Medicare, the Chiropractic Perspective
Written by Editor   
Tuesday, July 19, 2016 07:53 AM

In a 10-page letter to the Centers for Medicare and Medicaid Services (CMS) regarding Medicare programs, the American Chiropractic Association (ACA) made the following points regarding CMS Proposals.  The letter in its entirety is found here.  Portions have been highlighted for ease of reference.  You will find the information in this letter a helpful resource.

ACA appreciates the opportunity to provide comments … regarding the Merit‐Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive … published in the Federal Register on May 9, 2016.  ACA would like to begin by commending Congressional efforts to repeal the fatally flawed Sustainable Growth Rate (SGR) formula. We also applaud the Centers for Medicare and Medicaid Services (CMS) for the extensive work that has been done to transform the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) legislation into rules and regulations that would implement the Merit‐Based Incentive Payment System (MIPS) and the Alternative Payment Model (APM) program. We strongly support changes to the Medicare physician payment system that recognizes providers for value and quality of the care they provide versus the volume of patients seen … however, there is still concern by … doctors of chiropractic, regarding the number and complexity of the proposed rule provisions.

ACA supports CMS’ proposed use of the existing National Provider Identifier/Taxpayer Identification Number (NPI/TIN) as the identifier to assess performance of an individual MIPS eligible clinician. The use of existing identifiers to identify MIPS eligible clinicians will allow for an easy transition and avoid the increased administrative burden and potential confusion associated with creating a new MIPS identifier. However, ACA also recommends that CMS consider allowing for greater flexibility in the reporting requirements and allow providers to participate either individually or as a group for each of the four (4) performance categories. There are circumstances where it may be reasonable to report individually for some categories and as a group for other categories. … we believe that the MIPS program would benefit from greater flexibility in allowing a combination of individual and group reporting for the different categories, while using a single NPI/TIN identifier for assessing performance and applying the payment adjustment.

CMS proposes that in the first two years of the program, MIPS eligible clinicians with the low‐volume threshold will be exempt from participation in the MIPS program. Low‐volume threshold clinicians are defined as those who have Medicare billing charges less than or equal to $10,000 and who provide care for 100 or fewer Medicare Part B beneficiaries. … we strongly urge CMS to modify the exclusionary definition so that clinicians with Medicare charges less than or equal to $10,000, OR those who provide care for 100 or fewer Medicare Part B beneficiaries would be exempt from participation. … The only Medicare covered service provided by doctors of chiropractic is spinal chiropractic manipulative treatment (CMT) and the average participating provider reimbursement amount for CMT is only $35.00. Further, although clinically and legally required to take a history, perform an examination, and establish diagnoses and treatment plans, doctors of chiropractic are the only physician level providers who are not are not covered for reimbursement under Medicare for Evaluation and Management (E/M) CPT codes. Therefore, while a doctor of chiropractic could see 100 or more Medicare beneficiaries during a performance period, their Medicare charges may not meet the $10,000 threshold.

Additionally, there are concerns that the proposed exclusionary criteria may lead to eligible clinicians in solo or small practices withdrawing as Medicare providers, or limiting the number of Medicare patients they treat over the course of a performance period, to avoid the administrative burden, complexity of reporting, and additional expenses that would be incurred with the adoption/implementation of certified electronic health record technology and/or engaging a submission vendor. This could have some unintended consequences on Medicare beneficiaries who may experience decreased access to care, especially in medically underserved and rural settings. Given the burgeoning demand for primary care providers, and the access issues Medicare beneficiaries already encounter, this modified definition more appropriately accounts for clinicians who should be granted an exemption from the MIPS program requirements.

Within MACRA there is a provision which would allow voluntary virtual groups to be established for the purpose of certain MIPS assessment. … we are concerned with CMS’ proposal to limit virtual group size to not more than 10 eligible clinicians for a performance period of a year. … it seems odd to limit the size of a voluntary virtual group to just 10 clinicians. We encourage CMS to reconsider this size limitation to ensure clinicians that elect to move toward more organized systems are not discouraged.

