As the deadline neared for public comments on the proposed rule related to physician payment requirements under the MACRA (Medicare Access and CHIP Reauthorization Act of 2015) legislation, which created the MIPS (Merit-based Incentive Payment System) system for physician reimbursement under Medicare, a host of healthcare professional associations released public statements that encompassed their comments to the federal Centers for Medicare & Medicaid Services (CMS).
The key elements in the various sets of comments included: a request that CMS officials delay the onset of the program from its proposed start of January 1, 2017, to July 1, 2017 or beyond; requests that CMS officials make major modifications to value-based concepts under MACRA; numerous types of requests for changes in the final rule around measurements and other elements in the MIPS program.
The American Medical Group Association (AMGA), the American Medical Informatics Association (AMIA), and the Premier health alliance, were among the numerous healthcare associations publicly sharing their comments to CMS.
In a June 27 letter to Andy Slavitt, CMS Acting Administrator, Donald W. Fisher, Ph.D., president and CEO of the Alexandria, Va.-based AMGA, suggested a very wide range of changes to the proposed rule, including a delay to the start of the program from January 1 to July 1 of 2017. Among those that touch on physician practice and health IT, Dr. Fisher said that AMGA wants CMS officials to rethink how they frame the use of healthcare it (HIT). With regard to the new Advancing Care Information (ACI) program, Dr. Fisher wrote, “Generally, the ACI measure still emphasizes the simple use of health information technology, i.e., competency in sending healthcare information electronically. The ultimate goal of the ACI measure is to improve care outcomes via measures that incent a business rationale for Certified Electronic Health Record Technology (CEHRT). CMS should evolve the ACI measure to reach this goal.”
Further, Dr. Fisher wrote, “The base score still includes Meaningful Use’s pass/fail methodology. AMGA proposes CMS award points for each base score measure reported… AMGA proposes CMS continue to use or apply previous meaningful use exclusions and hardships under MIPS ACI. AMGA also encourages CMS to align in the final rule ACI measures with the forthcoming Office of the National Coordinator’s (ONC’s) interoperability recommendations.”
Meanwhile, the Chicago- and Washington, D.C.-based American Medical Association’s James L. Madara, M.D., also sent a letter on June 27 to CMS’s Slavitt, with a host of recommendations that took 67 pages to be specified. Near the top of the letter, Dr. Madara summarized his many recommendations with the following bullet points. He urged CMS to:
> “Establish a transitional period to allow for sufficient time to prepare physicians to have a successful launch of MACRA.
> Provide more flexibility for solo physicians and small group practices, including raising the low volume threshold.
> Provide physicians with more timely and actionable feedback in a more usable and clear format.
> Align the different components of MIPS so that it operates as a single program rather than four separate parts, such as creating a common definition for small practices.
> Simplify reporting burdens and improve chances of success by creating more opportunities for partial credit and fewer required measures within MIPS.
> Reduce the thresholds for reporting on quality measures.
> Reward reporting of outcome or cross-cutting measures under a bonus point structure rather than a requirement in order to achieve the maxium quality score.
> Improve risk adjustment and attribution methods before moving forward with the resource use category.
> Replace current cost measures that were developed for hospital-level measurement and refine and test new episode measures prior to widespread adoption.
> Permit proposals for more relevant measures, rather than keeping the current MU Stage 3 requirements.
> Remove the pass-fail component of the Advancing Care Information (ACI) score).
> Reduce the number of required Clinical Practice Improvement Activities (CPIAs) and allow more activities to count as “high-weighted.”
> Simplify and lower financial risk standards for Advanced APMs.”
With regard to the measurement of physician performance under the entire program, the AMA wants CMS officials to provide real-time feedback to practicing physicians. “We appreciate CMS’s efforts to conduct MIPS user assessments but are concerned these efforts fall short and do not address the complexity of accessing feedback reports,” Dr. Madera wrote to Slavitt. “We are also concerned with the timeliness of the release of feedback reports and benchmarking information. CMS should consult with stakeholder groups to determine the best presentation and most meaningful format for sharing ongoing, actionable performance feedback with physicians and practices. As technology is constantly changing,” he noted, “it is critical that CMS take an ongoing approach to improving he way performance information is dismmenatied to physicians and practices…” Rather, he wrote, “[W] encourage CMS to move towards a more iterative process where physicians and vendors submit data more routinely to CMS.”
AMIA Weighs In on Clinical Practice Improvement Activities (CPIAs)
The Bethesda, Md.-based American Medical Informatics Association (AMIA) also weighed in with detailed recommendations on June 27. The association noted on its website that “CMS announced in April new proposals to combine several federal programs into a single QPP [quality payment program] for physicians and other clinicians paid through Medicare. The QPP is composed of quality, resource use, technology and practice improvement requirements, and establishes two main pathways for physicians to receive payment: through a Merit-based Incentive Payment System (MIPS) or through an assortment of Alternative Payment Models (APMs), such as Pioneer ACOs. Beginning in 2019, clinicians paid through Medicare will receive bonuses or penalties based on a composite score in MIPS, or they will be subject to the risk-sharing terms of their APM.”
In its comments to CMS, AMIA stated that "We applaud CMS for proposing a set of policies and requirements across the four categories of MIPS and for Alternative Payment Models that clearly incorporate stakeholder feedback and lessons learned from the legacies of the Physician Quality Reporting System, Value-Based Modifier, EHR Incentive Program, and various alternative payment models,” AMIA said in comments. “AMIA believes CMS has an unprecedented opportunity to learn which components of these legacy programs will effectively support our healthcare system in moving toward the triple aim, and we strongly recommend that CMS engage medical informatics expertise more broadly to understand how technology should be leveraged to improve care experience, expense and efficacy."
