AMGA’s Regulatory Affairs Director on the Serious Issues in CMS’s Evolution of the MIPS Program

Nov. 6, 2019
Darryl Drevna, AMGA’s senior director for regulatory affairs, shares his perspectives on thorny issues in the MIPS Program that are frustrating practicing physicians who are trying to shift into value-based healthcare

On November 4, the Alexandria-based American Medical Group Association (AMGA) posted a press release to its website, commenting on changes being made by the Centers for Medicare & Medicaid Services (CMS) in two different areas—coding requirements for evaluation and management (E/M) services on the part of practicing physicians; and changes being made to the Merit-based Incentive Payment System (MIPS), both of which came in the form of the release of a final rule on November 1.

As the press release stated, “AMGA supports the Centers for Medicare & Medicaid Services’ (CMS’) decision to finalize changes to coding requirements for evaluation and management (E/M) services that acknowledge differences in patient complexity. In its final 2020 Physician Fee Schedule rule, CMS will maintain separate coding levels, rather than paying a blended rate. AMGA was concerned that collapsing E/M levels 2 through 5, as initially proposed by CMS, would disrupt care coordination efforts and result in fragmentation, which would hinder the transition to value-based care. AMGA is pleased that CMS reconsidered its 2019 regulation and in this year’s final rule opted to assign a separate payment rate to each of the office and outpatient E/M visit codes. CMS also finalized its proposal to maintain the level 1 visit code for established patients. AMGA recommended this approach, as the level 1 code helps facilitate a team-based approach to care delivery and allows various members of the care delivery team to develop a relationship with a patient.”

The press release quoted Jerry Penso, M.D., M.B.A., AMGA’s president and CEO, as stating that “A team-based approach to care requires an infrastructure to support it. It also requires the right policies and a payment system that will maintain that infrastructure. This change goes a long way to helping our members deliver the best possible care.”

But, under the subhead “Disappointed in MIPS Updates, AMGA stated that “The rule also finalized changes to the Merit-based Incentive Payment System (MIPS). Overall, CMS expects Part B payment adjustments of 1.4% for those providers who participate in the program. However, Congress authorized up to a 9% payment adjustment for the 2020 performance year. While not every provider will achieve the highest possible adjustment, CMS’ continued policy of excluding otherwise eligible providers from participating in MIPS makes it impossible to achieve substantial payments to cover the cost of participation. Thus, AMGA members have expressed that the program is no longer a viable tool to for transitioning to value-based care.”

With regard to the issues around the evolution of the MIPS system, Healthcare Innovation Editor-in-Chief Mark Hagland spoke with Darryl Drevna, AMGA’s senior director for regulatory affairs, around incentive- and reimbursement-based issues. Below are excerpts from that interview.

Can you articulate the issues that AMGA sees in the final rule that was just released?

AMGA continues to be disappointed in how CMS is implementing the MIPS program. Tweaking and changing the composite performance weights for the various categories is one thing, but ultimately, they’re continuing to pursue policies that result in negligible payment changes for those groups most interested in transitioning into value-based care. If you look at the impact table that CMS includes in the final rule—and they update this table every year—the overall payment adjustment is going to be 1.4 percent. Some groups will score higher, some lower, but either way, it’s far below what MACRA [the Medicare Access and CHIP Reauthorization Act of 2015] authorized, which plus or minus 9 percent for payment year 2022, which is performance year 2020. So for that year, CMS is estimating an aggregate payment adjustment of 1.4 percent.

And where I think CMS needs to evaluate where it’s implementing the MIPS program is that the only way you can get a payment adjustment of more than 1 percent is if you hit the exceptional performance threshold, meaning that the entirety of the group—they’ve got to hit 80 points out of 100 to get that payment adjustment.

That’s really difficult to do, to achieve such high performance levels in that system, correct?

It is. You’ve got to do really well on your quality and costs, and have very sophisticated health IT capabilities to do that. And AMGA isn’t opposed to that idea; but if you’re hitting the exceptional performance bonus, you should be one of the top performers, right? And even in reaching 80 to 90 points on a scale of 100, you’re only getting between 1 and 3 percent payment adjustment, and you’d basically have to be perfect to get more than 3 percent adjustment. That speaks to the fact that MIPS is a zero-sum game—there have to be winners and losers. And so if you exclude some providers, that doesn’t provide an accurate picture should be like if you excluded low-volume providers. By excluding such a large percentage of providers, you’ve skewed calculations.

And these are all programs that have been around for some time, with the value-based modifier, etc. MIPS repackaged some elements of existing programs.

What percentage of providers has CMS excluded from MIPS as low-volume clinicians?

