Sept. 20, 2018

Issue Spotlight

Proposed 2019 Medicare QPP rule: Top 7 things doctors should know

Physicians have weighed in on the Centers for Medicare & Medicaid Services' (CMS) plans to modify the Quality Payment Program (QPP) that is intended to transform the Medicare payment system by linking payment updates to physicians' efforts to improve quality of care, reduce health care spending and participate in alternative payment models. The AMA is calling on CMS to cut red tape that makes it difficult for physicians to succeed in QPP.

The comments on QPP came as part of a broader, 136-page letter that also addresses CMS' proposed changes to the 2019 Medicare physician fee schedule. These detailed comments on the rule elaborate on an earlier letter in which the AMA was one of 170 organizations representing physicians and other health care stakeholders that objected to the CMS plan to collapse payment rates for physician evaluation-and-management (E/M) office visit services over concern about its potential impact.

"This provision in the proposed rule should be filed under the category of unintended consequence—or good intentions that go awry," AMA President Barbara L. McAneny, MD, said of the E/M proposal."

On the QPP portion of this 1,500-plus page rule, here are seven things that physicians should know about the changes that CMS should make to its proposed rule.

Make virtual groups more viable. Given the small number of virtual groups participating in the Medicare-based Incentive Payment System (MIPS) program in 2018, CMS should implement additional changes to make this a more viable option for physicians in small practices.

Simplify MIPS scoring. The MIPS program should be improved to make it simpler and allow physicians to spend less time on reporting and more time with patients, but the CMS proposal did not move toward a more simplified scoring methodology. One area where the program could be significantly simplified is in the scoring used for each performance category to calculate a physician's final score. The AMA proposed a simplified scoring methodology that CMS should immediately implement.

Performance threshold and weights for MIPS categories. CMS should avoid raising the performance threshold, changing the category weights and removing quality measures, when there is no MIPS data to analyze. Decisions are being based on hypothetical assumptions from legacy programs such as the Physician Quality Reporting System. MIPS is a separate program with its own set of rules and requirements.

Reduce the required number of measures a physician must report under the Quality category. To immediately cut red tape and administrative burden, CMS should reduce the number of quality measures a physician must report under the Quality category. Without such a reduction, the AMA does not support immediate removal of the proposed measures but would support a modified phased approach to the topped out measure process.

Retain flexibility in Cost category. CMS should not increase the Cost category weight from 10 percent to 15 percent  and should remain flexible on weights for the next four years while the eight new episode-based cost measures are evaluated and more are developed and piloted. Several other provisions in the proposed rule are also objectionable because, in its desire to "capture more physicians in the cost category," CMS is undermining the reliability of and confidence in the measures.

Simplify requirements in the Promoting Interoperability (PI) category. CMS' overhaul of the Advancing Care Information category is laudable, as are many of the proposals within the renamed PI category. CMS should continue to limit regulatory requirements, including aligning the PI programs so that physicians must only achieve the same score as hospitals to receive full PI category credit, simplifying and reducing burden through Yes/No measure attestation, and scoring PI on the objective-level.

Move ahead on alternative payment models (APMs). CMS should finalize several of the proposed policies for APMs, such as the move to maintain the revenue-based financial risk requirement at no more than 8 percent for another four years. The agency should also raise the availability of well-designed APMs under the QPP.

Read more at AMA Wire®.

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National Update

Senate passes opioid epidemic legislation

On Sept. 17, the United States Senate passed comprehensive legislation to address opioid abuse, the "Opioid Crisis Response Act of 2018" (H.R. 6), by a vote of 99 to 1. The House of Representatives previously passed its version of H.R. 6 in June.

This package is a combination of many individual bills to address the opioid epidemic that were previously approved by the Senate Committees on Health, Education, Labor and Pensions (HELP); Finance; Judiciary; and Commerce, Science and Transportation. Within the package are policies affecting Medicare, Medicaid, public health, access to substance-abuse treatment, law-enforcement efforts and public safety programs that are intended to curb abuse.

The House and Senate are currently working to reconcile the differences between their two packages. It is possible that final opioid abuse legislation could be considered during the next few weeks.

Senate approves "gag clause" legislation

Also on Sept. 17, the Senate passed S. 2554, the "Patients Right to Know Drug Prices Act of 2018," by a vote of 98 to 2. This legislation, which was introduced by Sen.  Susan Collins, R-Maine, would prohibit health insurers and pharmacy benefit managers from using gag clauses that prevent pharmacists from sharing with patients the lower cost options when purchasing medically necessary medication.

The legislation will ensure that the Federal Trade Commission (FTC) will have the necessary authorities to combat anti-competitive pay-for-delay settlement agreements between manufacturers of biological reference products and follow-on biologicals. The Senate recently passed legislation (S. 2553) that would apply similar gag clause protections to Medicare and Medicare Advantage plans. The AMA sent a letter of support for this legislation as AMA policy supports legislation that will not only allow, but require pharmacies to inform patients of the actual cash price as well as the formulary price of any medication prior to purchase. 

