On July 29, the Centers for Medicare and Medicaid Services released a 1700-page proposed rule for the 2020 Medicare physician fee schedule (PFS). The rule covers diverse topics including evaluation and management (E/M) office visit services, a new participation framework in the Merit-based Incentive Payment System (MIPS), geographic payment adjustments and professional liability insurance relative values, and new payments for managing patients with opioid use disorder.
Two key issues that have been major priorities for the physician community in the American Medical Association’s advocacy with the federal CMS over the past year are revisions to the office visit codes and payment rates, and modifications to MIPS to make the program less fragmented and more clinically relevant. View the full AMA summary document here.
Office visits – Evaluation and Management
As CMS Administrator Seema Verma told the AMA House of Delegates in June, the federal CMS policy in last year’s rule to collapse payment for office visits was never intended to be the end of the discussion but a beginning, and a demonstration of the administration’s sincere commitment to reducing burden for physicians. The AMA and federal CMS worked in partnership to significantly modify the office visit policy included in the proposed rule. While retaining the important modifications to reduce documentation burden, the agency will implement coding and payment modifications in 2021 that are based on the resources required to perform various levels of office visits. This will ensure that physicians treating the sickest patients are not unfairly penalized, while providing simpler solutions to coding and documentation.
While the AMA is pleased that the agency has accepted the CPT framework and the RUC workgroup’s recommendations for office visit codes, two aspects of the proposal depart from these recommendations and exacerbate the negative payment impacts from this policy on physicians in certain specialties.
- As it did last year, the federal CMS would implement an add-on payment for office visits for primary care and patients with serious or complex conditions. This proposal redistributes an additional $2 billion, resulting in an additional 2 percent reduction to the Medicare conversion factor.
- Although the surgical specialties participated in the RUC survey and their data and vignettes were incorporated into the RUC recommendations, the federal CMS proposes not to apply the office visit increases to the global surgery packages.
If the proposal is not modified, redistributions will be significant, with family medicine increasing by 12 percent and many specialties that do not perform office visits decreasing by 7 percent or more. If the federal CMS does not implement the new add-on code, family medicine will experience a 7 percent increase while specialties that do not perform office visits would see cuts of 5 percent.
MIPS – Merit-based Incentive Payment System
The AMA is encouraged by results showing 95 percent of eligible clinicians successfully participated in MIPS in 2017, increasing to 98 percent in 2018 based on initial results. The AMA continues to hear the current program is too costly, however, and requires reporting for reporting’s sake, diverting time from patient care. AMA staff has worked with the physician community and federal CMS staff extensively to try to find solutions. For the past year, the AMA has discussed a proposed solution that would make MIPS more clinically relevant and less burdensome by tailoring participation around episodes of care, conditions or public health priorities.
In the 2020 proposed rule, the agency embraced the AMA’s proposed concept for streamlining MIPS. The agency outlined a high-level framework and seeks feedback on an episode-based approach to MIPS, which it is calling the MIPS Value Pathways (MVP). The attached MVP diagram is included in the rule.
In the AMA’s view, an MVP-type approach could be a turning point for the program because an option that ties MIPS to episodes of care has the potential to be more clinically relevant, less burdensome, and a stepping stone to alternative payment models. We do have concerns with several specific aspects of MVP that the federal CMS has proposed, such as a return to the use of controversial population health administrative claims measures that the AMA successfully fought to eliminate from the initial MIPS program. The AMA will work closely with the state medical and national specialty societies to address these concerns and provide detailed recommendations to ensure MVP is a practical solution to the problems with the current MIPS program. The MVP framework outlined in the proposed rule is a first step. The agency does not plan initial implementation of an MVP approach until 2021.