MMS Comments to CMS on Revisions to Medicare Program Payment Policies Under Physician Fee Schedule

Andrew  M. Slavitt
Acting 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: Medicare Program: Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2017; Medicare Advantage Pricing Data Release; Medicare Advantage and Part D Medical Low Ratio Data Release; Medicare Advantage Provider Network Requirements; Expansion of Medicare Diabetes Prevention Program Model; Proposed Rule (CMS-1654-P); and

Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Organ Procurement Organization  Reporting and Communication; Transplant Outcome Measures and Documentation Requirements; Proposed Rule (CMS-2016-011 5-0002).

Dear Acting Administrator Slavitt:

On behalf of the 25,000 physician, resident and medical students of the Massachusetts Medical  Society  (MMS), I am  pleased  to offer our comments to the Centers for Medicare & Medicaid  Services (CMS)  on two proposed  rules impacting Physicians: I ) NPRM  for (CY) 201 7 to revise the Medicare  Physician Fee Schedule and Part B, (81 Fed. Reg. 46, 162); and 2) Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical  Center Payment  Systems  and Quality Reporting Programs; Organ  Procurement Organization Reporting and Communication; Transplant Outcome Measures and Documentation Requirements; (Federal Register  Number: 2016-16098).

I. Medicare Program: Revisions  to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2017; Medicare Advantage Pricing Data Release; Medicare Advantage and  Part D Medical  Low Ratio  Data  Release; Medicare Advantage Provider Network Requirements; Expansion of Medicare Diabetes Prevention Program Model; Proposed Rule

There are a number of the provisions in the proposed rule which the MMS supports. These include:

1. Increased Payment for Primary Care and Patient Management Services
The proposed rule includes a number of proposals to improve payment accuracy for primary care, care management and patient centered services which the MMS supports. Specifically the proposal creates separate payments for non face to face prolonged Evaluation and Management services, separate payments for services furnished using the Psychiatric Collaborative Care Model, increased payment for Chronic Care Management and separate payments to recognize the physicians work in assessing and creating a care plan for patient with cognitive impairments. We believe these payment policies will help build the primary care foundation in Medicare and effectively help break down long-standing barriers to effective treatment of patients who have chronic and/or behavioral health conditions. Since Alternative Payment Models (APMs) and the Merit-Based Payment Incentive Payment System (MIPS) are built on fee for service, it is imperative to address inherent problems with the fee for service payment base now.

2. Expansion of the Diabetes Prevention Program (DPP) Model

The MMS supports CMS' proposal to expand the duration and scope of the Diabetes Prevention Model (DPP) model with the establishment of the Medicare DPP. The DPP is a preventive service with proven benefits in helping patients with prediabetes avoid progressing to Type 2 diabetes.

More than 11 million seniors, or 26.9 percent of the Medicare population, have diabetes and 26 million, half of all seniors over age 65, have prediabetes. In addition, one in every three Medicare dollars is spent on diabetes and its complications, such as cardiovascular disease. Diabetes is the leading cause of kidney failure, accounting for more than 44 percent of new cases of end-stage renal disease in 2011. Spending on Medicare beneficiaries with prediabetes and diabetes is estimated to be more than $2 trillion over the next 10 years, including $1.7 trillion in federal spending. Mounting evidence has found appropriate interventions like the DPP model are effective at preventing Type 2 diabetes and cardiovascular disease.

The proposed payment model for the Medicare DPP is highly dependent on patient adherence in attending the sessions and health outcomes as measured by weight loss. We urge CMS to give serious consideration to comments on this payment model that may be submitted by organizations with experience delivering the DPP to diverse patient populations. Adoption of a single one-size-fits-all payment model with no risk stratification could potentially lead to DPP providers cherry-picking locations for service delivery based on the probability that the patient population will attend more sessions, be more adherent to the education and counseling they receive, and be more likely to lose weight, while avoiding Medicare-Medicaid patients and others who might find DPP attendance and adherence more challenging.

