American Academy of Ophthalmology--DC

December 29, 2009 Ms. Charlene Frizzera, Acting Administrator Centers for Medicare and Medicaid Services Department of Health and Human Services Room 445-G Hubert H. Humphrey Building 200 Independence Avenue, S.W. Washington, D.C. 20201 Re: Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2009; [CMS-1413-FC] Dear Acting Administrator Frizzera: The American Academy of Ophthalmology is writing to comment on the CY2010 Final Medicare Physician Fee Schedule. The Academy is the world’s largest association of eye physicians and surgeons—Eye M.D.s—with more than 18,000 members in the U.S. We appreciate the opportunity to provide our input on these important regulations. Further, we would very much commend CMS for finalizing a rule that sets on a course of correcting a number of issues and problems that have plagued physician payments for numerous years. The Academy supports the Administration’s efforts to make Medicare payments accurate and fair as outlined in several aspects of this rule. While, the Academy believes that current Sustainable Growth Rate (SGR) formula used to determine Medicare physician payments is fatally flawed, we commend CMS for taking the steps necessary to make crucial improvements to the SGR as outlined in Section II. P. Physician fee schedule update for 2010. Acknowledging that the Secretary does have discretion in determining what are considered physician services in defining the expenditure targets and that the growth in utilization of physician administered drugs and laboratory test is driven by factors outside the control of the physician is fundamental step in improving the Medicare physician fee schedule. The Academy commends the proposal to remove these costs retroactively to the base year of 1996/97 and strongly supports CMS and the Secretary in finalizing that action. A summary highlighting all of the Academy’s main points follows. Summary of American Academy of Ophthalmology Comments on the 2010 Final Medicare Physician Fee Schedule Implementation of the PPIS is an important and necessary vehicle for paying all Medicare Part B physicians and other healthcare providers using the most up to 2 date data gathered simultaneously from Medicare providers. With PPIS, CMS has data that was uniformly collected and followed the exacting standards put forward by Medicare. The Academy is pleased that it is being used as an integral component now that we are in the final transition to a new practice expense methodology. Further we recognize the impact of the new data and support the transition that CMS has laid out in the final rule. Now that the 2008 PQRI Reporting incentives have gone out, the Academy continues to be concerned about CMS’ inability to provide timely and transparent information to participants about their PQRI reporting. Despite steps to make feedback reports more accessible, ophthalmologists continue to report significant problems in obtaining their individual reports. Additionally, there appears to be program-matic errors in computing accurate incentive payments. The Academy has been a leader in advocating appropriate quality measures and reporting but we fear that the agency’s failings in this area are creating poor perceptions regarding the program by physicians including ophthalmologists who have been one of the leading specialties participating in PQRI. The Academy appreciates that Measures 139 and 141continue to be claims based reporting in addition to being registry reported for 2010. Further, we hope that given CMS’ strong indication that they want to increase the numbers of physicians reporting on measure groups that you will re-examine the arbitrary number of measures that it currently recognizes as a group and move to expand to whatever number is appropriate for the measures that support a disease or condition. The Academy continues to request two measure groups one of cataract measures and the other for diabetic retinopathy. The Academy appreciates CMS’ recognition of the concerns expressed in our proposed rule comments regarding the use of Interservice Work Per Unit of Time (IWPUT) in the review of misvalued services. On the discussion regarding the upcoming Five Year Review, the Academy believes that the current RUC Review of Misvalued Codes has done a very thorough job in reviewing our codes and we have no codes to suggest for the upcoming review. We will await further CMS guidance in their upcoming rule in 2010. Provision II- A. Resource-based PE RVU’s – 2. PE Proposals for 2010 PPIS The Academy strongly commends CMS for moving forward with the decision to finalize usage of the PPIS data as part of the methodology for determining practice expense values for services under Medicare Part B. We stand behind our previous comments on the validity of the 3 PPIS. Our comments here will focus on new information that was posted to the CMS website as part of the final 2010 physician fee schedule rule-making. A new report from Lewin as requested and released by CMS, examines the validity of the supplemental surveys submitted by a small subset of specialties at different intervals versus the new PPIS surveys which were conducted across all major physician specialties and most non-physician providers. The Academy believes that Lewin correctly concludes that the “PPIS used a consistent survey methodology across all specialty and health care profession groups. This methodology is highly consistent with the prior SMS methodology as only small deviations were allowed to accommodate practice style differences across the various groups surveyed.” Furthermore, when responding to comments that the PPIS was not conducted in a consistent or contemporaneous manner, Lewin indicates that “The PPIS used a consistent survey instrument and methodology across all specialty and health care profession