As Healthcare Innovation reported on October 5, on that same date, “The leaders of the Alexandria, Virginia-based American Medical Group Association (AMGA), which represents large multispecialty medical groups, on Oct. 5 sent Seema Verma, Administrator of the Centers for Medicare and Medicaid Services (CMS) a letter, asking her to reconsider some elements in CMS’s proposed Physician Fee Schedule for calendar year 2021. They focused on dissatisfaction with such areas as the agency’s proposed revaluation of evaluation and management (E/M) reimbursement for physicians, as well as with proposed changes to the Medicare Shared Savings Program (MSSP) that could imperil some payment advantages for medical groups participating in the program. The letter was signed by Jerry Penso, M.D., the association’s president and CEO.”
The press release that AMGA published on Oct. 5 to notify the public of the letter quoted Dr. Penso as stating that, “More than anything right now, our members need certainty. CMS’ plan unfortunately would add yet another change into a system that is dealing with an upheaval in how care is provided. From canceled elective procedures to a rapid shift to telehealth, group practices are working to not only get their bearings and recognize what care delivery models are most effective for treating patients during this pandemic, but also to understand what practice patterns will be like after COVID-19,” Penso stated in the press release. “Changes to code values just add more uncertainty.”
The letter, which can be read in its entirety here, had several areas of focus. The press release noted that, “In their comments to CMS, AMGA specifically recommends that the agency not move forward with its proposal to revalue a number of office and outpatient evaluation and management (E/M) visits. The reduction in the conversion factor needed to maintain budget neutrality represents a significant decrease in support for Medicare providers and would decrease payments for a number of providers. AMGA also is opposed to CMS’ proposals for the Medicare Shared Savings Program (MSSP), such as a proposed reduction in the number of quality measures that accountable care organizations (ACOs) will report and the elimination of the pay-for-reporting year for ACOs in their initial contract. CMS also would revise the quality performance standard so it creates an “all-or-nothing” ability for an ACO to earn shared savings. AMGA opposes these changes, which increase the influence of any one measure on an ACO’s ability to earn shared savings. These significant proposals come shortly after CMS finalized a new structure to the ACO program in 2018.”
In the letter, AMGA made several key recommendations:
Payment for Evaluation and Management (E/M) Services
CMS should not finalize its proposal to increase the relative value units (RVUs) for the evaluation and management (E/M) codes due to the significant decrease in the conversion factor. This decrease, when combined with the effects of the novel coronavirus 2019 (COVID-19) pandemic, would create significant financial hardship for various specialties within AMGA member groups.
Additions to the Telehealth List
o AMGA believes that telehealth will be a core service moving forward and supports CMS’ efforts to add additional codes to the Medicare telehealth list.
o AMGA supports the proposal to add a number of codes to the telehealth list on a Category 1 basis.
o While outside the scope of this proposed rule, AMGA recommends that CMS exercise all administrative authority at its disposal to waive the telehealth geographic and originating site requirements.
Continuation of Payment for Audio-Only Visits
o AMGA strongly recommends that CMS permanently add payment for audio-only services.
Medicare Shared Savings Program
o APM Performance Pathway (APP): While AMGA supports burden reduction and streamlining quality reporting for entities participating in value-based models, we are concerned about the extent to which CMS is reducing the Medicare Shared Savings Program (MSSP) quality measure set. CMS should not implement the APP as proposed and should work to implement a mix of outcomes and process measures that align across various programs. Additionally, AMGA does not support CMS’ proposal to end the quality “phase-in” (eliminating the pay-for-reporting year) with the implementation of the APP.
o CMS should not apply the quality performance standard to shared savings the way it is proposed. ACOs should not be ineligible to share in savings if they do not meet the more stringent quality performance standard.
Quality Payment Program
o APP: AMGA supports the use of the APP as a scoring pathway for Merit-based Incentive Payment System (MIPS) alternative payment models (APMs), as long as CMS maintains its other reporting mechanisms in the process.
o CMS Web Interface: AMGA opposes the elimination of the CMS Web Interface, as doing so would impose undue burden on ACO participants.
o Cost Performance Category: AMGA recommends that there be more modeling on the impact of adding the costs associated with providing these telehealth services to the previously established cost measures.
o Quality Measure Benchmarks: AMGA supports CMS’ intended approach of using performance period benchmarks for the calendar year (CY) 2021 performance period.”
Shortly after AMGA sent the letter to Administrator Verma, Darryl Drevna, AMGA’s senior director of regulatory affairs, spoke with Healthcare Innovation Editor-in-Chief Mark Hagland about the broader context of the letter, and the prospects for policy adjustments and changes that the association is looking for. Below are excerpts from that interview.
What are your main concerns around the Medicare Shared Savings Program right now?
For the MSSP, CMS typically is going to make some technical changes. They do that when they propose the Medicare physician fee schedule every year, and everyone understands and expects that. This year, they made changes above and beyond what they typically do. If you’ll recall, CMS finalized a new framework to the MSSP through the Pathways to Success rule [in December 2018]. We thought we had gotten our bearings around that. And there was the Glide Path for Pathways to Success. But what CMS is doing now is making some pretty significant changes to the MSSP program, including by requiring participants to participate in the APM Performance Pathway. They’re sunsetting the web-based interface, and they’re linking your eligibility for shared savings to your quality performance.
Quality has always been a factor in the MSSP, and no one has problems with that. What they’re doing now is making it an all-or-nothing proposal: if you miss on one specific quality measure, you’re eliminated from any potential for earning shared savings. So it’s really setting up a cliff. So if for some reason you fail on one particular quality measure, you risk earning any savings at all, which we think is a significant change to an arrangement that CMS had finalized not even two years ago.