3. Telehealth
As we move forward there are many opportunities and challenges that will require focused efforts by CMS, physicians, policymakers, and other health care stakeholders to ensure the appropriate implementation of telehealth service. We support the relevant principles developed by the AMA, namely, telehealth must be validated, evidence-based, actionable, and connected while preserving important patient protections that are time-tested and relevant today. And, payers, including Medicare must provide viable payment and reimbursement models. For digital health to improve clinical practice in fundamental and new ways, digital medicine must bring patients and physicians closer together for the common purpose of improving health outcomes.

The MMS applauds the Agency's  efforts to increase the number of covered telehealth services and supports the addition of new telehealth services/codes. The MMS urges CMS to maximize existing authorities and discretion to expand coverage of telehealth services that Medicare has determined have an established evidence base, but which only a limited number of beneficiaries are eligible to receive.

The MMS urges CMS to finalize the rule to expand coverage of telehealth as proposed, but to develop a far more expansive set of strategic proposals that are cohesive and forward looking in order to expand coverage and access to telehealth services for Medicare beneficiaries in a meaningful manner that insures CMS is not creating barriers to delivery models and tools that improve medical care and access.

4. Incorporating Beneficiary Preference into ACO Assignment
The MMS strongly supports the CMS proposal to incorporate a voluntary patient choice process into the ACO assignment methodology. Allowing patients the opportunity to choose their principal physician and have their ACO assignment based on that choice will also help ACOs achieve more stability in their patient populations.

CMS proposes to modify the Medicare ACO assignment method to allow patients to designate a physician participating in an ACO as the physician as responsible for their overall care, and in so doing to be assigned to that ACO. This voluntary alignment with the ACO would take precedence over potential assignment to a different ACO based on claims data analysis of the plurality of primary care services provided to the patient. CMS proposes to use an "automated" approach to determine which physician patients' believe is responsible for coordinating their overall care (i.e. their "main doctor") using information collected from patients through a CMS system such as MyMedicare.gov, 1-800-Medicare or the Physician Compare website.

5. Release of Part C Medicare Advantage Bid Pricing Data and Part C and Part D MLR Data
The MMS supports the Agency's  proposal to provide greater transparency to the public generally on various aspects of the Medicare program and welcomes the proposal to extend this to Medicare Advantage and the Medicare Part D Prescription drug benefit programs. As part of the annual bidding process required under the Social Security Act, Medicare Advantage organizations (MAOs) submit bids for each plan they wish to offer in the upcoming contract year (calendar year). In addition, MAOs and Part D sponsors are required annually to provide CMS data supporting their medical loss ratios (MLR). CMS has proposed to release to the public MA bid pricing data and Part C and Part D MLR data on a specific schedule and subject to specified exclusions. The Agency also proposes to add contract terms and expand the basis and scope of regulations on MA bidding and Part C and Part D MLR submission to authorize disclosure.

The MMS agrees with the Agency that the release of such information will improve the public health by facilitating research on the utilization, safety, effectiveness, quality and efficiency of health care services. The MMS strongly agrees that this proposal would promote accountability in the MA and Part D programs, by making MLR information publicly available for use by beneficiaries who are making enrollment choices and by allowing the public to see whether and how privately-operated MA and Part D plans administer Medicare-and supplemental-benefits in an effective and efficient manner.

Furthermore, the MMS encourages the release of this information and all additional information that may be necessary to enable researchers, patients and interested health care stakeholders to assess the adequacy of the networks offered by MAOs.

Other comments

1. 10-90 Day Global Services Reporting Requirement
The MMS joins the AMA and RUC in opposing the proposed 10 and 90 day global services reporting requirements. We believe the proposed requirements are onerous and burdensome and go well beyond the legislative mandate to collect data in the surgical global period. In addition, we do not believe this process will result in accurate information. There are a number of problems with the proposal including the number of codes that are being surveyed, the level of visits that are being reviewed and the time increments per patients, e.g. the proposed rule would require physicians to document in 10 minute intervals what they doing with the new G codes. We urge CMS to work with the AMA, RUC, and relevant national medical specialty societies to develop a process that is simplistic and transparent and produces accurate data.