groups. The PPIS sample was drawn from the AMA’s Physician Master File, which is a listing of all member and non-member physicians in the United States. The survey was conducted in conjunction with national medical specialty societies and other health care professionals, representing 51 specialties and health professions in order to maximize the overall response rate. Respondents could submit information through multiple modalities; include telephone, fax, and web-based reporting.” Lewin then used the cardiology PPIS data as a further point of comparison and indicated that difference in PE/PrHr for cardiology that resulted from PPIS might be explained because of a disproportionate share of responses from cardiologists in smaller sized practices. Based on data provided by cardiology outside of the PPIS process and CMS review, which shows that PE costs have risen dramatically since 2004, Lewin speculates that there may be a variance in the PPIS data for cardiology versus its previous supplemental data. They show that the breakdown of practice size for cardiologists who participated in PPIS was significantly different than the data from cardiology’s supplemental survey when indicating that the PPIS survey may have been biased towards smaller cardiology practices. The reverse of that statement is that cardiology’s supplemental data may have been biased towards larger practices. Additionally, we would point out that any data which Lewin reviewed showing substantial increases in PE costs was also derived from groups who represent larger practices. The membership of MGMA is predominantly made up of larger group practices and while less is known about MedAxiom, a private cardiology practice management company, the same appears to be true based on information from their website that shows that only eight percent of the company’s membership is in solo practice and 45 percent are groups with 11 or more physicians. The Academy would like to see substantiated data that demonstrates what the true practice size is for cardiologists in the U.S. before any conclusion are made about the information provided to Lewin. Validity of the process and the survey. The PPIS was a highly scientific and controlled undertaking, using a survey instrument that the AMA took great care to design, test and implement. All groups involved in the effort had ample 4 time to review and provide input on the survey instrument and were given regular monthly updates on the response rate for their group. PPIS followed the exacting criteria that CMS has for gathering this type of data and for submitting results that are acceptable. The AMA worked with The Lewin Group, a CMS contractor, to ensure that all data met this criterion and were analyzed consistently across the various physicians and other healthcare providers. Any data that did not meet the criteria, were response outliers or were statistically unacceptable were excluded. The results of the survey were independently corroborated and Lewin recommended that CMS utilize the data. CMS showed its confidence in the data by choosing to fully implement it in 2010. Since the advent of the resource-based practice expense system in 1999, CMS has never had such up-to-date data on the indirect practice expenses of Medicare Part B physicians and other healthcare providers. Again, we appreciate the tough decisions that CMS had to make in finalizing the use of the PPIS data. Your compromise to transition the data in over four years acknowledges the impact for all groups and sets forth a manner to reconcile it over an extended time period. F. Potentially Misvalued Codes Under the Physician Fee Schedule The Academy appreciates CMS’ recognition of the concerns expressed in our proposed rule comments regarding the use of Interservice Work Per Unit of Time (IWPUT) in the review of misvalued services. We had several codes that were reviewed under the screen for High IWPUT for which we continue to disagree. As a result of the ongoing AMA RUC Review of Misvalued Codes, the Academy has or will have prepared comments, surveys and/or recommendations on approximately 16 ophthalmic services including cataract, retina, glaucoma and ocular plastics codes. We are exploring further issues regarding IWPUT and will be providing our review and research to the agency and the AMA RUC by the spring of 2010. In particular we disagree with recent actions taken by the AMA RUC Workgroup that has been conducting its reviews on the basis of IWPUT. G. MIPPA Issues 2. Physician Quality Reporting Initiative The Academy supports CMS’ efforts to expand the Physician Quality Reporting Initiative (PQRI) reporting options to improve participation. Further, we support streamlining reporting periods and criteria for these options to reduce reporting burden and confusion. In moving forward to implement these changes to the PQRI, it is critical that CMS initiate a strong educational program aimed at helping participating physicians successfully report data under the 2010 PQRI. We urge CMS to double its efforts and to work more closely with the AMA and other physician organizations to educate physicians about the requirements that must be met to successfully report under the various reporting options in 2010. Additionally, given the errors in analytics and in appropriate incentive levels, the Academy approves of recent legislative proposals that gives CMS authority to establish an appeals process and hopes that CMS moves quickly to implement. 