On June 24, the AAFP submitted formal comments in response to the "Medicare Program: Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models" proposed rule, which was published by HHS on May 9.
The AAFP’s 107-page response lays out a vision and series of recommendations on how CMS can improve the regulation to better align with the Congressional intent of the Medicare Access and CHIP Reauthorization Act (MACRA) and establish a framework that will allow family physicians to deliver high quality, efficient health care to their patients -- regardless of practice size and location.
A majority of our key recommendations are included in an executive summary and outlined in an excellent AAFP News story.
I am not going to attempt to provide you a complete summary in this posting. Instead, I am going to focus on three areas of our comment letter. I will continue to write on MACRA during the summer and fall, and future posts will focus on other key areas of the proposed regulation.
The AAFP noted in our response that the proposed rule and the general framework for both the MIPS and APM program was complex. In fact, really complex. The AAFP is concerned that family physicians will be challenged to understand the various layers of eligibility standards, reporting requirements, thresholds, weighting, risk-adjustment and evaluation/scoring criteria created by this rule. In fact, we are concerned that anyone outside of CMS will be challenged to understand. The MACRA law was far simpler in construct, and we strongly encouraged CMS to pull the throttle back and make this regulation far less complex.
We also called on CMS to issue an interim final rule with a comment period versus a final rule so that the AAFP and others would have an additional opportunity to provide comments on the various provisions implementing MACRA.
A key passage in our letter says, "While our support for MACRA remains strong, we must state that we see a strong and definite need and opportunity for CMS to step back and reconsider the approach to this proposed rule which we view as overly complex and burdensome to our members and indeed for all physicians. Given the significant complexity of the rule, we strongly encourage CMS to issue an interim final rule with comment period rather than to issue a final rule."
MACRA requires that physicians participate in a "performance period" that will determine their payment rate for a future year. Under the proposed rule, CMS establishes the initial performance year as Jan. 1, 2017 to Dec. 31, 2017 and uses a two-year cycle, meaning that physicians' performance in 2017 would determine their payments in 2019. The AAFP is concerned that a Jan. 1, 2017 initiation of the performance period is ambitious both for physicians and CMS.
Furthermore, we strongly disagree with the two-year data cycle that CMS is proposing. We believe that physicians should receive data and performance reports closer to the time care was provided in order to learn and adjust. If CMS officials think that quality and performance data will inform and influence care delivery, then they should place a priority on ensuring that the delta between the performance and payment years is no longer than six months.
Another key passage in our letter says, "the AAFP urgently and strongly recommends that the initial performance period should start no sooner than July 1, 2017."
Solo and Small Practices
The AAFP reserved its most aggressive and constructive comments for those provisions impacting solo and small practices. We see and promote the tremendous value that solo and small practices bring to the health care system. The quality of care provided by small practices has been well documented in literature, and there is broad agreement that preserving this practice model is essential to the success of MACRA and our health care system more broadly.
The AAFP worked aggressively to ensure that MACRA included protections and opportunities for solo and small practices. Some of these were captured in the proposed rule, but many were not. Due to our dissatisfaction with how the proposed rule promoted and protected this practice model, we proposed that CMS create a "safe harbor" for solo and small group practices until such time that policies specifically aimed at helping these practices, such as "virtual groups," are implemented. The lack of virtual groups may result in a "methodology bias" between solo and small practices and larger practices -- something that is unacceptable.
A key passage in our letter says, "Given the fact that a provision, mandated by law, to ensure the viability of solo and small physician practices in the MIPS program will not be available for such physicians and their practices in the initial performance period, we are strongly urging CMS to include an interim pathway to virtual groups, as outlined below, in the final regulation. Physician practices with five or fewer physicians, billing under a single tax identification number who participate in the MIPS program through the submission of quality data, use of a CEHRT electronic medical record, and participation in clinical practice improvement activities should be exempt from any negative payment updates resulting from the MIPS program until such time that virtual groups -- as outlined and mandated by MACRA -- are readily available. These physician practices are, however, eligible for any positive payment updates that they may warrant based upon their performance in any given performance period."
As a frequent reader of other news sources and blogs, I am well aware that many physicians are throwing shade on MACRA and the reforms that it advances. Some have gone so far as to suggest that the SGR was better. I fundamentally disagree that the flawed sustainable growth rate and current penalty performance programs (PQRS, MU, VBM) were better. Under the SGR methodology, the best you could hope for was level funding from year-to-year. There was never a plausible chance to secure positive payment updates. Furthermore, the penalties associated with PQRS, meaningful use, and the value-based modifier -- all currently in place -- are greater than those associated with the MACRA MIPS pathway. Putting a finer point on this, under the previous payment formula the best you could do was prevent reductions in payment, you were never able to pursue increased payments. MACRA creates opportunities to actually increase payments, something that hasn't existed for physicians participating in the Medicare program for more than a decade.
However, I do recognize that MACRA is not easily understood and it has inherent risks for all physicians in all practice models. It is our job to ensure that you have the appropriate information and resources to be successful in your practice. I encourage you to do three things this week.
The AAFP is committed to ensuring that you are MACRA Ready and we are equally committed to ensuring that this law is implemented in a manner that reflects Congressional intent and allows each of you to provide quality care to your patients, regardless of where and how you practice.
Stephanie Quinn, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy. Read author bio »