Letter to The Honorable Seema Verma regarding Medicare Physician Fee Schedules

Dear Administrator Verma:

On behalf of the 25,000 physician, resident and medical student members of the Massachusetts Medical Society I appreciate the opportunity to submit comments to the Centers for Medicare & Medicaid Services (CMS) on the 2020 Physician Fee Schedule (PFS) and Quality Payment Program (QPP) proposed rule, published in the Federal Register on August 14, 2019 (84 Fed. Reg. 40482). We urge the Department to carefully consider the extensive and thoughtful comments provided by the American Medical Association. Our comments highlight some key recommendations and as well as some areas of concern.

Key recommendations

I. Medicare Physician Fee Schedule

• The MMS supports CMS’s decision to adopt the RUC recommendations with respect to E&M payments in lieu of its proposal to collapse E&M levels and payments. We urge CMS to finalize the CPT codes, CPT guidelines, and RUC recommendations as implemented by the CPT Editorial Panel and submitted by the RUC. CMS should work with the medical community to urge Congress to implement positive updates to the Medicare conversion factor to offset the deserved increases to office visits.
• The MMS supports the recommendation of the AMA and surgical groups that CMS implement the proposed increases to office visits to the visits included within the surgical global payment packages.
• The MMS supports and endorses the recommendations and comments of the RUC regarding potentially mis valued services. We also support the RUC’s recommendations for valuation of specific codes.
• The MMS encourages CMS to continue to carefully consider all pricing data including invoices and other supporting evidence that it receives from the specialty societies, and to move to an ongoing update process for supplies and equipment that is open to public comment through the rulemaking process.
• The MMS supports several aspects of the proposed payment policies for office-based and opioid treatment program (OTP) management of OUD treatment which are consistent with previous policy recommendations and urges that these proposals be finalized. We recommend that CMS consider modifications to better account for patients who need a more resource-intensive bundle of services.
• The MMS is supportive of efforts to increase the utilization of care management services; however, CMS should inform Congress that positive updates to the Medicare conversion factor are needed to expand these services.
• The MMS urges CMS to eliminate any out-of-pocket costs associated with screening colonoscopies.

II. MIPS Value Pathways (MVPs)

The MMS greatly appreciates CMS’ efforts to further improve the MIPS program through MVPs and agrees with CMS that the goal of MVPs should be to reduce the complexity of the MIPS program and physicians’ reporting burden. The MVP approach responds to some of the recommendations made to CMS by the AMA after significant consultation with specialty and state medical societies, including reducing the number of measures to report, indicating MVPs would use cross-category measures and providing more feedback to physician practices participating in MVPs. We commend CMS for incorporating feedback from the physician community as it works to improve the MIPS program.

While we are appreciative of CMS’ efforts to develop a high-level MVP framework and recognize it is a first step in the right direction, we recommend that several policies included in the MVP framework outlined in the proposed rule be changed. Specifically, CMS should:

• Ensure participation in the MVP is voluntary by allowing physicians to opt-in to an MVP or continue in the existing MIPS program and choose to report on any of the existing measures and activities;
• Focus on measures that are meaningful to physicians rather than population health administrative claims measures;
• Make the MVP option a more holistic track for physicians to participate and be accountable for lower-cost, higher quality care for a specific health condition, procedure, or risk factor by permitting attestation in the PI category and automatically applying credit for IAs into MVPs to reduce reporting;
• Establish appropriate incentives for physicians to transition to a new QPP track and report on new measures;
• Engage with specialty societies to develop MVPs in a collaborative process like the process for developing specialty measure sets; and
• View the first few years of MVP implementation as a pilot testing period as it will take time and effort to develop, refine, and educate physicians on this new QPP track.

