AAFP Calls on CMS to Act to Stabilize Primary Care Practices 

Detailed Comments on the 2022 MPFS Press for Long-term Solutions

September 16, 2021, 4:05 p.m. News Staff — CMS has the power to direct that several foundational primary care services are fairly valued — and the agency must wield that power in the 2022 Medicare physician fee schedule and Quality Payment Program proposed rule to deliver stability to family medicine practices hobbled by the COVID-19 pandemic. 

Repeating recommendations it made last year, the Academy again urged CMS to “recognize the additional costs physician practices incur to protect their staff and patients from COVID-19” — a call made more urgent by the delta-variant surge. Compensating primary care practices for the still-increasing costs associated with personal protective equipment, social distancing and proper cleaning of equipment and patient rooms “is essential to ensuring they can remain open and care for patients during this national emergency, particularly as practices face reductions in Medicare payment rates in 2022,” the AAFP wrote. To achieve this, the agency should make code 99072 an active code (Status A), “paying appropriately for it, based on the recommendations of the (Relative Value Scale Update Committee) and others.”

Evaluation and Management

In a year when primary care practices were supposed to reap the benefits of a long-overdue payment increase, many front-line physicians are instead still waiting.

“Most family physicians are employed physicians, and many of their employers are not reflecting the increased relative value units or Medicare payment allowances in their employment contracts,” the Academy wrote. “Instead, the employers keep their employed physicians’ contracts at 2020 levels and pocket the increased Medicare payments for codes 99202-99215 or use those payment increases to offset decreases elsewhere in the fee schedule.”

“The AAFP urges CMS to use the tools at its disposal, including rulemaking and sub-regulatory guidance, to help ensure the 2021 evaluation and management RVU increases are passed down to primary care physicians,” the letter said. “We understand physicians’ contracts with private payers and the organizations that employ physicians are outside of CMS’ purview. However, we believe it’s important for CMS to know what is happening in this regard as it considers additional efforts to support primary care.”

Practice Expense Relative Value Units

CMS assigns relative value units to all services paid under the Medicare physician fee schedule based on three factors: physician work, practice expense and malpractice expense. A service’s RVUs are then multiplied by a conversion factor (the dollar amount CMS pays per RVU) and geographically adjusted to determine the Medicare allowed amount.

Influencing determination of RVUs is the Relative Value Scale Update Committee, the expert panel whose members include the AAFP and a number of other national medical specialty societies. CMS factors the RUC’s recommendations when deciding what RVUs to assign for each Medicare-covered service.

In 2022, after almost two decades without a change, CMS proposes to update the clinical labor pricing factor — one factor in the calculation of practice expense RVUs — using the most recent Bureau of Labor Statistics data as the primary source.

“We support this update and believe, after almost 20 years, that it’s long overdue,” the Academy said, noting that the lag in adjustment had likely disadvantaged family medicine for years. “This update will help ensure that CMS’ practice expense RVU methodology better approximates the most current practice expenses incurred by family physicians.

“We encourage CMS to fully implement the update in the pricing of clinical labor in 2022 and not phase in the changes over four years,” the letter added. “Further prolonging the necessary improvement in CMS’ practice expense RVU methodology will result in additional, unnecessary delays for an already overdue pricing update.”

Vaccine Administration

CMS used the fee schedule to solicit comments on how best to update payment methodology for vaccine administration, acknowledging — as the Academy has long pointed out — that Medicare payment for the service is insufficient.

“The AAFP strongly recommends CMS implement the spring 2021 RUC recommendations for vaccine administration services,” the letter said. In outlining the importance of such an update, the Academy cited 2020 survey results indicating that 80% of responding physician practices said increasing vaccine administration payment rates would help overcome pandemic-related vaccination barriers and costs. “Coupled with low vaccination rates among beneficiaries, these results suggest that updated Medicare payment rates for routine and seasonal vaccinations are urgently needed,” the letter said.

