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Podcast Library > NextGen Advisors Podcasts > Significant Potential Changes in the Proposed CMS 2021 Fee Schedule

August 28, 2020

Significant Potential Changes in the Proposed CMS 2021 Fee Schedule

In this episode, the NextGen® Advisors are joined by government affairs advisor, Chris Emper to discuss the potential game-changing impact of CMS’s proposed 2021 Physician Fee Schedule.  Tune in to learn more about how these payment changes could affect your practice’s staffing, workflow, documentation requirements and revenue.

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Transcript

Graham Brown:

Hello, this is Graham Brown, senior vice president with NextGen Healthcare and a principal with the NextGen Advisors. I'd like to welcome you to our podcast series, featuring senior leaders from the NextGen Advisors team. I'm joined today by my colleagues, Chris Emper, NextGen Healthcare's government affairs advisor, Dr. Marty Lustick and Dr. Betty Rabinowitz. Good afternoon, everyone.

Dr. Betty Rabinowitz:

Hi, Graham.

Dr. Martin Lustick:

Hello.

Graham Brown:

A few weeks ago, the Centers for Medicare and Medicaid Services or CMS, released their proposed rule, outlining physician payment changes, which will come into effect on January 1st, 2021. We're lucky to have an in-house expert who is willing and perhaps even eager to read the 1300 page rule. Chris, could you take a few minutes to give us a summary of the major components of the rule?

Chris Emper:

Sure, happy to, Graham. I'd say I was far from eager to read the rule, but always willing. This is an annual exercise wherein CMS updates their payment policies, as well as all the value based and quality provisions tied to their payment programs for physicians. And it's actually grown in size quite greatly over the last few years. And that's largely mirrored the transition from fee for service reimbursement to value based reimbursement. It used to be just a couple hundred pages about a decade ago when it was just a process of updating the RVUs and codes for the fee for service system. But as they've added in more and more programs, it's turned into something where it's not only updating the fee for service payment policies, but also your value based programs from the quality payment program and the MIPS, merit based incentive payment system, to ACO measures to other programs as well. So that's why it's just thousand plus page regulation. And this year it was highly anticipated for a few reasons, one of them being we're in the midst of the COVID crisis, and there are a lot of temporary emergency policies that are tied to the emergency declaration and that the industry has been really actively looking to see whether they're going to be made permanent or temporary, what CMS would propose. And the telehealth services changes that were included over the last few months was certainly one key element of the rule. Other than that, we had major reforms that were actually established in last year's rule. One of them on the evaluation and management office visit documentation coding and payment system changes and another around the MIPS system that were set into place last year, but because they were so big, we're actually given a year to be delayed in terms of implementation. So the rule really covered all those different topics and has some pretty significant implications for the physician community, where after the public comment period, which takes about 60 days and the different trade associations and especially societies will comment and say what they want changed and what they like. They'll come final later this fall and ultimately will be implemented January 1st, 2021.

Graham Brown:

Thanks for the overview. Let's focus maybe a little bit it on the evaluation and management code updates that you referenced. I'd love to get Betty and Marty's perspective on some of this. So one of the big changes in the rule, as you noted, allows clinicians to choose a visit level based on either medical decision making or time. How is that different from the current rules and how do you think providers might alter how they spend time with patients as a result? Betty?

Dr. Betty Rabinowitz:

I'm really celebrating these changes to the current rules and even though there's been some changes in recent years, but predominantly encourage and require physicians to devote their medical documentation to justifying the level of service that they provide. It does not recognize preparatory work, the work that is done in reviewing teaching, wrapping up a visit, not in the room with the patient. It does not recognize the cognitive relationship, counseling work that occurs in a typical primary care visit and requires physicians to justify with bullets of history of present illness and number of review of systems, and has really captured all of medical documentation, rather harnessing it to the clinical purpose, requiring it for billing purposes. And this really, if you will, puts the clutch in between billing and the clinical work and compensates for the clinical work, the complexity of medical decision making or the time spent with the patient. So from my perspective, hallelujah.

Dr. Martin Lustick:

So interesting, because I really completely agree with everything that Betty said. The historical components that have driven the coding have created all kinds of perverse activities occurring that aren't related to meeting the needs of patients throughout the course of the day. All that said, I do think the other interesting side of this is that it's been going on for so long and physicians are such creatures of habit and they now have EHRs that are designed to support the traditional coding rules that it will be interesting to see how quickly and how nimbly they're able to shift to think in terms of how much time they're spending and how complex the patients are. It's ironic because from the beginning of all of this, that's what physicians have argued they should be paid for, but it hasn't happened for so long, it'll be interesting to see how it actually plays out.