I’m drawing this from table 122 in the final rule. There are just fewer than 880,000 clinicians who are eligible for and participating in the MIPS program, out of a total of 1.6 million total clinicians. Some of those are categorically ineligible. There are a total of 728,000 who are ineligible, and most are either not opting in or are below the criteria for the low-volume threshold. It was about 60 percent a year or so ago, but it’s still about half of clinicians who are excused, and MIPS is intended to be the transition vehicle into value-based care. So we’re concerned that if you are excluding half of the otherwise-eligible clinicians from the pathway to value, we won’t get there in any reasonable timeframe.

Do you see some core issues, with regard to the ACOs in the MSSP [Medicare Shared Savings Program] program also, in the ways that CMS is trying to push providers towards value?

There seems to be an inconsistency here, in terms of the incentives and policies involved.

The rewards are pretty small relative to the investment of effort, then, correct?

I definitely agree that the rewards are not commensurate with what our members are investing in information technology, staffing, and culture change, to not only prepare for, but ideally succeed in, value-based models of care. And when they go into this based on what CMS’s stated goals are and to see, well, at the end of the road, the reward you receive is significantly less than you had anticipated, that’s frustrating. I think CMS is very concerned about how this is going to impact the solo practitioners and very small practices, and they’re being very cautious in how they roll out their programs. And if they continue to implement MIPS in this fashion, it’s going to hinder the overall transition to value.

What can be done in the next year, about this?

AMGA is going to continue to advocate and get our message out there that we’re invested in working with our partners on the commercial side, to work with innovative, creative, value-based models of care. Our members are willing to be accountable for the value o care they provide. And at some point we’ll hit a decision point, and we’ll have to decide, are we actually going to pursue policies in rulemaking, to do this, or is this going to continue to be a regulatory/compliance exercise, and our member will adjust accordingly.

The tremendous amount of investment in healthcare IT is part of what your member groups are doing, correct?

If you’re in a shared-savings model or are assuming risk, in any type of model, you need to have a clear understanding of who your patients are; so you need access to data almost on a continuous basis. You need to know who’s treating your patients, where they’re accessing care, and need to know how to keep your patients as healthy as possible. And you can’t do that on paper. Our member groups’ clinicians are connecting on an almost daily basis to do care management. That’s incredibly labor-intensive, and requires a lot of support from the IT side of the house. When you’re talking about population health, you’re targeting interventions on behalf of the patients who most need them. And without that IT support, you’re virtually flying blind.

And where I think CMS needs to evaluate where it’s implementing the MIPS program is that the only way you can get a payment adjustment of more than 1 percent is if you hit the exceptional performance threshold, meaning that the entirety of the group—they’ve got to hit 80 points out of 100 to get that payment adjustment.

That’s really difficult to do, to achieve such high performance levels in that system, correct?

It is. You’ve got to do really well on your quality and costs, and have very sophisticated health IT capabilities to do that. And AMGA isn’t opposed to that idea; but if you’re hitting the exceptional performance bonus, you should be one of the top performers, right? And even in reaching 80 to 90 points on a scale of 100, you’re only getting between 1 and 3 percent payment adjustment, and you’d basically have to be perfect to get more than 3 percent adjustment. That speaks to the fact that MIPS is a zero-sum game—there have to be winners and losers. And so if you exclude some providers, that doesn’t provide an accurate picture should be like if you excluded low-volume providers. By excluding such a large percentage of providers, you’ve skewed calculations.

And these are all programs that have been around for some time, with the value-based modifier, etc. MIPS repackaged some elements of existing programs.

What percentage of providers has CMS excluded from MIPS as low-volume clinicians?

I’m drawing this from table 122 in the final rule. There are just fewer than 880,000 clinicians who are eligible for and participating in the MIPS program, out of a total of 1.6 million total clinicians. Some of those are categorically ineligible. There are a total of 728,000 who are ineligible, and most are either not opting in or are below the criteria for the low-volume threshold. It was about 60 percent a year or so ago, but it’s still about half of clinicians who are excused, and MIPS is intended to be the transition vehicle into value-based care. So we’re concerned that if you are excluding half of the otherwise-eligible clinicians from the pathway to value, we won’t get there in any reasonable timeframe.

Do you see some core issues, with regard to the ACOs accountable care organizations in the MSSP [Medicare Shared Savings Program] program also, in the ways that CMS is trying to push providers towards value?

There seems to be an inconsistency here, in terms of the incentives and policies involved.

The rewards are pretty small relative to the investment of effort, then, correct?

I definitely agree that the rewards are not commensurate with what our members are investing in information technology, staffing, and culture change, to not only prepare for, but ideally succeed in, value-based models of care. And when they go into this based on what CMS’s stated goals are and to see, well, at the end of the road, the reward you receive is significantly less than you had anticipated, that’s frustrating. I think CMS is very concerned about how this is going to impact the solo practitioners and very small practices, and they’re being very cautious in how they roll out their programs. And if they continue to implement MIPS in this fashion, it’s going to hinder the overall transition to value.

