On July 12, 2018, the Centers for Medicare & Medicaid Services (CMS) released their proposed changes to the Physician Fee Schedule (PFS), which include their proposed update to the Quality Payment Program (QPP) in the Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2019; Medicare Shared Savings Program Requirements Proposed Rule.
We had a conversation with Jeff Coughlin, senior director, federal and state affairs, and Eli Fleet, director, federal affairs at HIMSS to learn how the proposed changes from CMS, if finalized, could expand access to telehealth, support progress toward addressing the opioid epidemic, and ultimately address the issue of clinician burden.
Expanding Telehealth to Reduce Physician Burden
Coughlin: In terms of the telehealth provisions of the rule, there are great opportunities to expand Medicare access to virtual visits, which could provide beneficiaries another avenue to meet with physicians. CMS has been working to broaden clinician access to this modality to address the fact that many times, certain patient needs arise that can be resolved without an in-person visit. This really ties into the proposed rules’ focus on minimizing clinician burden issues by providing additional coverage opportunities for treating patients, but not always requiring clinicians to have actual face-to-face visits with patients.
Fleet: I agree with Jeff, and I think the overarching theme is finding ways to reduce the burden on clinicians. Throughout the 1,400 plus page rule, it’s evident they’re looking for ways – whether it’s time, resources, etc. – to lessen their burden. The inclusion of telehealth-related changes in the rules address this issue by providing additional means for Medicare coverage of patient visits including in some cases where a face to face visit is not necessary, means a patient would not need to necessarily come in for an office visit solely for a simple test or monitoring procedure if the tools exist to perform them virtually.
Coughlin: This all signals greater recognition of telehealth’s value by CMS. The agency dipped its toe in the water last year and added coverage of telehealth services for several of their billing codes, and this year it went even further and expanded access to telehealth coverage for other conditions and care settings. There’s a lot that touches on this in the June 25 letter HIMSS partnered with the Association of Medical Directors of Information Systems (AMDIS) on; it discusses several issues related to reducing clinician burden. HIMSS and several other stakeholder organizations have been talking about how to address clinician burden issues for a long time; CMS heard us and responded to our inquiries. Our letter reinforced these key points.
Physician Fee Schedule & Quality Payment Program Updates
Coughlin: On the physician fee schedule side, there are also a lot of changes that they included in the proposed rule related to evaluation and management documentation requirements. Several of the topics included in our clinician burden letter, released June 25, were included in the proposed rule, like what a physician has to do in order to document a visit with a patient; also, how CMS is lowering the number of requirements to relieve clinician burden regarding coding and documentation.
For instance, if a doctor can review and verify what another member of the healthcare team has documented in a patient’s record, it eliminates the need for them to cut and paste and then re-document a visit—and they can therefore spend more time interacting with the patient. A physician can simply review the information that’s there, decide if they need to do a further evaluation of the patient, and then just document that they’ve reviewed and verified the accuracy of that information. Again, that’s going to be a huge help for reducing clinician burden. It all kind of comes back to that issue.
There’s also a lot related to evaluation and management codes that the proposed changes cover from the billing and payment side of things. Regarding those, the general issue we identified in our clinical burden letter was the fact that this is an area ripe for changes that would positively impact clinician burden. Several parts of our letter are relevant to what CMS is proposing.
Fleet: The QPP side of the proposed rule is a continuation of this new program that CMS has been working to really reform; all of this emanates from the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) law; the QPP has been in place the past couple of years.
To refer back to what CMS Administrator Seema Verma announced at the HIMSS18 Global Conference & Exhibition, related to changes to the Promoting Interoperability Program – part of the clinician piece for that new program is included in the QPP, and the Advancing Care Information component of the Merit-Based Incentive Payment System (MIPS) has been renamed the Promoting Interoperability performance category.
There are two sides to QPP: the advanced alternative payment model side, where clinicians have to be part of an Accountable Care Organization or some sort of risk-based sharing arrangement in order to receive incentives – or there’s the alternate route of participating in MIPS. Much like in the previous rule they published for the inpatient prospective payment system, which covers how acute care hospitals participate with Medicare, the agency changed several pieces into the Promoting Interoperability Programs for hospitals, so this is the clinician side of what they are proposing to change.
Acknowledgement of Opioid Epidemic by CMS
Fleet: CMS is continuing to make opioids a high priority, and this proposed rule would give clinicians additional opportunities to earn points toward their MIPS score by leveraging opioid-related measures.
In an effort to emphasize the focus on the opioid epidemic in these proposed changes, CMS asked for comment on how best to measure progress in this area. For example, they’re seeking to explore new ways to integrate and incentivize providers using Prescription Drug Monitoring Program (PDMP) queries, which we will look to comment on as they seek feedback. CMS is a crucial part of the overall federal government response to the opioid crisis, so the changes that they are proposing are very timely.
Coughlin: In the recent Inpatient Prospective Payment System (IPPS) rule which HIMSS commented on, there were several mechanisms CMS included to reward hospitals for improving treatment and measuring the progress of patients with opioid issues. CMS is making many of the same proposals in this proposed rule, and are asking a lot of the same questions on the clinician side. HIMSS is hosting a webinar on July 30 on the opioid epidemic where we’ll have several federal agency speakers who will speak on their work related to this topic, and so we encourage you to attend if you’d like to learn more about how information and technology can help address the epidemic.
The ‘Call to Action’ for the HIMSS Community
Fleet: The key call to action for HIMSS community is to provide feedback on the proposed changes. The deadline for submitting comments is September 10 and we’ve been formulating plans for member feedback by late July or early August. Any engagement that the entire HIMSS community can provide for feedback that will give us that ‘boots on the ground’ perspective would be greatly appreciated.
Coughlin: I think any time when you have a 1,400 page rule, there’s always a nuance in there that we may not see, that other advocates may not see – but someone ‘in the trenches’ might. For example, some sort of small change that CMS is including in the rule that we don’t really have our eyes specifically focused on. Like Eli said, having that ‘boots on the ground’ perspective about how these changes will impact day-to-day practice is important. That’s why we do member-wide calls, and do specific outreach to the HIMSS Physician Committee and HIMSS Nursing Informatics Committee, and keep our minds open to what other HIMSS members, committees, and community participants contribute as we gather input in developing a cohesive letter to submit. Overall, we look forward to working with the HIMSS community on how to move forward in these efforts.
The HIMSS government relations team will be providing updates and feedback on these issues as more details become readily available. We encourage you to reach out to HIMSS with questions or feedback, and to submit comments for consideration to CMS by September 10.