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More experts weigh in on the physician fee schedule proposed rule

Part B News has examined the basics of the 2021 physician fee schedule proposed rule that was released on August 4, and we'll have plenty more analysis and guidance on the topic in the days to come. Meanwhile, here are some reflections on different parts of the rule by some of Part B News' stable of experts. 
Harry Nelson, co-managing partner of the Nelson Hardiman law firm in Los Angeles and author of The United States of Opioidson opioid-related changes: 
Personally I think there's further to go. But I think on balance [the changes, including Part B coverage for Narcan] are positive.
My frustration is, besides them moving so slowly, is that they seem not to fully recognize is this [Opioid Treatment Program] iteration of opioid treatment -- that these medical services, whatever the medicine is, needs to be integrated with support services, and they're still limiting access to outpatient programs and only giving professional support. They're still denying people access to the full continuum.  Its almost either/or -- either you get something medication-based, or you get treatment services which we don't actually cover.  
They also limit which programs they allow to those certified by SAMSHA. That's unnecessary. There are almost no other health care services I can think of that that Medicare requires to have federal certification [vs just state licensing].
Dan Golder, principal with Impact Advisors in Naperville, IL., on Merit-Based Incentive Payment System (MIPS) scoring:
We’ve been watching for this shift from quality to cost as MIPS scoring evolves. MIPS started quality-heavy. Now it’s shifting more toward cost (which is mandated by the legislation, which requires cost to be 30% in 2022). Providers will have to come to grips with that – it’s likely going to be challenging for some to score well, as most providers feel they have more control over quality than they do cost.
...the challenge with cost [for accountable care organizations] is that it’s calculated externally for providers by CMS. Unlike quality scores (which a provider can tie back to the patient record and understand how the scores are calculated), cost calculations are more of an unknown, and that makes them more difficult for providers to feel they can control.
Additionally, beginning in 2022 the MIPS Performance Threshold will be required to be equal to the mean or median of the final scores from a prior period. Because we know many providers are scoring well now, that likely means that the MIPS Performance Threshold will increase substantially. If that median turns out to be high – let’s say from 45-50 points to maybe 75 or 80 points or higher – this could pose a challenge for many providers. And if you compound this with the legislative requirement to have the cost component be equal to 30% of the MIPS score, this may mean that many providers currently receiving an incentive could be faced with a penalty in 2022.
Lauren Patrick, founder and president of Healthmonix in Malvern, Pa.​on qualified clinical data registries (QCDRs) in the Quality Payment Program (QPP):
A big ongoing message from CMS is reducing burden on clinicians.  To this point, they are trying to improve partnerships with third party intermediaries such as registries and health IT companies... Part of the partnering is the work on [the delayed MVP program], but in addition, it is proposed that QCDRs, qualified registries and health IT vendors support the APM Performance Pathway (APP) starting in 2021. We support this proposal, in that it provides more alignment between the MIPS and APM programs. This helps clinical organizations better understand the performance measurement and transition between various value-based programs.   
Additionally, CMS is proposing placing more reliance on these third party intermediaries for data validation from clinicians. The QPP program is maturing, and as such, CMS is working with these organizations to refine the process and further increase the reliability of the data being submitted. In addition, as third party intermediaries continue to participate in the process, CMS is strengthening the approval and review process by placing more review criteria on these entities. 
CMS is looking towards QCDRs, in particular, to provide more robust testing of quality measures being included in the program.  In the past, the testing requirements have been minimal, but again, in order to move forward, there will be more stringent requirements...
In the 2020 final rule and in meetings held with registries and CMS, one of the directives from CMS was that registries were going to need to provide feedback on performance against current year data in the registry. This is to enable providers to understand their performance against more timely benchmarks. CMS was indicating that this was a 2021 goal. With the onset of the PHE, there is additional concern that the benchmarks for 2020 will be skewed and or not representative of quality practices in normal times. So the urgency of more up-to-date benchmarks has increased. 
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