EHRs for patient care, but also cautions that mistakes are often made when caring for children.

One potentially devastating case occurred in 2013, when “a 16-year-old patient in California was inadvertently given 38 times the appropriate amount of an antibiotic; the physician didn’t realize that the EHR’s default setting multiplied the amount entered by the patient’s weight. As a result, the patient suffered a near-fatal grand mal seizure.”

Researchers at Pew emphasize that “ONC should focus on rules to better monitor and test EHRs—including safety evaluations of high-risk functions such as weight-based drug dosing in pediatric care—that go beyond current requirements for EHRs and focus on the issues that emerge in the care of children.”

While requirements are currently in place for certified EHR usage, including certification for electronic prescriptions, researchers are strongly recommending that EHRs also undergo a certification process specifically for use in pediatric care given the many physical differences between adult patients and children.

Sam Peirce
October 31, 2018

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How lack of interoperability affects value-based care

Healthcare providers transitioning to value-based care face many challenges. The shift from the traditional fee-for-service emphasis on quantity of patient visits to the value-based reimbursement model requires extensive reporting and compliance with Centers for Medicare & Medicaid Services (CMS) regulations. Administrative burdens can hamper the delivery of value-based care for independent physicians. Another challenge is the practical application of electronic health record (EHR) interoperability for coordinated care.

The independent physician’s ability to collaborate with other healthcare providers, particularly to care for patients with chronic or complex conditions, is a critical factor in value-based care delivery. The challenges in EHR interoperability for coordinated care can impede the physician’s ability to share patient data and to electronically receive data from other physicians that could be crucial for the proper care of that patient.

Nishant Anand, MD, Chief Medical Officer for Population Health Services, Chief Transformation Officer for Adventist Health System and Chairman of the Adventist Health System ACO, recently provided written testimony at a House subcommittee hearing on Examining Barriers to Expanding Innovative, Value-Based Care in Medicare. In regard to interoperability, Dr. Anand stated that “As patients navigate throughout the continuum of care—through physician offices, hospitals, same-day surgery centers, or community clinics—their records should be easily transferrable between all organizations.

To provide true value-based care, physicians must be able to communicate with each other and with patients seamlessly and in real-time. Physicians who take advantage of EHR interoperability for coordinated care are able to receive and view test results, specialty physician visit notes, and other vital information related to the care of the patient electronically. Without interoperability, the patient must bring records to each physician visit or the primary care physician must request records from specialty providers. Either of those options could be time-consuming and result in lower quality care.

Dr. Anand adds that “One of the greatest challenges to achieve this level of interoperability is the lack of a single patient identifier that can move from system to system and ensure records can be passed between disparate entities without fail.” Without EHR interoperability, the patient and the independent physician face an “experience that is difficult and cumbersome, tests and treatments that are duplicated, and vital lifesaving information that is not always available.”

Sam Peirce
October 29, 2018

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How adopting health data standards could enable interoperability

Electronic health record (EHR) interoperability is a key piece in the sharing of patient information between different EHR systems and healthcare providers, improving the ease with which doctors can provide care to their patients and patients can move in and out of different care facilities. However, there are a number of EHR interoperability challenges that must be overcome to allow for true coordination of patient care among multiple providers.

Adopting health data standards can be part of the solution to overcoming those EHR interoperability challenges. The Office of the National Coordinator (ONC) for Health Information Technology (Health IT) is “working to enable the health IT community to convene and rapidly prioritize health IT challenges and subsequently develop and harmonize standards, specifications and implementation guidance to solve those challenges.”

The ONC publishes the Interoperability Standards Advisory (ISA) as “a way of recognizing interoperability standards and implementation specifications for industry use to fulfill specific clinical health IT interoperability needs.” Included on the list of standards “to watch,” that could impact and help overcome EHR interoperability challenges, include:

  • Consolidated-Clinical Document Architecture (C-CDA) — C-CDA is a framework for creating clinical documents that contain both human-readable text and machine-readable XML. Targets include Health Information Exchanges that comply to the Health Information Technology for Economic and Clinical Health (HITECH) provisions of the American Recovery and Reinvestment Act of 2009, the Final Rules for Stage 1 Meaningful Use, and the 45 CFR Part 170 – Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology; Final Rule, as well as EHR vendors.
  • Direct — is a standard for sending health information securely over the internet. The ability to send secure direct messages is critical for independent physicians to communicate with specialty providers and with patients.

ONC is responsible for “curating the set of standards and specifications that support interoperability and ensuring that they can be assembled into solutions for a variety of health information exchange scenarios.”

