September 10, 2018 The Honorable Seema Verma Administrator Centers for Medicare & Medicaid Services U.S. Department of Health and Human Services Hubert H. Humphrey Building, Room 445–G 200 Independence Avenue, SW Washington, DC 20201 Re: File Code CMS–1693–P; Medicare Program: Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2019; Medicare Shared Savings Program Requirements; Quality Payment Program; and Medicaid Promoting Interoperability Program Dear Administrator Verma: On behalf of the physician and medical student members of the American Medical Association (AMA), I appreciate the opportunity to offer our comments to the Centers for Medicare & Medicaid Services (CMS) on the 2019 Physician Fee Schedule (PFS) and Quality Payment Program (QPP) proposed rule, published in the Federal Register on July 27, 2018 (83 Fed. Reg. 35704). At the outset, we wish to express our sincere appreciation for your efforts to reduce paperwork and allow physicians to spend more time with their patients. The AMA strongly supports and urges finalization in 2019 for a number of this rule’s proposals to reduce documentation of office visits. However, we have serious concerns and questions about the accompanying proposal to restructure payment and coding for these services, including its potential to harm complex patients and its failure to comply with existing statutes that govern Medicare payment to physicians. The proposed restructuring has generated a groundswell of opposition from individual physicians and nearly every physician and health professional organization in the country, including those whose members are projected to see increases in their Medicare payments. We ask that this part of the CMS proposal be set aside while an expert physician work group, with input from a broad spectrum of physicians and other health professionals, develops an alternative that could be implemented in 2020. Our questions and concerns about this proposal are discussed in detail beginning on pages 7 to 15 of the comments that follow this letter. A separately submitted letter, signed by 50 state medical societies and 120 national organizations of physicians and other health professionals, demonstrates the widespread support for moving forward with documentation changes while putting off any restructuring as the expert panel and stakeholders work to find a better solution. Legal issues are detailed in Appendix B. entitled, MPFS Legal Concerns. The Honorable Seema Verma September 10, 2018 Page 2 The following outlines our other principal recommendations on the 2019 proposed rule: PFS: • The AMA strongly supports a number of proposals to reduce documentation of office visits; in particular, we urge immediate adoption of the proposals that would change the required documentation of the patient’s history to focus only on the interval history since the previous visit, eliminate the requirement for physicians to re-document information that has already been documented in the patient’s record by practice staff or by the patient, and remove the need to justify providing a home visit instead of an office visit. • Given the groundswell of opposition from individual physicians and nearly every physician and health professional organization in the country, including the AMA, we ask that CMS set aside its proposal to restructure payment and coding for E/M office and other outpatient visits while an expert physician work group, with input from a broad spectrum of physicians and other health professionals, develops an alternative that could be implemented in 2020. • The AMA does not support the expansion of the number of physician office laboratories required to report payment data as part of the calculation of the average weighted median payment amount for each test on the clinical laboratory fee schedule since the Office of the Inspector General has already concluded that this will not alter materially the payment amounts, and it will impose a substantial regulatory burden on physician practices. • The AMA opposes reducing Medicare reimbursement for new drugs from Wholesale Acquisition Cost (WAC) + 6% to WAC + 3%. This proposal would limit use of these drugs in physician offices and hinder Medicare patients’ access to new and innovative therapies that are more effective and/or less debilitating than existing drugs. • The AMA supports proposed revisions to teaching physician documentation requirements related to the presence of the teaching physician during procedures and E/M services as well as the extent of the teaching physician’s participation in the review and direction of services furnished to each beneficiary; however, we urge CMS to incorporate in the final rule its recently updated policy regarding E/M documentation provided by students. • The AMA fully supports and endorses the recommendations and comments of the RVS Update Committee (RUC) regarding work, practice expense, and professional liability insurance relative values. • The AMA applauds the Agency’s proposal to advance coverage of digital medicine modalities in the proposed