CMS thought a proposal to save doctors paperwork would be a public relations bonanza. Instead, most doctor groups view it as disastrous.
A provision tucked into the agency’s 1,472-page payment rule in July does away with a lot of paper-pushing, but it also appears to strip away the financial incentives to see patients with more complex conditions — upending a payment structure that has existed for two decades. The proposed rule followed months of consultation with medical groups, but many groups were caught unawares by the final product.
“To most of the physician community it was a surprise,” said Brian Outland, the director of regulatory affairs for the American College of Physicians. “All the groups that we’ve chatted with and talked with, it seemed to come out of nowhere.”
The uproar concerns CMS’ plans to make changes in the “evaluation and management” codes, last updated in 1997. Doctors like the proposed reduction in documentation, but not the perceived tradeoff: reduced payments for time spent with difficult patients, with incentives for quick visits. CMS has tried to mitigate the problem by adding bonus payments for treating sicker patients, but the solution doesn’t go far enough, doctors’ groups and academics say.
At a news conference Monday, CMS Administrator Seema Verma called the proposed changes in the evaluation and management codes “the most comprehensive” since their inception. When pressed on the building furor, Verma indicated the agency would be attentive to concerns. “We really do look at all the comments we receive,” she said.
The medical industry has issued many critiques of the current guidelines, including a 2015 position paper from the American College of Physicians. But the CMS rule didn’t accomplish what the doctors were seeking.
The original CMS evaluation and management rule, issued in 1995, was meant to inform doctors about how to write notes providing evidence of the amount and intensity of work they’d done during a clinical visit. The more intense the work, the more payment they received, with up to five levels of intensity possible.
But in the digital age, especially, the documentation has become repetitive, as doctors used formulaic notes to justify billing the most expensive codes possible. While imposing a high level of busy work, the guidelines facilitated exaggeration or outright fraud. A 2012 HHS inspector general report suggested some doctors were cheating the system.
Widespread dissatisfaction among both payers and providers led to efforts to reform the system. “The doctors have been concerned about this for a long time,” said neurologist Marc Raphaelson, a member of the American Academy of Neurology’s coding subcommittee. Specialty societies and the American Medical Association got together in a series of work-groups to suggest changes.
CMS rejected the 2015 doctors’ proposals, leaving the problem unsolved as the Trump administration took power. Overhauling the requirements looked like a natural target for the deregulation-minded newcomers.
“Documenting on things that aren’t really relevant to the vast bulk of patients is very time-consuming, very expensive,” Don Rucker, the national coordinator for health IT, told POLITICO’s Pulse Check podcast in August. Crunching the code levels from five to two and cutting documentation “will be one of the biggest deregulatory things, arguably the biggest deregulatory thing,” he said.
But collapsing the codes means doctors will be paid less for treating complex patients over long periods of time, critics say, because the most intense levels of care won’t be rewarded accordingly. According to an analysis in the New England Journal of Medicine, a doctor seeing a complex patient over half an hour or more could better spend her time, financially speaking, seeing three simpler patients.
CMS thinks it can ease that problem by adding side codes that reward doctors for lengthy visits and treating complex patients. Yet even so, some specialty groups say their payments will be cut harshly. The American Society of Clinical Oncology, for example, thinks the new payment rule will cut payments for oncologists and hematologists by 4 percent overall. Opthalmologists and interventional cardiologists would also see big pay cuts.
Perhaps there will be a few winners and losers, Rucker acknowledged, but “we’re encouraging docs to think about their time.”
It’s not just the impact of the proposal that has doctors’ groups steamed. The agency’s rollout process was also unsatisfactory, they say. In developing its ideas about cutting doctors’ paperwork, CMS issued a request for information and had several meetings. Doctors eagerly participated but feel the actual proposal blindsided them.
“We were surprised by the magnitude of this proposal and the proposed changes to payment in particular, and that it had not been vetted or discussed with the medical community,” said Dan Trucil, an American Geriatrics Society spokesman.
Critics add that CMS did not provide the voluminous data with which it generally accompanies its decisions, and which aid observers in their analysis and critique of annual payment rules. “Without data, the basis for the E&M proposal is not publicly transparent,” said a statement from the clinical oncologists.
In previous years, CMS has used historical payment data to lay out its case for the next year’s payment proposals, said Mary Jo Braid-Forbes, a consultant who constructs economic models for her specialty society clients.
This year, the agency’s description was notably short on steps, rendering it difficult to figure out how to provide detailed technical analysis and recommend alternative options, she said in a comment letter. “This year there were pieces missing,” said Braid-Forbes.
While CMS has offered additional explanation in webinars and other discussions, some said the agency had been standoffish about its proposal.
Specialty groups said CMS had been baffled by the resistance to its ostensibly historic plan, and presented it as a “take it or leave it” proposition. CMS officials have said during webinars that the documentation and payment changes were a “package deal” that couldn’t be separately changed, said Trucil, from the geriatrics society.
Scores of medical groups have weighed in against the rule. Ninety bipartisan House members sent a letter Sept. 7, and a group of senators are reportedly preparing another.
A CMS spokesperson wrote in an email that the agency “extensively sought input from stakeholders, particularly the medical community” on the rule, and will review additional comments before finalizing it, likely in November. The spokesperson declined to answer specific questions on the evaluation and management portions of the rule.
Raphaelson acknowledged that some might find CMS’ approach “aggressive,” but said the agency had to balance priorities — keeping a lid on fraud while it cut red tape.
The solution might be for the medical community to unite behind a simple idea, he said: replacing the evaluation and management structure entirely with a framework that rewards doctors for their time, sidestepping the current debate. That idea was echoed by scholars in a recent Health Affairs article.