CMS REGION III PROFESSIONAL PARTNERS’ QUARTERLY CALL

AUGUST 2019

Agenda

• Proposed Changes to the Medicare Physician Fee Schedule for CY 2020- General Provisions- Payment for Evaluation and Management (E/M) Services (CY 2021)- Quality Payment Program Year 4 (2020)- Opioid Treatment Programs (OTPs)

• Outpatient Prospective Payment System (OPPS) & Ambulatory Surgical Center (ASC) Proposed Rule

- General Provisions- Price Transparency

• Proposed Changes to ESRD PPS and DMEPOS Fee Schedule (2020)

• Center for Medicare and Medicaid Innovation Updates

• Patients over Paperwork

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Proposed Changes to the Medicare Physician Fee Schedule for CY 2020

• Proposed CY 2020 PFS conversion factor of $36.09

• Additions to telehealth services for bundled episode of care for treatment of opioid use disorders

• Modifying regulation on physician supervision of physician assistants

• Modifications to documentation policy for physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse-midwives

• Increase payments for Transitional Care Management (TCM)

• Bundled payments for substance use disorders

• Soliciting comments on how to align the Medicare Shared Savings Program quality performance scoring methodology more closely with MIPS

General Provisions

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Proposed Changes to the Medicare Physician Fee Schedule for CY 2020

• Worked with American Medical Association CPT Editorial Panel to revise the office/outpatient E/M code descriptors and assign separate payment rates to each of the codes

• Summary of Revisions:1. Eliminate history and physical as elements for code selection2. Allow physicians to choose whether documentation is based on Medical

Decision Making (MDM) or time3. Modifications to the criteria for MDM4. Deletion of CPT code 992015. Creation of a shorter Prolonged Services code

• Proposing to accept the RUC-recommended values for E/M codes (eff. 1/1/21)

• Proposing a single add-on code that describes ongoing primary care and/or ongoing medical care related to a single, serious, complex chronic condition billable with every office/outpatient E/M visit meeting criteria

Payment for Evaluation and Management (E/M) Services (CY 2021)

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Proposed Changes to the Medicare Physician Fee Schedule for CY 2020

• Quality (40%): Remove low-bar, standard of care, process measures, focus on high-priority outcome measures, and add new specialty sets; increase sample to 70% for data completeness; introduce a benchmarking policy for 2022 payment year.

• Cost (20%): Add 10 episode-based measures and revise current global measures’ attribution methodologies (TPCC and MSPB Clinician).

• Improvement Activities (15%): Addition of 2 new Improvement Activities, modification of 7 existing Improvement Activities, removal of 15 existing Improvement Activities; new requirement for Improvement Activity credit for groups (at least 50% of MIPS eligible clinicians participate).

• Promoting Interoperability (25%): New reweighting standards for hospital-based MIPS eligible clinicians in groups; revised the Query of Prescription Drug Monitoring Program (PDMP) measure and removed the Verify Opioid Treatment Agreement measure in alignment with the Medicare PI program for eligible hospitals and CAHs.

• Performance threshold: 45 points; Exceptional performance Bonus: 80 points; payment adjustment (CY 2022): Up to 9%

• Changes to requirements for third-party intermediaries

• Introducing MIPS Value Pathways

Quality Payment Program Year 4 (2020)

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MIPS Value Pathways

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Future State of MIPS(In Next 3-5 Years)

Current Structure ofMIPS(In 2020)

New MIPS Value PathwaysFramework(In Next 1-2 Years)

Building PathwaysFrameworkMIPS Value Pathways

Clinicians report on fewer measures and activities baseon specialty and/or outcome within a MIPS ValuePathway

Moving toValue

Fully ImplementedPathwaysContinue to increase CMS provided data and feedback to

reduce reporting burden on clinicians

• Many Choices• Not MeaningfullyAligned• Higher Reporting Burden

• Cohesive• Lower Reporting Burden• Focused Participation around Pathways that are Meaningful

to Clinician’s Practice/Specialty or Public Health Priority

• Simplified• Increased Voice of thePatient• Increased CMS Provided Data• Facilitates Movement to Alternative Payment Models (APMs)

2-4Activities

ImprovementActivities

Quality

6+Measures

PromotingInteroperability

6+Measures

Cost

1 or MoreMeasures

CostQuality and IA aligned

Foundation

Promoting InteroperabilityPopulation Health Measures

FoundationPromoting Interoperability

Population Health MeasuresEnhanced Performance Feedback

Patient-Reported Outcomes

Value

Quality ImprovementActivities

Cost

We Need Your Feedback on:

Population Health Measures: a set of administrative claims-based quality measures that focus on public health priorities and/or cross-cutting population health issues;CMS provides the data through administrative claims measures, for example, the All-Cause Hospital Readmissionmeasure.

Goal is for clinicians to report less burdensome data as MIPS evolves and for CMS to provide more datathroughadministrative claims and enhanced performance feedback that is meaningful to clinicians and patients.Clinician/Group Reported Data CMS Provided Data

Pathways:What should be the structure and focus of the Pathways? What criteria should we use to select measures and activities?

Participation:What policies are needed for small practices and multi-specialty practices?Should there be a choice of measures and activities within Pathways?

Public Reporting:How should information be reported to patients?Should we move toward reporting at the individual clinician level?

