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CMS Proposes Changes to Quality Payment Program, Reimbursement for New Drugs

Mary Caffrey
CMS Administator Seema Verma said the changes are designed to reduce administrative burdens for physicians so they can spend more time with patients. A group representing community oncologists said a reimbursement change for new drugs could have unintended consequences.
CMS on Thursday proposed sweeping changes to the way doctors bill Medicare, which its top administrator said are designed to make life less bureaucratic for physicians and give them more time with patients.

But in exchange, Trump administration officials call for scaling back what physicians get paid to administer brand-new drugs through Medicare Part B, cutting the “add-on” percentage to the wholesale acquisition cost (WAC) from 6% to 3%. The change will mean savings for CMS, although officials declined to say how much, as well as lower out-of-pocket costs for patients.

The proposals, contained in the 2019 Physician Fee Schedule (PFS) and changes to the Quality Payment Program (QPP), were unveiled in a press call CMS Administrator Seema Verma had with reporters. Verma said the proposed changes were a direct result of conversations with providers across the country, which she said revealed widespread frustration with the amount of time spent dealing with paperwork and billing codes.

“If we are serious about improving quality and access for patients, we have to address the concerns of physicians on the front lines,” she said. Time spent at the computer is time not spent with patients, Verma said.

Changes proposed for the QPP include changes to streamline interoperability reporting, changes to benefit small practices, and an ability for some low-volume practices to “opt in” to reporting under the Merit-based Incentive Payment System (MIPS).

Among the proposals released yesterday:

Telemedicine. A key change to the PFS would allow doctors to bill Medicare for brief “check-ins” with beneficiaries done virtually, by “phone or video chat.” A patient who just wants to ask about the effects of a medication could avoid a time-consuming trip to the office, for example. The change “is not intended to replace office visits, but augment them,” Verma said. Another change would reimburse physicians for evaluating a patient photo of a skin condition. 

CMS’ steps into telemedicine did not extend into changes to expand telemedicine reimbursement to genetic counselors, which cancer specialists have identified as a barrier to administering some new therapies.

E/M Payments. Documentation guidelines for “evaluation and management” would be overhauled, allowing physicians to account for time spent with patients. Instead of the current 5 levels of visits, CMS is proposing a blended rate for levels 2 through 5 with add-on codes, as well as other changes to reduce required documentation. Physicians would have some choices about how they document visits, which Verma said would allow them to record more clinically meaningful data.

Verma said that CMS expects that for most physicians, the changes will result in revenue changes of 1% to 2% “up or down,” and that any negative effects will be “outweighed by the dramatic reduction in administrative burden.”

CMS estimates that its overall proposal will save physicians 51 hours per clinician per year.

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