July 1, 2021

ACEP Responds to Major Medicare Hospital Payment Regulation

On Monday, ACEP submitted a formal response to the Fiscal Year (FY) 2022 Inpatient Prospective Payment System (IPPS) proposed regulation—the major reg that the Centers for Medicare & Medicaid Services (CMS) releases annually that updates Medicare hospital payments. CMS issues multiple Medicare payment regs each year, and the Calendar Year (CY) 2022 Physician Fee Schedule (PFS) and Quality Payment Program (QPP) proposed reg—the major reg that impacts Medicare physician payments—will be released sometime in the next couple of weeks.

As you may recall from a previous Regs & Eggs post summarizing the FY 2022 IPPS proposed reg, it includes a few issues that either directly or indirectly affect you as emergency physicians and your patients. While you are more than welcome to read our full response to the reg, some highlights of the response are found below:

Removal of ED Boarding Measure: In the reg, CMS proposes to add, modify, or eliminate measures in Medicare’s hospital quality reporting programs, including the Hospital Inpatient Quality Reporting (IQR) Program. One measure that CMS is proposing to eliminate starting in 2024 is the only existing measure related to emergency department (ED) boarding: ED-2, the Admit Decision Time to ED Departure Time for Admitted Patients Measure.

As soon as the IPPS reg was released, many people across the emergency medicine community immediately raised concerns with this specific proposal, strongly believing that boarding in the ED should continue to be tracked diligently and that this measure was absolutely necessary. Based on this loud and clear message from you all, ACEP decided to strongly oppose this proposal and request that CMS retain the measure in the Hospital IQR program.

To justify its proposal, CMS relies heavily on one analysis that looked at 12 studies that did not find a clear association between ED boarding and in-hospital mortality. However, ACEP disagrees with CMS’ assessment of the studies and its ultimate conclusion. Although CMS believes that there is not a clear linkage between boarding and patient mortality, there is indisputable evidence showing the opposite to be true. We include nearly 70 studies in an appendix to our response that demonstrate the linkage between boarding and patient morbidity and mortality. These references show that ED crowding leads to increased cases of mortality related to downstream delays of treatment for both high and low acuity patients. Boarding can also lead to ambulance diversion, increased adverse events, preventable medical errors, lower patient satisfaction, violent episodes in the ED and higher overall health care costs. We offer CMS the opportunity to meet to walk through these studies.

Hospital Value-based Purchasing (HVBP) Program: Due to the COVID-19 pandemic, CMS proposes to “suppress” most measures under another hospital reporting program, the HVBP Program, in 2022. By suppressing the measures, CMS will not have enough data to give hospitals a HVBP score—and therefore, hospitals will not be eligible for any positive or negative payment adjustments based on their performance in the program.

While ACEP supports this proposal (as hospitals should be held harmless from HVBP payment adjustments if not enough data is available), we request that CMS—perhaps in the CY 2022 PFS and QPP proposed reg—clarify how the proposal will impact the facility-based scoring option under the Merit-based Incentive Payment System (MIPS).

As background, under MIPS, many hospital-based clinicians, like emergency physicians, are eligible for the facility-based scoring option. If they do qualify, they can automatically receive the quality and cost performance score for their hospital through the HVBP Program. Hospital-based clinicians still have the opportunity to report quality measures through a traditional mechanism, such as a qualified clinical data registry (QCDR)—and CMS will automatically take the higher of that quality score and the facility score when determining clinicians’ final MIPS performance score.

While many hospital-based clinicians do report traditionally through MIPS and do not solely rely on the facility-based scoring option, some clinicians, especially those in small practices and those located in rural areas, do count on the facility-based scoring option to receive a MIPS performance score. In some cases, these clinicians do not have the resources or technological capability to report quality measures through an electronic health record, registry, or QCDR.

Since there will be no HVBP score in FY 2022, it is unclear what will happen with the facility-based scoring option. To protect hospital-based clinicians that depend on this option, we believe that CMS should ensure that hospital-based clinicians have a viable opportunity to utilize it. If CMS is not able to determine a facility score using previous data, then CMS should create a hold harmless provision to ensure that hospital-based clinicians are not penalized and do not receive a penalty simply because a facility score is not able to be calculated. 

Graduate Medical Education: CMS is implementing provisions of the Consolidated Appropriations Act of 2021 relating to payments to hospitals for direct graduate medical education (GME) and indirect medical education (IME) costs—including distributing 1,000 new Medicare-funded medical residency positions. The agency plans to distribute 200 slots a year over a five-year period starting in 2023. The first round of applications for hospitals to apply for the slots are due on January 31, 2022. CMS proposes to only distribute one full-time equivalent slot to a hospital at a time. There are no restrictions on what residency programs can be funded—they can be new or existing programs and they can be for any specialty. However, in line with the statute, CMS will prioritize applications from hospitals that fall into specific categories. 

In our comments, we state that we appreciate CMS’ attempt to distribute the slots in a fair and equitable way as well as the agency’s commitment to improving access to care in rural and underserved areas. While we recognize that the statute does not distinguish between physician specialties for purposes of allocating the additional residency positions, we believe that CMS should fund primary care residency programs and programs for any other specialties for which there is a shortage of physicians.

As alluded to previously, the IPPS reg is only the beginning of the annual regs that we expect to see. Not only will the CY 2022 PFS and QPP proposed reg be released very soon, but so will the major reg affecting Medicare hospital outpatient payments. Added on top of these annual regs is the first reg implementing the No Surprises Act—the federal surprise medical billing legislation—which could be released today. The season of Regs is in full swing!

Until next week, this is Jeffrey saying, enjoy reading regs with your eggs.

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