Hospitals support the CMS' proposed changes to medical billing coding and new payments for opioid treatment programs, but they're worried that changes to quality measures could hurt providers.
Major medical groups and hospitals back the CMS' decision to abandon a provision of the finalized 2019 Medicare physician-fee schedule rule that would have consolidated the number of evaluation and management payment levels into one payment rate beginning in 2021. The agency initially proposed the E/M coding measure to reduce clinicans' work to get reimbursed for Medicare services. However, providers worried that lower reimbursement rates would cut into their bottom lines and create a number of unintended consequences that could hurt patients
"Paying a single rate likely would have resulted in a number of negative consequences, such as requiring the most complex patients to have more visits, referring such patients to specialists, or shifting them to more acute care settings," the American Medical Group Association said in its comments. "AMGA was particularly concerned that … would disrupt care coordination efforts and result in fragmentation, all of which would hinder the transition to value-based care."
But many commenters saw the E/M policy reversal as a shift in who loses under the 2020 fee schedule. Physical therapists, social workers, psychologists, radiologists and other care providers opposed cuts to their services. They say the new payments for E/M services were supposed to be based on resource use and weren't designed to redistribute payments between different specialties.
"Despite this assertion, the opposite has occurred largely because of the sheer volume with which the office-based codes are billed compared to other specialty services," the American College of Radiology said in its comments on the rule.
Physical therapists and other specialty care providers also argued that cuts to their reimbursements could reduce access to the services they provide, which would drive up healthcare costs over the long term.
"If CMS wants to reach the stated goal of decreasing opioid use, access to physical therapy should be expanded—not cut," the Alliance for Physical Therapy Quality and Innovation said. "Moving forward, it is imperative that CMS acknowledge the important role physical therapists play in the prevention and treatment of acute and chronic pain. The solution requires more than limiting access to drugs."
Hospitals and other provider groups also backed new payments for opioid treatment programs and a new bundled-payment model for some substance use disorders. The payments include bundled telehealth treatment for people addicted to opioids, which rural health providers saw as a barrier to treatment. They were concerned that the reimbursements might be insufficient or fail to account for differences in social determinants of health. Health systems that service disproportionally poorer, more vulnerable populations were especially concerned.
"Patients seeking this care at essential hospitals often face comorbid conditions or multiple addictions that make them more difficult to treat and require more costly care," said America's Essential Hospitals. "CMS should ensure the proposed bundle accounts for the complex patient populations essential hospitals treat for (opioid use disorder) and ensure reimbursement for these services adequately covers all associated costs."
The Federation of American Hospitals added that the CMS should, "consider how to coordinate those services that may need to be provided alongside those captured in the bundle that are important to the successful completion of the (opioid use disorder) treatment."
Several groups were also concerned about the CMS' proposal to change how providers report under the Merit-based Incentive Payment System, a program designed to encourage clinicians' transition to value-based care by tying Medicare Part B payments to clinician quality and cost performance. Providers have complained that the program is too complicated and challenging to comply with since it started in 2017.
The CMS also issued a request for information regarding the MIPS Value Pathways, or MVPs, in the 2020 physician fee schedule. Beginning in 2021, the MVPs program is supposed to simplify reporting requirements by creating a small set of measures for each specialty that are based on outcomes and aligned with alternative payment models.
But hospitals worry about imposing a new set of criteria for evaluating clinicians so soon, especially without giving providers time to implement the new system before they're held accountable by it. They welcomed the CMS' request for information, but they're concerned that the CMS is rushing the process and isn't focusing enough on the details of implementation.
The CMS in the request for information asked hospitals how to construct MVPs, how to select measures and activities, how to determine MVP assignment and how to transition to from the current state of MIPS to MVPs.
"These are extraordinarily broad questions that we do not believe they can be fully answered through an RFI, one rulemaking cycle, or other short time period," CommonSpirit Health said in its comments.