Sam Peirce
October 16, 2018

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Eligible physicians have until October 15 to resolve MIPs scoring errors for 2017

Physicians participating in the Merit-based Incentive Payment System (MIPS) during the 2017 performance year have until October 15, 2018, to access and review their performance feedback. The Centers for Medicare & Medicaid Services (CMS) has extended the deadline for a targeted review to offer additional time given the complexities of the scoring system, the impact the score will have on 2019 MIPS payment adjustments, and the concerns received by CMS from physicians.

A targeted review provides the opportunity for clinicians, groups, or those participating in certain Alternative Payment Models (APMs) to request that CMS review their MIPS payment adjustment factor(s), if they believe there is an error with the 2019 MIPS payment adjustment calculation.

Concerns received by CMS included the application of the 2017 Advancing Care Information (ACI) and Extreme and Uncontrollable Circumstances hardship exceptions, the awarding of Improvement Activity credit for successful participation in the Improvement Activities (IA) Burden Reduction Study, and the addition of the All-Cause Readmission (ACR) measure to the MIPS final score. After reviewing the concerns, CMS identified a few errors in the scoring logic and implemented solutions.

Eligible physicians should sign-in to the Quality Payment Program website now to review their performance feedback. If an error still exists with the 2019 MIPS payment adjustment calculation, the targeted review process is available until the deadline of October 15, 2018.

For those physicians who need additional assistance or answers to specific questions, the Quality Payment Program Service Center can be reached by phone at 1-866-288-8292, (TTY) 1-877-715- 6222, or by email at QPP@cms.hhs.gov.

2017 was the first performance year for the Quality Payment Program, which CMS refers to as the transition year. The 2017 MIPS final score will affect the associated 2019 MIPS payment adjustment. CMS encourages all eligible physicians to conduct their targeted review before the deadline of October 15, 2018 at 8:00pm (EDT).

Sam Peirce
October 10, 2018

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Learning more about the Primary Care Medical Home Model (PCMH)

The Primary Care Medical Home, or Patient Centered Medical Home is a model for transforming the organization and delivery of primary care. The Agency for Healthcare Research and Quality (AHRQ) defines a medical home not only as a place but as a model of the organization that delivers the core functions of primary health care.

The medical home incorporates five functions and attributes:

Comprehensive Care

  • Meeting most of each patient’s physical and mental health care needs, including prevention and wellness, acute care, and chronic care.
  • The team of care providers may include physicians, advanced practice nurses, physician assistants, nurses, pharmacists, nutritionists, social workers, educators, and care coordinators.
  • Many smaller practices build virtual teams connecting themselves and their patients to providers and services in their communities.

Patient-Centered

  • Provides health care that is relationship-based and actively supports patients in learning to manage and organize their own care at the level the patient is comfortable with.
  • Patients and their families are also members of the care team and therefore are informed partners in creating care plans.

Coordinated Care

  • The PCMH coordinates care across all aspects of the health care system, including specialty care, hospitals, home health care, community services and supports.
  • Creating clear and open communication among patients and families, the medical home, and members of the larger care team.

Accessible Services

  • Responsive to patients’ preferences regarding access.
  • Gives available services with shorter waiting times for urgent needs, improved in-person hours, 24/7 telephone or electronic availability to a member of the care team, and alternative methods of communication like email and telephone care.

Quality and Safety

  • Public sharing of quality and safety data and improvement activities is an important indicator of a complete commitment to quality.
  • Dedicated to quality improvement by engaging in activities like using evidence-based medicine and clinical decision-support tools to advise decisions with patients and families, engaging in performance measurement and improvement, measuring and responding to patient experiences and patient satisfaction, and practicing population health management.

Tools and resources to help implement PCMH

The Primary Care Practice Facilitation (PCPF) Curriculum: supports the development of the workforce that is prepared to help transform primary care by supporting a widespread adoption of the new models of care delivery and the use of continuous quality improvement. It is used to train both new and experienced practice facilitators in the knowledge and skills needed to support meaningful improvement in primary care practices.

Foundational Supports for the PCMH Model:

The Agency for Healthcare Research and Quality (AHRQ) also recognizes the central role of health IT in being able to successfully implement the medical home.

Health IT

  • Can support the PCMH model by collecting, storing, and managing personal health information, and aggregate data that can be used to improve processes and outcomes. It can also support communication, clinical decision making, and patient self-management.

Workforce

  • A primary care workforce including physicians, physician assistants, nurses, medical assistants, nutritionists, social workers, and care managers all trained in providing care based on the elements of the PCMH, is an important factor in the model.

Finance

  • Current fee for service payment policies are incapable of fully achieving the PCMH goals.
  • Payment reform is needed to achieve the potential of primary care and the medical home.

Sam Peirce
October 1, 2018

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