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Proposed rule changes from CMS get mixed reviews


Small practices score some wins, but work remains to be done under Medicare’s Quality Payment Program and Physician Fee Schedule.

The proposed 2019 rule for the Medicare Quality Payment Program (QPP) was released July 12 by CMS, along with changes to the Physician Fee Schedule, and while doctors will find some beneficial changes, physician advocate groups say more needs to be done.

CMS is proposing changes to eligibility requirements, coding, some documentation requirements and how certain categories are weighted, among others, with a goal of streamlining billing and expanding access to high-quality care.
“Internists are excited to see that CMS is proposing long overdue improvements in the physician fee schedule and the QPP that will help physicians provide the highest quality care to patients, said Ana Maria Lopez, MD, MPH, president of the American College of Physicians in a statement.

The proposed changes to the 2019 rule governing the QPP include:

• Expanded exemptions. A third low-volume threshold has been proposed: provide 200 or fewer covered professional services under the Physician Fee Schedule. Any doctor who met this requirement, or one of the previous two-$90,000 or less in Part B charges or caring for 200 or fewer Medicare beneficiaries-would be exempt from the QPP.

• Ability to opt-in to the Merit-based Incentive Payment System (MIPS). Any clinician or group that did not meet all of the low-volume exemptions could choose to opt-in to MIPS, if desired. However, the decision to opt-in is irrevocable.

• Changes to general performance category weights used to calculate MIPS scores. Quality would decrease from 50 percent of the total to 45 percent, while cost increases from 10 percent to 15 percent. Promoting interoperability (formerly called advancing care) and improvement activities remain at 25 percent and 15 percent of the total score, respectively.

• Removal of 34 quality measures deemed by CMS to be of low value.

• Requiring the use of 2015 Edition Certified EHR Technology in 2019. This was originally proposed for 2018, but CMS backtracked to allow 2014 Edition Certification because EHR vendors were not ready.

Two notable changes to the Physician Fee Schedule are:

• Adding reimbursable codes for virtual check-ins. This covers remote consults of patient videos and photos plus interprofessional online consultations.

• Significant changes to the payment structure. All level two to five office-based and outpatient E/M visits would be consolidated into two payment amounts: one for new patients and one for established payments.

One notable change from the 2018 QPP rule that physician advocates lobbied for but did not receive was to have 90-day reporting periods for all four performance categories. Instead, quality and cost will remain 12-month reporting periods and improvement activities and promoting interoperability will remain at 90-day reporting periods.

“Reducing the reporting burden would allow more physicians to participate in MIPS and focus the program on rewarding quality care rather than quality reporting,” said Anders Gilberg, senior vice president, government affairs, Medical Group Management Association, in a statement. “Requiring medical groups to submit excessive amounts of data to the government has little impact on the quality of care delivered to Medicare beneficiaries.”

Brian Outland, director of regulatory affairs for ACP, says that while the organization appreciates that CMS heard some of their suggestions, there are concerns on certain proposals, including the collapsing of the level two to five E/M codes in the Physician Fee Schedule.

“We want to make sure there is no disadvantage to physicians taking care of complex and frail patients,” he says. “A doctor could have a patient come in that has a cold or some less-sensitive problem and get paid the same as a physician taking care of someone with four or five chronic conditions that require attention and care and much more time.”

The ACP also continues to argue that a 12-month reporting period for the MIPS performance categories does not offer any more insight to a practice than a 90-day period. “We are advocating for shortening the reporting period to reduce the burden and shorten the feedback loop,” says Suzanne Falk, senior associate, regulatory affairs, ACP, adding that a quarterly report with real-time feedback would add more value to the program for physicians.

Complicating the MIPS cost category is that not only is it increasing in weight for the overall score, there are eight new replacement episode-based measures that are untested. For 2018, MIPS used cost measures that cover the total cost of care during the year or during a hospital stay. Medicare claims data was used to calculate scores. Now, it’s proposed that new episode-based measures be used to calculate costs. “Increasing the weight of the category while adding eight new measures is not a smart move,” says Falk.

Another area of concern is the proposal to mandate EHRs with 2015 certification. The required upgrade can put an undue burden on smaller practices, says Falk. She says vendors are still scrambling to catch up and many do not have a 2015 certified product to offer. Practices also need time to implement the new software, and with the 12-month reporting requirements, this means they need to be ready January 1. “Vendors need more time and practices need more time to work out the kinks in the systems,” says Falk.

Small practices required to participate in the QPP are still at a performance disadvantage because of the financial and labor requirements to be successful. “The performance gap between small and large practices is not because small practices aren’t providing good care or thinking about value,” says Falk. “It comes down to a matter of resources and having people on staff to navigate the program.”

The public comment period on the proposed rule is open until Sept. 10. Those wishing to comment can do so at For more information on the program or the proposed changes for 2019, go to

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Jennifer N. Lee, MD, FAAFP
© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health