Dr. Betty Rabinowitz:

It's interesting Marty, that you say that I had exactly the same feeling that physicians, primary care physicians particularly are so beleaguered that even being handed what they've asked for, for so long will be perceived as a burden in some way. It also remains to be seen what the unintended consequences of all of this might be, but I'm sure we'll talk about it more in a moment.

Chris Emper:

Yeah. And I would add, I think just having these guidelines, prior guidelines in place from 1995 to 1997, we're looking at 25 years of physician behavior and really industry behavior, including EHR design and workflow that were designed around this old system. And it's taken a few years now for them to finalize the new system, but it'll certainly take longer than flipping a switch on January 1st, 2021, to see what the ultimate impacts will be here.

Graham Brown:

Chris, you raise a good point. It'd be interesting indeed, to see how some of the different rules might ultimately have implications for operations and staffing impact. What are some of the things that you might anticipate in that regard in terms of they've worked in this way for 25 years, provider practices are now going to have to think perhaps in a new way, what are some of those implications from your perspective?

Chris Emper:

Yeah, I think it's going to be very, very practice specific, very specialty specific and very physician and clinical practice preference specific. If you choose the time route, one key distinction to understand here is it's not just time that is spent with the patient, it's time spent on the day of the encounter, the total time, both to face to face and non-face to face time. And in the American Medical Association's editorial guidance that really guides what CMS has adopted here in the industry adopts around these CPC codes, they've specifically listed several different items that count into this non face to face work time that can be counted. One of those is documenting clinical information in the EHR. Another is issuing orders, preparing to see the patient by reviewing tests, obtaining clinical histories from other providers, all of these administrative tasks that perhaps had been designed with a care team or a physician and other care team members trying to operate at the top of their license because they weren't reimbursed for the position that now you might want to take a second look on, or depending on the preference of the position they might choose to do those tasks themselves or have a member of their team do them. But ultimately, I would pose that question to our physicians as well.

Dr. Betty Rabinowitz:

So, that's fascinating. I would say just recognizing the time primary care physicians spend in documenting the visits, evenings, nights, weekends, early mornings. I have colleagues who to this day arrive at the office a couple of hours before office hours begin with patients to review labs, to review charts, to respond to patients portal messages, which was a completely unreimbursed activity. Obviously, portal message will not be able to be reimbursed if they don't have a visit attached to them on the same day, but it's recognizing the work that goes into seeing a patient is far beyond what only happens in the room. I never thought of Chris's approach to physicians wanting now to take back work that they had, if you will, outsource, because it was not reimbursed to other care team members because now they can bill for it. I hope that team based care remains a focus of many practices and there's plenty of work for the physicians to bill for in that regard, but it certainly is an interesting question.

Dr. Martin Lustick:

Yeah. I'd like to add to Chris's point about I think solutions or responses to this will be different in different practices. In my experience, I suspect that because of outside of behavioral health, providers have no familiarity with time tracking and I'm sure there are time tracking tools out there, lawyers and others have been using them for a long time, but in order to do that in the short run, they would literally, I think have to assign staff to keep track of their time in the short run. The complexity issue seems to me a simpler first step in this direction. And it'll be interesting to see how much, depending on how many dollars are assigned to the different approaches and from a practice management point of view, when they analyze the financial impact of using different models, they're going to have to make decisions. Is it worth dedicating human resources to implementing quickly this new approach, whether it's the time or the complexity to support changes in workflow that would occur in order to make sure it's working in aligning what they're getting paid with, all the work that they're actually doing? This is going to be a watershed, I think.

Dr. Betty Rabinowitz:

Chris wrote a terrific blog about this, which was just published today on our advisors blog on nextgen.com and he brings up a good point about the difference between the different specialties, the cognitive specialties, primary care, and the fact that because of budget neutrality, other specialties will need to now make changes in their workflows, the supplement or change mitigate the impact of these decreases in reimbursement. So, this is a very significant, this is a shift that is going to have huge, huge impact.

Graham Brown:

Betty, I want to pick up on that because Chris wrote in his blog about one of the constraints that you just mentioned, that budget neutrality requirement. And so the proposed increase is in the E&M payment rates being budget neutral, ultimately are going to trigger a nearly 11% cut to the overall Medicare conversion factor. So it'd be interesting to think from your perspective, you've alluded to it a little bit here, but it sounds like there might be some winners and losers quote, unquote, from these proposed changes. Talk a little bit about that.

