August 31, 2016

Andrew Slavitt, Acting Administrator
Center for Medicare & Medicaid Services
7500 Security Blvd.
Baltimore, MD 21244
www.regulations.gov

Attention: CMS-1654-P

Dear Acting Administrator Slavitt:

Thank you for the opportunity to comment on the proposed revisions to physician fee schedule payment policies for 2017. We agree with most of the revisions that you are proposing.

We especially support proposals to strengthen primary care and patient-centered care management. This is particularly vital with the pending transition to the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs) under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The new codes, higher payments and provisions to reduce burden in the proposed rule will clearly help with this.

We applaud your continued diligence in identifying and addressing misvalued codes that have potential to undermine value-based incentives enacted into law under MACRA. We strongly support expansion of the Diabetes Prevention Program, addition of new measures to the Medicare Shared Savings Program, and greater transparency on Medicare Advantage bid pricing and medical loss ratio data. We further support expansions in telehealth coverage, but believe current telehealth criteria are too narrow and harming beneficiaries who lack needed access to services that telehealth can effectively deliver.

We support proposed protections for clinicians from quality or resource use serious data errors that are not their fault. However, you could prevent such errors by encouraging approval of more effective, independent eMeasure validation systems such as the one NCQA has developed and discussed with the Office of the National Coordinator for Health IT and the Center for Medicare & Medicaid Innovation.

However, we have reservations about not requiring individuals providing Chronic Care Management (CCM) services after hours to have access to beneficiaries’ care plans. Access to care plans is not difficult to provide and not knowing information in care plans creates potential for potentially harmful knowledge gaps. We also are concerned that challenges you face in developing appropriate use criteria for advanced diagnostic imaging may cause delay in their implementation, and urge you to address these challenges as quickly and effectively as feasible.

Detailed comments on these and other issues in the proposed rule are below.

Telehealth: We support the proposed additions to telehealth services that Medicare covers. Allowing advanced care planning via teleheatlh is particularly important for expanding efforts to help beneficiaries document their end-of-life care preferences in advanced directives. We also support coverage for critical care consultations provided via teleheatlh.

We continue to believe, however, that CMS fails to include a comprehensive set of services eligible for telehealth and is harming beneficiaries who need access to care that telehealth can provide. For example, medication therapy management, chronic care management and palliative care all could be provided via telehealth. We understand concerns about telehealth’s potential for fraud, waste and abuse. However, advanced models of care such as PCMH and APMs that are designed to manage costs and improve quality should be able to expand access through telehealth. We urge you to work with other public and private payers who use telehealth much more extensively to identify best practices for expanding its use in Medicare while protecting program integrity.

Misvalued Services: We applaud your continued diligence in identifying and addressing misvalued codes. We particularly commend innovative approaches, such as contracting for independent data validation and studying how surgery-related service use may differ for clinicians in accountable care organizations (ACOs), which have financial incentives to provide high quality care efficiently. Reducing overvalued codes is essential to prevent excessive payments from creating incentives that undermine value-based payments aimed at promoting efficient, high-quality patient-centered care. Increasing payments for undervalued services, particularly for primary care, care coordination, collaboration and other cognitive work, is essential to ensure fairness and access. As MACRA requires across-the-board cuts if net misvalued code spending is not reduced by 0.5%, it is critical to identify enough over-valued codes to prevent cuts in payments for needed, appropriate care.

Primary Care & Care Management: As noted above, we strongly support your proposals to improve primary care payments, which is vital given the pivotal role primary care plays in delivery system reforms and value-based payment. These include:

  • New codes for primary/behavioral collaboration in the Collaborative Care Model as well as general behavioral health integration. This will:
    • Let primary care clinicians bill for psychiatric consultation, care manager interventions and follow-up,
    • Increase their ability to get psychiatrists to help manage patients; and
    • Alleviate mental health resource shortages.
  • Higher payment for assessment and care planning of cognitive impairment patients;
  • New codes for the additional resources needed to serve patients with mobility-related disabilities;
  • New codes and reduced administrative burden for CCM;
  • Diabetes Self-Management Training policy clarifications to promote use of this valuable service; and
  • Higher pay and use of codes for non-face-to-face prolonged evaluation and management services that have been bundled and undervalued.