III. Quality Payment Program

Because 2020 is a transition period to the MIPS Value Pathways (MVPs), we believe it is especially important to provide stability and continue to encourage participation while specialty societies and physicians shift their time and focus toward developing or preparing to report on MVPs to make the MIPS program more sustainable in the long run. Specifically, we urge CMS to:

• Gradually increase the performance threshold in 2020 to 35 points to ensure continued high participation in the program, to support small practices, and to be consistent with the size of the proposed increase in the exceptional performance threshold.
• Maintain the existing MIPS quality measures to ensure consistency with program requirements, reduce the creation of additional burden, and allow for more measures to form the basis of MVPs. We also recommend that CMS not finalize the new measure removal factor.
• Maintain the data completeness threshold at 60% for all reporting mechanisms.
• Institute a manual data driven approach to calculate measure benchmarks. Ensure licensing/sharing a measure with another QCDR or Third-Party Intermediary (qualified registry or EHR) is at the discretion of the QCDR measure steward and not at the expense of jeopardizing data integrity and if the steward does not comply then they are subject to CMS automatically removing the measure(s) from the program.
• Not move to adopt global and population health administrative claims measures in MIPS, specifically we do not support finalizing the proposal to include the All-Cause Unplanned Admission for Patients with Multiple Chronic to the Quality Performance Category starting with the 2021 performance period.
• Focus opioid related quality or promoting interoperability measures on how well patients’ pain is controlled, whether functional improvement goals are met, and therapies used as opposed to the current approach of only focusing on preventing and/or reducing opioid use.
• Retain the cost category weight at 15 percent of the final MIPS score for at least 2020.
• Remove the Total Per Capita Cost and Medicare Spending Per Beneficiary measures that hold physicians accountable for costs outside their control.
• Maintain the existing participation threshold of requiring one clinician in a group to perform an IA for the TIN to receive IA credit to ensure consistency with program requirements and minimize burden. We support CMS’ proposal for a 90-day performance period.
• Reduce the burden of health IT measurement in the Promoting Interoperability (PI) category by focusing on relevance of measure to clinical practice and patien improvement and eliminating any additional electronic data collection that does not align with a physician’s clinical workflow. CMS should move away from prescriptive PI measures tied directly to certified EHR use and instead score measures based on an “yes/no” attestation.
• Issue the lump-sum incentive payments to 2017 Qualified Participants (QPs) immediately.
• Exercise greater flexibility in allowing Advanced APMs and Other Payer APMs, including medical home models and capitation arrangements, to be counted for purposes of achieving QP status.

Specific Comments

PROVISIONS OF THE PROPOSED RULE FOR THE 2020 PHYSICIAN FEE SCHEDULE

A. Updates to the Geographic Practice Cost Indices (GPCIs) & C Determination of Professional Liability Insurance Relative Value Units (PLI RVUs)

• Recommendation: CMS review the rent indices in Massachusetts and ensure that the relative difference in the indices accurately reflect the relative differences in rents form the source data file.

The MMS has serious concerns about the accuracy of the data used to calculate the GPCI and PLI RVUs as well as the actual formulaic calculations. For example, according to the appendix, Suffolk and Nantucket Counties have the lowest two rent indexes in the country, which defies reason. It is difficult to understand how Middlesex County could have the highest index and Suffolk County the lowest index. Specifically, when comparing the county rent indices in the August County GPCI file posted on the CMS website with the 2013-2017 5-year ACS 2 bedroom rent source data file there are consistent discrepancies in the New England state. For example, Middlesex County has a median rent listed at $1569 (the 26th highest rent in the US) and a rent index of 2.337 (the highest in the country). Suffolk County has a median rent listed at $1457 and a rent index of 0.161 and Nantucket County has a median rent of $1733 and a rent index of 0.051.

As a result of these suggested concerns in calculating the rent indices, we are concerned that these errors are carried over to the proposed practice expense GPCIs for other localities when published budget neutrality factors and the weighing of the other indicis used in calculating practices expense GPCI. We completely understand that these are complex calculations. A simple keystroke error buried among 10,000 data sets can have a significant impact.