2. New Mobility Related Payment
The MMS is very concerned about how CMS is proposing to implement and finance the new add-on payment for services provided to patients with mobility-related disabilities. At the outset, it is important to underscore that the MMS supports payment policies that improve access to care for these patients and patients with other impairments. The problem is that the process and methodology the agency is using to both to analyze the issue and implement a response is significantly flawed. In this proposal, CMS has bypassed the normal process and standing rules for valuing services in fee for service Medicare. As a result, CMS has eliminated any positive update to the Medicare fee schedule as mandated by MACRA. Clearly this was not the intent of Congress.

In the proposed rule, CMS states that treating patients with mobility-related disabilities can require more physician time and increased equipment costs. To validate this argument, CMS notes that Medicare beneficiaries under age 65 have more difficulty finding a doctor who accepts Medicare than beneficiaries over 65 and that people with disabilities report worse experiences than people without disabilities on many quality measures. We agree with CMS that these are serious issues that need to be evaluated further, and taken into consideration when making policy decisions.

The MMS joins with the AMA and urges CMS to work with stakeholders to conduct additional studies that will provide information on why younger Medicare patients have more difficulty finding a physician, and why certain quality measurement scores may be lower among patients with disabilities. Once further studies have been done to diagnose the root cause of these issues, CMS should with the AMA, other stakeholders, the CPT Editorial Panel and the RUC to develop an appropriate solution.

3. Changes to Geographic Practice Cost Indexes (GPCIs) Update
CMS is required to update the Medicare Geographic Practice Cost Indexes (GPCIs) at least every three years, and has proposed changes to this element of the RBRVS in the eighth GPCI update. The key data sources to be used are the same as in the previous GPCI update, although CMS would be using more recent data. In particular, CMS is proposing to use Bureau of Labor Statistics wage data for 2011-2014 in calculating the physician work and practice expense GPCIs in place of 2009-2011 wage data. They are proposing to use residential rent data for 2009-2013 to calculate the office rent portion of the practice expense GPCI in place of 2006-2008 rent data. And, they are proposing to use 2014-2015 professional liability insurance (PLI) premium data to calculate the PLI GPCI in place of 2011-2012 premium data.

In the seventh GPCI update CMS sought comment on whether it should use a proprietary source it had identified for commercial rent data, instead of continuing to use residential rent data in the practice expense GPCI. The MMS has long objected to the use of residential rents as a proxy for physician office space costs, and encouraged CMS to explore the opportunity to improve the accuracy of the GPCIs. We continue to urge CMS to explore the collection or use of commercial rent data, either as the basis for measuring geographic differences in physician office rents, or if this is not feasible, to validate the use of residential rents as a proxy.

4. Open Payments
The MMS agrees that the Open Payments program was intended by Congress to create transparency around the nature and extent of relationships that exist between drug, device, biologicals and medical supply manufacturers, and physicians and teaching hospitals (covered recipients and physician owner or investors). At the same time, Congress provided that certain transfers should be exempt from reporting in order to avoid chilling the transfer of information that directly benefits patients, for instance, and it is safe to say that Congress supported transparency of accurately reported data.

We are pleased that the Agency is considering a requirement for applicable manufacturers and applicable group purchasing organizations (GPOs) to pre-vet payment information with physicians and other covered recipients. The vast majority of the Open Payments program data has not been validated beyond the manufacturers and GPOs as most physicians have faced significant barriers accessing the Open Payments dispute resolution online portal offered by CMS and, as a result, physicians have been effectively unable to dispute inaccurate reports without expending substantial time and resources.

The MMS supports provisions requiring manufacturers to provide physicians with an opportunity to review physician data before it is transmitted to CMS. A growing number of manufacturers have incorporated this important feature in their Open Payments compliance efforts in order to insure that accurate data is reported to the Agency in the first instance. We look forward to the Agency's identification of effective methods and models that have been successfully implemented. This would help to prevent the transmission of erroneous data to CMS.

The Agency also requested suggestions on ways to streamline or make the Open Payments process more efficient. The MMS, AMA and over 100 national and state medical organizations have expressed long standing concerns with the Agency's decision to expand the scope of the reporting requirements to include journal reprints, medical textbooks, and other educational materials that directly benefit patients or are intended for patient use. The inclusion of these materials in the Open Payments system is not consistent with congressional intent and has added significantly to the reporting burden. There is no transfer of value, as defined in the statute, when physicians receive a reprint from a medical journal. Most physicians already have access to the materials through a subscription and many of the leading journals are offering access to these studies to the public for free within the calendar year after publication. The MMS urges the Agency to simplify the reporting requirements and to support medical innovations that directly benefit patients by following congressional intent and excluding educational material from the Open Payments System.