We also support your proposals to use clearer CPT language on CCM scope of service elements for 24/7 Access and Continuity of Care, and to clarify that 24/7 Access is for all urgent needs, not just those related to chronic conditions. We further support proposals to streamline CCM requirements, which could encourage broader uptake, with one important exception.

We have reservations, however, about not requiring individuals providing CCM after hours have access to patients’ electronic care plans. The stated rationale for this proposal is that some after-hours care does not warrant feedback with clinicians managing beneficiaries’ overall care or that feedback can be provided via less sophisticated means.

However, there may be potential for harm to patients from lack of information in their care plans, and access to care plans generally should not be difficult to provide. We suggest you instead explore a hardship exceptions system for circumstances where there are legitimate difficulties in providing access to the car plan.

Appropriate Use Criteria for Advanced Diagnostic Imaging: We appreciate the challenges in moving forward with this and the importance of establishing the right criteria. Delaying the requirement to consult clinical decision support mechanism (CDSM) is nonetheless disconcerting given the cost and patient harm from widespread inappropriate imaging. We therefore urge you to work diligently to implement this requirement as quickly as feasible. We similarly urge you to work diligently to incorporate CDSMs into electronic health records and health IT environments as quickly as feasible.

We agree with your initial focus on the eight top clinical groupings by volume, such as low back pain, that account for roughly 40% of part B advanced diagnostic imaging services. NCQA’s Use of Imaging Studies for Low Back Pain HEDIS measure has seen only minimal progress and appropriate use criteria could drive much-needed improvement.

Expand the Diabetes Prevention Program: We strongly support expanding the DPP throughout Medicare as quickly as is feasible. This demonstration saves money while preventing the avoidable disease of diabetes and its serious comorbidities, and it should be made available to all Medicare enrollees who could benefit as soon as possible.

For public reporting on DPP, we suggest process measures on how the program is administered, for example whether patients meet contact hour expectations. You also should monitor patient biometrics at 3 or 6 months after program completion to track longer term outcomes. Data gathering for such measurement should start promptly as it will take time for programs to be able to track and report outcomes.

Medicare Shared Savings Program: We support addition of the proposed four new measures and alignment with the Core Quality Measures Collaborative recommendations and the Quality Payment Program under MACRA. We are particularly pleased with inclusion of NCQA’s Use of Imaging Studies for Low Back Pain. This measure tracks the inappropriate but far too common use of imaging for uncomplicated low back pain, which the American Radiological Association says is unnecessary and harmful to patients both in needlessly exposing them to radiation and often leading to unnecessary biopsies and other invasive procedures.

We also support the proposal to apply penalties if quality data validation audit match rates are below 90%. The potential for penalties will create a stronger incentive to report accurately, ensure fairness and protect program integrity.

Value-Based Payment Modifier & Physician Feedback: We support your proposal to adjust PQRS ratings for clinicians with serious data problems that your informal review process confirms were caused by vendors or other factors outside the clinician’s control. It is essential to protect clinicians from being penalized for data problems that are not their fault as we move to performance-based payment. In our experience with the NCQA eMeasures Certification program, we have documented instances when the calculations by vendors of measure results are inaccurate. When these errors go unnoticed, they undermine the credibility of performance-based reimbursement and frustrate physicians who are already overstressed by the complexities of MIPS and EHR reporting as a whole.

Moving forward, we urge you to address PQRS, and then MIPS, data problems proactively at the source. NCQA’s independent eMeasures certification program is demonstrably better at accurately validating electronic quality measure reporting systems than any other methodology, including Project Cypress. Since 2011 regulations have authorized the Office of the National Coordinator for Health IT to approve other test tool and/or test procedure like ours for use by NVLAP accredited testing laboratories. However, to date none has been approved. We therefore urge you to work with the Office of the National Coordinator to promptly approve more effective, independent eMeasures certification programs such as ours. These programs may have greater abilities to directly address the serious data problems occurring with PQRS and EHR systems as they work on the ground in physicians’ offices.

Thanks again for the opportunity to comment. Please contact Paul Cotton, Director of Federal Affairs, at 202 955 5162 or cotton@ncqa.org if you have any questions.

Sincerely,

Margaret O’Kane,
President