ACS Regulatory Relief Asks

To help surgeons succeed in the ever-changing health care system, the American College of Surgeons Division of Advocacy and Health Policy (ACS DAHP) is constantly engaged in efforts to identify and combat policies that could further overburden physicians and their practices.

When the College determines a regulation to be impractical and unnecessary in the practice of high-quality surgical care, the ACS DAHP recommends to policymakers specific actions that should be taken to reduce burdens and enable surgeons to reinvest their time and resources in patient care.

Some of the College’s regulatory asks include:

MIPS Scoring

• Set the MIPS performance threshold—the final score a physician must meet in order to avoid a payment penalty under the MIPS program—at a level that fairly measures and compares physicians’ performance

Advancing Care Information Performance Category

• Maintain flexibility in certified electronic health records technology (CEHRT) requirements

Quality Performance Category

• Offer a bonus payment to physicians who report quality measures via qualified clinical data registries (QCDR) or other applicable registries

Improvement Activity Performance Category

• Reclassify the use of Enhanced Recovery after Surgery (ERAS) protocols, which are intended to accelerate recovery after surgery, as a high-value, rather than medium-value, improvement activity

• Avoid using data collected on postoperative visits furnished in the 10- and 90-day global period to revalue surgical services until CMS addresses outstanding reporting and data collection issues, as well as provides a detailed plan for data validation
  
  Read more about the ACS’ regulatory and legislative efforts to avoid reductions in payment for global services.
  

  The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) requires that CMS collect data on the number and level of post-operative visits related to 10- and 90-day global surgical services, and that CMS use those data to improve the accuracy of global code values starting in 2019. CMS is currently in the process of collecting post-operative visit data by requiring physicians who are part of practices with 10 or more practitioners and who live in one of nine specified states are required to report CPT code 99024 (Post-operative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a post-operative period for a reason(s) related to the original procedure) for each postoperative evaluation and management visit they provide within the global period. CMS will soon implement a nationwide survey to collect data on the types of services provided during post-operative visits.
  
  Over the past several years, ACS has been the leader in advocating on various aspects of this issue, both at the legislative and regulatory levels. Such efforts include sending letters to Congress and CMS; meeting with Congressional members, CMS staff, and government contractors; attending CMS town hall meetings; facilitating strategic meetings of the ACS Health Policy and Advocacy Group and the General Surgery Coding and Reimbursement Committee; and establishing an ACS-led Global Services Coalition.
  
  The College continues to assert that global codes data collection should be implemented fairly and in a way that does not create an unreasonable reporting burden, and stresses that only accurate and complete data be used to revise the values of global codes. The DAHP has serious concerns about the data that CMS has collected thus far, and will be increasing advocacy efforts to object to the use of inaccurate or incomplete data as a basis for any updates to global code values.

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• Withhold any modifications to the malpractice (MP) insurance component of Medicare payments until more robust data are collected to ensure fair reimbursement for surgeons and other physician specialties
• Delay further implementation of patient relationship codes until CMS provides clarification on the use of, and implications associated with, such codes

• Examine issues surrounding clinician burden associated with use of electronic health records (EHRs) and partner with government agencies to develop recommendations and solutions
  
  Read more about EHR clinician burden and the College’s plan to address this problem.
  

  EHRs are too lengthy, difficult to use efficiently, and can be prone to errors. As a result, many physicians use automated medical records, checkboxes, cut and paste options, and templates, even when such functionalities are not appropriate. Notes then can become so voluminous that physicians have difficulties finding relevant information, and in some cases the information needed for patient care is obscured or the note itself is not readable. There is also a lack of standardization of the location of data within EHRs, and data errors are often propagated once they have been introduced into the record, as the common practice of cutting and pasting can replicate incorrect information.
  
  A number of other factors further complicate the challenges to using EHRs. For example, the CMS documentation guidelines are not efficient or appropriate in a digital health environment and have created unnecessary burden because they have become cumbersome in pragmatic use within and across EHRs. Another concern is the inability to adapt EHRs to clinical workflow and the needs of a particular practice. Now that EHRs are being used by a large number of physicians and facilities, lack of interoperability is another hurdle.
  
  Use of EHRs has also uncovered serious unintended consequences that must be addressed in order for the benefits of the technology to be fully realized, for the healthcare industry to continue to move toward interoperability, and, most importantly, to avoid patient harm. One of main drivers of physician burnout is use of EHRs, which is a cause of professional dissatisfaction and early retirement. EHRs can also pose a risk to patient safety, as the number of pop-up screens and inbox notifications lead to alert fatigue and problems in communication among providers. The ACS is closely examining the issues surrounding use of EHRs and is providing feedback to the Office of the National Coordinator for Health Information Technology on solutions to improve usability.

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• Complete a full review and modernization of E/M guidelines to remove redundancies and align use with EHRs
• Establish an EHR interoperability framework and collaborate with the physician community to determine best practices for leveraging digital health information
• Standardize prior authorization (PA) policies across all insurers and require that PA requests, decisions, and appeals processes be automated through uniform electronic transaction portals for medical and pharmacy services. In addition, limit PA requirements to complex cases or to physicians whose ordering patterns differ substantially from their colleagues’ after adjusting for patient population
  
  Read more about ACS Fellows’ feedback on how inefficient PA processes disrupt the clinical workflow and delay patient care, along with what the College is doing to address these issues.
  

  PA is a process through which approval for coverage of a medical service or supply item must be obtained by a health care provider before the service or item may be furnished to a patient. The administrative burdens imposed by PA requirements on surgeons often delay or interrupt treatment and can lead to severe, life-threatening health outcomes.
  
  A 2017 ACS survey of nearly 300 Fellows and their practice staff indicated that on average a medical practice receives approximately 37 PA requests per physician per week, taking providers and staff 25 hours—the equivalent of three business days—to complete.
  
  The ACS is actively working with surgeons and practice staff to identify ways to reduce administrative burden associated with PA, better integrate PA processes into the clinical workflow, and ensure that patients have timely access to care. Further, the College supports legislative and regulatory reforms that streamline PA. The ACS sent a support letter for H.R. 4841, which would allow for electronic PA under Medicare Part D and allow for the creation of technical standards for the electronic transmission of PA, and urged the bill sponsors to expand the legislation to include any medical services, supplies, and prescription drugs requiring PA under the Medicare program.

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• Rescind the two-midnight rule, under which a hospital inpatient stay is not considered medically necessary if the stay does not extend across two midnights after the point of admission, in favor of physicians’ clinical judgment for determining a patient’s inpatient/outpatient status
• Conduct an in-depth review of the skilled nursing facility (SNF) three-day stay requirement, under which Medicare Part A coverage is denied for SNF care if a patient is not admitted to a hospital as an inpatient for at least three days, to determine if patients’ care and financial obligations are adversely affected because of their admission status and length of hospital stay
• Streamline documentation and recertification of the medical necessity of services and supplies, especially for patients with chronic conditions
• In the event of an audit, implement standard pre- and post-payment medical record review processes through which auditors notify physicians of a review, request medical records, inform physicians of the specific reason why a claim is denied and clearly state a physician’s appeal rights
• Provide federal funding to physicians for the purposes of hiring medical translators to ensure that patients with disabilities or limited English proficiency do not lose access to care