First Word

Improve caregiver-patient quality time

It has been clear for some time that changes are on the way in the relationship between health care plans, including government programs like Medicare and Medicaid, and health care providers and physicians. Those who pay the bills are looking for value-based approaches to care that lead to identifiable improvement in outcomes. The fee-for-service payment system is fading.

To move to a value-based system, a number of things will need to change. That includes physician-patient engagement. In nephrology, where patient care requires a team approach, the ongoing Comprehensive ESRD Care demonstration with more than 30,000 dialysis patients is a good test to see whether outcomes can improve with a multispecialty approach. The demonstration focuses on taking care of all the patient’s needs – not just kidney disease. A progress report on the demonstration is expected from the Lewin Group this month.

Mark E. Neumann

Physician-patient time

The Medicare program is a large payer. With that comes bureaucracy and paperwork. CMS is trying to reduce the burden in its proposed rules for 2019 that govern the quality payment program (QPP) and the physician fee schedule (PFS). In a July 12 press release, the agency said it is proposing “historic changes that would increase the amount of time that doctors and other clinicians can spend with their patients by reducing the burden of paperwork that clinicians face when billing Medicare.”

“Today’s reforms proposed by CMS bring us one step closer to a modern health care system that delivers better care for Americans at a lower cost,” HHS Secretary Alex Azar said in the release. “Such a system requires empowering American patients by giving them price and quality transparency and control over their own interoperable health records, goals supported by CMS’s proposals. These proposals will also advance the successful Medicare Advantage program and accomplish a historic regulatory rollback to help physicians put patients over paperwork ... ”

The proposals would also modernize Medicare payment policies to promote access to virtual care, using telecommunications technology to determine whether patients need an in-person visit.

“If today’s proposals were finalized, clinicians would see a significant increase in productivity – leading to substantially more and better care provided to their patients. Removing unnecessary paperwork requirements through the PFS proposal would save individual clinicians an estimated 51 hours per year if 40% of their patients are in Medicare. Changes in the QPP proposal would collectively save clinicians an estimated 29,305 hours and approximately $2.6 million in reduced administrative costs in [calendar year] 2019,” CMS said.

Support of the telecommunications technology has important value for the nephrology community. Patients on dialysis can be evaluated off site – in their homes, for example, or in clinic settings - using telehealth. CMS will pay clinicians for virtual check-ins – brief, non-face-to-face appointments via communications technology – pay for evaluation of patient-submitted photos and expand Medicare-covered telehealth services to include prolonged preventive services.

Potential drawbacks, controversy

One potentially controversial topic is price transparency. CMS is seeking comment through a request for information asking whether providers and suppliers can and should be required to inform patients about charge and payment information for health care services and out-of-pocket costs, what data elements would be most useful to promote price shopping and what other changes are needed to empower health care consumers.

The proposed rule may have some drawbacks. The Renal Physicians Association has expressed concerns that the “relatively radical changes” in the 2019 proposed PFS involving both documentation requirements and a new payment approach for evaluation and management codes will have an impact on nephrology practice income. “ ... While nephrology is projected to experience a 1% reimbursement reduction in 2019, sweeping proposed changes in evaluation and management services cast doubt on the CMS projections,” the organization wrote in its September 2018 issue of RPA News. The RPA, citing an AMA analysis, reports that nephrologists could see up to a 13% reduction in payments for patient care. “While the easing of the documentation burden is certainly a positive change, the reimbursement changes are profound, were not anticipated, and have a disproportionally negative impact on specialties treating patients with chronic illnesses, like nephrology,” the RPA wrote.

For its part, CMS is recognizing that the bureaucracy it has created for physicians to document the care they provide has become obstructive. Hopefully, there is a happy median between change and fair compensation for care.

It has been clear for some time that changes are on the way in the relationship between health care plans, including government programs like Medicare and Medicaid, and health care providers and physicians. Those who pay the bills are looking for value-based approaches to care that lead to identifiable improvement in outcomes. The fee-for-service payment system is fading.

To move to a value-based system, a number of things will need to change. That includes physician-patient engagement. In nephrology, where patient care requires a team approach, the ongoing Comprehensive ESRD Care demonstration with more than 30,000 dialysis patients is a good test to see whether outcomes can improve with a multispecialty approach. The demonstration focuses on taking care of all the patient’s needs – not just kidney disease. A progress report on the demonstration is expected from the Lewin Group this month.

Mark E. Neumann

Physician-patient time

The Medicare program is a large payer. With that comes bureaucracy and paperwork. CMS is trying to reduce the burden in its proposed rules for 2019 that govern the quality payment program (QPP) and the physician fee schedule (PFS). In a July 12 press release, the agency said it is proposing “historic changes that would increase the amount of time that doctors and other clinicians can spend with their patients by reducing the burden of paperwork that clinicians face when billing Medicare.”

“Today’s reforms proposed by CMS bring us one step closer to a modern health care system that delivers better care for Americans at a lower cost,” HHS Secretary Alex Azar said in the release. “Such a system requires empowering American patients by giving them price and quality transparency and control over their own interoperable health records, goals supported by CMS’s proposals. These proposals will also advance the successful Medicare Advantage program and accomplish a historic regulatory rollback to help physicians put patients over paperwork ... ”

The proposals would also modernize Medicare payment policies to promote access to virtual care, using telecommunications technology to determine whether patients need an in-person visit.

“If today’s proposals were finalized, clinicians would see a significant increase in productivity – leading to substantially more and better care provided to their patients. Removing unnecessary paperwork requirements through the PFS proposal would save individual clinicians an estimated 51 hours per year if 40% of their patients are in Medicare. Changes in the QPP proposal would collectively save clinicians an estimated 29,305 hours and approximately $2.6 million in reduced administrative costs in [calendar year] 2019,” CMS said.

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Support of the telecommunications technology has important value for the nephrology community. Patients on dialysis can be evaluated off site – in their homes, for example, or in clinic settings - using telehealth. CMS will pay clinicians for virtual check-ins – brief, non-face-to-face appointments via communications technology – pay for evaluation of patient-submitted photos and expand Medicare-covered telehealth services to include prolonged preventive services.

Potential drawbacks, controversy

One potentially controversial topic is price transparency. CMS is seeking comment through a request for information asking whether providers and suppliers can and should be required to inform patients about charge and payment information for health care services and out-of-pocket costs, what data elements would be most useful to promote price shopping and what other changes are needed to empower health care consumers.

The proposed rule may have some drawbacks. The Renal Physicians Association has expressed concerns that the “relatively radical changes” in the 2019 proposed PFS involving both documentation requirements and a new payment approach for evaluation and management codes will have an impact on nephrology practice income. “ ... While nephrology is projected to experience a 1% reimbursement reduction in 2019, sweeping proposed changes in evaluation and management services cast doubt on the CMS projections,” the organization wrote in its September 2018 issue of RPA News. The RPA, citing an AMA analysis, reports that nephrologists could see up to a 13% reduction in payments for patient care. “While the easing of the documentation burden is certainly a positive change, the reimbursement changes are profound, were not anticipated, and have a disproportionally negative impact on specialties treating patients with chronic illnesses, like nephrology,” the RPA wrote.

For its part, CMS is recognizing that the bureaucracy it has created for physicians to document the care they provide has become obstructive. Hopefully, there is a happy median between change and fair compensation for care.