AMIA, Premier, AHA and AMA Comment on CMS’s 2018 MACRA Proposed Rule

Aug. 21, 2017
Several healthcare and health IT organizations submitted recommendations and comments to the Centers for Medicare & Medicaid Services’ (CMS’s) 2018 proposed rule on the Quality Payment Program (QPP) established under the Medicare Access and CHIP Reauthorization Act (MACRA). Comments on the proposed rule were due today.

Several healthcare and health IT organizations submitted recommendations and comments to the Centers for Medicare & Medicaid Services’ (CMS’s) 2018 proposed rule on the Quality Payment Program (QPP) established under the Medicare Access and CHIP Reauthorization Act (MACRA). Comments on the proposed rule were due today.

In the last year, there has been significant discussion about MACRA’s potential impact on small practices. In the final rule released last fall, CMS said that it was taking additional steps to aid these practices, including excluding many of them by implementing a low-volume threshold for MIPS (the Merit-based Incentive Payment System) of at least $30,000 in Medicare Part B charges or having less than 100 Medicare patients. In sum, the new policy excluded an estimated 380,000 clinicians for 2017 due to this low-volume threshold.

For 2018, that low-volume threshold was raised significantly, from $30,000 in Medicare Part B charges to $90,000; and from having less than 100 Medicare patients to fewer than 200. The impact of that, Broome says, is not only that 200,000 more clinicians will be excluded from MIPS in 2018, but also that the amount of Medicare spend has been increased by 300 percent—from $30,000 to $90,000—now representing more than 10 percent of the total money that Medicare spends on Part B.

In its comments on the 2018 updates to the Quality Payment Program, the American Medical Informatics Association (AMIA) praised the flexibilities offered by CMS to acclimate MIPS eligible clinicians to a new payment and performance measurement paradigm in the first year of the program and praised the additional flexibilities proposed for Year 2.  “We also are pleased that CMS has proposed a series of exemptions and policies intended to help small and under-resourced practices,” AMIA wrote.

AMIA also commends CMS for expanding the list of potential Improvement Activities that are eligible for the Advancing Care Information (ACI) performance category bonus score if completed using certified electronic health record technology. And AMIA recommends that CMS continue to identify MIPS requirements that are mutually reinforcing across performance categories.

“With the sunset of Meaningful Use for Medicare, we view MIPS and APM requirements as a primary mechanism to incentivize continued investment and use of certified EHR technology among ambulatory providers. It is important that CMS continue to view CEHRT as a means to encourage adoption and maintenance of modern information and communication technology in care delivery, and focus on making the use of such systems easier for clinicians,” AMIA wrote. AMIA also urges CMS to “clearly state its intentions to require 2015 edition CEHRT in 2019 for QPP participation.”

AMIA also supports the CMS Blueprint for the Measurement Management System and encourages the agency to develop similar processes for the MIPS ACI and IA performance categories. “To this end, AMIA recommends that CMS measure and determine the value of ACI measures with as much vigor as it does quality measures,” AMIA wrote.

In its comments on CMS’s proposed changes for 2020 payment, or the 2017 performance year, Charlotte, N.C.-based Premier Inc. said it opposes the agency’s proposal to increase the low-volume threshold and urges the agency to maintain the current threshold noting that the increase would significantly reduce the clinicians participating in the value-based payment. Rather, Premier recommends that CMS bring clinicians into the program and ease their reporting requirements.

Further, Premier commented on the facility-based reporting option, recommending that CMS develop clinician-level measures comparable to the facilities for those clinicians without sufficient options, rather than use the facilities performance in the Hospital Value-Based Purchasing Program to score facility-based clinicians.

Premier also commented on proposed changes for each of the four performance categories in MIPS. For the Quality measure, Premier wrote that it supports removing topped-out measures after the fourth year of being topped-out but requests that the cap for topped-out measures be increased.

Regarding the Cost category, which CMS proposes keeping at zero percent in 2020 and increasing to 30 percent in 2021 in beyond, Premier said it supports weighting the cost category at zero percent and asks that CMS address the organization’s ongoing concerns with the cost measures, such as risk adjusting for socio-demographic factors.

The American Medical Association (AMA) also weighed in, saying that while CMS has proposed a number of important improvements in the program, but organization urges CMS to seek ways to simplify and further streamline the program and create more opportunities for physicians to participate in new value-based payment options. AMA proposed specific revisions to the Merit-Based Incentive Payment System (MIPS) and the Alternative Payment Model (APM) option, both of which were created by MACRA. 

In its letter to CMS, the AMA outlines steps the agency should take to ensure a smooth transition to the new payment system so physicians have time to adopt and invest in practices that can enhance patient care and constrain costs. The AMA also proposed steps the agency should take to promote physician-led APMs. In MIPS, the AMA applauded CMS’s response to the concerns of small and rural practices, including an option for small groups and solo practitioners to form virtual groups.

“When physicians are asked to move to a new program, we expect some bumps along the way. CMS has been a good partner in smoothing out the bumps but the program still needs to be more understandable and less burdensome. The complexity is an obstacle to the goal of promoting innovative approaches to encourage higher value care. We applaud CMS’ decision to allow for another transition year for MIPS, recognizing the challenges physicians face both bureaucratic and technological. The willingness to compromise will help physicians and patients alike,” AMA President David O. Barbe, M.D., said in a statement.

What’s more, the American Hospital Association also submitted comments. In its letter, the AHA said that while it supports many of CMS’s proposed policy changes that relieve regulatory burden and foster greater collaboration, it urged the agency to “better align the meaningful use requirements of EHRs for hospitals with those of clinicians, enhance its approaches to risk adjustment and provide additional opportunities for clinicians to earn incentives for collaborating with hospitals to enhance the quality and efficiency of care through advanced APMs.”

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