Proposed Changes to the Medicare Physician Fee Schedule for CY 2020

• Section 2005 of the SUPPORT Act establishes a new Medicare Part B benefit for opioid use disorder (OUD) treatment services furnished by OTPs on or after January 1, 2020

• Medicare currently covers office-based opioid treatment with buprenorphine and naltrexone but has historically not covered OTPs, which are the only entities authorized to use methadone for the treatment of OUD. Coverage of OTPs is a new benefit that we anticipate will expand access to care

• OTP proposals in the NPRM:- Definition of opioid treatment programs- OUD treatment service provided by OTPs- Coding structure for OUD treatment services- Payments (partial episodes, add-on code for intensity)- Use of telecommunications- Beneficiary copayment/deductible- OTP enrollment

Opioid Treatment Programs (OTPs)

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Outpatient Prospective Payment System (OPPS) & Ambulatory Surgical Center (ASC) Proposed Rule

• Proposed OPPS update of 2.7 percent• Proposed ASC update of 2.7 percent• Completing two-year phase-in of method to reduce unnecessary

utilization of outpatient services• Changes to the Inpatient Only List• Addresses Wage Disparities to Aid Rural Health• Changes to Hospital Outpatient Quality Reporting and ASC

Quality Reporting Programs to Further Meaningful Measures Initiative

General Provisions

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Outpatient Prospective Payment System (OPPS) & Ambulatory Surgical Center (ASC) Proposed Rule

• On June 24, the President signed an Executive Order on Improving Price and Quality Transparency in American Healthcare to Put Patients First

• Proposed definitions:

• Proposing requirements for making public all standard charges for all items and services

• Proposing requirements for making public consumer-friendly standard charges for a limited set of “shoppable services”

• Proposing regulations for monitoring and enforcement

• RFI: best way to capture the information on the quality of hospital inpatient care to be provided to patients in a way that is useful when comparing care options

Price Transparency

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“Hospital” “an institution in any State in which State or applicable local law provides for the licensing of hospitals and which is licensed as a hospital pursuant to such law, or is approved by the agency of such State or locality responsible for licensing hospitals as meeting the standards established for such licensing”

“Items and Services” “includes all items and services (including individual items and services and service packages) provided by a hospital to a patient in connection with an inpatient admission or an outpatient department visit for which the hospital has established a charge”

“Standard Charges” “means the hospital’s gross charge and payer-specific negotiated charge for an item or service”

Proposed Changes to ESRD PPS and DMEPOS Fee Schedule (2020)

• Implementing President’s Executive Order on Advancing American Kidney Health to better recognize costs for new therapies under the ESRD PPS

• Proposing a transitional add-on payment adjustment for new and innovative equipment/supplies

• Proposing refinements to eligibility for the transitional drug add-on payment adjustment (TDAPA)

• Soliciting comments on stakeholder concerns regarding wage index used to adjust labor-related portion of ESRD PPS base rate

• Proposing how Medicare pricing is determined for new DMEPOS items without a pricing history

General Provisions

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How to Comment on the 2020 Proposed Rules

Comments due no later than Friday, September 27, 2019 at 5:00 PM

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Rule Press Release Fact Sheet Comment at FederalRegister

Physician Fee Schedule (CMS-1715-P)

https://www.cms.gov/newsroom/press-releases/trump-administrations-patients-over-paperwork-delivers-doctors

https://www.cms.gov/newsroom/fact-sheets/proposed-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year-2QPP: https://qpp-cm-prod-content.s3.amazonaws.com/uploads/594/2020%20QPP%20Proposed%20Rule%20Fact%20Sheet.pdf

https://www.federalregister.gov/documents/2019/08/14/2019-16041/medicare-program-cy-2020-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other

OPPS (CMS-1717-P) https://www.cms.gov/newsroom/press-releases/cms-takes-bold-action-implement-key-elements-president-trumps-executive-order-empower-patients-price

https://www.cms.gov/newsroom/fact-sheets/cy-2020-medicare-hospital-outpatient-prospective-payment-system-and-ambulatory-surgical-center

https://www.federalregister.gov/documents/2019/08/09/2019-16107/medicare-program-proposed-changes-to-hospital-outpatient-prospective-payment-and-ambulatory-surgical

ESRD/DME (CMS-1713-P) https://www.cms.gov/newsroom/press-releases/new-cms-proposals-strengthen-medicare-unleash-innovation-and-promote-competition-provide-kidney

https://www.cms.gov/newsroom/fact-sheets/end-stage-renal-disease-esrd-and-durable-medical-equipment-prosthetics-orthotics-and-supplies-dmepos

https://www.federalregister.gov/documents/2019/08/06/2019-16369/medicare-program-end-stage-renal-disease-prospective-payment-system-payment-for-renal-dialysis

Submit via: electronically through Regulations.gov; regular mail; express/overnight mail; by hand/courier (faxes NOT accepted)

Center for Medicare and Medicaid Innovation Updates

• Primary Care First and Direct Contracting Request for Applications coming soon

• Emergency Triage, Treat, and Transport (ET3) Model Request for Application (RFA) portal open now at: https://innovation.cms.gov/initiatives/et3/

• Voluntary Kidney Models: Kidney Care First (KCF) and Comprehensive Kidney Care Contracting (CKCC) (Graduated, Professional, and Global models)

- Expected to run from January 1, 2020, through December 31, 2023, with the option for one or two additional performance years at CMS’s discretion. Health care providers interested in participating will apply to participate in the fall of 2019, and if selected, begin model participation in 2020

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Patients over Paperwork

• CMS continues to use the Patients over Paperwork initiative to engage with the clinician community to address burden reduction opportunities

• Using human-centered design

• Opportunities for listening sessions:- Prior authorizations- Proposed rules- SUPPPORT ACT implementation- MIPS Value Pathways- Program Integrity

• We thank you for your continued cooperation and partnership!

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Contact Info

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Patrick M. Hamilton, M.P.A.Health Insurance SpecialistCMS Region IIIP: 215-861-4097Patrick.Hamilton@cms.hhs.gov

Barbara J. Connors, D.O., M.P.H.Chief Medical OfficerCMS Region IIIP: 215-861-4218Barbara.Connors@cms.hhs.gov