A powerhouse group of medical organizations spoke with one voice recently in urging CMS to take another look at key portions of its proposed rule that, when finalized, will steer implementation of the massive Medicare Access and CHIP Reauthorization Act (MACRA).
In a June 24 letter(8 page PDF) to CMS Acting Administrator Andy Slavitt, the AAFP and more than 100 other organizations pushed renewed action on three main fronts, asking CMS to
- simplify the Merit-Based Incentive Payment System (MIPS) so physicians can improve performance but with fewer administrative and compliance burdens,
- provide a stronger pathway to alternative payment models (APMs) -- one that will support physicians eager to transition to new delivery and payment models -- and
- support physicians in solo, small and rural practices so they, too, have opportunities for success and can avoid unintended consequences.
The joint letter, in many instances, reinforced recommendations the AAFP made in its own 100-plus page letter fired off to Slavitt on June 24.
- The AAFP joined more than 100 medical organizations in asking CMS to make changes to the proposed rule implementing the Medicare Access and CHIP Reauthorization Act.
- The letter voiced disappointment in a number of areas, including the Merit-Based Incentive Payment System, alternative payment models and the lack of support for physicians in solo, small and rural practices.
- The groups made a number of recommendations, some of which mirrored suggestions made by the Academy in its own comment letter to CMS.
The organizations told CMS that MIPS should, above all else, "create a more unified reporting program with greater choice and fewer requirements." As written, said the groups, the proposed rule lays out four components as separate programs -- meaning each has its own measures, scoring system and requirements.
"This has created significant complexity in the program as a whole, leading us to be very concerned that physicians will not be able to understand the complete MIPS program," said the letter.
The organizations gave CMS a dozen suggestions for improvement. For instance, they asked the agency to
- create more opportunities for partial credit and reduce the number of required measures within MIPS;
- consider the differences in practice size, specialty group and availability of measures and then provide greater flexibility "to address the unique concerns of small, rural and other practices";
- reduce the proposed increase in the reporting threshold for quality measures;
- focus on methodological improvements and, in particular, work to eliminate flaws that have made practices carrying the largest number of high-risk patients "more susceptible to penalties than other physicians"; and
- speed adoption of the virtual group concept from the proposed 2018 implementation date.
Without this virtual group assistance, "small practices may face even greater challenges when attempting to move into the MIPS program structure," noted the letter.
The organizations began this portion of their suggestions by urging CMS to refine its definition of financial risk.
"With multiple components that include total risk, marginal risk and minimum loss rate, it would be difficult for physicians contemplating participation in advanced APMs to understand their financial risks and avoid losses," said the letter.
The organizations called on CMS to "increase medical home flexibility" and prevent the extension of proposed risk requirements to primary care medical homes serving vulnerable populations including children with Medicaid coverage.
The letter also urged CMS to create additional APM opportunities. It pointed out that MACRA provided two pathways for physician participation -- MIPS and APMs -- but the proposed rule tightens participation and therefore severely limits opportunities.
Fix that situation, said the organizations, by establishing a process that would allow modification of other models so as to qualify them.
The letter also called on CMS to establish a "timely and predictable" CMS review process for stakeholder APM proposals.
"Physicians are especially concerned by comments from some CMS officials that stakeholder models proposed by the independent advisory committee established by Congress will then have to go through the entire CMS model review process, which suggests it will be years before any physician-focused APMs are available."
Fix Low-volume Thresholds
The groups also expressed concerned about the proposed low-volume threshold as it relates to the impact of MIPS on solo and small practices. They asked CMS to tweak the low-volume threshold to exempt physicians who bill less than $30,000 in Medicare allowed charges or who care for fewer than 100 unique Medicare patients per year.
CMS' proposal calls for an exemption threshold of less than $10,000 in Medicare charges and fewer than 100 unique Medicare patients per year.
By implementing this change, "CMS would provide a better safety net for small providers," said the letter.
Change Performance Reporting Periods
Lastly, the organizations asked CMS to change the Jan. 1, 2017, start date for APM and MIPS performance and reporting periods.
"We believe the start date should be moved back" so physicians have time to prepare and adequate notice of final program requirements and thresholds, can see a final list of qualified APMs, and have the benefit of a timeline that puts the performance period closer to incentive payouts.
"We believe this extra time will also be helpful for vendors, registries and others to update their systems to accommodate the new program requirements," said the letter.
In addition, the organizations urged CMS to "allow more suitable reporting periods" for MIPS and APMs. They pointed out that a "full calendar year requirement" created a significant administrative burden on some practices.
The letter recommended that physicians be given the option to use the full calendar year or select a shorter reporting period.
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