rule. We are particularly pleased with the proposed coverage of interprofessional internet consultations and the chronic care remote physiologic monitoring and management codes, but we urge CMS to adopt the recommended RUC work RVU and practice expense recommendations. • CMS should seek statutory authority to exempt physicians from participation in the appropriate use criteria consultations mandated under the Protecting Access to Medicare Act if the physicians participate in the QPP because physicians participating in either Alternative Payment Models The Honorable Seema Verma September 10, 2018 Page 3 (APM) or the Merit-based Incentive Payment System (MIPS) are already being held accountable for costs and outcomes. QPP: • The AMA supports CMS’ proposals to add a third criterion for physicians to qualify for the low- volume threshold in 2019 and to allow practices to opt-in to participate in the MIPS program or create virtual groups if they meet or exceed one or two but not all of the low-volume threshold elements. • Given the small number of virtual groups that we believe chose to participate in the MIPS program in 2018, the AMA highly recommends that CMS implement additional changes to turn this into a viable option for physicians in small practices. • One of the AMA’s goals has been to make improvements to the MIPS program that will reduce complexity and allow physicians to spend less time on reporting and more time with patients. We are disappointed that CMS did not move toward a more simplified scoring methodology in this proposed rule. One area where we think the program could be significantly simplified is the scoring of each performance category to calculate a physician’s final score. We urge CMS to move forward immediately to implement the AMA’s scoring proposal. • CMS should avoid making policy changes, such as increasing the performance threshold, changing the category weights and removing quality measures, when there is no MIPS data to analyze. Decisions are being based on hypothetical assumptions from the legacy programs (PQRS, MU and Value Modifier). MIPS is a separate program with its own set of rules and requirements. • To immediately reduce red tape and administrative burden, we continue to strongly advocate that CMS reduce the number of quality measures a physician must report under the Quality category. Without this reduction, the AMA does not support immediate removal of the proposed measures but would support a modified phased approach to the topped out measure process. • The AMA strongly urges CMS to retain a 10 percent weight for the cost category and remain flexible on weights for the next four years while the eight new episode-based cost measures are evaluated and more are developed and piloted. We also object to several other provisions in the proposed rule, discussed in the attached detailed comments, because we believe that in its desire to “capture more physicians in the cost category,” CMS is undermining the reliability of and confidence in the measures. • The AMA applauds CMS’ overhaul of the Advancing Care Information (ACI) category and supports many of the proposals within the Promoting Interoperability (PI) program. We urge CMS to continue to limit regulatory requirements, including aligning the PI programs so that hospitals and physicians achieve the same score to receive full PI Program credit; simplifying and reducing burden through Yes/No measure attestation, and scoring PI on the objective-level. The Honorable Seema Verma September 10, 2018 Page 4 • The AMA appreciates and urges CMS to finalize several of the proposed policies for alternative payment models, such as the proposal to maintain the revenue-based financial risk requirement at no more than eight percent for an additional four years. The AMA also urges CMS to increase the availability of well-designed alternative payment models under the Quality Payment Program. We thank you for the opportunity to provide input on this proposed rule. Our detailed comments on the proposed rule are located in the enclosed attachment. If you have any questions regarding this letter, please contact Margaret Garikes, Vice President of Federal Affairs, at [email protected] or 202-789-7409. Sincerely, James L. Madara, MD Enclosure The Honorable Seema Verma September 10, 2018 Page 5 2019 Physician Fee Schedule and Quality Payment Program Proposed Rule Detailed Comments of the American Medical Association I. PROVISIONS OF THE PROPOSED RULE FOR THE 2019 PHYSICIAN FEE SCHEDULE A. Evaluation & Management (E/M) Visits [p. 7] i. E/M Visits Background [p. 7] ii. Documentation Changes [p. 8] iii. Payment-Linked Coding and Documentation Changes [p. 9] iv. Multiple Procedure Payment Reductions [p. 14] v. Practice Expense Impact of Code Collapse-Single Payment Proposal [p. 14] vi. E/M Payment Collapse Proposal Disregards Statutory Requirements [p. 15] vii. E/M Visits: Conclusion [p. 15] B. Determination of Relative Value Units (RVUs) [p. 16] C. Modernizing Medicare Physician Payment by Recognizing Communication Technology-Based Services [p.