CMS Request for Information

AAFP Expends Huge Effort to Shape New Payment System

November 17, 2015 11:36 am Sheri Porter

For 39 days this fall, a team of AAFP staffers and selected family physician members toiled in unison to construct comprehensive feedback in response to a request for information (RFI) from CMS that was published in the Oct. 1 Federal Register.(

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The AAFP's response(53 page PDF) to that RFI -- a document that covers implementation of the Merit-based Incentive Payment System (MIPS) and promotion of alternative payment models (APMs) as part of the larger Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 -- is arguably one of the most important pieces of work undertaken by the AAFP in recent history.

According to Amy Mullins, M.D., the AAFP's medical director for quality improvement, that's because portions of the MACRA law stand to impact how Medicare will pay physicians beginning in 2019.

She noted that in more than 100 instances in the legislation, the HHS secretary is called on to develop policy to implement MIPS and APM payment methodologies.

"MACRA must now be implemented, and we're providing details for the HHS secretary. It's important for the Academy (and other stakeholders) to step up to the plate now to ensure that the program is created in a way that is favorable to physicians," said Mullins in an interview with AAFP News. "These comments will help define what physician payment will look like far into the future."

Story Highlights
  • The AAFP recently submitted detailed responses to 126 questions as part of a CMS request for information on how to implement new payment models associated with the Medicare Access and CHIP Reauthorization Act (MACRA).
  • Those responses were compiled by a team of AAFP staff members and family physician experts.
  • Amy Mullins, M.D., the AAFP's medical director for quality improvement, pointed out the importance of the AAFP's input given that portions of MACRA stand to impact how Medicare will pay physicians beginning in 2019.

As a family physician who spent more than 12 years in a three-physician clinic working, as she put it, to "achieve practice transformation on a shoestring budget," Mullins speaks from experience about this critical work.

"It's our job to make sure that the collective voice of family physicians is heard -- and heard clearly," she said.

The Academy's response is detailed in a 49-page document prefaced by a four-page cover letter signed by AAFP Board Chair Robert Wergin, M.D., of Milford, Neb.

Diving Into Details

The AAFP team answered 126 questions in the RFI. In addition to the 20 staff members who had a direct hand in the writing, family physicians serving on the Academy's Commission on Governmental Advocacy and Commission on Quality and Practice, as well as participants in a number of the AAFP's member interest groups, lent their expertise.

In his letter, Wergin first reiterated the AAFP's "full support" for MACRA. "This law not only repealed the faulty sustainable growth rate (SGR) formula, but it also set our health care system on a path away from episodic fee-for-service payments toward more comprehensive and value-based payment," he said.

"Futhermore, MACRA enables us to rebalance U.S. care delivery systems to place greater emphasis on the value of comprehensive, continuous, coordinated and connected primary care," Wergin added.

But despite supporting MACRA as a whole, Wergin made clear the AAFP's concerns that the MIPS and APM programs might be built on the "biased and inaccurate" relative value data currently used in the fee-for-service system.

"We strongly recommend that more be done to ensure Medicare pays appropriately for primary care physician services in these new payment models rather than paying based on this biased actuarial data that further exacerbates the undervaluation of primary care services," he stated.

In a brief summary of the full response, Wergin noted a few of the themes on which the AAFP focused its remarks.

Take, for example, "measure harmonization."

"The AAFP opposes an approach that requires physicians to report on a complex set of measures that do not impact or influence the quality of care provided to patients," as is the case with the current Physician Quality Reporting System, said Wergin.

CMS must "streamline, harmonize and reduce the complexity of quality reporting in the MIPS and APM programs," he added.

Wergin described CMS' meaningful use program as "poorly designed" and called it the "first and most significant barrier" to any future success physicians might have meeting MIPS quality performance standards.

"Until the meaningful use program is improved and the (electronic health record) issues are resolved, it is difficult to foresee a large percentage of physicians -- particularly physicians in small and independent practices -- being successful in MACRA programs," said Wergin.

Seize the Moment

Mullins stressed the effort that went into the RFI response. "The AAFP wanted to get this right -- right for family physicians," she said.

And she saluted the work of her physician colleagues on the front lines.

"When you're in the midst of doing the clinical work -- seeing patients and taking care of people -- that's the most important thing your world," said Mullins. "This payment stuff -- all these new terms and acronyms -- it's confusing and hard to wrap your head around it all.

"I remember that feeling of just not caring about those kinds of administrative details -- just wanting the payment situation to get better," she added.

Mullins reminded family physicians of their painfully long wait for the demise of the SGR. "As technically difficult as this new law is to grasp, it's easy to understand that thanks to MACRA, the 21.5 percent Medicare pay cut forecast for 2016 didn't happen," she said.

"This new payment system is unfamiliar territory for all of us," said Mullins. "But we have to find a way to maximize its benefit. It's time for family medicine and primary care to own this law."

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