ACA supports CMS’ decision to maintain and streamline existing quality reporting programs while transitioning to MIPS; however, ACA is greatly concerned with how rapidly CMS has proposed to implement the new Quality Payment Program. … the newly developed programs are very complex for many clinicians, especially those that are solo practitioners or in and small practices, as are the majority of doctors of chiropractic. … Following publication, specialty societies and other stakeholders will need time to digest the final provisions, and develop and execute an extensive outreach and education effort to ensure that all clinician types are fully prepared not only to participate, but successfully achieve the goals and principles of the underlying MACRA bipartisan legislation. … it is our recommendation that that CMS consider extending implementation to, at minimum, 6 months (June 2017) to allow sufficient time for providers to learn how to implement the new reporting requirements, as well as train their staff on the new requirements.

ACA agrees that CMS’ proposal for the Quality Performance Category could provide eligible clinicians with greater flexibility, a more simplified reporting process, and more meaningful measurement of quality. We appreciate CMS’ proposal to maintain the claims‐based reporting option. Several clinician types, including doctors of chiropractic, are currently in the process of implementing registry and/or QCDR reporting options for the profession. Additionally, there are numerous limitations for the majority of the chiropractic profession to report using EHR data submission vendor products.  That said, ACA continues to have great concerns for the chiropractic profession regarding submission criteria. CMS proposes reporting at least six measures including one cost‐cutting measure and at least one outcome measure. Year after year doctors of chiropractic have only been eligible to report on the following two quality measures under the Physician Quality Reporting System (PQRS):  Measure #131: Pain Assessment and Follow Up; and  Measure #182: Functional Outcome Assessment.  Under Medicare, covered chiropractic services are limited to spinal chiropractic manipulative treatment (CMT) codes. Although clinically and legally required (e.g., by licensure statutes and Medicare) to take a history, perform an examination, and establish diagnoses and treatment plans, DCs are not covered for reimbursement under Medicare for Evaluation and Management (E/M) CPT codes. DCs are the only physician level providers who are not reimbursed for such services by Medicare. Therefore, the profession has been precluded from a number of reportable measures due to their limited coverage under Medicare. As quality or value‐based care dictates, the majority of measures are both work and diagnosis specific and therefore coverage of E/M codes is mandatory to report these measures. 

Further, CMS has also proposed to increase the thresholds for reporting on quality measures from 50 percent of Medicare Part B beneficiaries to 90 percent of all patients if through a registry/QCDR and electronic health record (EHR), or 80 percent of Medicare Part B beneficiaries if reporting via claims. This is a considerable increase in reporting thresholds and it is our recommendation that CMS maintain the 50 percent denominator data submission threshold for all reporting options to allow eligible clinicians sufficient time to adopt the changes to this performance category, as well as any modifications made to individual measure specifications.  

CMS has proposed to eliminate 13 cost‐cutting measures that were available under PQRS for 2016 reporting but are not being proposed as cost‐cutting measures for 2017 reporting.  ACA disagrees … CMS’ proposal to eliminate PQRS measure #131 – Pain Assessment and Follow Up, and measure #182 – Functional Outcome Assessment from the list of cross‐cutting measures for 2017 reporting … due to their limited coverage under Medicare, the chiropractic profession has been precluded from all but two reportable measures under PQRS since the program’s inception; therefore, the list of cross‐cutting measures does not contain measures for which all patient‐facing MIPS eligible clinicians can report. Additionally, the elimination of Measure #131 and #182 from the list of cost‐cutting measures for 2017 reporting establishes yet another barrier for doctors of chiropractic to successfully participate in the MIPS quality performance category by proposing to eliminate the only two measures on which doctors of chiropractic are currently eligible to report. Therefore, ACA urges CMS to include one, if not both, of the above stated measures in the list of cost‐cutting measures for 2017 reporting.

