AMGA’s Ambivalent First Reaction to the Quality Payment Program’s Proposed Rule Release

June 21, 2017
Late Thursday afternoon, following the release by CMS of the proposed rule for the 2018 Quality Payment Program under the MACRA law, AMGA’s Chet Speed spoke with Healthcare Informatics regarding what his association sees as the plusses—and minuses—of the proposed rule

Late on Thursday afternoon, not long after the federal Centers for Medicare & Medicaid Services (CMS) had released a proposed rule that would make changes in the second year of the Quality Payment Program (QPP) under the MACRA law (the Medicare Access and CHIP Reauthorization Act of 2015), with the aim to simplify the program, leaders of the Alexandria, Va.-based American Medical Group Association (AMGA), which represents 440 large medical groups encompassing 175,000 U.S. physicians, reacted to the rule’s release.

The rule itself is 1,058 pages in length, and is the first major update to the MACRA law under new federal healthcare leaders in the Trump administration. The MACRA final rule was released in October, just a few months before the first reporting year of the QPP—inclusive of two payment paths that eligible Medicare-participating physicians could partake in—MIPS (the Merit-based Incentive Payment System) and the advanced alternative payment models (APM) track—was set to begin in January 2017. This new proposed rule aims to make changes to year two of the Quality Payment Program in 2018.

In their initial statement in the hours after the proposed rule’s release, AMGA’s leaders said, “AMGA thanks the Centers for Medicare & Medicaid Services (CMS) for its efforts in drafting the proposed rule to implement the Quality Payment Program (QPP) for 2018. AMGA recognizes the burden the Medicare Access and CHIP Reauthorization Act (MACRA) places on small practices and appreciates the options for them to participate. However, AMGA remains concerned the proposed rule delays the transition to value and does not recognize the investment that AMGA members have made in preparing for a value-based health care system.”

The statement also quoted Chester A. Speed, AMGA’s vice president, public policy, as saying, “If CMS wants to transition to value-based payment for care, the program needs to be fully implemented. We recommend that CMS revise its proposal to fully incentivize high performers in the Medicare program.”

Chet Speed

And the statement added that “AMGA welcomes CMS’ invitation to provide comment on options to allow clinicians’ contracts with Medicare Advantage (MA) plans that meet the risk, quality, and certified electronic health information technology requirements to be included under the beneficiary count test for the 5-percent Advanced Alternative Payment Model (APM) bonus in 2019 and 2020. Even though CMS expects all current Advanced APM participants to meet the thresholds for Advanced APM qualifications, revising the regulations to allow additional providers to be considered will encourage participation in such value-focused models. In addition, more than 31 percent of Medicare beneficiaries are enrolled in a MA plan and with the popularity of the program, numbers are increasing. By providing another pathway for participation, CMS would include more patients and providers in Advanced APMs.”

And the AMGA statement went to quote Speed as saying that “CMS has an opportunity to revise this proposal to reflect Congress’ intent to move the Medicare system to one that rewards results. AMGA members have already started on this journey, and they should be recognized for being leaders in health care.” The association promised to “review the rule closely and provide detailed comments.”

Shortly afterwards, Speed spoke with Healthcare Informatics Editor-in-Chief Mark Hagland regarding the proposed rule’s release. Below are excerpts from that interview.

I know it’s extremely soon after the release of the proposed rule, but what are your first-impression thoughts of what you’ve been able to absorb so far?

Yes, my and our reactions are very initial right now. So, the proposed rule recognizes that there’s a tension in getting to value. On the one hand, everyone wants to get to value, which is essentially improved care quality at lower cost. At the same time, HHS [the Department of Health and Human Services] recognizes that getting to measured value can be a real burden on physician practices. So they’ve excluded a fairly big chunk of small practices from MACRA, recognizing that it’s a burden on them. At the same time, those who have invested in the people and technology to improve care and lower costs, the typical AMGA members, are not being rewarded for these investments and efforts, which frankly take millions of dollars and many hundreds of hours of people efforts, to get to value.

So they expect that those groups with over 100 doctors, which represent 99 percent of AMGA members, their MACRA bonus will only be 1.4 percent. And the maximum is 5 percent. So by excluding all these small practices, you’re crunching the bell curve and reducing rewards to high performers. So that’s the tension involved; you’re not rewarding those that have done all the work to get to value. So I think about our members who have put millions of dollars into this and have spent so much leadership time and effort to get to value; 1.4 percent in MACRA hardly rewards you for all the effort you’ve made; and it’s not really the signal you want to say, we’re going to value.

So the “Pick Your Pace” option from 2017 won’t be extended into 2018, correct?

That’s correct. “Pick Your Pace” allowed ECs [eligible clinicians] to submit just one measure in 2017 and not be penalized. This year, under the proposed rule, you’re required to do what you had to do before Pick Your Pace happened, which is to submit six quality measures, and also measures for , which is now called ACI, as well as the care coordination measure. So “Pick Your Pace” was not continued one more year. So you do have to go through the full measurement regime to get the highest score in 2018. But what they did do to address the small-practice concerns, was that they doubled the exclusions to get out of MACRA. They’re implementing quality, MU/ACI, and care coordination. But to address small-practice concerns, they tripled the low-volume thresholds, so that more small practices would be exempted from MACRA. So when Pick Your Pace is no longer in place, they’re exempting more practitioners from MIPS. So if you billed less than $30,000 in Medicare billings, you were exempted from MACRA in 2017; in 2018, the level at which you are exempted from MACRA is $90,000 in Medicare billings.

As a result, last year under the proposed rule, CMS expected 751,000 physicians to be in MACRA. Now, they expect 554,000 physicians to be in MACRA. So they’ve basically excluded about 206,000 more providers from MACRA, recognizing the burden on small providers.

It sounds as though you think that federal healthcare officials have fallen a little bit too far to one side in this?

I’d have to say so, yes. On the one hand, I completely understand the plight of small practices. My parents go to a solo practitioner, they love him—he tells them about the burdens. And as a lawyer, if I were in sole practice, I could understand how such requirements would impact me. At the same time, when our members are expecting the potential of a 5-percent bonus in Medicare Part B, and it’s limited to 1.4 percent, yes, I think they’ve gone too far. The idea was that this was Congress’s value agenda, and this was the way to transition from volume to value. At the same time, I don’t think you’re incentivizing value, when you’re not rewarding sufficiently those who’ve done the right thing and gotten ready.

Will the evolution of the MACRA-related requirements, especially those around collecting and reporting outcomes data, accelerate physicians’ impulses towards full employment or pseudo-employment, by medical groups, hospitals, and health systems?

Yes, absolutely. The small practices look at all the things coming out of Washington, and say, we need the back-office support that a hospital or system or large medical group can offer us. And the younger physicians coming out of medical school, like the support. And so they do want to be employed. Thirty years ago, the physicians coming out of medical school wanted to hang out a shingle. But that has changed.

In terms of the requirements around collecting and reporting the data, is that process turning out to be more, less, or about as difficult as you had expected?

I think it’s about as difficult as I’d expected.

Is it where it should be?

That’s a larger discussion. This veers off MACRA, but quality measures, the way the system is configured now, it’s very process-oriented, towards things like, did you schedule a diabetic eye exam? Frankly, I think the process measures aren’t really clinically relevant. I think the system needs to focus on outcomes measures, like readmissions for COPD or diabetes. Those are measures that actually measure the quality of the care you’re providing. We need to reconfigure measurement, because it’s not measuring what needs to be measured.