What can be done in the next year, about this?

AMGA is going to continue to advocate and get our message out there that we’re invested in working with our partners on the commercial side, to work with innovative, creative, value-based models of care. Our members are willing to be accountable for the value o care they provide. And at some point we’ll hit a decision point, and we’ll have to decide, are we actually going to pursue policies in rulemaking, to do this, or is this going to continue to be a regulatory/compliance exercise, and our member will adjust accordingly.

The tremendous amount of investment in healthcare IT is part of what your member groups are doing, correct?

If you’re in a shared-savings model or are assuming risk, in any type of model, you need to have a clear understanding of who your patients are; so you need access to data almost on a continuous basis. You need to know who’s treating your patients, where they’re accessing care, and need to know how to keep your patients as healthy as possible. And you can’t do that on paper. Our member groups’ clinicians are connecting on an almost daily basis to do care management. That’s incredibly labor-intensive, and requires a lot of support from the IT side of the house. When you’re talking about population health, you’re targeting interventions on behalf of the patients who most need them. And without that IT support, you’re virtually flying blind.

And where I think CMS needs to evaluate where it’s implementing the MIPS program is that the only way you can get a payment adjustment of more than 1 percent is if you hit the exceptional performance threshold, meaning that the entirety of the group—they’ve got to hit 80 points out of 100 to get that payment adjustment.

That’s really difficult to do, to achieve such high performance levels in that system, correct?

It is. You’ve got to do really well on your quality and costs, and have very sophisticated health IT capabilities to do that. And AMGA isn’t opposed to that idea; but if you’re hitting the exceptional performance bonus, you should be one of the top performers, right? And even in reaching 80 to 90 points on a scale of 100, you’re only getting between 1 and 3 percent payment adjustment, and you’d basically have to be perfect to get more than 3 percent adjustment. That speaks to the fact that MIPS is a zero-sum game—there have to be winners and losers. And so if you exclude some providers, that doesn’t provide an accurate picture should be like if you excluded low-volume providers. By excluding such a large percentage of providers, you’ve skewed calculations.

And these are all programs that have been around for some time, with the value-based modifier, etc. MIPS repackaged some elements of existing programs.

What percentage of providers has CMS excluded from MIPS as low-volume clinicians?

I’m drawing this from table 122 in the final rule. There are just fewer than 880,000 clinicians who are eligible for and participating in the MIPS program, out of a total of 1.6 million total clinicians. Some of those are categorically ineligible. There are a total of 728,000 who are ineligible, and most are either not opting in or are below the criteria for the low-volume threshold. It was about 60 percent a year or so ago, but it’s still about half of clinicians who are excused, and MIPS is intended to be the transition vehicle into value-based care. So we’re concerned that if you are excluding half of the otherwise-eligible clinicians from the pathway to value, we won’t get there in any reasonable timeframe.

Do you see some core issues, with regard to the ACOs accountable care organizations in the MSSP [Medicare Shared Savings Program] program also, in the ways that CMS is trying to push providers towards value?

There seems to be an inconsistency here, in terms of the incentives and policies involved.

The rewards are pretty small relative to the investment of effort, then, correct?

I definitely agree that the rewards are not commensurate with what our members are investing in information technology, staffing, and culture change, to not only prepare for, but ideally succeed in, value-based models of care. And when they go into this based on what CMS’s stated goals are and to see, well, at the end of the road, the reward you receive is significantly less than you had anticipated, that’s frustrating. I think CMS is very concerned about how this is going to impact the solo practitioners and very small practices, and they’re being very cautious in how they roll out their programs. And if they continue to implement MIPS in this fashion, it’s going to hinder the overall transition to value.

What can be done in the next year, about this?

AMGA is going to continue to advocate and get our message out there that we’re invested in working with our partners on the commercial side, to work with innovative, creative, value-based models of care. Our members are willing to be accountable for the value o care they provide. And at some point we’ll hit a decision point, and we’ll have to decide, are we actually going to pursue policies in rulemaking, to do this, or is this going to continue to be a regulatory/compliance exercise, and our member will adjust accordingly.

The tremendous amount of investment in healthcare IT is part of what your member groups are doing, correct?

If you’re in a shared-savings model or are assuming risk, in any type of model, you need to have a clear understanding of who your patients are; so you need access to data almost on a continuous basis. You need to know who’s treating your patients, where they’re accessing care, and need to know how to keep your patients as healthy as possible. And you can’t do that on paper. Our member groups’ clinicians are connecting on an almost daily basis to do care management. That’s incredibly labor-intensive, and requires a lot of support from the IT side of the house. When you’re talking about population health, you’re targeting interventions on behalf of the patients who most need them. And without that IT support, you’re virtually flying blind.

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