ACA has identified several areas of concern with CMS’ proposal for the resource use category.  We believe that there are serious flaws with the existing Physician Value‐based Payment Modifier (VM) program many of the measures were created for hospitals, not individual clinician providers, and are therefore inappropriate.  The current methodologies  have many serious weaknesses that have the potential to harm providers, particularly solo practitioners and small practices.  This issue is specifically critical to doctors of chiropractic due to the limited coverage of services allowed and reimbursed under the Medicare payment system. Without the ability to bill for evaluation and management (E/M) services, doctors of chiropractic will be unable to have patients attributed to them. However, Medicare’s rapid movement towards data‐driven, value‐based care provides a unique opportunity to evaluate the care provided by doctors of chiropractic within a broader health care delivery context.

Treatment options that are effective, conservative, and inexpensive should be encouraged for Medicare beneficiaries. CMT services, including associated but separately defined E/M services are among such treatment options for the following reasons: CMT has been extensively studied: A recent systematic review revealed that spinal manipulative therapy more effectively treated chronic low back pain (LBP) than sham or an ineffective control intervention and had a similar treatment effect when compared to analgesics, exercise, or medical care.  Practice guidelines recommend CMT:  The American Pain Society/American College of Physicians Clinical Practice guidelines found good  evidence that spinal manipulative treatment is effective for chronic LBP.  In January 2015 the Joint Commission revised its pain management standard to include chiropractic therapy.  The American Geriatric Society has found chiropractic care to be an appropriate method for managing chronic back pain.  The risk profile of CMT is extremely low: Calculated at between 5‐10 serious complications per 10 million manipulations.  Chiropractic care is effective: Beneficiaries are protected from declines in functioning as measured by Activities of Daily Living, instrumental Activities of Daily Living and self‐rated health.  High levels of Patient Satisfaction: Chiropractic patients report very high levels of satisfaction with the chiropractic care they receive. The Brandeis Report to Congress on the Demonstration of Expanded Coverage of Chiropractic Services under Medicare noted that 60% of chiropractic patients reported “complete” or “a lot” of relief from symptoms and 87% reported high satisfaction with care. 

Chiropractic care provides an alternative to more invasive treatments that are increasingly used and may have severe drawbacks:  Medicare spending on various invasive treatments for back pain increased substantially over the decade. According to an article published in 2009, a review of the literature found that over approximately a decade, epidural steroid injections increased by 629% and spinal fusions, by 220%; however, these increases were not accompanied by improvements in patient outcomes or reductions in disability rates. Indeed, several recent articles have documented the potential negative impacts of spinal fusion. During that same period, opiate use increased by 429% and recent studies have documented high utilization rates of opiate use among younger, disabled Medicare beneficiaries. Opiates are expensive, addictive, and present health risks that may result in downstream treatment costs.

While we are happy that doctors of chiropractic are included in the definition of MIPS Eligible Clinician at the onset of the Quality Payment Program, it is the opinion of ACA that doctors of chiropractic are at an enormous disadvantage for participation in the program due to the limited coverage under the Medicare program. Current policy dictates that DCs are expected to perform E/M services that are not currently reimbursed by Medicare, as a condition of payment for another service that is reimbursed by Medicare. Because E/M services must be delivered as a prerequisite of the spinal manipulation itself, they clearly fall within the statute’s description of “chiropractic services.” As such, E/M services should be covered as required in statute. ACA encourages CMS to expand the billing codes for doctors of chiropractic to cover the full scope of licensure, which not only allows for equal opportunities for chiropractic in the Quality Payment Program, but to allows greater patient access and expansion of spine care that achieves improved care, positive health outcomes, and reduced costs.

