|THIS WEEK IN HEALTHCARE
What happened in healthcare this week—and what we think about it.
Medicare proposes a major overhaul to physician payment
The Centers for Medicare and Medicaid Services (CMS) trumpeted “historic changes” to physicians’ documentation burden and promised to restore the doctor-patient relationship with the release of the 2019 proposed Physician Fee Schedule on Thursday. While unlikely to be a panacea for physicians’ frustrations with electronic medical records (EMRs), we were impressed by the extensive revamp that CMS is considering, and believe the proposed changes provide a meaningful step toward reducing burdens on doctors, which could help to align outpatient visit coding, documentation and payment with the demands of modern practice.
To save you the pain, we’ve been wading through the 1,473-page rule, and want to highlight three critical proposed changes:
1. “Choose your own adventure” solution to reducing visit documentation burdens. Doctors have long complained about the volume of irrelevant medical history and exam information required to document a higher-level evaluation and management (E/M) visit. The current process generates reams of checklists in the EMR that fail to capture the true patient problem or nature of the visit. CMS proposes two new alternatives to allow physicians to document visit intensity: time spent with the patient and “Medical Decision Management”, or MDM. (Practices who have successfully designed workflow around checklist templates needn’t worry, doctors can also choose to stick with the old system.) Another big win for clinicians: CMS also proposes removing the requirement for doctors to re-document information entered by clinical assistants or patients. Despite concerns that the proposed options could reward less efficient doctors, feedback from the physician community has been resoundingly positive. Dr. Bob Wachter, Chair of the UCSF Department of Medicine, sums it up: “If this pans out, could be awesome. There’s no more soul-sapping experience than documenting 9 Review of Systems elements & 10 body parts examined to justify a billing level – when what really took time was talking to patient, family, consultants, reviewing the chart, & thinking.”
2. Broad expansion of telemedicine reimbursement. As we’ve discussed, today CMS only pays for telemedicine services when provided to rural patients, through downside-risk ACOs or Medicare Advantage plans. In this rule CMS now proposes to cover telemedicine and telephone visits for brief check-ins, evaluation of patient-submitted images or remote monitoring data, as well as more comprehensive and preventive care visits. Should this move forward, it will be a substantial step toward increasing access for the two-thirds of Medicare beneficiaries who are ineligible for telemedicine coverage.
3. Some “relief” on MACRA—but not as much as doctors wanted. CMS proposes to remove 34 quality measures in the Merit-Based Incentive Program (MIPS) flagged by doctors as “low-value” and to raise the thresholds for doctors to opt out of MIPS, exempting those with fewer than 200 Medicare patients or less than $90K in Medicare revenue. The rule affirms that 365 days of reporting will be required in 2019, dashing hopes for a 90-day window, as supported by many physician advocacy groups. Most critical for systems and physician groups looking to increase their risk portfolio is the inclusion of Medicare Advantage patients in MACRA risk calculations. This change, teed up in the proposed rule, closes a gaping hole in MACRA’s alternative payment model framework that has kept many of the nation’s most progressive physician groups from participating.
Given how much has yet to be defined about the specifics of these changes (including how time and MDM would be documented for E/M visits), feedback from providers and other stakeholders is essential—the comment period remains open until September 10.
Supreme Court pick likely to re-energize healthcare debate
Senate confirmation of Brett Kavanaugh, President Trump’s pick to replace Supreme Court justice Anthony Kennedy, is a near-certainty. Much has already been written about Kavanaugh’s healthcare views and precedents (here are two brief summaries); with few exceptions, his work has been consistent with conservative judicial thinking. The prospect of another reliable conservative on the Court will likely accelerate the movement of several key healthcare cases through the judicial system, enhancing Republican efforts to dismantle key elements of the Affordable Care Act (ACA)—and providing Democrats new talking points in the run-up to the midterm elections.
Discussions will likely center on two key cases: the New Mexico federal court ruling against risk adjustment methodology, which resulted in CMS recently halting payments to insurers; and the pending case filed by the Texas Attorney General questioning the severability of the individual mandate from other tenets of the ACA, endangering protections for pre-existing conditions and other elements of the law. Some experts feel that Kavanaugh’s rulings on these cases may not be easily predictable (as a career Federal judge, he has limited case history on states’ rights), and the greater risk to the ACA may stem from Kavanaugh’s clear support of executive power, making him likely to uphold executive actions and agency rules that attempt to dismantle the ACA in a piecemeal fashion. Regardless, expect Kavanaugh’s appointment to be used as leverage for both Republicans and Democrats to put the fate of Obamacare at the heart of yet another election cycle.
The imminent demise of a national healthcare resource
Outside of a small community of healthcare quality mavens, few have heard of the National Guideline Clearinghouse (NGC), a division of the Agency for Healthcare Research and Quality (AHRQ). The NGC has painstakingly vetted, synthesized and summarized tens of thousands of clinical guidelines across dozens of specialties. Clinical leaders looking to develop standards often use the NGC as a starting place, describing it as a “go-to source…nothing else like it in the world”. With its funding stripped in the current AHRQ budget, this public repository and its twenty years of evidence-based standards is set to go dark on July 16th. The annual operating budget for the NGC is a paltry $1.2M, a “rounding error” in the larger Health and Human Services agency budget—and challenges to the NGC appear to be motivated by politics and special interests rather than finances or efficacy. Funding for the NGC has been threatened several times before, as former AHRQ medical officer Dr. Kenneth Lin details. As early as 1994, AHRQ was nearly shuttered after issuing a guideline stating that surgery was often ineffective for back pain management. Congressmen with ties to the North American Spine Society and others who stood to lose if the guideline was broadly implemented mounted a challenge to the agency’s funding.
NGC leaders are working to find an outside stakeholder to take over the data set and website operations. Developing evidence-based clinical standards is central to the cost and quality strategies of nearly every health system we work with—wouldn’t it align with their non-profit missions to be part of a consortium taking on the continued work of NGC? (One could also surmise that the many healthcare consultants working in quality improvement—who have surely benefitted from free NGC resources—might also take a role in rescuing the resource from extinction.) As the need to deliver consumer value and reduce healthcare cost grows, an independent source of vetted, evidence-based care standards has never been more important—and the loss of decades of knowledge represented in the NGC would be a huge blow to American healthcare.