AAMC Submits Comments on Physician Fee Schedule 2021 Proposed Rule

The AAMC submitted comments on Oct. 5 on the Medicare Physician Fee Schedule 2021 proposed rule. The association urges the Centers for Medicare and Medicaid Services (CMS) to prevent steep cuts to payment and  recommends making waivers and flexibilities allowed during the COVID-19 public health emergency (PHE) permanent [see Washington Highlights, Aug. 7]. In its comments, the AAMC urges CMS to remove restrictions to allow expanded telehealth coverage and allow virtual supervision of residents.

In a key proposal, the AAMC supports the increases in payment for evaluation and management (E/M) services in 2021 but raises significant concerns with the 10.61% budget neutrality cut to physician payment to offset the payment increases. The AAMC urges Congress and CMS to waive budget neutrality to avert steep cuts that would have a devastating impact on physician practices, especially during the pandemic.

On the Quality Payment Program, the AAMC acknowledges CMS’s plan to limit 2021 performance year proposals in light of the COVID-19 pandemic to promote program stability. However, it urges CMS to postpone the termination of the Group Practice Reporting Option (GPRO) Web Interface for at least one year. In addition, the AAMC opposes the elimination of the Merit-based Incentive Program (MIPS) scoring standard and the requirement to transition to the Alternative Payment Model Performance Pathway (APP).

Additional recommendations from the AAMC include the following:

Physician Fee Schedule

• E/M Coding Changes and Relative Value Units (RVUs): The AAMC strongly supports CMS’ proposal to adopt the coding changes and RVUs for E/M services recommended by the RVS Updated Committee.
• E/M Visit Level Selection and Documentation: The AAMC supports finalizing the policy for 2021 that would allow physicians to select a level and document based on either medical decision-making or time.
• Add-On Code (GPCIX): The AAMC recommends that CMS postpone implementation of GPCIX until there is further clarification on how it would be used and what the impact would be on payment and redistributions among specialties. If CMS implements this add-on code in 2021, the AAMC urges CMS to reconsider its utilization assumptions that account for a significant portion of the decrease in the conversion factor. If CMS finalizes the GPCIX code for 2021, the AAMC recommends CMS not apply budget neutrality to that code.
• Telehealth: The AAMC urges Congress and CMS to make changes to legislation and regulations that will allow the current changes to telehealth, including the removal of geographic and site-of-service restrictions, to be made permanent while ensuring that reimbursement remains at a level that will support the infrastructure needed to continue providing telehealth services.
• Expansion of Telehealth Services: The AAMC recommends that CMS allow all the services added to the telehealth services list during the public health emergency (PHE) to continue to remain on the telehealth list post-pandemic to allow further study of the benefits.
• Category 3 Telehealth Services: The AAMC encourages CMS to make Category 3 permanent as an option to temporarily allow services to be billable for a defined period, while providers collect data and perform analysis on the clinical benefit of the telehealth services. 
• Audio-Only Telephone E/M Services: The AAMC recommends payment for audio-only telephone E/M services be allowed beyond the end of the PHE for patients who need telecommunications-based services in the home but do not have access to a video connection or cannot successfully use one.
• Virtual Supervision of Residents: The AAMC recommends CMS permanently adopt the policies in place during the PHE that allow the teaching physician presence during the provision of services by a resident to be met using real-time audio/video communications technology.
• Residents Providing Telehealth: The AAMC recommends CMS allow residents to provide telehealth services permanently while a teaching physician is present via real-time audio/video communications technology after the PHE ends.
• Resident Moonlighting: Provided that moonlighting is consistent with accreditation requirements by the Accreditation Council for Graduate Medical Education, the AAMC supports permanently allowing residents to moonlight in the inpatient setting if the services are not related to their graduate medical education program.

Medicare Shared Savings Program (MSSP)

• MSSP Quality Changes: The AAMC encourages CMS to postpone any changes to the current quality scoring program for at least one year.
• Web Interface for Accountable Care Organizations (ACOs): To give ACOs more time to prepare, the AAMC urges CMS to provide a more gradual transition away from the use of the Web Interface reporting option. At a minimum, the Web Interface must be continued as a reporting option until at least 2022.
• Quality Measure Set for ACOs: While we appreciate the significant reduction in measures, the AAMC recommends CMS seek stakeholder input from the Measures Application Partnership and others prior to implementing the new measure set for ACOs.

Quality Payment Program

• MIPS Value Pathways (MVPs): The AAMC strongly supports CMS’ proposal to delay implementation of the MVPs. The MVPs should be gradually implemented to ensure that they are meaningful for clinicians and their patients and are not burdensome to report.
• MVPs and Large Multispecialty Practices: With the large number of distinct specialties reporting under one tax identification number in academic medical centers, the AAMC believes it would be very challenging to identify MVPs that would be meaningful for all specialties in the practice. A better solution would be to have subgroup identifiers that allow measurement of the performance at the subgroup level.
• Elimination of MIPS Alternative Payment Models (APM) Scoring Standard: The AAMC recommends CMS maintain the MIPS APM Scoring Standard and not require a transition to the APP.
• Removal of Web Interface: The AAMC strongly urges CMS to provide a gradual transition away from the use of the Web Interface reporting option for group practices. At a minimum, the Web Interface must be continued for at least one additional year to give sufficient time for affected practices to implement a new reporting method.
• Cost Category: Given the multiple concerns under the cost performance category — including the impact of COVID-19 on patterns of care, clinicians’ lack of familiarity with cost measures, the need for risk adjustment, and the need for better attribution methodologies — the AAMC strongly urges CMS to maintain the weight of the cost category at 15%.
• Risk Adjustment: As appropriate, the AAMC recommends CMS risk-adjust outcome measures, population-based measures, and cost measures for clinical complexity and sociodemographic factors.
• Advanced Alternative Payment Models (AAPM): The AAMC recommends CMS support any congressional efforts that would give the agency the discretion to set the thresholds to be qualified participants in an AAPM at an appropriate level to encourage participation.