ACA is pleased with CMS’ recognition of the flaws and impediments that clinicians experienced with the Meaningful Use program. We are encouraged to see that CMS is proposing to offer greater flexibility and time for providers to update their software, train staff, and change practice workflows to accommodate new technology. It is critical to have a program that is truly meaningful and applicable to all provider types, and does not cause serious financial and administrative burdens. The chiropractic profession has experienced a slower adoption rate for Electronic Heath Records (EHR), which could be attributed to several factors. First is the fact that Regional Extensions Centers, while well intentioned to serve as a support and resource center to assist providers in EHR implementation and Health IT needs, did not consider chiropractic physicians as a “priority provider” for EHR adoption. Secondly, a very high percentage of doctors of chiropractic are solo practitioners that employ little or no staff in their practice, and face significant burdens to adopt and maintain this type of technology. Third, these burdens are exacerbated by the low reimbursement amounts for a very limited number of covered services that doctors of chiropractic provide to Medicare beneficiaries, as well as non‐coverage for services that they do provide and are included in their full scope licensure. 

CMS estimates that only 1.5 percent of doctors of chiropractic will receive a positive MIPS payment adjustment, while the remaining 98.4 percent are likely to receive a negative adjustment. Furthermore, the smaller the practice size, the greater the burden of participation and increased likelihood of a negative adjustment. We strongly encourage CMS to develop timely, actionable, and detailed feedback reports for MIPS eligible clinicians to improve performance. In the past, CMS has not adequately provided information that providers needed to make necessary changes during a reporting period that would allow them to meet satisfactory reporting requirements for specific measures. As a result, providers have incurred negative payment adjustments, without explanation or full understanding of how to change their reporting practices to successfully meet requirements and avoid future reductions to their Medicare reimbursement. Under the MIPS quality performance category, eligible clinicians may score poorly if they: 1) reported on less than 90 percent of his or her MIPS eligible patients; 2) did not report on a cross‐cutting measure if he or she is a patient‐facing clinician; 3) had a zero performance rate on a measure or a 100 percent performance rate for an inverse measure; or 4) did not pass the validation process. The quality performance category is critical to all eligible clinicians, but especially for doctors of chiropractic. Therefore, it is imperative that eligible clinicians are adequately notified, in a timely manner, about specific elements that are leading to satisfactory or unsatisfactory reporting within this category.  While ACA appreciates the technical problems that lead to the proposed two‐year gap between the performance period (2017) and application of the related payment adjustment (2019), eligible clinicians need and should be afforded the opportunity to receive feedback in a timely manner so that, if necessary, the provider can make modifications in order to meet the criteria for each performance category. Ideally, six months should be the target, to allow for unavoidable claim run‐out and adjudication processes.

Due to the complexity of the new Quality Payment Program, the extent of outreach and education that will be required to prepare eligible clinicians and the significant time investment required for clinicians to make changes in their practices workflows to accommodate the new reporting systems – all while continuing to treat their patients and run their practices – ACA strongly urges CMS to consider the first two years of the program as a trial period for providers to learn and properly implement the program. We believe it would be more beneficial and valuable to build the data and grow the program, allowing providers to adapt to the program requirements, similar to the opportunity being provided to non‐eligible MIPS clinicians. Additionally, it will allow CMS time to develop and implement a mechanism to provide actionable, timely, detailed feedback reports to MIPS eligible clinicians as well as close the time gap between performance and payment.

We encourage CMS to allow stakeholders, such as ACA and The Spine Institute for QualityTM (Spine IQTM), the opportunity to develop and test models that are simple to implement and flexible enough to allow clinicians to provide patient centered care that yields improved patient outcomes. Spine IQ is a not‐for‐profit organization with the mission to increase the patient‐centered value of spine care by leveraging multi‐disciplinary models, measures, education, and research. This is critical given the overwhelming public health significance of musculoskeletal or spine‐related disorders and increasing concern that currently widely used interventions may be ineffective and/or carry unacceptable levels of risk.

Again, ACA applauds CMS for the extensive work in developing the Quality Payment Program and we sincerely appreciate the opportunity to provide comments on the proposed rule. We will be happy to work with CMS going forward to ensure successful implementation of MACRA and the associated payment and quality reporting programs.