Aug. 9, 2018: National Advocacy Update

The AMA has previously sent to the Federation information on the 2019 Medicare Physician Fee Schedule (PFS) and Quality Payment Program (QPP) Notice of Proposed Rulemaking. On July 31, the Advocacy Group hosted a conference call with state and specialty medical society staff to discuss key issues in the 2019 proposed rule. As part of its standard operating process, the Advocacy Group also convened a meeting with national specialty representatives and Centers for Medicare & Medicaid Services (CMS) staff on Aug. 1.

While the AMA is pleased that in the proposed rule the administration continues to recognize the need to reduce the administrative burden for physicians, the AMA has heard concerns from a number of specialty and state medical societies about the Evaluation and Management (E&M) coding and payment proposals in the proposed rule.

As part of its standard process to respond to major policy proposals, the AMA is working with national specialty, state and other physician groups to develop recommendations that have broad support across the profession. A joint working group of Current Procedural Terminology (CPT®) and the RVS Update Committee (RUC) experts has been formed to develop recommendations for adjusting E&M coding policies. Given the complexity in this space, a coding change application may not be finalized until early November for potential adoption by the CPT Editorial Panel in early February.

While the E&M coding issues have become a major focus of the proposed rule, there also are many important issues as part of the QPP implementation that will have a significant impact on physician practices. The AMA will work with its Merit-based Incentive Payment System (MIPS) and Alternative Payment Model (APM) workgroups to develop its comments. The AMA hopes to share its comments with the Federation in advance of the Sept. 10 deadline.

Top line positive elements in the proposed rule:

• Reduced documentation burden for Evaluation & Management office visit codes.
  • Note: At this time, the degree of actual burden reduction is uncertain. Will practices still need to document items for legal reasons and to justify medical necessity and/or eligibility for add-on codes? Further, electronic health records (EHR) may still prompt physicians to supply information designed for compliance with old requirements.

• New payments for physician services that are not part of a face-to-face visit (virtual check-ins with patients, remote consults with patients using videos/photographs, online consults with other physicians).
• Continuation of low-volume threshold policy to exempt small practices from MIPS.
• A reduction in problematic measures in the Promoting Interoperability (PI) provisions (formerly Meaningful Use and Advancing Care Information).

Areas of concern/AMA will recommend changes:

• E&M coding and related policies (add-on codes, multiple same-day service reduction).
• Reducing quality measure requirements to reflect reductions in available quality measures.
• Simplifying the MIPS scoring framework to make it more clinically relevant and understandable for physicians.
• Keeping the cost category weight at 10 percent rather than increasing it to 15 percent.

On Aug. 2 CMS released the 2019 Hospital Inpatient Prospective Payment (IPPS) system final rule (PDF). In the rule, CMS finalized several changes in an effort to reduce physicians' administrative burden. Specifically, CMS finalized changes to the new PI program, which will focus the program on interoperability and improved patient access to health information as opposed to burdensome, prescriptive data-capture and measurement policies.

The AMA will continue to push CMS to develop an attestation-based approach to reporting within the PI program that will allow physicians and hospitals to attest to using technology that works for their practice and their patient care needs.

CMS also finalized policies to reduce physicians' and hospitals' reporting burden by removing many quality measures within the hospital quality reporting programs. In total, CMS finalized the removal of 18 measures and the de-duplication of 25 measures from quality reporting programs. CMS also finalized a requirement that hospitals must post a list of their standard charges online, which the AMA supported in its comment letter on the proposed rule. This requirement will take effect Jan. 1, 2019.

On July 26, the United States Pharmacopeia (USP) released a revised draft of its Chapter 797, which provides standards for sterile compounding in pharmacy, hospital and office settings. The new draft Chapter makes accommodation for the preparation of sterile drug products by physicians in office settings, a departure from previous USP proposals that would have subjected physicians to the full requirements of the chapter.

The new draft chapter proposes to exempt physicians preparing sterile drug products for administration to patients when the product is administered to a patient in an office setting within one hour of its preparation. For allergy and immunotherapy products, USP has created a new, separate section of Chapter 797 that would provide standards for preparation of those products. This new section includes stringent safety standards for the preparation of allergy/immunotherapy products but is more appropriate for physician practices.

