CMS says it wants to cut red tape, and players across the healthcare industry are weighing in with a plethora of suggestions.
The agency received roughly 440 comments in response to its Patients over Paperwork initiative in which provider, payer and pharma groups lobbied to reduce the individual regulatory requirements they say cut into their bottom lines.
The American Hospital Association says providers spend nearly $39 billion a year to ensure compliance with government regulations.
As of June, CMS said it resolved or is addressing more than 80% of the actionable items identified in the original 2017 request for comment on its effort to cut administrative burden.
But from the large number of comments received, it's clear industry doesn't think CMS has done enough. Companies took the request for information as an opportunity to air perennial grievances about the highly regulated environment, including inequitable quality measures and reporting requirements, prior authorization that slows down care delivery for patients and problems with interoperability and telehealth.
The American Association of Colleges of Nursing wants the agency to adopt provider-neutral language in its regulations. The Critical Access Hospital Coalition wants a longer timeframe to submit Medicaid claims because critical access facilities are often understaffed. The Coalition of Long-Term Acute Care Hospitals wants CMS to loosen its 25-day length of stay requirement for its hospitals. The National Association of Rural Health Clinics wants to reduce "burdensome regulations" such as forcing clinics to stock anti-venom for snakebites.
Medicare programs, quality reporting
CMS' June 6 RFI asked for comments due this week on a variety of areas, including streamlining documentation requirements, aligning public and private payer coding and processes and making operations and data sharing more flexible and helpful for providers.
In their comments, payer and provider groups said CMS needs to revamp how the agency looks at quality, arguing the metrics it uses now are too heavily focused on improvement over time, haven't adapted to changing industry guidelines and unfairly penalize certain types of facilities.
CMS, as part of its "Meaningful Measures" framework, removed a number of measures across its reporting programs last year. But that's not enough, groups say.
"Quality reporting is an example of redundancy where checkboxes and data collection requirements add significant administration burden," Cigna said in its comments.
The Merit-based Incentive Payment System was a popular target. The quality payment incentive program is currently in its third year and has been rocky from the start, with the Medicare Payment Advisory Commission pushing for its repeal in 2017 due to the high reporting burden it places on providers.
Some 95% of eligible physicians participated in MIPS in 2017, CMS said, and 98% in 2018. But a majority of respondents to an American College of Physicians survey said current MIPS measures fail to reflect the quality of care they provide patients.
MIPS "has not achieved year-to-year stability," the American Academy of Ophthalmology said in its comments. "Physicians are required to annually redefine their understanding of the program and implement ever-increasing and ever-more-expensive (in staff time and other resources) compliance requirements, often with little or no effect on patient care or outcomes."
And provider groups like the American Academy of Family Physicians, America's Essential Hospitals, American Medical Association and AHA re-aired concerns quality reporting overly penalized rural providers and those caring for a more vulnerable population.
Current reporting requirements "necessitate an expanded human and technological infrastructure that many practices cannot afford, including most small rural practices," the AAFP said, noting compliance, a moving target because CMS continually changes program requirements, is harder for understaffed rural practices to achieve.
CMS has tried to make its sweeping payment reforms under 2015's Medicare Access and CHIP Reauthorization Act more flexible, introducing more points of entry and injecting additional incentives into MIPS and its alternate payment models.
However, the agency still isn't looking at the right measures, providers said in response to the RFI.
"When evaluating quality, Medicare programs should account for the socioeconomic and sociodemographic complexities of vulnerable populations to ensure hospitals are assessed on their work, rather than on the complexities of the patients they serve," America's Essential Hospitals said in its comments. AEH has 300 member hospitals serving a disproportionate number of vulnerable patients.
Another point of contention was the beleaguered star ratings system, currently under review from an expert panel. But the AHA argued the quality ratings should be suspended altogether from CMS' Hospital Compare website as the agency works out its kinks.
The star ratings have proved deeply unpopular since their 2005 introduction. AHA, in one of its more than 30 areas of comment, once again asked CMS refine and ease the requirements in the program.
"Data collection and reporting activities would be more valuable if federal agencies, private payers and others requiring quality data agreed on a manageable list of high-priority aspects of care," AHA said.
Payers say prior authorization is an important management tool to cut costs. The American Academy of Ophthalmology called it the "most burdensome requirement in Medicare" in its comments.
According to the AMA, 65% of physicians have had to wait one business day for PA decisions from insurers, while 26% said they have had to wait three. More than one-quarter say PA led to a serious adverse health event, such as permanent disability or death.
"PA programs remain a true threat to both ordering and referring physicians alike as it presents considerable administrative costs and operates in a non-transparency manner," the American College of Radiology wrote. "In fact, the underlying goal of PA programs is to limit utilization of services, thus potentially impeding patient access to needed care at the right time."
Big Pharma also took the time to lobby against the practice.
"Utilization management tools such as prior authorization or step therapy can interfere with the provider-patient relationship by preventing prescribers from being able to select the most appropriate medication for each patient's individual circumstance," the trade group PhRMA wrote. "Such blunt tools can lead to poor health outcomes and increased expenditures."
Payers were playing defense. Fewer than 15% of medical services or treatments actually require PA, according to America's Health Insurance Plans, and saved Medicare almost $2 billion through March 2017.
"While medical management on the front end may be considered challenging for some, it can prevent unnecessary overutilization and potential complications related to non-medically necessary care," the Blue Cross Blue Shield Association noted.
One potential method to ease provider burden is electronic prior authorization. Health IT vendor and EHR giant Cerner, seeing an opportunity, called prior authorization is an "ideal" area for automation.
Both AHA and AHIP support ePA, which backers say lowers barriers to medication access, helps speed patients to therapy and can even help combat health disparities. The Office of the National Coordinator for Health IT is already looking at ways to improve ePA adoption.
Interoperability was also a hot topic in the comments.
The agency should "consider revisions to existing federal programs that will enable providers to fully leverage the potential of health IT while not being constrained by rigid program requirements," AEH wrote.
In light of the immense administrative and technological burden needed to electronically share information efficiently, the industry needs more wiggle room.
"We strongly encourage CMS to reevaluate the need for prescriptive [Promoting Interoperability] measures," AMA said, while AHIP's SVP of private market innovations and quality initiatives Danielle Lloyd argued "transparency and access must be balanced with the need to maintain patient protection, minimize administrative burden on all stakeholders, and establish clear data standards and operational protocols."
Multiple comments stressed the need for CMS to remove barriers to virtual care or telehealth in the U.S.
Enthusiasm in both the private and public sectors seems to be growing. In April, CMS finalized a rule giving Medicare Advantage plans the option to pay for additional telehealth benefits for patients treated in their home starting 2020.
But public programs have also proved a roadblock for telemedicine. Some 19 states lack parity policies for virtual care in Medicaid, meaning payers get reimbursed at much lower rates for the practice then for comparable in-person services. Additionally, distance restrictions and limitations on eligible settings in many states (along with requirements staff be immediately available) have restricted adoption.
"We encourage CMS to continue to loosen requirements on originating site requirements to expand home as the originating site to an even broader array of services," Cerner commented, to which the AHA added increasing federal research on the cost-benefits of telehealth and improving the Fedearl Communication Commission's Rural Health Care Program.
The FCC revamped the RHCP in August in favor of rural providers.