AMGA’s Chief Policy Officer Shares the Association’s Concerns Over Proposed CMS MD Payment Changes

July 31, 2019
Chet Speed, AMGA’s chief policy officer, shares his perspectives on CMS’s proposed changes to the Medicare physician fee schedule that were announced on Monday

Leaders at the Alexandria, Virginia-based American Medical Group Association (AMGA) on July 29 expressed their deep concerns with the proposed calendar year 2020 changes to the physician fee schedule under the Medicare program that were announced earlier in the day by Seema Verma, Administrator of the Centers for Medicare & Medicaid Services (CMS).

As the association stated in a press release published on AMGA’s website, “Based on initial review of the proposed CY 2020 Revisions to Payment Policies under the Physician Fee Schedule, AMGA is concerned that the estimated program year payment adjustments for the 2020 Merit-based Incentive Payment System (MIPS) do not reflect congressional intent or provide reimbursement that is commensurate with the investments that AMGA members made in response to the Medicare Access and CHIP Reauthorization Act (MACRA). As authorized by MACRA, providers have the opportunity to earn an adjustment of up to 9 percent on their Medicare Part B payments in 2022 based on their 2020 performance,” the association stated. “However, as indicated in today’s proposal, the Centers for Medicare & Medicaid Services (CMS) estimates the overall payment adjustment will be 1.4 percent.”

As the press release stated, “In light of this significantly reduced adjustment, AMGA is concerned that MIPS is no longer a transition tool to value-based care, but instead represents a regulatory burden that does not support physician group practices and integrated systems of care that are investing in delivery models based on care coordination and improving population health. In addition, this adjustment undermines the intent of Congress to use MACRA to move the healthcare system to value-based payment.”

And the press release quoted Jerry Penso, M.D., AMGA’s president and CEO, as stating that “We are entering the fourth year of MIPS, and our members expected to have the opportunity to earn a significant payment adjustment if they performed well,” By proposing an overly cautious approach, CMS is not rewarding those organizations that made the necessary investments in and championed value-based care as envisioned by congressional leaders,” Dr. Penso said.

The next day, Chet Speed, AMGA’s chief policy officer, who has been working on such issues for the association for years, spoke with Healthcare Innovation Editor-in-Chief Mark Hagland regarding AMGA’s statement, and the broader situation around value-based reimbursement incentives in the current landscape. Below are excerpts from that interview.

Looking at the situation from a “40,000-feet-up” perspective, what are your thoughts overall on the proposed set of changes to physician reimbursement, as announced by CMS yesterday?

Let’s actually start at 80,000 feet up. When MACRA [the Medicare Access and CHIP Reauthorization Act of 2015] was originally passed, our members looked at MIPS [the Merit-based Incentive and Payment System, under the MACRA law]. Everyone focused on MACRA as a transition tool to APMs [advanced payment models] , but when we looked at MIPS itself, it was clear that it was quite a significant transition tool, because you went from 4 percent to 9 percent by 2022 in terms of upside and downside risk under MIPS.

So member leaders said, we’ll actually do really well [under MIPS]. Everyone looked at APMs as risk transition programs—ACOs [accountable care organizations], Next Gen the Next Generation ACO program under Medicare]. But MIPS had significant levels of upside and downside risk also, from 4 to 9 percent. So when you look at 2022, with at-risk payment changes of up to 9 percent upside-downside, that’s as significant as participating in an APM.

So members felt, we can make these investments, but because the upside is really strong, we’ll be rewarded for the investments we make, if we do well. But what has happened is that CMS has excluded just under half of eligible clinicians; and because MIPS is budget-neutral, some clinicians have to do poorly for others to do well [in terms of reimbursement adjustments, up or down]. And what they said yesterday was, there’s a high of plus 9 percent in 2022. And CMS estimates now you’ll only be able to make 1.4 percent more, rather than the anticipated 9 percent. The statute had said you could make up to 7 percent, and last year, CMS said, you’ll get 2 percent, tops.

So members went into MIPS [the Medicare Shared Savings Program] believing they could do well. So there’s a tremendous sense of disappointment among members right now, given that the rewards are dwindling to virtually nothing. So there’s a tremendous sense of disappointment that this program has not lived up to its promise.

What is the fix for that?

What we’ve been calling for, for four years, is that CMS end the exclusions, given that it’s a budget-neutral program. Just fewer than half [of the physicians who might have been required to participate] have been excluded from the program. And what’s interesting is that, prior to MACRA, which consolidated PQRS, meaningful use, and the value-based modifier (which is cost); and those three programs had zero exclusions. When MACRA was developed, they combined all those programs into one, and started excluding providers, and now half the folks are excluded, so that makes it tough for everyone in it, and that’s why you have these very difficult percentages.

So they messed up their own math, then?

Well, actually, they meant to exclude all those folks. And to be fair, CMS looked at solo practitioners, very small practices, and rural practices, and wanted to give them a break. And it actually started with the Obama administration, with “Pick Your Pace.” And then it became a programmatic rule under the Trump administration.

One of the challenges right now seems to be around mixed messages from CMS. They’ve made the MSSP program more rigorous and are trying to force providers to take on downside risk faster. But that could backfire, leading to defections from the program. Meanwhile, this move seems to contradict that one. Your thoughts?

That’s a great point, and you’re right. But Secretary [of Health and Human Services Alex] Azar and Administrator Verma keep talking about shifting to value. And they said, per the MSSP, we’re moving to value, and if you can’t make that shift, we don’t really care. There is that desire to move to value; but in MIPS, they’ve actually done the opposite. They’ve taken their foot off the gas pedal. So it’s essentially just a compliance exercise, with little to no emphasis on value in MIPS.

Do you see an inconsistency of policy approach in all of that?

If you look at where they’re moving the Medicare program to value, it’s with the large physician practices. But when you look at the Part B program writ large, they’re deciding that smaller providers can’t do it. So you’re left with programs that our members are involved in being pushed relatively aggressively towards value, while smaller-group practitioners aren’t being. But insurance companies, DME, and pharma, aren’t being pushed to value. You can’t silo to move to value.

What will you be advising your members about this latest announcement?

I think they’ll be surprised about this rule and the approach that came out yesterday. Some will remain in MIPS and just sort of report data and expect little from it. Some will look at APMs. The biggest group will move towards Medicare Advantage. That’s a stable program, it’s predictable; and frankly, you know who’s in your program, which marks a vast difference from ACOs. So when our members look at all these programs, they’re saying, you know what? We’ll just stay in Medicare Advantage.

Where is this federal policy/regulatory train headed in the next two years, more broadly?

I will give Azar and Verma credit for their stated commitment to shifting to value. ESRP and radiation oncology therapy demos in CMMI. I think that that will continue. And Ms. Verma has set her sights firmly on equalizing payments across sites of care. That will continue. We’ll see if they do something around drug prices; they seem committed to that. That’s a heftier lift.

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