An avalanche of new pay proposals from the CMS seeks to reduce provider burden, so much so that it could undermine efforts to shift Medicare to a value-based system, doctors warned.
The agency released a 1,400-page proposed rule July 12 that for the first time combined the annual physician fee schedule and the Medicare Quality Payment Program rules, which implements sections of MACRA each year.
Reducing burden on providers was the key goal of the document, according to the CMS, but doctors wonder if the agency went too far in some instances.
For instance, the agency estimated that 42% of physicians participating in Medicare in 2019—roughly 1.5 million doctors—will actually need to comply with one of MACRA's two payment tracks: the Merit-based Incentive Payment System, or advanced alternative payment models like accountable care organizations.
The CMS estimated that between 160,000 and 215,000 eligible clinicians would be part of an alternative pay model and that 650,000 clinicians will participate in MIPS.
Officials at a major physician-group association, the AMGA, called the rule “a missed opportunity to move Medicare provider payments to value.”
At issue is that for the second year in a row, physician practices with less than $90,000 in Medicare revenue or fewer than 200 unique Medicare patients per year would be exempt from MIPS.
Under MIPS, doctors must hit certain quality thresholds. Those who don't must pay a penalty that is redistributed to the high performers.
So as more doctors get a pass, the size of the incentive pool has shriveled substantially. Practices were initially eligible for $833 million in incentive payments under MIPS in 2019, but it could fall to $118 million in 2020. For 2021, practices are eligible for up to $372 million in incentive payments. That spike is partly because more clinicians, including physical therapists, occupational therapists, clinical social workers and clinical psychologists would be eligible for MIPS.
Because of the opt-outs, MIPS participants can expect a potential pay increase of just 2% if they perform well, according to Darryl Drevna, director of regulatory and policy at the AMGA. That's well below the 7% envisioned by lawmakers who drafted MACRA, he said.
“As we enter the program's third year, it is time for CMS to honor congressional intent and use MIPS to create value for Medicare,” Dr. Jerry Penso, CEO of the AMGA, said in a statement.
In hopes of driving more participation in MIPS, the CMS proposed that exempted doctors could voluntarily opt in to the program. It estimated that as many as 42,000 physicians would do so.
“I'm not sure how many clinicians will take advantage of it, but it's good to give them the choice, especially for those on the cusp of eligibility who may otherwise churn in and out of MIPS over the years,” said Anders Gilberg, senior vice president of government affairs at the Medical Group Management Association.
CMS Administrator Seema Verma said the proposed changes not only address physician concerns about being overburdened by regulatory requirements, but will allow them to focus more squarely on patient care. Included in that push is a move to focus more on outcomes.
The agency proposed removing 34 quality measures from MIPS, but adding 10 that emphasize outcomes over process.
An ongoing criticism of the program is that it focuses too much on how doctors do things rather than if the patient is getting better.
“The streamlined measures signify that CMS is listening to clinicians and acknowledging the need to lessen their administrative burden by focusing on the measures that will make the most tangible impact on care delivery and patient outcomes,” said Dr. Gerald Maccioli, chief quality officer at Envision Healthcare, a Nashville-based physician practice management company.
Elsewhere in the rulemaking, the CMS proposed overhauling a set of generic codes that most doctors use to distinguish the level of complexity and site of care. The evaluation and management visit codes have been in place since 1995. The proposal would cut pay for the evaluation and management of more complex cancer cases from $172 to $135, which is a 22% decrease. It also aims to reduce pay for exams for new oncology patients from $148 to $93, a 37% reduction.
The pay changes undervalue care visits for seniors with cancer, especially life-threatening complex cases, according to the Community Oncology Alliance.
“Their scheme to pay a physician the same amount for evaluating a case of sniffles and a complex brain cancer simply defies all logic,” Ted Okon, executive director of the alliance, said in a statement. “It is the antithesis of value-based healthcare and cheapens the medical care seniors are entitled to under Medicare.”
The American Hospital Association is also concerned about some of the proposed pay tweaks for patient evaluation visits.
Physicians who provide care for a disproportionate number of high-acuity patients would consistently, and unfairly, receive underpayment, according to Tom Nickels, executive vice president at the AHA.
In addition, the agency is proposing to cut payments to doctors for administering new drugs to Medicare patients.
The CMS now pays for drugs new to the market at the wholesale acquisition cost plus 6%. It is now proposing a 3% cut.
The agency believes this proposal will help curb excessive spending in Medicare Part B and lower out-of-pocket costs by better aligning payments and drug acquisition costs, especially for drugs with high launch prices.
Launch prices for single doses for some new drugs may range from tens to hundreds of thousands of dollars, so a 3% reduction could reduce a patient's Medicare Part B copayment by as much as 20%, according to a CMS spokesman.
Nickels was against the idea and feels that the agency is inappropriately targeting providers.
“CMS should instead address the skyrocketing list prices of drugs directly with pharmaceutical manufacturers,” Nickels said in a statement.
An analyst note from Leerink Partners agreed that doctors, not drug companies, would be hurt by the proposal.
“This change may reduce some reimbursement rates to physicians but we do not view the change as being overly negative for the drug distributors,” the note said.
