Each year, the Centers for Medicare and Medicaid Services (CMS) puts out several regulations that impact how emergency physicians are paid under Medicare. Federal regulations provide details needed to implement legislation once it has been passed by Congress and signed into law by the president. They are promulgated in draft form by the federal agency with jurisdiction over that area, in this case CMS, and released to the public for comment. Some months later, the agency will then release a final rule incorporating any changes it deemed appropriate based in part on the feedback collected from the commenting public. Some regulations, such as the CMS payment rules, require annual updates and are therefore released with proposed revisions each year for stakeholders such as ACEP to comment on.

ACEP provided extensive comment to CMS in August on the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Quality Payment Program (QPP) proposed rule. At over 1,000 pages, the rule offers details of CMS’s vision for the second year of this new payment program for physicians in Medicare. For 2018, CMS proposes to continue many of the “pick-your-pace” flexibilities it provided in 2017 for the merit-based incentive payment system (MIPS) (ie, fee-for-service) component in the program’s initial year, but it is starting to raise the bar in order to encourage participating clinicians to more fully embrace a transition. Of note, CMS proposed to significantly increase the threshold for a “low-volume” exception from the requirement to participate in MIPS to fewer than $90,000 in Part B charges or 200 patients. ACEP supported CMS’s proposal to allow hospital-based physicians to have some of their performance for MIPS be based on that of their facility, rather than on their individual or group performance, if offered as an option. ACEP also strongly supported CMS’s proposal to offer bonus points for clinicians who care for sicker patients and to risk-adjust some components of MIPS scores by sociodemographic factors.

In September, the CY 2018 Medicare physician fee schedule proposed rule provided another opportunity for ACEP to provide extensive input on regulations affecting emergency medicine. While CMS proposed a welcome additional delay for the appropriate use criteria (AUC) program for advanced imaging to 2019, ACEP expressed strong concerns with the program overall and the significant administrative burdens it will create for emergency physicians and called, once again, on CMS to exempt emergency medical conditions as Congress intended.

Continuing the efforts of former US Health and Human Services Secretary Tom Price, MD, to reduce administrative burdens for physicians in Medicare, CMS is proposing to streamline or even do away with documentation requirements for the history and physical portion for evaluation and management (E/M) visits at all levels. ACEP noted its appreciation for such efforts, but urged caution given the unique environment in emergency departments that often necessitates a significant amount of documentation for clinical, legal, operational, and coverage reasons.

CMS also proposed including emergency medicine E/M codes this year as part of its “misvalued codes” initiative that each year looks to identify codes in the fee schedule for potential revaluation in order to ensure better payment accuracy in Medicare. ACEP emphasized that the intensity in reported ED services has increased significantly over the past years but noted that it is premature to advise specifics on potential revaluation of any E/M codes at this time for a number of reasons.

While they are less impactful for emergency physicians, ACEP provided a response to several provisions of the hospital outpatient prospective payment system (HOPPS) proposed rule that suggests changes to the Hospital Outpatient Quality Reporting (OQR) program. ACEP strongly supported a new proposal to account for social risk factors in the OQR. While noting the importance of measuring ED throughput times for psychiatric patients, ACEP expressed strong concerns with CMS’s proposal to publicly report results on the Physician Compare website of this measure in the OQR program, given a lack of context that would be reported along with the results.

The final rule for the MACRA QPP program is expected sometime in October, while the fee schedule and HOPPS rules are both expected to be released in final form in November. ACEP will provide a summary to members of any changes in Medicare these rules will bring to their practice for the 2018 calendar year.

Ms. Wooster is ACEP’s associate executive director of public affairs, overseeing the College’s federal legislative, regulatory, grassroots, and public relations functions. Prior to joining ACEP, Ms. Wooster served as senior vice president of public policy for the American Osteopathic Association. She also spent five years at the Blue Cross Blue Shield Association, first developing policy on delivery system reform and health IT, then as a congressional and administration lobbyist. Ms. Wooster holds a Bachelor of Science degree in biology from the University of Michigan and a master’s degree in public health from the University of Illinois School of Public Health.