In Asking for MIPS Flexibilities, Providers Make Legitimate Points

April 23, 2018
I was quite intrigued to see the specifics in the recent letter that healthcare provider groups sent CMS about reducing the burden that MIPS requirements have put on clinicians.

I was quite intrigued to see the specifics in the recent letter that healthcare provider groups sent the Centers for Medicare & Medicaid Services (CMS) about reducing the burden that the Merit-based Incentive Payment System (MIPS) requirements have put on clinicians.

The letter, dated April 16, came from some of the industry’s heavy-hitting stakeholder groups, such as the Medical Group Management Association (MGMA), the American Medical Association (AMA) and the American Academy of Family Physicians (AAFP). At the core of the organizations’ requests was to shorten the data reporting period for the “Quality” component of MIPS from 365 to 90 days.

For a refresher, CMS published its calendar-year 2018 Quality Payment Program (QPP) final rule, under the MACRA (Medicare Access and CHIP Reauthorization Act of 2015) law back in early November. Many trade associations, including MGMA, recommended at the time that CMS institute a 90-day reporting period for the Quality component of MIPS; nonetheless, in the rule, CMS increased the 2018 MIPS quality reporting period from 90 days and mandated full-year quality reporting.

In the recent letter to CMS, the group of associations said that the reduction of calendar year to a minimum of 90 consecutive days is necessary to them, “due to the lack of timely and direct notification by CMS on whether a physician is considered MIPS eligible, as well as a severe delay by CMS in updating the Quality Payment Program interactive website with 2018 information.”

More specifically, the letter noted that although CMS posted eligibility information on the QPP website earlier this month, the trade groups are still concerned that the late notification will impact physicians’ ability to satisfactorily participate in MIPS. The letter stated, “Several policy changes in 2018 from 2017 complicate physicians’ ability to determine their MIPS eligibility status. For example, CMS expanded the 2018 low-volume threshold exemption. While the undersigned organizations strongly support the increased low-volume threshold and believe it will assist small practices and physicians who treat a small number of Medicare patients, it may create changes in physicians’ eligibility status.”

The associations added that since they were responsible for data tracking and collection for the QPP since the start of 2018, there was a two-month lag between January and April, which is when they were finally given MIPS eligibility information. What’s more, in order to see if they are eligible for a MIPS program, physicians must actively check CMS’ website, whereas in the past they would be mailed letters. This lack of direct outreach could leave some clinicians “in the dark” regarding their eligibility status, they said.

It should be noted that Healthcare Informatics reached out to CMS for comment, and the agency noted that it is aware of the letter and will be responding to the organizations at some point soon.

Fair Requests?

Sometimes when provider groups write to CMS requesting certain regulatory rule changes, it comes off as an agenda-based complaint rather than a reasonable ask that’s supported with evidence. In this case, though, I completely understand what the provider groups are asking for, and believe that it’s a logical and fair request.

Let’s consider the details. When CMS introduced the first QPP calendar-year rule for 2017—the very first year of the reporting program—it attested that eligible clinicians could use 2017 as a transitional “pick your pace” period. In other words, as long as clinicians reported at least some data to CMS, even the minimum amount, they would not be dinged with penalties. What’s more, 90-day reporting periods were permitted in 2017 and submitting data for a three-month window rather than for 365 days still enabled clinicians to qualify for maximum payment adjustments, if other criteria were met.

But then when CMS released the 2018 QPP rule, the agency said that clinicians must submit a full-years’ worth of data for the Cost and Quality components of MIPS; meanwhile, the Advancing Care Information and Improvement Activities performance categories only required data for a 90-day period.  At the time of the 2018 rule’s release, Anders Gilberg, senior vice president of government affairs at MGMA, said in a statement, “MGMA is very disappointed that CMS quadrupled the length of the quality reporting period under MIPS from the current 90 days to 365 days in 2018. This fourfold increase to the quality reporting requirements is in stark contrast to the agency’s statements today that the final rule reduces regulatory burdens. CMS is in effect prioritizing quantity over quality and giving physicians less than 60 days to prepare for the 2018 MIPS requirements.”

Indeed, while CMS is clearly trying to “up the ante” in the second year of MIPS, the agency should be more aware about how its own internal delays are affecting clinicians’ ability to report data. For one, as Gilberg noted, the government didn’t even release the 2018 final rule until November 2, 2017—just two months before the 2018 reporting period was set to begin. That window gave providers very little opportunity to read through the intricacies of the rule—all 1,600+ pages of it—and get ready for year two of MIPS.

What’s more, as MGMA and others pointed out in the letter, CMS didn’t release MIPS eligibility information for 2018 until just a few weeks ago, via a “participation lookup tool.” This was incredibly significant information, because due to new threshold program requirements for 2018, a great deal of clinicians would again be exempt from MIPS this year. But that’s the rub: these folks weren’t told if they would be eligible or not until the participation lookup tool was released earlier this month. So, for those who are eligible, and required to report, they were subjected to a two-month gap between the start of 2018 and when they were notified of their eligibility.

In my opinion, this time gap alone should result in CMS—the agency responsible for the delay—to reduce the reporting period to 90 days for this calendar year. Mandating that clinicians report on 365 days of data when they weren’t made aware of their eligibility for the first two months of the year just feels unfair. And to make matters worse, CMS did the same thing for the 2017 calendar year, releasing the final rule in mid-October 2016 and waiting until April of 2017 before posting MIPS eligibility information. The lesson apparently was not learned!

In the end, I once again stress that I don’t always side with the providers when they write to CMS pleading for one thing or the other when it comes to federal regulations. For instance, in the above letter, the groups asked for eligibility letters to be mailed physically rather than make physicians actively check CMS’ website. To me, this seems trivial and I would wager that many folks probably prefer checking online.

But for something as important as quality data reporting that affects clinicians’ bottom lines, it’s quite easy to understand their frustrations in this situation. And if CMS were more on-time with their rule releases and eligibility updates, maybe these provider groups wouldn’t have as much of a gripe.  But considering the information in front of us, it’s more than reasonable that the feds cut down the reporting periods for the Quality component of MIPS to 90 days. Here’s hoping that they do the right thing.

Comments? Questions? Send to @RajivLeventhal or comment below.

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