Thread by @MarilynHeineMD

🔥Proposed Medicare cuts:

•Threaten patients' access to care

•Further jeopardize physician practice sustainability, and

•Risk penalizing physicians unfairly.

🔥CMS’s policies increase
administrative demands on physicians.

🧵

2/ This week, @AmerMedicalAssn submitted a 122-page comment letter in response to the @CMSGov proposed rule for the 2024 #Medicare Physician Fee Schedule (PFS) and Quality Payment Program (QPP).

To read the letter, please see here: tinyurl.com/2hc9ce6e

3/ Unsustainable:

“Physician practices cannot continue to absorb increasing costs while their payment rates dwindle. We already know how that story ends, and it is not a happy ending” for patients.

4/ “According to the Medicare Trustees, if physician payment does not change, access to Medicare-participating physicians will become a significant issue in the long term.”

Read: tinyurl.com/8dzz88y3

5/ “Some Medicare patients are already experiencing inequitable delays in care, and we know that when care is delayed, health outcomes worsen.

These problems particularly impact minoritized and marginalized patients and those who live in rural areas.”

tinyurl.com/2x4rvm79

6/ “We appreciate that in the Consolidated Appropriations Act of 2023, Congress partially mitigated a 4.5 percent cut to Medicare physician payment rates,

but physicians still endured a two percent pay cut this year…

7/ …and for 2024, physicians are facing another 1.25 percent cut, once again confronting the grim task of reconciling how to keep their lights on while getting paid less, while their expenses continue to rise.”

[on top of an ongoing 2% sequester cut]

tinyurl.com/bdfv6ynf

8/ 2001 to 2023:

❗️Cost of running a medical practice ⬆️ 4️⃣7️⃣% (1.8%/y)

❗️Physician payment rates have ⬆️ just 9️⃣% (0.4%/y), per Medicare Trustees.

❗️Adjusted for inflation, Medicare physician payment rates ⬇️ 2️⃣6️⃣% from 2001 to 2023, or by 1.3% /year.

9/ “Hospitals, skilled nursing facilities, and nearly every other Medicare provider receive an annual update.”

[Not physicians]

10/ “Physicians compete in the same marketplaces as these providers for clinical and administrative staff, equipment, and supplies.

Yet physicians are at a significant disadvantage due to payment cuts and because their payments have failed to keep up with inflation.”

11/ ❗️“It is no wonder that these trends are driving consolidation,

❗️which is highly likely to increase future Medicare costs

❗️as these other providers receive increasingly higher payments than

❗️the diminishing number of independent medical practices.”

12/ “This Administration has acknowledged that health care consolidation is leaving many areas, particularly rural communities, with inadequate or more expensive health care options.”

tinyurl.com/mry2p76d

13/ AMA analysis:

The “most cited reason that independent physicians sell their practices to hospitals or health systems:”

1. Inadequate payment.

2. Better manage payers’ regulatory & administrative requirements

3. Improve access to costly resources

tinyurl.com/ym5xkrhj

14/ “The AMA strongly supports policies that promote market competition and patient choice.

Payment adequacy is necessary for physicians to continue to have the ability to practice independently.”

tinyurl.com/5wpsjdhu

15/ In March, “the Medicare Payment Advisory Commission (MedPAC) recommended that Congress increase 2024 Medicare physician payments above current law by linking the payment update to the MEI, something the AMA and organized medicine have long supported.”

tinyurl.com/2p9buzv9

16/ “MedPAC raised concerns about the growing gap between what it costs to run a medical practice and what Medicare pays.”

17/ CMS is strongly urged:

🎇”Use every policy lever available to reduce the proposed budget neutrality reduction for physician services in 2024”

…CMS should ⬇️ utilization estimate for office visit add-on code, which would ⬇️ the budget neutrality cut to conversion factor.

18/ CMS is strongly urged:

🎇”Close the gap between the Medicare physician payment update and the rising cost of practicing medicine, which is estimated to increase by 4.5 percent next year.”

19/ AMA and Federation “strongly support H.R. 2474, the ‘Strengthening Medicare for Patients and Providers Act,’ which provides a permanent annual update equal to the increase in the MEI.”

tinyurl.com/4r3z5pdy

20/ “Such an update would allow physicians to invest in their practices and implement new strategies to provide high-value, patient-centered care.

We hope the agency will work with the AMA and Congress to seek this legislative relief.”

tinyurl.com/mr8mupn8

21/ Enactment of an inflation-based update for physicians would “…enable CMS to prioritize advancing high-quality care for Medicare beneficiaries without the constant specter of market consolidation or inadequate access to care.”

22/ “These concerns stem from the disparity between Medicare physician payment rates and the actual costs associated with delivering high-quality care.”