Chris Emper:

Yeah. So, in the role and this comes from the authorizing law from Congress, they're required to have some level of budget neutrality in the projections for spending each year. So even if they change codes to value some codes more highly and others more lowly, they'll have to balance that out at some point. And because in addition to making these reforms around how you select your codes, they've actually increased payment for these codes by about 15% for level three, four or five for established patient visits, which ends up being a pretty significant change for those specialists and those in field to bill a lot of those codes. It triggered an automatic cut of almost 11% in this overall conversion factor that impacts all of the codes and updates their payment values January one of next year. So CMS actually projected in the rule that family practice would see a 13% increase, general practice an 8% increase, oncology a 14% increase. Meanwhile, you have general surgery projected to receive a 7% decrease and radiologists projected at 11% pay cut. And I would see this has triggered a little bit of a lobbying backlash from some of those great associations who haven't made out so well, but I think this is just a sense of some of the impacts here where it absolutely does create a system of some winners or losers based on your specialty and which of those codes you bill on a high proportion.

Graham Brown:

Okay. So final topic for all of you. And we will start with Marty, given your background as a payer executive. The commercial payers or health plans often follow the lead of CMS when it comes to implementing policy and pricing changes. And we've certainly seen that with the COVID pandemic and some of the emergency measure changes to what's covered for telehealth services, for example. Do you think that's going to happen here? And if so, under what timeline?

Dr. Martin Lustick:

Yeah, I think it'll happen. It's happened every other time. So there's no reason to think that it won't happen. I think for most plans, there's a delay because administratively it takes them quite a while to reconfigure their claims systems, to follow all the new rules. But depending on whether they see these changes as helping or hurting them financially has some impact on how quickly they move. Most plans have a fairly standard timeframe, whether it's six months or a year between when the CMS rules take effect and when they implement them internally, but they will drag their feet if they think that it's going to cost more and they might take a year and a half instead of a year. I've seen that. So I think that's the likely way this is going to play out for each payer will look at it that way.

Dr. Betty Rabinowitz:

I defer to Marty on the inner thinking of commercial payers. I was always puzzled by those. So I agree with Marty. I just think this issue of the change to the way primary care physicians think and work can really not be underestimated if this is implemented correctly. Where physicians theoretically can take back some of the responsibilities they have provided to specialists and have addressed by referring patients up, now that they can bill for thoughtful time, thorough workup, starting with patients with less well defined problems, but not immediately referring them to specialists, actually doing a lot of the workup themselves. This may have changes to the way primary care is practiced, the way primary care physicians are trained, med school training will need to address it. It could really change the balance between primary care and the patterns of referral to specialists, which have become absolute refuge because physicians will require to churn through these short visits and really couldn't spend the time to do the workups, to do the thinking. So I'm very hopeful. I hope it doesn't get watered down and diluted to smithereens in that we can see a boost to primary care as a result of this.

Dr. Martin Lustick:

The one other thing I'd want to say about this is that the silver lining in the commercial payer�s approach is that it gives providers the opportunity to look at 2021 as a time to sort through these issues and figure it out since there is going to be a gradual implementation across all of their practice. For most providers, it's not, they don't have to have their solution to this shift in place in January of next year. They really can use next year to sort through the issues and figure out what does this mean for them, what do they want it to mean for them and how can they use it in the ways that Betty's describing to actually drive towards a future that's more sustainable.

Graham Brown:

What comes to mind for me is that in some ways, the greatest winners in all of this might be the patients, particularly those who have complex care and needs, are poly chronic and have in the past, perhaps not really being able to spend as much time with their physician as they feel that they would benefit from, get the education. As Betty was saying, really get that worked up diagnosis and their primary care doc, really having the ability to create a care plan, really understand what their needs and challenges are and set them on the path to success. Some of these changes really speak to the ability for providers to do that in a way that they may have been restricted from doing before to Marty's point around needing to churn through and just continue to manage a large panel and benefit the patients in a new way. Well, thank to our participants here. I'd like to thank my colleagues, Dr. Betty Rabinowitz, Chris Emper and Dr. Marty Lustick for sharing your insights. If you've enjoyed today's topic, consider subscribing to our podcast. This is Graham Brown with NextGen Healthcare. Have a great day.