The House Energy and Commerce Committee approved similar gag clause legislation, HR. 6733, the "Know the Cost Act of 2018," by voice vote on Sept. 13. This bill, which the AMA also supports, applies to both private insurance plans and Medicare Advantage plans. The full House is expected to consider this legislation after it returns from recess.

Medicine objects to Medicare Advantage step-therapy policy for Part B drugs

On Sept. 7, the AMA and 93 state medical associations and national medical specialty societies raised extensive concerns with CMS regarding its new policy allowing Medicare Advantage (MA) plans, starting in 2019, to utilize step-therapy protocols for physician-administered drugs covered under Medicare Part B. 

The letter points out that many patients receiving drugs under Part B are suffering with serious or life-threatening conditions. Consequently, delays in getting appropriate treatment can mean prolonged symptomatic periods and irreversible damage.

Furthermore, the communication highlights the significant burden step therapy places on physician practices. Because electronic health records do not make patient benefit or formulary information available at the point of prescribing, it is extremely difficult for physicians to determine what treatments are preferred by payers. 

In addition, the payer exemption and appeals process can be extremely complicated and lengthy, which adds significant burden for patients and physicians. For all these reasons, the AMA urges CMS to reinstate its 2012 policy prohibiting MA plans from using step-therapy protocols for Part B physician-administered medications. 

AMA wants coverage for gender alterations in VA benefits package

In response to a request for comments on whether gender alterations should be included in the medical benefits package for the Department of Veterans Affairs (VA) the AMA sent a letter urging the VA to amend its medical regulations by removing a provision that excludes gender alterations from its medical benefits package.

The effect of this change would be to authorize gender alteration surgery as part of VA care when medically necessary. The AMA supports the rights of all eligible veterans to receive medically necessary care, and acknowledges that medical and surgical treatments for gender dysphoria as determined by shared decision-making between patient and physician are medically necessary. 

CMS recalculates 2017 MIPS final scores, extends targeted review deadline

Recently, CMS released physicians' 2017 Merit-based Incentive Payment System (MIPS) performance feedback and upon release opened the targeted review process. Based on the AMA flagging calculation error concerns and the initial targeted review requests CMS received, CMS has revised the scoring logic and reissued the 2017 MIPS final scores for the physicians who were impacted. In addition to ensure CMS maintains the budget neutrality that is required by law under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), some physicians will see slight changes in their payment adjustment because of the reapplication of budget neutrality.

The revisions were made to the performance feedback on the Quality Payment Program website on Sept. 13. The AMA encourages physicians and groups to sign in to the Quality Payment Program website as soon as possible to review their performance feedback. If a physician believes an error still exists with your 2019 MIPS payment adjustment calculation, the targeted review process is available.

To offer additional time for physicians, groups, and APM entities and their participants to access and review their performance feedback, CMS is extending the targeted review deadline to Oct. 15, 8 p.m. Eastern time. CMS also has several resources available on the Quality Payment Program Resource Library website to help physicians and practices understand their performance feedback and the targeted review process. For additional assistance physicians can reach out to the Quality Payment Program Service Center by phone at 1-866-288-8292, (TTY) 1-877-715-6222 or by email at, or contact their local technical assistance organization for free support.

Update on Alternative Payment Models

The Physician-focused Payment Model Technical Advisory Committee (PTAC) held its most recent meeting Sept. 6–7 and reviewed four APM proposals. PTAC commended all four proposals but only recommended one for implementation, the Acute Unscheduled Care Model submitted by the American College of Emergency Physicians.

In public comments supporting the Acute Unscheduled Care APM, the AMA said the model fills an important gap in the current APM portfolio. The AMA noted that the fee-for-service system allows emergency physicians only a short amount of time to make what are often high-stakes decisions about patient diagnosis and treatment, and there are no payments to support the time and staffing needed beyond face-to-face encounters to help emergency physicians evaluate the timeliness and quality of care a patient would receive in the community if they were discharged from the emergency department.

At its September meeting, the PTAC also sought public feedback on certain aspects of its process. In response, the AMA and the American Society of Radiation Oncology made public comments on the need for the committee to expand on its plans for providing technical assistance and data analyses to physicians and organizations developing proposals to facilitate stakeholders' development of better APM proposals for the committee.

This month CMS began accepting information from physicians on APMs supported by their state's Medicaid programs for inclusion in calculations of all-payer APM participation during the 2019 QPP performance period. Earlier this year, CMS sought information on Medicaid APMs from the states and developed a list of four states with Medicaid APMs that qualify as Other Payer APMs under the QPP.

For 2019, the threshold APM participation level increased from 25 to 50 percent for practices to earn the five percent APM incentive payment payable in 2021. Practices that receive more than 25 percent but less than 50 percent of their total revenues through Medicare Advanced APMs can make up the difference by participating in qualified Other Payer APMs. Physicians wishing to inform CMS of Medicaid APMs in which they will be participating during 2019 must submit a completed form to CMS by Nov. 1.