5. ACOs
The MMS has significant concerns regarding CMS' proposals to change the quality measures that ACOs report.  We also continue to urge CMS to improve its risk-adjustment model to ensure that MSSP participants who treat socio-disadvantaged  patients are not unfairly penalized.

In addition, we urge CMS to recognize that ACOs should be able to utilize health information technology in ways that best and most effectively meet the needs of their patient population, as opposed to being required to comply with prescriptive regulations. More flexible health information technology requirements will help ensure the MSSP is aligned with the Quality Payment Program (QPP).

The comments of the American Medical Association provide detailed recommendations on each of these critical issues.

6. Medicare Advantage Seamless Conversions
The MMS urges CMS to review and revise its policies on Medicare Advantage seamless conversions to ensure that appropriate patient protections are in place. According to national press reports, some managed plans are automatically enrolling new Medicare beneficiaries in one of their products without fully informing the Medicare beneficiary as to their choices. These so called "seamless conversions" can have unintended consequences. Problems arise when patients either are not adequately informed about their choices or do not understand how to avoid the conversion. Problems also arise when the physician networks for the MA plan are narrower than those offered by their pre-Medicare health insurance product.

II. Medicare Program: Hospital  Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Organ Procurement Organization Reporting and Communication; Transplant Outcome Measures and Documentation Requirements; (CMS-2016-0115-0002). (CFR:42 CFR Parts 416,419,
482, 486, 488, and 495)

1. Meaningful Use Revisions
The proposal makes several changes to the meaningful use rules which we support.

1. Hardship Exemption for New Meaningful Use Physicians
The NPRM proposes that a new hardship exemption be extended to physicians who would be qualifying for meaningful use in 2017. 2017 is also the first performance year for the new Advancing Care Information program under MIPS. A new MU participant would be required to participate in both the existing MU program and the new Advancing Care Information program. To avoid any penalties and additional burdens on practices, CMS is proposing that these physicians apply for a hardship exemption from the MU penalties. In order to qualify, practices will need to show why they are eligible for the hardship, why they are applying for MU for the first time in 2017 and how this poses a hardship.

At a minimum, the MMS supports exempting practices that have not achieved Meaningful Use and encourages the department to be expansive in granting these exemptions. From this point on, our focus must be on the implementation of MACRA and its component parts. As we have stated previously, Meaningful Use II and III, were not only ill conceived, but a costly distraction from time and the data collection necessary for quality patient care. Any time or energy spent on the meaningful use program is misguided. Our goal is to work with CMS on a revised and updated ACI module which is simple, physician focused and patient centered.

Of note, the MMS, AMA and many national organizations have urged CMS to delay the beginning of the performance period for the MIPS until at least July of 2017. The MMS has also requested that additional time be granted to small practices for implementation. Assuming that many of the practices that have not met Meaningful Use will fall into the small practice category, we urge CMS to give further consideration to allowing these practices more time to comply with the new ACI program requirements.

2. 90 day Reporting Period for Meaningful Use
CMS proposes to use a 90 day reporting period for meaningful use and for clinical quality measure reporting, as opposed to the current requirement of one calendar year. The MMS supports this change. We urge the agency to the change the rules for PQRS reporting, which are currently one year, to make the timelines consistent.

3. Hospital Value-based Purchasing Pain Measures
CMS proposes to remove the current pain management questions from the Hospital Consumer Assessment of Health Care Providers and Systems (HCAHPS) patient experience of care survey. CMS is developing alternative question for the Pain Management dimension. We support this effort as part of overall strategy to reduce the amount of opioids that are being prescribed to address pain. We would welcome the opportunity to work with CMS on the new approach.

As always, the Massachusetts Medical Society looks forward to working with the Department on these and other issues impacting the care of our patients and the practice of quality health care in the Commonwealth.

Sincerely,

James Gessner Signature 200





James S. Gessner, MD
President, Massachusetts Medical Society















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