The Academy also suggested that CMS develop “a payment methodology for vaccine administration that considers the value of preventive vaccinations instead of only considering the cost of furnishing these services.”

The proposed rule would continue to provide an add-on payment for physicians to provide COVID-19 vaccines to patients in their homes, policy the Academy welcomed.

Telehealth

The proposed rule would retain certain services added to the Medicare telehealth services list on a Category 3, or temporary, basis until the end of 2023, a decision the Academy supported while urging CMS to add the telephone E/M codes to the Medicare telehealth services list on a Category 3 basis, as well as implement a more permanent solution for audio-only services. “Audio-only telehealth services have been crucial to improving equitable access to care during the PHE,” the AAFP wrote.

The letter expressed strong support for the rule’s proposal to change the definition of “interactive telecommunications system” and permanently allow audio-only technology for tele-mental health services, but objected to a requirement that an in-person service be provided within six months of a telehealth mental health service. “Evidence does not support the need for such an ongoing requirement for mental health services,” the Academy said. “We oppose arbitrary in-person service requirements for mental health services.”

The Academy also supported proposals to implement the removal of geographic restrictions and add home as an originating site for tele-mental health services after the end of the public health emergency. The latter step would “improve access to mental and behavioral health care for beneficiaries, many of whom may struggle to access these services easily in their community,” the AAFP said.

Administrative Simplification

Following steady AAFP advocacy, CMS proposes in the rule to delay full implementation of the Appropriate Use Criteria program for advanced diagnostic imaging until Jan. 1, 2023, or Jan. 1 of the year after the COVID-19 public health emergency ends, whichever is later. This delay could give Congress a chance to repeal the program, an outcome for which the Academy also has lobbied.

In expressing strong support for this change, the Academy reiterated its position that the AUC program “is overly burdensome, complex and … does not consider quality, patient outcomes or other important factors, which are more appropriately addressed in alternative payment models.”

Quality Payment Program: Merit-based Incentive Payment System

The fee schedule’s proposed changes to the traditional MIPS track of the QPP include making the performance threshold 75 points in 2022, and the exceptional performance threshold 89 points. The cost category would be weighted at 30% of the MIPS score, and the rule would add five new episode-based cost measures, including two for chronic conditions. The quality, promoting interoperability and improvement activities categories would be weighted at 30%, 25% and 15%, respectively.

The AAFP expressed concern with the MIPS program moving ahead despite the most recent surge in COVID-19 cases. “Setting the performance threshold at 75 for the 2022 performance period will represent a 30-point increase since the 2020 performance period,” the Academy said — a steep increase that the ongoing pandemic will make untenable for many practices. “The AAFP encourages CMS to explore ways to use its authority, including emergency authorities under the PHE, to adjust the performance threshold beginning with the 2022 performance period.”

The AAFP also called on CMS to apply the extreme and uncontrollable circumstances exception for the 2021 performance period. “It is vital that family medicine and other physician practices focus on providing patient care during this time and not be required to comply with a burdensome MIPS reporting process,” the letter said.

MIPS Value Pathways

The Academy objected to elements of the proposed rule’s transition timeline for replacing traditional MIPS reporting with the MIPS Value Pathways program, set to start in 2023. The agency’s goal is a more focused reporting option, and it plans to phase out traditional MIPS in 2027.

“We are hopeful that MVPs can serve as a path to prepare practices to transition out of fee-for-service,” the Academy said, prefacing a number of suggestions for ways in which CMS might “meaningfully reduce the burden of reporting to MIPS.” For example, the Academy pointed out that CMS’ prioritization of an MVP focused on chronic care management, a core tenet of primary care, includes several opportunities for cross-category credit, allowing family physicians “a more meaningful and less burdensome reporting experience.”

“However, we remain concerned that the transition away from FFS will be hampered by the shortage of APMs available for practices — particularly small and independent practices,” the letter added. “We strongly urge CMS to work with the Center for Medicare & Medicaid Innovation to develop a clearer path out of FFS for all practices, including developing options that span the risk spectrum.”