Digital Medicine

The MMS applauds the significant steps forward to advance digital medicine in the Medicare program. There remains a compelling need to modernize the Medicare program to enable practice transformations to ensure that Medicare can meet the needs of beneficiaries while advancing the quintuple aim including improved patient health outcomes, cost effectiveness, improved population health, enhanced care team experience, and equity. The rapid advances in technology should be leveraged and deployed to achieve these essential goals.

1. Telehealth

Telehealth, two-way audio-visual real time communications, continues to evolve. CMS has suggested that all the services that could be covered as telehealth services have been identified. We caution against the assumption that all services that can be delivered via telehealth have already been covered. Notably, the Veterans Health Administration and commercial insurers are deploying peripherals and diagnostic tools to support telehealth services that will enable increased data collection to aid an interactive session between a patient and their physician. Careful consideration is underway to evaluate evolving technologies and norms in this area and expanded services that can be delivered via telehealth with peripherals by the DMPAG.

The MMS also strongly urges CMS to conduct demonstrations under existing wavier authorities by lifting geographic restrictions on several states to allow Medicare beneficiaries in urban locations to receive telehealth services. This will provide CMS with essential information on beneficiary outcomes and potential cost savings or cost neutrality. We also urge CMS, similarly, to lift originating site restrictions for Medicare beneficiaries across the board in several states to, again, assess impact and generate essential data concerning health outcome benefits and relative costs for beneficiaries receiving services in their residencies, for example.

The MMS also urges CMS to issue guidance to state Medicaid directors concerning the changed coverage policies starting in 2019 and proposed for 2020 to ensure the dual eligible beneficiaries receive the benefit of the expanded coverage of these new technology-enabled services. And, the AMA strongly urges CMS to meet with the Federal Communications Commission to identify either joint or coordinated demonstrations under each agency existing authorities to expand access to telehealth and other technology enabled services.

The MMS also strongly urges CMS to issue a comprehensive list of telehealth services along with comprehensive guidance that is user-friendly and easy to navigate in order to aid stakeholders to identify those covered telehealth services that no long have originating and geographic restrictions.

The AMA has submitted a detailed list of HCPCS II codes for substance abuse treatment via telehealth for both offices based and remote monitoring services, which we support.

Bundled Payments for Opioid Use Disorder (OUD) Treatment

• Recommendations: The MMS supports several aspects of the proposed payment policies for office-based and opioid treatment program (OTP) management of OUD treatment finalized. We urge CMS to consider modifications to better account for patients who need a more resource-intensive bundle of services. We support the jointly referenced recommendations of the AMA and the American Society of Addiction Medicine, referenced below.

1. Office-based OUD Treatment Payment Proposals

In the proposed rule for 2019, CMS sought comments on designing a new bundled payment for office-based management of patients with substance use disorders. In response, the AMA recommended that CMS focus the bundled payment policy on treatment for OUD rather than trying to craft something that would be appropriate for more broadly defined substance use disorders. AMA comments were based on a concept paper jointly developed by the AMA and the American Society of Addiction Medicine (ASAM), and recommended five major elements:

• A payment to support the initial evaluation, diagnosis, and treatment planning for a patient with OUD and the initial month of medication-assisted treatment (MAT);
• A monthly payment to provide MAT for as long as continued therapy is determined to be appropriate, including providing or coordinating the provision of counseling and social services;
• Higher payments for patients with more complex needs;
• Flexibility to support services of both primary care physicians and addiction medicine specialists, including consultation between them; and
• Add-on payments to support integration of technology-based treatment and recovery support tools.

In the current rule, CMS proposes new codes that would provide monthly payments for a bundled episode of care including development of a treatment plan, care coordination, individual and group therapy, and counseling for patients with OUD. The bundled payments would exclude medications approved by FDA for use in the treatment of OUD. There would be separate payments for the first month of treatment to cover induction and development of the treatment plan, payments for subsequent months of treatment (with no limit on duration of treatment), and an add-on code to cover patient circumstances that require substantial extra resources to manage.

