4 ways doctor reimbursement could change next year

Getting paid has never been so complicated for primary care doctors.

An uncertain policy landscape, ever-changing regulatory requirements, and evolving practice and reimbursement models mean that physicians must constantly stay on top of how they are being paid to ensure they receive what they are owed.

In recent weeks, CMS officials have released a bevy of proposals that will affect how Medicare will pay physicians in 2019. The regulations cover value-based payments, level of care changes that will impact reimbursement rates, and continued efforts to equalize payments between office- and hospital-based doctors.

Physicians should remember these proposals could change after federal officials consider comments from the public and stakeholders. Final determination on all these issues is expected in late 2018.

Here are the proposed changes physicians should monitor:

• streamlining the Quality Payment Program (QPP), Medicare’s value-based payment initiative;
• restructuring the evaluation and management (E/M) level-of-care coding system as part of the 2019 Medicare Physician Fee Schedule (PFS), which sets out reimbursement rates for fee-for-service payments;
• making brief patient check-ins via phone, text message, or video a reimbursable service; and
• taking additional steps towards site-neutral payments for outpatient visits.

No. 1: The QPP and value-based care are here to stay

While doctors will find some beneficial changes, physician groups say the QPP needs to become more physician-friendly.

CMS is proposing changes to eligibility requirements, coding, some documentation requirements, and how certain categories are weighted, among others, with goals of streamlining billing and expanding access to care.

“Internists are excited to see that CMS is proposing long overdue improvements in the physician fee schedule and the QPP that will help physicians provide the highest quality care to patients,” says Ana Maria Lopez, MD, MPH, president of the American College of Physicians, in a statement.

The proposed changes to the 2019 rule governing the QPP include:

• Expanded exemptions. A third low-volume threshold has been proposed: providing 200 or fewer covered professional services under the PFS. Any doctor who meets this requirement, or one of the previous two-$90,000 or less in Part B charges or caring for 200 or fewer Medicare beneficiaries-would be exempt from program participation.
• Ability to opt in to the Merit-based Incentive Payment System (MIPS). Any clinician or group that does not meet the low-volume exemptions could choose to opt in to MIPS. However, the decision to do so is irrevocable.
• Changes to general performance category weights used to calculate MIPS scores. Quality would decrease from 50 percent of the total to 45 percent, while cost increases from 10 percent to 15 percent. Promoting interoperability (formerly called advancing care information) and improvement activities remain at 25 percent and 15 percent of the total score, respectively.
• Removal of 34 quality measures deemed by CMS to be of low value.
• Requiring the use of 2015 Edition Certified EHR Technology in 2019. This was originally proposed for 2018, but CMS backtracked to allow 2014 Edition certification because EHR vendors were not ready.

One notable change from the 2018 QPP rule that physician advocates lobbied for but did not receive was 90-day reporting periods for all four performance categories. Instead, quality and cost will remain 12-month reporting periods, and improvement activities and promoting interoperability will remain 90-day reporting periods.

“Reducing the reporting burden would allow more physicians to participate in MIPS and focus the program on rewarding quality care rather than quality reporting,” Anders Gilberg, senior vice president, government affairs, for the Medical Group Management Association, said in a statement. “Requiring medical groups to submit excessive amounts of data to the government has little impact on the quality of care delivered to Medicare beneficiaries.”

The ACP also continues to argue that a 12-month reporting period for the MIPS performance categories does not offer any more insight to a practice than a 90-day period. “We are advocating for shortening the reporting period to reduce the burden and shorten the feedback loop,” says Suzanne Falk, MPP, senior associate of regulatory affairs for the ACP, adding that a quarterly report with real-time feedback would add more value to the program for physicians.

Complicating the MIPS cost category is that not only is its weight increasing in the overall score, but it will include eight new episode-based measures. For 2018, MIPS is using cost measures that cover the total cost of care during the year or during a hospital stay. Now, CMS is proposing to use new episode-based measures to calculate costs. “Increasing the weight of the category while adding eight new measures is not a smart move,” says Faulk.

Another possible area of concern is the proposal to mandate use of EHRs with 2015 certification. The required upgrade could put an undue burden on smaller practices, says Faulk. She says many vendors do not have a 2015-certified product to offer. Practices also need time to implement the new software, and the 12-month reporting requirement means they would need to be ready January 1. “Vendors need more time and practices need more time to work out the kinks in the systems,” says Faulk.

Small practices required to participate in the QPP are still at a performance disadvantage because of the financial and labor requirements to be successful. “The performance gap between small and large practices is not because small practices aren’t providing good care or thinking about value,” says Faulk. “It comes down to a matter of resources and having people on staff to navigate the program.”

Valinda Rutledge, vice president of federal affairs for America’s Physician Groups (APG), a group which represents physicians practicing capitated, coordinated care, says the changes to QPP look to include “real action to advance the value movement” and indicate that MIPS is “here to stay.”

No. 2: The Medicare PFS may simplify levels of care

A major proposed change in the PFS is to restructure the E/M codes. Currently, office-based physicians code for five different levels of care, with different codes and reimbursement rates for new and established patients based on the complexity of the visit. CMS Administrator Seema Verma pitches the proposal as a bid to simplify and offer more flexibility in documentation requirements, delivering on the agency’s pledge to “put patients over paperwork.”

Under the proposal, E/M levels 2 through 5 would be combined into one payment rate, with add-on codes included to address visits of greater complexity. The potential impact is that office-based physicians who see more patients with less complex health issues (levels 1 through 3) could see reimbursement rates rise, while physicians who deal largely in levels 4 and five 5 complexity, could see reimbursement rates fall.