23/ 🚩CMS must meaningfully reduce burden for MVP participants

“…CMS must make meaningful reductions in burdensome reporting requirements for MVP participants, and we offer…recommendations to do so:”

24/ CMS should:

🚩Develop MVPs by condition, episode of care and clinical priority areas, not by specialty; working work with national medical specialty societies

🚩Ensure MVPs and subgroup reporting remain voluntary

Don’t simply repackage problematic measures.

25/ 🚩Reduce substantial administrative burdens of MIPS

Physician practice leaders from a variety of specialties, practice types and locations reported that MIPS caused substantial administrative burden.

tinyurl.com/2p9d3ney

26/ 🚩MIPS participation has significant time and unreimbursed financial costs:

In a study evaluating the time and financial costs of MIPS, researchers found that it takes 201 hours per physician per year to comply with MIPS.

tinyurl.com/n593chtw

27/ “In a survey of 400 physician practices, 76 percent of respondents felt that MIPS is very or extremely burdensome, and 87 percent reported that MIPS payment adjustments do not cover the cost of time and resources needed for program participation.”

tinyurl.com/2p8p9vhy

28/ 🚩Must ensure options:

•Since there may not be a viable APM for every sub/specialty,

•Traditional MIPS should be permanently retained as an option for those clinicians.

•AMA continues to strongly oppose retiring traditional MIPS and making MVP participation mandatory.

29/ Precarious time for physician practices:

Compounding this financial distress with an expansion of MIPS penalties threatens the viability of physician practices & patient access to care.

⬇️ the performance threshold in 2024 or, at a minimum, maintain the 75-point threshold.

30/🚩Physician practice instability:

“While the AMA is calling on Congress to replace the statutory freeze with inflationary updates, CMS must avoid exacerbating the financial distress facing physicians with the proposed increased performance threshold.”

tinyurl.com/zwvkuzyy

31/ GAO reports concerns with MIPS:

“The Government Accountability Office has highlighted these barriers [undue administrative burden and high costs of complying with MIPS] to participation for small and rural practices.”

tinyurl.com/yrfc25yk

32/Reverse Robin Hood Effect:

Physicians caring for more medically/socially underserved, more likely to receive low scores despite high-quality care, penalized for social factors outside of their control

Resources moved to those caring for more affluent

tinyurl.com/23csk2j8

33/“CMS should not expand this flawed program to increasingly penalize physicians with [up to] 9% ⬇️ of Medicare payments, particularly on the heels of the COVID-19 PHE, when physicians must absorb highest practice costs in recent history despite lack of an inflationary update.”

34/ 🚩Remove Total Per Capita Cost Measure from MVPs

•Outdated measure specifications
•Significantly impact reliability and validity of the measures
•Lead to inaccurate measure results and unintended consequences for physicians and physician groups

tinyurl.com/2embm73b

35/ 🚩Attribution:

Physicians should not be held responsible for costs that occurred long after they saw the patient.

The same costs should not be attributed to multiple physicians in different practices when there is no evidence that they are practicing as a team.

36/🚩Promoting Interoperability [PI] will 2️⃣❌ admin & EHR requirements:

Ignoring: “EHR burden also continues to ⬆️. Half of physician time is spent in EHR, 37% of physician/patient time is spent on nonclinical tasks, & physicians spend 2 hours of extra work outside the clinic.”

37/🚩Burnout and patient harm:

“Increasing EHR use may increase patient harm, rather than reduce it. It is a falsehood to believe that expanding physicians’ EHR demonstration requirements will reduce patient harm—CMS’s belief is neither backed by data nor evidence.”

38/ “AHRQ states that ‘burned-out doctors are more likely to leave practice, which reduces patients’ access to and continuity of care.’”

tinyurl.com/2p8ne8sp

39/ 🚩Health inequity:

“Research also shows that MIPS can have a disproportionately negative association with certain practices, including those that are small, rural, independent, or serve a high proportion of patients with low-income.”

tinyurl.com/n593chtw

40/ 🚩Decreased patient choice:

“The AMA’s 2022 Physician Practice Benchmark Survey shows that 71 percent of physicians cite regulatory and administrative requirements as their reason to leave independent medical practice.”

tinyurl.com/ym5xkrhj

41/ 🚩Cumulative adverse impact:

CMS should:

Continue with a 90-day PI performance period.

Work with @ONC_HealthIT to update the Safety Assurance Factors for EHR Resilience Guides prior to making their use a requirement of PI participation.

@ONC_HealthIT 42/ “CMS continues to ignore the clear evidence that physician administrative burden is linked to MIPS participation and EHR use.”

“The AMA reiterates that CMS’s policies should ⬇️ administrative demands on physicians, not ⬆️ them.”

#FixMedicareNow
tinyurl.com/j4959dcd

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