5 The Academy would like to thank CMS for changing its proposal to make measures 139, Cataracts: comprehensive preoperative assessment for cataract surgery with intraocular lens (IOL) placement; and 141, primary open-angle glaucoma (POAG) reduction of intraocular pressure (IOP) by 15% or documentation of a plan of care registry and claims based reportable. At this time there are no Academy sponsored registries available for reporting of eye care measures and if the final rule implemented the measures as registry reportable only it would have significantly decreased the number of ophthalmologists who are participating in the program. The Academy continues to recommend that CMS explore the inclusion of additional measures across the various methods of reporting to increase the number of measures for a clinical condition. We strongly urge CMS to consider reducing the number of measures required for inclusion in a measures group. If this criterion were to be changed, the number of measures groups could be expanded a repeated goal stated by CMS. Measure groups are less of an administrative burden on carriers and physicians. As the PQRI advances, we support flexibility to allow participants to report on sets or groups of measures, as well as individual measures. There are two potential measure groups in ophthalmology which address two of the major eye diseases found in the Medicare population: diabetic retinopathy, and cataract surgery. For diabetic retinopathy, three measures cover critical aspects of patient management: ongoing evaluation (dilated eye exam in diabetic patient); appropriate evaluation (documentation of presence or absence of macular edema and levels of severity of retinopathy); and care coordination (communication with the physician managing ongoing diabetes care). Data from these three measures provides an overall assessment of a diabetic patient’s eye care and coordination with the primary care provider. For cataracts, three measures provide the means to assess the pre-operative and post-operative status of patients: appropriateness of surgery and appropriate pre-operative evaluation (comprehensive preoperative assessment for cataract surgery with intraocular lens (IOL) placement); clinical outcomes (complications within 30 days of cataract surgery requiring additional surgical procedures); and patient outcomes related to daily functioning and activities (20/40 or better visual acuity within 90 days following cataract surgery). Results from these three measures provide a comprehensive picture of patients’ appropriateness for and successful outcomes of cataract surgery. The Academy continues to be concerned about CMS’ inability to provide timely and transparent information to participants about their reporting and fear that this gap is creating poor perceptions regarding the program by physicians including ophthalmologists. Despite some changes, access to feedback reports continues to be extremely cumbersome and is especially burdensome for small practices. We have heard from individual providers that they are unable to obtain an individual feedback report and are told by their carrier they cannot provide them with an individual 2008 PQRI feedback report because they previously registered in IACS. Many practices let their IACS accounts lapse so they cannot access either the group or individual feedback report. Re-registering in IACS is extremely time-consuming and small practices do not have the necessary staff to deal with such a timely task. 6 Furthermore, even when the reports can be accessed, they are not timely and provide little or no meaningful information to guide physicians in determining or correcting reporting errors in the current cycle or much of the subsequent cycle. Physicians are looking for real time data and information that specifically addresses where they are reporting incorrectly. If they do not know how they are specifically reporting they cannot correct their mistakes. We strongly suspect that lack of a chance to review meaningful feedback will lead to decreased participation going forward. Despite the propensity that the specialty of ophthalmology has shown in adopting new technology and being a leader in quality reporting, there is currently no ophthalmology EHR reporting mechanism for PQRI since no eye care measures are included in this option. In order to receive greater participation in EHR reporting of quality measures, CMS needs to expand upon the list to include measures that are applicable to ophthalmology and other medical specialties. P. Five-Year Refinement of Relative Value Units With the ongoing work of the RUC on Misvalued Services, the Academy will have reviewed a minimum of 16 services including cataract, complex cataract and from all other areas of ophthalmology. The agencies proposal to collect additional information on the summary recommendations for the next review should not be too burdensome for specialties to calculate and the Academy will work with our survey data to provide the additional work value percentages but we would be concerned about the consideration of values that were at the 5th or 95th percentage of work value for any service. Additionally, the suggestion of using the geometric mean in order to more closely calculate the annual rate of growth in the value of services is an interesting proposal going forward. The Academy is concerned that it would not be able to accurately compare any growth in values for many years out and only if it is uniformly applied across all services. Additionally, the Academy suggests that CMS make any PQRI data that it indicates it may also review services available to the RUC and the organizations who participate in it before making any determinations from it. As expressed in our comments earlier on PQRI, the Academy remains concerned about the lack of transparency and reporting for PQRI. Finally, we have no suggested codes for the Fourth Review of Work and will await the agencies upcoming rule regarding the upcoming Review. This concludes the Academy’s comments on the 2010 Final Medicare Physician Fee Schedule. We appreciate the opportunity to provide our comments. Sincerely, Michael X. Repka, M.D. AAO Federal Affairs Secretary