It’s unclear if the proposal will be approved, as it has received mixed reviews from healthcare observers. Organizations representing primary care physicians have expressed support for the proposal’s simplification and additional flexibility. Organizations that advocate for specialty physicians oppose it.

Jennifer Breuer, JD, vice chair of healthcare group for the law firm Drinker Biddle, says the rules will reallocate money to better reflect how care is provided.

“They will pay more for the kind of visits people are having to better reflect the actual resources involved,” she says. “There’s long been a concern that the reimbursement rates applied to services don’t necessarily reflect the true cost or value of services. This is meant to emphasize with respect to primary care, what a visit means.”

The ACP supports CMS’s efforts, particularly documentation streamlining and the use of add-on codes, which the organization says can reimburse for services provided by internists that “are currently not adequately supported in the traditional E/M structure.”

“We strongly support the proposal to reduce the burden of current E/M documentation requirements, specifically by allowing E/M documentation to focus on medical decision making, as ACP has strongly advocated for in the past,” the ACP statement reads.

Brian Outland, director of regulatory affairs for ACP, told Medical Economics that while the organization appreciates that CMS took some of their suggestions on easing physician burden, the college remains concerned about certain proposals, including the reduction of five E/M codes to two in.

“We want to make sure there is no disadvantage to physicians taking care of complex and frail patients,” he says. “A doctor could have a patient come in that has a cold or some less-sensitive problem and get paid the same as a physician taking care of someone with four or five chronic conditions that require attention and care and much more time.”

Others are skeptical of making these sweeping changes in such a short timeframe. Rutledge, with APG, says the organization is concerned about implementing changes of this magnitude by Jan. 1, 2019, as proposed. “The flattening of the E/M codes from five to two is a massive undertaking and will create winners and losers among physician specialties,” she says.

Terry Fletcher BS, CPC, healthcare coding executive with Terry Fletcher Consulting, says CMS officials seem to have designed the proposal with only primary care physicians in mind. “Paying the same amount, regardless of the patient’s condition, presenting problems or the complexity of services provided, makes absolutely no sense to me.”

Fletcher also believes that if this proposal or any form of it goes through, it is setting up practices to see fewer Medicare patients, and more commercial plans that won’t follow the Medicare model. “I also see this giving a big boost to concierge medicine, as physicians will simply be frustrated that their most consistent payer has now abandoned them for a one-code price,” she says.

Jennifer McLaughlin, senior associate director of government affairs for MGMA, says these broad changes will have trickle-down consequences into almost every aspect of Medicare payment policy and would impact a lot of physician practice workflows.

“Some of our members are cautiously optimistic that it could reduce some of the documentation burden and increase a physician’s ability to spend more time with the patient,” she says. “On the flip side, what we’re hearing is documentation isn’t just driven by coding requirements; a lot of it is driven by clinical needs and external factors.”

No. 3: New payment opportunities for 'technology-based services'

A third major proposed change in the PFS includes streamlining documentation requirements and modernizing payment policies to enable Medicare beneficiaries to take advantage of the latest technologies to provide care.

For the first time, physicians would get reimbursed for services provided with the use of technology, but outside of telemedicine services and in-patient visits. For example, a brief, non-face-to-face check-in with a patient via phone, text messages, e-mail, or video conferencing to evaluate whether the patient needs to be seen in the office could be reimbursed under this proposal.

Furthermore, Medicare is also proposing to pay even when patients initiate the virtual communication, another first, Rutledge says.

Rutledge says that the reimbursement is proposed at $14 per virtual visit as opposed to $90 for an office visit, but it allows for more convenient check-ins and will be more efficient for patients and doctors alike.

No. 4: Changes to site-neutral payment rules

In late July, CMS proposed a rule under which it would pay for most clinic visits under the PFS, rather than the more costly Outpatient Prospective Payment System (OPPS). The change, if approved, would represent another step toward the achieving the agency’s long-sought goal of site-payment neutrality-paying the same amount for a patient visit, regardless of whether it occurs in an independent or hospital-owned practice.

“The bottom line is, patients should not pay more for a service or procedure based on the building it’s done in. That’s the underlying logic here,” says Marni Jameson Carey, executive director of the Association of Independent Doctors, which supports the proposed rule.

CMS estimates that the rule would save it $760 million annually in the form of reduced payments to hospitals and lower Medicare beneficiary copayments. The OPPS is higher because it includes facility fees, charges hospitals add to cover the range of other services they provide, ranging from 24/7 emergency departments to imaging equipment. CMS says clinic visits-which it defines as “check- ups with a clinician”-are the most common type of service billed under the OPPS.

“Part of the reasoning around charging facility fees is to have these services at the ready should they be needed,” says Shari Erickson, MPH, vice president for governmental affairs and medical practice with the American College of Physicians. “But in most cases they aren’t necessary for these types of visits. So having insurers and patients pay more for them really isn’t appropriate.”

The rule would apply only to hospital-owned practices that are not part of a hospital’s main campus. Practices located on hospital campuses would be exempt.

Erickson adds that the proposed rule will likely encounter stiff opposition from hospitals. “The challenge is that many of them have become reliant on facility fees along with other types of funding to pay for many of the things that hospitals do,” she says. “So I recognize there are challenges, but at the same time there needs to be other options to fund the needs of inpatient facilities.”