We commend CMS for proposing separate payments for the induction and maintenance phases of OUD treatment. Addiction medicine and many other specialties that have been working to develop alternative payment models have identified the lack of adequate financial support for the services patients should initially receive -- a complete diagnostic work-up, development of an initial treatment plan, and educating patients about their condition and how best to manage it at home -- as a serious shortcoming in the fee-for- service system. We also support CMS’s proposal that the monthly maintenance payments may continue for as long as the patient’s OUD treatment continues. Arbitrary limits on OUD management with MAT have been a major problem in many health plans.

The MMS supports the following recommendations detailed in the AMA comments:

• Payment amounts should be risk stratified to reflect patients who need more services or more resource-intensive services. For example, some patients may need the services of a typical care manager, but others will need a trained behavioral health specialist. The current proposal allows only for an add-on code based on additional minutes of service provided but that is inadequate to recognize real differences in patients’ needs and the different mix of services that may be required to address those needs, not just differences in the amount of time. If the payment amounts for the initial and ongoing service bundles are stratified into at least two categories reflecting different levels of patient need, using the criteria that ASAM has defined for different levels of services, the add-on code could then serve as an outlier payment. After there is more experience with the bundled payments, the relative values should be reviewed to ensure they reflect the actual resources needed to provide the services.
• Payment amounts should recognize different types of practice arrangements. Some practices will include addiction specialists and behavioral health counselors and be able to directly provide all the services in the bundle, but some practices may need to consult with specialists and/or refer patients for counseling, a social worker, or other support services outside the practice, and the cost of doing this must be reflected in the payment amounts in order to ensure that small practices and practices in rural areas will be able to offer these critical services.
• CMS should consider how its proposed policies could be best applied or modified to address patients transitioning from a different treatment setting to office-based OUD treatment. This could occur, for example, if a patient begins treatment for OUD with methadone and then transitions to office-based treatment with buprenorphine, or in other cases where a patient might need to move to office-based treatment after being in a facility setting.

2. OTP Payment Proposals

CMS also provides an extensive and detailed proposal to implement the new Medicare Part B benefit for OTPs that was established by the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act, including definitions of terms such as OUD and OTP, a methodology for determining Medicare payment for services and drugs provided by OTPs, and Medicare enrollment requirements for OTPs. The SUPPORT Act provides for payments to OTPs accredited by the Substance Abuse and Mental Health Services Administration to cover medications used in the treatment of OUD, including oral, injected, and implanted buprenorphine, methadone, and naltrexone; medication dispensing and administration; counseling; individual andgroup therapy; toxicology testing; and other services deemed appropriate. While the new payments for office-based OUD treatment would be monthly, the OTP services would be defined on a weekly basis.

The proposed payment policies for OTPs are consistent with the proposed payment policies for office-based treatment of OUD, except where the statute requires differences, such as including medication and laboratory test costs in the OTP bundled payments. The AMA recommends that similar modifications be made in the OTP policies as are recommended above for the office-based OUD treatment services. For example, although the proposed rule notes that CMS recognizes “that there is a range of service intensity depending on the severity of a patient’s OUD,” it has not actually proposed variations in the weekly payment bundles to reflect differences in severity.

Care Management Services

• Recommendations: The MMS is supportive of efforts to increase the utilization of care management services; however, CMS should inform Congress that positive updates to the Medicare conversion factor are needed to expand these services.

The MMS is supportive of efforts to increase the utilization of these services and expand care management to additional patients. However, it is unfair to ask physicians to pay for these newly described services by redistributing money away from other important physician services. CMS must account for the savings for these services in decreased hospital visits and emergency visits to offset the cost of new and expanding coverage of care management services. CMS should also inform Congress that positive updates to the Medicare conversion factor are critical to expand these services, while maintaining the integrity of the valuation within the Resource-Based Relative Value System (RBRVS).

As always, the Massachusetts Medical Society appreciates the opportunity to provide comment and work with the agency on our shared goal of providing the highest quality health care to patients.

Sincerely,

Maryanne C. Bombaugh, MD, MSc, MBA, FACOG