In June, the Centers for Medicare & Medicaid Services (CMS) released a Request for Information (RFI), titled “Reducing Administrative Burden to Put Patients Over Paperwork.” The proposal, which CMS Administrator Seema Verma first introduced in October 2017, aims to decrease the regulatory requirements that lead to overly burdensome reporting measures for clinicians. The RFI sought input on several topics, including prior authorization and quality reporting, linking patient data from an electronic health record (EHR) with qualified clinical data registries (QCDRs), streamlining reporting and documentation requirements, and enabling operational flexibility.

With such broad themes, AAOS took the opportunity to share its position on the issues that are most relevant to its members. Although the intent to streamline documentation requirements has the potential to lessen administrative burden, the implementation of such programs must make certain that reporting measures ensure that compensation is accurately reflecting the work being done. Similarly, the medical decision-making component of evaluation and management (E/M) visits should account for all relevant factors and not be based solely on the length of a visit.

Reducing burden

Although the prospect of a perceived burden reduction is theoretically positive, as evidenced by a shift to the Level 2 documentation requirements for E/M visits as a minimum standard, AAOS has concerns regarding the incorporation of new add-on codes. For example, many EHR and institutional billing systems are currently programmed to code visits based on documentation elements. New add-on codes would require additional training and novel activities to defend against audits. To address this, AAOS has been actively participating in an E/M workgroup through the American Medical Association.

CMS also sought recommendations to address the cost of care for the burgeoning dual-eligible Medicare and Medicaid population. Given the disproportionate share of resources such patients utilize in both programs, there is an explicit need to bridge the gap in care and expand payment models. AAOS supports CMS’ proposal for “state-specific models,” which encourage the development of bundled payment models for dual-eligibles.

The Stark Law is also a significant barrier to improved operational flexibility. Liability statutes, such as the Stark Law, do not encourage physicians to participate in coordinated care models. The Bundled Payments for Care Improvement initiative and Comprehensive Care for Joint Replacement model reveal weaknesses in current law. The costs of compliance and disclosures required are often prohibitive for small- and medium-sized physician practices participating in those models. Yet, physician referrals in accountable care organizations are theoretically exempt from the Stark Law requirements through fraud and abuse waivers.

There should be similar exceptions or protections for physicians participating in alternative payment models (APMs). In particular, the EHR safe harbor should be extended and made permanent beyond its current 2021 expiration date. As CMS has already recognized, EHR adoption and use are critical components of care delivery both inside and outside of the Medicare program and allow for improved efficiency for care teams participating in APMs.

Promoting interoperability

To further promote interoperability, AAOS welcomed CMS’ interest in utilizing existing federal mechanisms to promote it within the healthcare ecosystem. EHRs are a valuable tool, filled with useful data for both providers and payers. The Department of Health and Human Services (HHS) Strategy of Reducing Regulatory and Administrative Burden Relating to the Use of Health Information Technology and EHRs (the Strategy) takes a step in the right direction by recommending additional data standards that make access, extraction, integration, and analysis of data easier and less costly for physicians and hospitals. However, efforts to promote effective, interoperable measures of data exchange should ensure a focus on the value of qualitative data, not just quantitative measures.

AAOS also appreciates that the Strategy recognizes that prior authorization is challenging for clinicians, frustrating for patients, and evermore burdensome. In 2017, AAOS joined more than 25 organizations in drafting a comprehensive list of 21 principles for reducing the burden of prior authorization requirements. Several of the principles are particularly salient, as they relate to the aims of the Patients Over Paperwork initiative. They include updated formularies with prior authorization and step-therapy requirements embedded in EHRs to reduce the frequency of prescription rejections when patients are already at the pharmacy, a minimum 45-day window of prior authorization validity to guarantee the presence of coverage over the time period necessary to receive care, standardized utilization review entity prior authorization review criteria, an alternative clinical quality measure that payers may recognize in lieu of prior authorization, and the exemption of providers who participate in a financial risk-sharing model from the prior authorization and step-therapy requirements for those services included in the plan’s benefits.

Moreover, last year AAOS joined 20 other medical specialty societies in writing a letter to Ms. Verma, urging HHS to “allow eligible clinicians utilizing a certified EHR to participate in a clinician-led QCDR to qualify them as fully achieving all points for the promoting interoperability category of the Quality Payment Program’s Merit-based Incentive Payment System (MIPS).” This change would not only help reduce reporting burdens, improve MIPS performance, increase use of Certified EHR Technology, drive interoperability, and improve quality and outcomes, but it also would satisfy the goal of simplifying the scoring model under the “promoting interoperability performance” category. AAOS encouraged HHS to adopt that proposal.

Streamlining documentation

As the industry continues to focus on value-based care, increase reliance on technology, and explore the utilization of team-based care, we must reevaluate our methods of documentation. APM adoption has remained slow for a variety of reasons, including the lack of specialty-specific advanced APMs and an inability to satisfy the qualifying participant threshold. Nevertheless, waiving onerous documentation requirements for the purposes of testing or administering APMs could help facilitate faster adoption. CMS also should simplify reporting (such as shortening the reporting period to 90 days) and scoring under the “promoting interoperability” category of MIPS.

To that end, AAOS, along with more than 100 other organizations, recently signed a letter urging Congress to implement technical changes to the Medicare Access and CHIP Reauthorization Act (MACRA). The letter outlined three major requests: positive payment adjustments for physicians that would replace the current payment freeze in effect for the next six years, an extension of APM bonus payments for six years, and an update to MIPS scoring to reduce physician burden. To further integrate the practice experience and the MIPS reimbursement process, AAOS supports scoring based on multicategory measures—for example, by awarding bonus points at the composite score level instead of in the “quality performance” category. Other technical improvements to MACRA could include removal of the total cost-of-care mandate and the latitude for CMS to create separate performance thresholds for urban and rural practices.

Finally, AAOS strongly believes that the electronic prescribing of medications promotes patient safety and that it should be possible for a surgeon or pharmacist to see all prescriptions filled throughout the country by a single patient. The ability to access this type of database would enable physicians to help reduce opioid use, misuse, and abuse. The opioid epidemic and the importance of mechanisms such as prescription drug monitoring programs (PDMPs) represent another area where health information technology could play a role in reducing burden for rural patients and providers.

Investments as straightforward as expanding access to a high-speed data connection or the technology to send and receive encrypted patient health information would give providers important tools for higher-quality patient care. For example, they would enable providers to incorporate PDMP access more smoothly into their workflow. AAOS shares CMS’ desire to ensure that rural providers have the resources and tools that represent the best approach to expanding the healthcare workforce into underserved areas.

The Patients Over Paperwork RFI presented AAOS an opportunity to reiterate its position on a handful of the most pressing regulatory issues facing its members. AAOS looks forward to CMS’ consideration of the suggestions and working collaboratively to provide the highest-quality musculoskeletal care.

Alix Braun, MPH, is a regulatory advocacy specialist in the AAOS Office of Government Relations.