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Grassroots Newsletter

Fall/Winter 2018

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In this newsletter:

Rule Season Refresh: How Medicare's Regulations Impact Hospital Medicine

Inpatient Prospective Payment System Proposed Rule

Physician Fee Schedule Proposed Rule: E&M Documentation

Physician Fee Schedule Proposed Rule: Quality Payment Program

Outpatient Prospective Payment System (OPPS): HCAHPS

Public Policy Committee Meeting Recap

Hill Day 2019

Rule Season Refresh: How Medicare's Regulations Impact Hospital Medicine

As in past years, SHM has submitted comments on behalf of hospitalists to the Centers for Medicare and Medicaid Services (CMS) on the proposed rules that impact hospital medicine. CMS proposed regulations at the beginning of the summer that lay out changes or updates for healthcare payment systems and pay-for-performance programs, such as the Hospital Value-Based Purchasing and the Quality Payment Program. Stakeholders, including SHM, review the rules and submit comments during a public comment period. CMS then has 60 days to review the comments and publish a final rule. These proposed rules lay the groundwork for changes to both individual and systems-level policies. This is a large part of the work that SHM staff does each year on behalf of hospitalists.

Inpatient Prospective Payment System Proposed Rule

This year's Inpatient Prospective Payment System (IPPS) rule proposed changes to hospital level programs such as the Hospital Value-Based Purchasing (HVBP) program and Inpatient Quality Reporting (IQR), as well as to inpatient admission order documentation. CMS proposed to remove more than ten duplicative measures across inpatient reporting programs. For example the National Healthcare Safety Network (NHSN) Healthcare-Associated Infection measures (CAUTI outcome, CLABSI outcome, MRSA outcome, C. diff outcome) are assessed in the HVBP, IQR and Hospital-Acquired Conditions (HAC) Reduction programs. The proposal would have eliminated this duplication and retained those measures in just the HAC Reduction program. SHM supported these changes as a way to streamline and simplify pay-for-performance programs. However, CMS did not finalize their proposal to remove at this time. This means that broadly, the measures in the programs will remain the same and hospitals will continue to be assessed on the same measure in different programs. SHM will continue to raise this issue with CMS and maintain our position advocating for changes in the future.

CMS proposed and finalized changes to admission orders for inpatients to eliminate a physician signature as part of the requirement for inpatient part A payment and to allow non-physician providers to admit patients without the supervision of a physician has been finalized. SHM was supportive of this change and advocated for its removal.

You can read our full comments on the proposed rule here.

 

Physician Fee Schedule Proposed Rule: E&M Documentation

In the 2019 Physician Fee Schedule proposed rule, CMS explored changes to the outpatient office E&M documentation guidelines that included reducing the documentation requirements and collapsing the five payment levels down to two. The proposals for documentation requirements would allow physicians to choose between three options for proper reporting: 1995 or 1997 guidelines, Medical Decision Making (MDM), or time spent with the patient. The payment changes would take the rates of E&M Levels 2-5 and blend them into a single unified rate for an office visit at any of those levels.

While the proposed rule was limited to the outpatient office setting, SHM believes these proposals will set precedents for the other settings, such as inpatient, that bill E&M codes. In our comments to CMS, we supported reducing documentation burden but also stated that changes to the payment rates need more work and refinement before going live. We also encouraged CMS to consider how these changes would impact other settings before finalizing any changes. We recently echoed this sentiment in a letter to the AMA.

CMS is currently reviewing the comments that have been submitted and will make final decisions in the final rule. You can view our comments on the proposed rule here.

Physician Fee Schedule Proposed Rule: Quality Payment Program

The Physician Fee Schedule proposed rule also contained changes to the Medicare Access and CHIP Reauthorization Act (MACRA) Quality Payment Program (QPP). The QPP has two pathways for pay-for-performance, the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs), both of which have barriers to meaningful participation for hospitalists. The MIPS requires reporting on quality measures, assessments on cost measures, performing practice improvement activities, and using Certified Electronic Health Record Technology. Hospitalists do not have many measures available for reporting, and those that do exist are generally not good indicators of hospitalist practice.

