Late on Monday, August 3, CMS released the latest Physician Fee Schedule proposed rule. The rule outlines Medicare physician payment policies for 2021, including extensions of many of the telehealth and virtual care flexibilities made available on an emergency basis due to the COVID-19 pandemic. The rule also proposes significant changes to quality assessment for Medicare Shared Savings Program ACOs, the MIPS-APM scoring standards, and the Qualifying APM Participant (QP) calculation. Some initial thoughts on the rule are below.

Extended Availability of Services Delivered through Telehealth
Some of the most anticipated policies in this rule relate to telehealth. Telehealth and virtual care service delivery have been important avenues for maintaining high quality care as well as a dependable revenue stream for those practices that have made the transition. As of now, the flexibility to provide many services through telehealth is only available through the length of the COVID-19 public health emergency (PHE), which was just extended through the end of October.

CMS is proposing to make certain services available through telehealth permanently – an extension of the new telehealth waivers offered during the PHE. Those services including certain office and outpatient evaluation and management (E/M) visits and services for those with cognitive impairments. CMS proposes a separate list of services that would be extended after the PHE, but not permanently. Certain home visits, ER services, and psychological testing would be available through the end of the calendar year in which the PHE ends.

CMS is proposing these extensions with an eye toward helping rural Americans access the care they need. The agency cannot extend all the telehealth flexibilities administratively – extending some changes to eligible providers beyond the PHE would take an act of Congress. CMS mentions they do not have the authority to make the audio-only telephone E/M service permanent and seeks comment on how they might develop new codes to fill this need. The telephonic care delivery is particularly important to rural providers and patients where broadband infrastructure may not be available.

For more about how to make virtual care work for your practice, download our virtual care guide here. 

Increase in Rates for Office Visits
Last year’s PFS rule included an historically large increase in office and outpatient E/M payment, effective as of January 2021. Due to budget neutrality requirements, this results in widely varying proposed payment adjustments for different medical specialties. Specialties that bill a lot of E/M office visits are seeing relatively large increases, and many procedure-based specialties would get their payments cut. For example, Family Practice Physicians are projected to get a 13% increase while Nurse Anesthetists and Anesthesiology Assistants would see an 11% decrease. This increase for E/M services reflects recommendations from the American Medical Association and acknowledges the time and effort required to care for Medicare patients, particularly those with time-intensive chronic conditions. However, the budget neutrality requirements could inappropriately penalize certain specialties and Congress should consider how to make this right.

Reduced Quality Reporting Requirements for ACOs
Starting in 2021, CMS is proposing that ACOs will only need to actively report 3 clinical quality measures rather than the current 10 (with an additional 3 collected from patient surveys and claims measures). This set of streamlined measures, shown in the chart below, would satisfy quality reporting for both the Medicare Shared Savings Program (MSSP) and MIPS. This change retains several of the most important quality measures tied to serious chronic conditions, such as Controlling High Blood Pressure, Depression Screening, and Diabetes Control.

As part of this change, CMS is phasing out Web Interface reporting starting in 2021 and replacing it with their proposed parallel framework to MVP for MIPS-APM participants, called the APM Performance Pathway (APP). The new APP framework includes the fixed set of measures above, will be used for both the MSSP and MIPS programs and will allow for multiple submission types. CMS is proposing to use performance period benchmarks instead of historical to compensate for PHE complications in the data.

Increase quality performance standard
CMS proposes to increase the quality performance standard from 30 to 40th percentile across all measures. An ACO would have to score at or above the 40th percentile on all measures to be eligible for shared savings, a more difficult standard to meet. CMS is also proposing to no longer prorate the shared savings for ACOs that fall below the threshold.

Treatment of 2020 ACO Quality Scores
ACOs are concerned that the pandemic could adversely affect performance on quality measures during 2020, as well as hinder the ability to report quality. ACOs and stakeholders, including Caravan Health, have suggested quality reporting relief, such as paying for reporting rather than paying for performance during 2020 to account for the unusual circumstances. CMS does not propose specific quality reporting scoring in this rule, but states that all ACOs should be encouraged to report quality measures for 2020. CMS believes that the automatic full credit for CAHPS reporting, along with the existing extreme and uncontrollable circumstances policy, may be sufficient relief for ACO quality reporting in 2020. They are seeking comment on an alternative scoring methodology approach under the extreme and uncontrollable circumstances policy.
The ACO extreme and uncontrollable circumstances policy allows ACOs to be awarded the higher of their own reported quality score or, if they can’t report, the average score of other ACOs. This policy will be in effect for 2020 because of the PHE. CMS asks for comment on an alternative extreme and uncontrollable circumstances policy that would allow an ACO to substitute its 2019 reported quality score in place of a 2020 reported score.

The rule proposed a host of changes to the Merit-based Incentive Payment System, including:

  • An increase of the maximum MIPS adjustment from 6 percent in 2020 to 7 percent in 2021. This significant increase is anticipated even with a 10-percentage point reduction in the threshold cutoff to avoid a negative adjustment and makes MIPS comparably attractive as the 5 percent bonus for participating in advanced (risk-bearing) APMs.
  • The Cost category for standard MIPS will count for 20% for 2021. The law requires that Cost account for 30% of the standard MIPS score starting in 2022.
  • MIPS weighting stays the same for ACOs - Quality: 50%, Cost: 0%, Promoting Interoperability: 30%, Improvement Activities: 20%.
  • For 2020, CMS is increasing the complex patient bonus to from 5 to 10 points to account for the effects of the COVID-19 pandemic.
  •  The MIPS Value Pathways (MVP) framework, expected to be rolled out in 2021 as a replacement for standard MIPS, would be delayed until 2022.
  • CMS proposes that APM entities can apply to reweight MIPS performance categories as a result of the PHE.
  • CMS is amending the Qualifying APM Participant (QP) calculation by excluding prospectively attributed patients. CMS is also proposing a targeted review process for an APM Entity or individual clinician to appeal an omission from the participant list.

CMS is accepting comments on this proposed rule until October 5, 2020. Make your voice heard on these important issues by submitting your comments here

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