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State Update

California governor urged to sign bill to increase access to MAT

The American Medical Association joined the California Medical Association in urging California Governor Edmund G. Brown to sign a bill that would enact sweeping patient protections for patients with substance use disorders. Assembly Bill 2384 would, among other things, remove barriers such as prior authorization and step therapy for medication assisted treatment (MAT). In a letter to Gov. Brown, AMA Executive Vice President and CEO James L. Madara, MD, emphasized that "MAT is proven to save lives," and that A.B. 2384 "by removing barriers, will unquestionably help save many lives."

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Other News

Only a few spots remain for AMPAC Campaign School

Only a few spots are left and registration closes tomorrow, Sept. 21, for the AMPAC Campaign School, which will take place Dec. 6–9 at the AMA office in Washington, D.C. The Campaign School is open to AMA members, their spouses, medical students, residents and state medical association staff who want to become more involved in campaigning process. 

The Campaign School provides participants with the skills and strategic approach they need to run a successful political campaign. During the two-and-a-half day in-person portion of the program, participants will be broken into campaign staff teams to run a simulated congressional campaign using what they have learned during group sessions on strategy, vote targeting, social media, advertising and more. 

Faculty, materials and all meals during the meeting are covered by the AMA. Participants are responsible for the registration fee and hotel accommodations at the Hyatt Regency Washington on Capitol Hill. For information or to apply visit: or contact

2019 CPT code set released

The American Medical Association has released its 2019 Current Procedural Terminology (CPT®) code set, which includes 335 changes reflecting the CPT Editorial Panel and the health care community's combined annual effort to capture and describe the latest scientific and technological advances in medical, surgical and diagnostic services.

The changes include three new remote patient monitoring codes and two new inter-professional internet consultation codes, reflecting how health care professionals can more effectively and efficiently use technology to connect with patients at home and gather data for care management and coordination. The AMA's Digital Medicine Payment Advisory Group provided recommendations on these and other new codes to better integrate digital medicine modalities into clinical practice.

Additional new codes for 2019 include revised codes for skin biopsy, fine needle aspiration, leadless pacemaker procedures, breast MRI with computer aided detection and psychological and neuropsychological testing.

New CPT category I codes are effective for reporting as of Jan. 1, 2019. The Centers for Medicare and Medicaid Services is proposing to cover the new CPT codes and adopting, for the most part, recommendations from the RVS Update Committee for cost year 2019 on the Medicare Physician Fee Schedule.  

To assist the health care system in an orderly annual transition to a new CPT code set, the AMA releases each new edition four months ahead of the Jan. 1 operational date and develops an insider's view with detailed information on the new code changes.

Secure devices mean safer patients

Check out the latest edition of the Office of Civil Rights' monthly newsletter, which focuses on securing electronic media and devices as a part of physician practices' security management programs. Electronic devices and media play an essential role in the operations of many health care organizations, but because of their portability and storage capacity, safeguards must be in place to secure these devices and the patient information they contain.

This must include ensuring only authorized personnel have physical or electronic access to sensitive information. Device security is equally as important to the adoption of digital health tools as usability and interoperability. Visit the AMA website for more information and resources on cybersecurity.

Medicare Diabetes Prevention Program: New covered service call

Physicians can help their Medicare patients prevent or delay type 2 diabetes and understand their treatment options. The 2019 "Medicare and You Handbook" includes information on the Medicare Diabetes Prevention Program (MDPP), a first-of-its-kind Medicare service to receive a positive recommendation from the Innovation Center and a key advocacy priority of the AMA.

Register for a CMS-hosted call on Sept. 26 to learn about the MDPP service, eligibility requirements and how to refer patients.

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Upcoming Events

Oct. 17: M.A.P. blood pressure improvement program webinar
Learn about the Target: BP national initiative to prioritize blood pressure control. M.A.P. is an evidence-based, real-world-proven program to help physicians improve the health of their patients with hypertension. The webinar takes place from noon to 1 p.m. Central time. Register now.

Oct. 24: Prior authorization—overview of AMA advocacy strategy
Register to attend an informative discussion of the AMA's multifaceted advocacy campaign for prior authorization reform, and learn about resources available to help streamline the prior authorization process. The webinar takes place from noon to 1 p.m. Central time. Register now.

Oct. 24: Panel discussion on the new RAND study results
Register to attend this educational event from 9:30 a.m. to noon on Oct. 24 in Washington, D.C. The event will highlight the findings of the AMA-RAND follow-up study on payment models. Panel discussions will cover how the challenges still experienced, improvements realized and strategies implemented affect the shift to value-based care. Opening remarks will be given by AMA President Barbara L. McAneny, MD. Space is limited so reserve your spot now and be the first to hear the research results. 

Oct. 30 & Nov. 15: Webinars offer emergency medicine perspective on climate change, health
In this webinar series, emergency medicine experts will explore the health impacts of climate change and opportunities to advance solutions that address human health and our health system. This activity has been designated for AMA PRA Category 1 Credit™. Topics are "Preparing for climate emergencies" on Oct. 30 at 1 p.m. Eastern time and "Delivering climate-smart health care" on Nov. 15 at 1 p.m. Eastern time. Register now.

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