However, AMIA also expressed doubt over the ability of clinicians to successfully participate in a full-year reporting period beginning January 1, 2017. "AMIA recommends CMS issue an interim final rule with a comment period to further refine proposed policies based on stakeholder feedback, and we recommend CMS consider a 90- or 180-day reporting period in 2017." The organization said success in the first year would be critical to the long-term success of the reforms.
Among AMIA’s recommendations, as stated on its website and in its letter to CMS:
“In order to improve the current proposal and to help guide future proposals, AMIA established several principles CMS should consider related to QPP, which included:
> Use data reporting requirements to learn, not simply to grade.
> Focus on defining clear, expected outcomes, rather than prescriptive process measures.
> Engage organizations and experts to perform scientifically rigorous, peer-review studies to determine which requirements should be retained in future years.
> Develop feedback loops that are accurate, timely and meaningful.
> Encourage increased data exchange and interoperability whenever possible.”
The announcement on its website included a statement from AMIA president and CEO Douglas B. Fridsma, M.D., Ph.D. "CMS has been tasked with changing our fundamentally flawed fee-for-service Medicare reimbursement system, and has issued an ambitious set of proposals to do so, Dr. Fridsma wrote. “While the new Quality Payments Program is complex, we are hopeful that these policies will enable informatics to play a central role in lowering costs, improving quality and delivering better outcomes."
Specifically, AMIA supported the newly conceptualized Clinical Practice Improvement Activities (CPIAs) Performance Category and proposed a number of enhancements to the proposed Advancing Care Information (ACI) Performance Category, which will replace Meaningful Use for clinicians participating in MIPS. AMIA recommended CMS emphasize CPIAs that leverage team-based and transdisciplinary care, and encouraged CMS to score maintenance of certification IV activities with a "high" weighting to take advantage of robust continuing medical education programs already in place. AMIA also recommended CMS reinstitute exclusion criteria for certain ACI Performance Category measures, and asked CMS to reconsider how they calculate the ACI Performance Score to give clinicians additional flexibility to focus on meaningful IT functionalities.
"AMIA has a strong interest in seeing the ACI Performance Category work for all stakeholders, and I foresee clinicians demonstrating tremendous innovation to achieve credit for the CPIA category," said AMIA Board Chair and Medical Director of IT Services at the University of Washington’s UW Medicine, Thomas H. Payne, M.D., Ph.D., FACMI. “While imperfect, these proposals will give clinicians the tools they need to track progress on quality, improve resource use and utilize informatics to deliver better care for patients."
Premier Asks for Streamlining, Simplification
The Charlotte-based Premier health alliance offered some very specific recommendations. With regard to the MIPS payment system, the leaders at Premier asked that CMS do the following:
> Quality measure domain (50 percent weighted): We support CMS’ proposed reduction in measures from 9 to 6 and recommend that CMS reduce the data completeness requirements in 2017. We also oppose use of the AHRQ PQI measures the all-cause readmission measure over concerns with its validity and reliability. We support awarding bonus points for high-priority measures and suggests stronger incentives by increasing the maximum bonus points to 10 percent of the total possible score.
> Resource Use (10 percent): We urge CMS to allow clinicians to use only total costs or condition-specific episodes, submit all of the measures for NQF approval, and make adjustments for socio-demographic factors.
> Clinical Practice Improvement Activities (15 percent): We recommend that CMS modify the scoring so that clinicians complete only two to four activities per year and one activity per year for small, rural and Health Professional Shortage Areas (HPSA).
> Advancing Care Information (25 percent): In this formerly “Meaningful Use” measurement category, we support the approach to recognizing levels of achievement rather than an all or nothing approach. We propose CMS provide more bonus points for optional registry reporting and urge the use of benchmarks and deciles to award performance points.
Premier also said, “We ask that CMS allow facility-led APMs to use the APM scoring standard. We also ask CMS to create a pathway for models that do not directly tie clinician quality performance to payment but do so through a facility measure. We also emphasize that CMS needs to provide feedback on performance earlier during the performance year, particularly for claims-based measures.”
With regard to the APM payment system, Premier recommended the following:
> "We strongly urge CMS to implement new Advanced APMs eligible for the bonus payment.
> Medical home model definition: We support the choice of 4 out of the 7 proposed discretionary elements that qualify a medical home model and asks CMS to consider incorporation of specialists who act as the primary care provider for patients within the medical home.
> Advanced APM Criteria, financial risk for monetary losses: We ask CMS to reconsider investment risk for what constitutes “nominal financial risk,” at least until a lesser risk track can be developed and implemented in the Medicare Shared Savings Program (MSSP). We also recommend CMS lower the proposed loss sharing limit for Advanced APMs from 4% to a reasonable threshold such as 10% of Part B professional services or 1% of total Part A and B costs.
> Capitation: We support making full capitation risk arrangements qualify as an Advanced APM and encourage including partial capitation.
> Application of criteria to bundled payment: We recommend that Comprehensive Care for Joint Replacement (CJR) and Bundled Payment for Care Improvement (BPCI) models count as Advanced APMs.
> Other-Payer Advanced APM Models: We ask that the recommendations in our letter be applied to the Other-Payer Advanced APMS and that there be some flexibility on quality and CERHT requirements that are fitting for the population and payment models."
As this situation continues to evolve forward, Healthcare Informatics will continue to update readers on new developments.
