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AGS Response to Medicare Physician Fee Schedule Proposed Rule for 2019 (#MPFS2019), a work in progress.

By Nancy Lundebjerg posted 08-15-2018 04:37 PM

  

Since my initial blog post about the proposed #MPFS2019 rule, AGS leaders, staff, and consultants have been working on our response to the proposed changes that CMS has put forward.  To date, we have largely maintained a focus on the E/M proposal because of the implications that that has for our members. In addition, our leaders, staff, and consultants have also reviewed the entire proposed rule to identify the proposals that could impact care of older Americans and we have engaged additional AGS leaders to help us with our comments. It really does take a village to analyze and then respond to a 1,400 page rule.

On E/M, our work (which is described in more detail below) has been focused on:

  • Leading a multi-specialty coalition of 40+ medical specialty societies with the goal of finding common ground and submitting a joint comment letter to CMS.
  • Visiting with key Republican and Democratic staff for the committees with jurisdiction over Medicare (Senate Finance and House Energy & Commerce) and with staff in member offices.
  • Creating a list of states with elected representatives who sit on these committees where we will be asking for expert member outreach.
  • Working to develop a common set of parameters that members can use to analyze the impact of the proposed changes to E/M on their own practice.
  • Developing messaging for all members to use to contact their members of Congress.
  • Attending CMS stakeholder meetings with a twofold goal: (1) listening to CMS so we better understand their goals and plans for future direction and to inform them, along with other stakeholders, about our concerns, and (2) to determine whether we can come together to find a solution.

In addition to our work within medicine, I have reached out to colleagues at other organizations to inform them of our work and ascertain whether they will be working on responding to the rule. This includes family caregiver, consumer, and other health professional organizations – this outreach will be ongoing. Today, the Health Affairs blog published an analysis of the new proposal by Alan Lazaroff (an AGS Board member and our representative to the RUC) and Bob Berenson of the Urban Institute that points out the deficiencies of the current proposal while offering an alternative solution. As evidenced by the first comment on Alan and Bob’s piece, from Frank Opelka of the American College of Surgeons (ACS), we are going to need more than a 60 day comment period to arrive at a consensus on what changes to the current system would support provision of coordinated care to older Americans by all providers who bill on the physician fee schedule. We will continue to articulate this message to CMS – that this proposal should not be implemented in its current form and that they should seek broad input and comment from all stakeholders. This includes older Americans and those who care for them.

I would be remiss if I did not give a quick shout out to our Public Policy staff team of Alanna Goldstein and Anna Mikhailovich for their talent in keeping a number of balls in the air as we juggle our own and the coalition response to the proposed #MPFS2019 rule. All while maintaining a close eye on a number of other policies that are important to geriatrics health professions (e.g., appropriations, personnel changes at Veterans Affairs, and Title VII geriatrics health professions reauthorization). We are fortunate to have them in our corner.

How You Can Help Now
I’ve been appreciative of the AGS members who have been out early on Twitter raising questions and commenting on the proposed rule directly to CMS. Keep it up – this will be important to do throughout the fall. And to those of you who are offering your assistance via MyAGSOnline – a huge thank you! It is wonderful to know that we have AGS members who are ready to make some noise with their members of Congress. 

In light of that interest and knowing that our opportunity to impact the outcome of this rule will be a marathon that will last until the final rule is released, we will be posting a campaign in the AGS Advocacy Center tomorrow (here) with some early messages that we will be asking members to convey to their elected representatives every day. Yes, I just said every day – this is an important tactic for keeping your concerns about the impacts of the proposed rule on your patients on the radar of your Congressional representatives. 

CMS Position on the E/M Proposal
In stakeholder meetings, CMS has been very clear that this proposed rule is in response to longstanding requests from clinicians to simplify the E/M documentation guidelines. In particular, they have emphasized that they believe the documentation and payment revisions they have proposed in this rule are linked. In these meetings, CMS has consistently messaged that they are looking for suggestions from the medical community on how the payment proposal might be modified so as to better serve older Americans. This makes our work leading a multi-society coalition all the more important to our long-term success.

AGS Activities to Date

Multispecialty Coalition
Since that blog post, we have been leading a coalition of over 40 specialty societies with the goal of developing a letter responding to the rule and are currently seeking coalition meetings with CMS, OMB, as well as coordinating efforts on the Hill. We have also been working with a data consultant to model alternative payment models to restructure outpatient E/M visits that we can bring to CMS. Parallel to that effort, we have been working on the AGS response to the proposed E/M changes as well as our response to other sections of the rule where we see potential impacts on the practice of geriatrics. AGS is also pursuing a separate AGS meeting with CMS where we can focus on our concerns specific to geriatrics.

July 31st Hill Visits
On July 31, we were on the Hill speaking with key staff on the committees with Medicare oversight and also with key members of Congress to express our concerns about the E/M proposal. Our meetings were with staff on both sides of the aisle and many staffers noted that we very early in coming to meet with them. In these meetings, we highlighted the potential impacts on Medicare beneficiaries and family caregivers of these changes – including that the most complex patients would potentially no longer have access to coordinated care because how people practice would change (e.g., more visits, less time per visit or clinicians cherry picking healthier patients). Then, we highlighted the potential revenue impacts on geriatrics practices, particularly academic practices which typically care for frail, older people, with multiple chronic conditions. Finally, we noted that CMS was not following usual practices in making this proposal and that practices would be unable to implement needed changes to EHR and billing by January 1, 2019.  Overall congressional staff were in a listening mode at that point. However, no matter which side of the aisle they sat on, they were pleased to learn that AGS is leading the effort to develop a cohesive response from specialty societies to the proposed rule.

Future Needs for Member Engagement
As noted above, we will be launching a campaign in our advocacy center tomorrow. Upcoming will be outreach to AGS and ADGAP members residing in states where representatives are members of the two committees of jurisdiction (Senate Finance, House E&C). The states are: CA, CO, GA, IN, LS, MD, NY NC, OH, PA, RI, SC, TN, TX, UT, VA, and WY. Our outreach to members will occur once we have finalized a set of shared talking points and also developed a set of parameters for analysis of the impact of the proposed rule on your practice revenue. We think that it is important that individual analysis of the impact on revenue reflect a common approach to analysis by practices. 

For those of you in states that are not listed above, our AGS priority list is mainly to make sure we reach members of Congress who sit on committees of jurisdiction (Senate Finance, House E&C). To that end, we will be sharing talking points and the parameters that we put together for the analysis of impact on practice revenue with every AGS and ADGAP member.

External to AGS Work
External to our work, Pete Hollmann has been tapped by the American Medical Association’s CPT Editorial Panel and the AMA/Specialty Society RVS Update Committee (RUC) to co-chair an E/M workgroup, which recently convened and is looking to identify alternative ways for CMS to restructure E/M payment and consider relativity issues for outpatient office visits. AGS will continue to stay abreast of the AMA’s ongoing work in this area and share feedback as part of the larger medical community. 

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08-16-2018 10:08 AM

​Nancy and AGS staff:  Thanks for your expedient and grand attention to this matter.  Also thanks for your leadership in pulling such a coalition together.   This proposed change seemed to "pop up" with little forewarning or could be just not listening or paying attention.   This blog also outlines practical approaches from the organization(s) to the membership.

08-16-2018 06:08 AM

Thank you for this update and your leadership in very important matter.