For the last several years, SHM has been spearheading a "facility alignment" option to ensure hospitalists have a simple and low burden pathway to be evaluated on measures that are meaningful to their practice. The idea is to align the work hospitalists are already doing at their hospitals with their physician-level reporting requirements. SHM has worked with CMS closely over the past few years, including workshopping ideas on how such an option might function.

As a result of our advocacy, CMS proposed to finalize for reporting in 2019 a facility based reporting option, that aligns an individual or group's score with their hospital's Hospital Value Based Purchasing Score for the Quality and Cost sections of the Merit-based Incentive Payment System (MIPS) portion of the QPP. This means that hospitalists can continue doing the work they do on a daily basis and the administrative burden of reporting individual metrics is lessened. CMS proposed that they will automatically calculate the score for facility-based providers who are eligible. Eligible providers are those that have 75% or more of their Medicare Part B covered services in place of service 21 (inpatient), 22 (hospital outpatient), and 23 (emergency room). This is a voluntary option for physicians/groups, and if they so wish, providers can still report separately through the MIPS and CMS will take the higher score of the two options. In our comments, SHM is very supportive of finalizing this option, but we recognize more work needs to be done to make it meaningful for groups.

CMS is currently reviewing the comments that have been submitted and will make final decisions in the final rule. You can view our comments on the proposed rule here.

Have Q's on MACRA and the QPP? We have resources available online.

 

Outpatient Prospective Payment System (OPPS): HCAHPS

The Outpatient Prospective Payment System (OPPS) proposed rule covered updates specific to the Hospital Consumer Assessment of Healthcare Providers Survey (HCAHPS). Over the past two years, SHM has been advocating for changes to the pain questions in the HCAHPS. Changes were necessary as many hospitalists have reported that "pain control" can inadvertently create a perverse incentive to overprescribe opioids, which is not the intended use of the survey or the questions. Last year, CMS responded to our advocacy and changed the survey questions from pain management to communication about pain, which they hoped would alleviate this pressure. SHM supported this change as a step in the right direction but continued to voice concern over unintended consequences of these questions around opioid prescribing.

This year, the OPPS proposed rule fully answers our concerns and removes the pain questions entirely from the survey. SHM supports removing the communication about pain questions from the HCAHPS survey and offered to work with CMS on a better mechanism for assessing pain management and communication about pain during hospitalizations. In the coming weeks, we hope CMS will finalize these changes when they publish the final rule. You can read our full comments on the OPPS here.

Public Policy Committee Meeting Recap

Each year, the SHM Public Policy Committee (PPC) meets in Washington, DC to strategize for the coming year and to visit Hill offices on behalf of hospitalists. This meeting helps to create a focused advocacy agenda for the organization. This year, PPC members met with Congress members on observation reform, asking them to work with SHM on a complete overhaul of observation policy as contemplated in our observation white paper. They also asked for support of the Fairness for High-Skilled Immigrants Act, which removes per-country caps for high-skilled immigrants (H1Bs) wishing to enter the visa/green card process. The meetings were productive and informative. At our strategy meeting, the committee reaffirmed our commitment to diving deeper on observation care and finding sensible immigration solutions to support the hospital medicine workforce. We also talked about ways to better communicate with and engage the membership in SHM's advocacy work-so keep a lookout as we try to grow in the future.

Hill Day 2019

We need you to join us on Capitol Hill to advocate for the issues that matter to your patients and practice. As part of the HM19 Annual Conference in March 2019, SHM Advocacy will bring hospitalists to Washington, DC to meet with their Congressional offices. Hill Day takes place on the last day of the meeting, March 27th. Sign up as part of your HM19 registration. For more details, go to https://shmannualconference.org/hill-day/.