WHA Urges CMS to Revise Proposed CY 2021 Physician Fee Schedule Rule

October 08, 2020

WHA submitted comments on the CY 2021 Medicare Physician Fee Schedule (PFS) proposed rule to the Centers for Medicare and Medicaid Services (CMS) on October 5. WHA expects a final rule in early December. A summary of  WHA’s comments follow:
Conversion Factor.  In the rule, CMS proposed a decrease in Medicare physician payment rates of 10.61% in CY 2021. This proposed reduction would result in an estimated conversion factor of $32.26, a reduction of $3.83 from the CY 2020 conversion factor of $36.09.  WHA strongly opposed this decrease.  This significant reduction of the conversion factor could result in drastic cuts to many physician specialties. CMS proposed this conversion factor cut without any clear, transparent explanation into how it was calculated. Moreover, while these proposed changes may be budget neutral for Medicare as a whole, they would not be budget neutral for individual providers, including hospitals and health systems.
This change was made in conjunction with a revaluation of some Evaluation and Management (E/M) and related codes, which WHA urges CMS to finalize.  Because of budget neutrality requirements, WHA urged CMS to work with Congress to secure a waiver of budget neutrality for the PFS for at least calendar years 2021 and 2022. Doing so would allow CMS to protect patient access to care by increasing payments for E/M visit codes without an overall cut to payments in excess of 10 percent.
If CMS cannot secure a waiver of budget neutrality from Congress, WHA asks CMS to delay the implementation of the revaluation of the E/M and related visit codes and the corresponding budget neutrality adjustment so as not to hinder the ongoing work hospitals and health systems must do in response to COVID-19.
Telehealth flexibilities. Highlights of the rule’s telehealth provisions include:
New category for adding telehealth services. In the rule, CMS proposes to create a new category for adding telehealth services to the Medicare telehealth list. In this new Category 3, services added to the Medicare telehealth list during the public health emergency (PHE) for the COVID-19 pandemic, and for which there is likely to be clinical benefit but there is not yet sufficient evidence available to consider the services as permanent additions, will remain on the list through the calendar year in which the PHE ends. 
 WHA asked CMS to provide additional direction regarding the type of evidence CMS is looking for in order for these codes to qualify for more permanent inclusion. WHA also asked CMS to consider keeping Category 3 services on the list for a longer period of time than a calendar year. This would allow more time to gather evidence which would support or refute the permanent addition of these services.
Audio-only services. WHA members have emphasized the importance of retaining reimbursement for audio-only telehealth services that was authorized during the PHE. These services have literally been a lifeline for patients without internet access, whether or not they live in rural areas. Senior citizens especially benefit from audio-only services as they may not have computers or if they do, may not feel comfortable using them for telehealth visits. Our members also report that behavioral health patients have embraced the opportunity to receive services over the telephone. 
Because CMS does not believe it has authority, without Congressional action, to permanently add audio-only services to the Medicare telehealth list it is not proposing to continue to recognize audio-only payment codes under the PFS in the absence of the PHE for the COVID-19 pandemic. However, it acknowledges that the need for audio-only interactions could remain as beneficiaries continue to try to avoid sources of potential infection.
In its comment letter, WHA strongly urged CMS to move forward with coding and payment for a service similar to the virtual check-in, but for a longer unit of time and a higher value that would allow for use of telephone. Even when the PHE ends, it is likely that many patients will not feel comfortable leaving their homes until a vaccine is widely available, and in those cases, telephone may be the only way some patients have to access providers, and not all of them will have a pre-existing relationship.
Remote Patient Monitoring (RPM). CMS proposes to continue reimbursement policies for RPM that it established during the PHE, but only for established patients. WHA disagrees with this limitation and urged CMS to retain RPM for new patients, as has been permitted under the PHE.
Virtual supervision definition. For the duration of the PHE for the COVID-19 pandemic, for purposes of limiting exposure to COVID-19, CMS adopted an interim final policy revising the definition of direct supervision to include virtual presence of the supervising physician or practitioner using interactive audio/ video real-time communications technology. WHA supports continuing this policy beyond 2021, relying on the clinical expertise and discretion of as supervising physician or practitioner regarding the use of virtual supervision.
Quality Payment Program: 
Merit-Based Incentive Payment System (MIPS). Under current MIPS policy, MIPS-eligible clinicians and groups participating in certain Alternative Payment Models (APMs) – including the Medicare Shared Savings Program (MSSP) – receive special scoring under the MIPS APM scoring standard. For CY 2021, CMS proposes to sunset the MIPS APM scoring standard, and replace it with a new APM performance pathway (APP) While the APP is similar to the APM scoring standard in several ways, it would significantly diverge from it by requiring clinicians and groups to report and be scored on a common set of six quality measures. These measures reflect diabetes control, depression screening/follow up, blood pressure control, patient experience, hospital-wide readmissions and admissions for multiple chronic conditions. This requirement would apply to APP participants regardless of the APM model in which they participate.
In our comment letter, WHA stated that requiring all MIPS APMs to report on the same six quality measures would be a misguided, “one size fits all” policy that fails to improve upon current policy, and urged CMS not to adopt it. WHA wrote that it is hard to understand how the six proposed measures could be equally relevant to all 12 of the APMs that currently meet MIPS APM requirements. For example, for clinicians participating in the Bundled Payment for Care Improvement Advanced (BPCI A) model, it is not clear how depression screening and follow up are relevant to those models that are focused on procedural inpatient care. Instead of adopting the APP model, we are asking CMS to instead to retain the existing requirement that MIPS APMs report the measures already required under their models.
Removal of the Web Interface Reporting Option. CMS proposes to abruptly end the use of the Web Interface reporting mechanism, a tool that has been used since the MSSP’s inception. Removing this option for all ACOs with no notice is ill timed and unfair.  WHA urged CMS to restore this reporting mechanism in the final rule.
If you have questions about the proposed rule and WHA’s comments, please contact WHA's Laura Rose or Laura Leitch.

This story originally appeared in the October 08, 2020 edition of WHA Newsletter