In the past, you had the MSSP, Medicare Advantage, individual contracting, and fee-for-service payment, and each system has its own set of quality measures. And it can be difficult even for sophisticated medical groups to be able to manage all those systems. It can get fairly convoluted. And of course, you’re always going to provide the best care you can, but how it gets measured can have significant impacts. And in this proposed rule, they’ve reduced the measure set down to six, and two of those are utilization measures. Controlling utilization is an important part of population health, which any value-based contract has. But if you put too much emphasis on a single measure, that distorts the program. And you’re putting a lot of emphasis on the reduced-measures set, and then you’re eliminated from any opportunity to earn any savings.
The other thing we’re recommending is around the quality phase-in. And it’s in that first year when you go from fee-for-service payment to caring for a population of patients. And it’s not possible to turn on a dime. You have to do things with case management and numerous processes. There’s a glide path. And if you talk to our members, they’ll tell you that it takes years to figure out how to work with measures. That’s why we recommend that CMS keep that phase-in element.
The time of year is difficult, too; not only did CMS finalize a new framework to the program, and many member groups have just signed their contracts; but you add to their challenges what’s going on with the pandemic, it can get very convoluted. If you’re a provider, you have to quickly figure out which patients need care; and the pandemic has upended that. People are scared to come into the office; so it’s really a weird year.
So it can be difficult to get patients into care management programs?
Yes, and also, a lot of our member groups are more sophisticated and have more resources than other groups; and they were able to pivot to telehealth very early on. But not everybody was able to do so. And because they are more sophisticated, all of a sudden, they have patients who hadn’t previously attributed to them.
So the populations are very unstable?
That was our initial concern, yes. We’ll have to see.
Tell me about your overall concerns with the QPP.
One of the things that we’ve hit on with the QPP in the past few years is the low-volume threshold. CMS is not proposing any changes to that threshold; we didn’t expect that they would. We’ve long opposed the low-volume threshold—as a rule, we’ve supporting eliminating the low-volume threshold either in MIPS or in an APM.
You’ve opposed it because it ends up being unfair to larger groups?
We’ve long supported the idea of shifting the Medicare payment to one based on value, and it’s very difficult to do that if you’re exempting more than 365,000 physicians. If we’re all in this together, everyone needs to be moving in the same direction. Also, the way that Congress set this up is a stick-and-carrot approach; and you need a significant number of physicians involved for the payment structure to be meaningful. If you made the investments and scored well, there was the potential to earn up to 9 percent, which is really significant. And a lot of member groups went into APMs—in the APM pathway, you can earn a 5-percent bonus. And some member groups decided to stay in MIPS based on the potential for earning 7 to 9 percent under MIPS. And now, either way, it’s going to be really hard to earn more than 1.3 percent. And CMS is saying if you want to get more than a 1-percent payment adjustment, you have to meet the exceptional-performance threshold—you have to earn 85 points or better out of 100 to clear a 1-percent payment adjustment.
It’s a lopsided distribution, which is not what Congress had intended. It’s not only our members putting time, investments, and process changes into this, to implement a value-based system, but then you see nearly 400,000 physicians not participating, and that’s not a good thing. You either participate in an APM such as the MSSP or other models—and you have to qualify and meet criteria, and you’re exempt from MIPS—and exchange for participating in APMs, you earn a 5-percent bonus on your Part B revenue; or you can decide, OK, we don’t think we have either the numbers or the expertise or the resources right now to stand up, say, an ACO; but we can operate under this new quality regime, this new cost regime, under MIPS. What was intriguing as part of the way that the incentives were framed was, early on in the program, it was a smaller payment adjustment (plus or minus 5 percent) on how you scored—but in the “out years”—later on in the program—you could earn 7-9 percent.
There are performance years and payment years, linked. We’re in performance year 2020. And based on your score, CMS will give you a MIPS adjustment two years from now in payment year 2022. And Congress authorized plus or minus 7 percent, but in fact, it’s going to end up being only 1 percent. And our members thought they might earn plus or minus 9 percent on their Part B payment two years down the road. So many member groups decided to stay in MIPS rather than go into an APM, as a result. Unfortunately, the way the program has been implemented it’s nearly impossible to earn that 9 percent, regardless of how well you do. Someone out there might get 6 or 7 percent, but the aggregate adjustment is going to be 1.3 percent. So you’d have to be the top of the class to think about getting more than 2 percent.
So are you saying that, for some groups, it would have been better to go into the MSSP rather than stay in MIPS, had people known?
It really depends on what your population looks like, where you are in your development, and so on. It’s really a unique circumstance for each group, to make the best decision as to how they’d like to structure their delivery model; but they also need to know what the parameters are, what the framework is like. And members are making decisions now based on what they’ll be doing four or five years down the road. There’s a whole lot that goes into both of these programs. So there’s some dissatisfaction with the uncertainty around all of this. We understand that CMS is doing the best they can do; and there’s a whole lot of pressure to keep the thresholds in place. And CMS didn’t just pull these programs out of a hat. These programs were based on the Physician Quality Reporting System and meaningful use and the value-based modifier program.
What are you hoping, as this rule-making process moves forward?
I hope that CMS reconsiders its proposals for the MSSP Program. Everyone needs to take a more holistic view of this. Sometimes, I think that CMS tends to look at some of these programs in isolation, and doesn’t consider some of the headwinds that providers are facing. When you consider making MSSP an all-or-nothing proposition while at the same time making the adjustments under MIPS very small, and providers are trying to figure out what care delivery patterns will be operative post-pandemic—there’s a whole lot of uncertainty going on now, and I would urge CMS to factor all those things in. Also, CMS is pushing this out fast—the final rule is supposed to come out in December, and to be implemented in January. That is a really, really tight timetable.