The AMA has worked closely with numerous medical specialty societies as well as USP on this draft revision. The AMA understands that while the new proposal will be workable for many physicians, it may still be burdensome on some specialties. The AMA will continue to work closely with those groups to ensure continued access to the products at issue.

The current proposal has been issued as a draft and is still open to further revision before it is finalized later this year. Public comments will be accepted until Nov. 30. USP is also holding a virtual "open microphone" session on Sept. 5 to receive comment and answer questions. The AMA strongly encourages physicians with concerns about the proposed revision to submit comment and participate in the open mic session.

On Aug. 1, the administration issued a final rule that would make it easier for insurers to offer short-term limited-duration insurance plans. The new rule reverses the Obama Administration's efforts to limit the duration of such plans to three months by expanding the duration of the plans to just under 12 months and allows the plans to be renewed for up to three years.

The rule requires that issuers of short-term plans display prominently in consumer materials a notice explaining that the policy they are purchasing is not required to comply with the Affordable Care Act's (ACA) federal market requirements. In response to comments, the Administration strengthened the language required in the notice.

The language in the proposed rule would have stated, in relevant part, "Be sure to check your policy carefully to make sure you understand what the policy does and doesn't cover." The required language in the final rule is, "Be sure to check your policy carefully to make sure you are aware of any exclusions or limitations regarding coverage of preexisting conditions or health benefits (such as hospitalization, emergency services, maternity care, preventive care, prescription drugs, and mental health and substance use disorder services).

Your policy might also have lifetime and/or annual dollar limits on health benefits." The final rule also requires the consumer notices to include any additional information required by state law. The final rule is effective 60 days after publication in the Federal Register.

The AMA had significant concerns with the proposed rule and had urged the U.S. Department of Health and Human Services (HHS) to withdraw it (PDF). These concerns remain. Short-term policies will be exempt from any ACA requirements but will be marketed alongside with ACA-compliant plans. Without the consumer protections and coverage required by the ACA, the short-term insurance plans will be considerably less expensive than ACA-compliant plans and hence presumably will be very attractive to healthy individuals who do not want or think they do not need comprehensive coverage.

It is predicted by health policy experts that the expansion of short-term insurance plans will undermine the individual insurance market and create an uneven playing field by luring away healthy consumers, thereby damaging the risk pool and driving up premiums for consumers left in the ACA-compliant market. Moreover, increased use of the skimpier plans could leave many patients with large medical bills or facing the prospect of going without needed treatment.

On July 31 the AMA urged HHS Secretary Alex M. Azar, II, to withdraw the Administration's Notice of Proposed Rulemaking (NPRM) that proposes to significantly revise the regulations governing the federal Title X family planning program.

"We are very concerned that the proposed changes, if implemented, would undermine patients' access to high-quality medical care and information, dangerously interfere with the patient-physician relationship and conflict with physicians' ethical obligations, exclude qualified providers, and jeopardize public health," wrote AMA CEO and Executive Vice President James L. Madara, M.D. "Given our concerns, we urge HHS to withdraw this [proposal]."

Read the letter (PDF) for more details.

On July 26, the House Energy and Commerce Subcommittee on Health held a hearing entitled "MACRA and MIPS: An Update on the Merit-based Incentive Payment System." David Barbe, MD, Immediate Past-President, testified (PDF) on behalf of the AMA. Dr. Barbe stated that it is important for all types and sizes of physician practices to have opportunities to succeed under the Medicare Access and Chip Reauthorization Act (MACRA).

He expressed the AMA's commitment to working with both Congress and CMS to ensure physicians are able to continue to make progress in the MIPS program each year and are not exposed to large penalties as CMS continues to refine the program.

Dr. Barbe also noted that while progress has been made, the AMA believes there are numerous additional improvements that can be made to further simplify MIPS. He also raised concerns that three years into the program, none of the APMs recommended by the Physician-Focused Payment Model Technical Advisory Committee (PTAC) to the Secretary of Health and Human Services have been tested or implemented, and there is currently no robust pathway to approve and implement APMs. Chairman Michael Burgess, MD (R-TX), indicated the subcommittee would hold hearings on APMs in the fall.

• Aug. 9, 2018: Advocacy spotlight on AMA urges DOJ to block CVS-Aetna merger 
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