• Academy Gives Senate Strong Prescription to Improve MACRA

    AAFP President Tells Finance Committee It's Time to Simplify

    May 15, 2019 01:50 pm News Staff – For family physicians eager to see Medicare reward value rather than volume, 2015's Medicare Access and CHIP Reauthorization Act checked a number of key boxes.

    But MACRA's departure from the fee-for-service payment model also came with a host of new boxes for physicians to check -- an administrative hamstringing, the Academy recently told lawmakers, that must be addressed as the program advances.

    Delivering oral and written testimony(8 page PDF) before the Senate Finance Committee on May 8, AAFP President John Cullen, M.D., of Valdez, Alaska, cautioned that MACRA's Merit-based Incentive Payment System "has created a burdensome and extremely complex program that has increased practice costs and is contributing to physician burnout."

    "Understanding the requirements and scoring for each MIPS performance category and reporting required data to CMS is a complex task and detracts from physicians' ability to focus on patients," he added. "Many of my colleagues are frustrated and angry. We urge Congress to work with CMS to reduce the complexity and administrative burden of MIPS."

    AAFP President John Cullen, M.D., testifies before the Senate Finance Committee on May 8.

    The Academy's testimony -- which commended MACRA's potential to support a primary care-based health system -- outlined areas of concern and suggested potential improvements.

    Noting that recent Academy survey results indicated strong commitment to value-based care and payment among family physicians, with 54% of members reporting that they practice in value-based payment models or contracts, the AAFP told the committee its recommendations were based on that data.


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    The AAFP continues to support MACRA, which "created an opportunity for physicians to pursue non-fee-for-service payment," the Academy said in its written testimony. "MACRA also created an opportunity for physicians to create and propose alternative payment models through the Physician-Focused Payment Model Technical Advisory Committee."

    In fact, the Academy was one of the first organizations to make a successful submission to the PTAC with its Advanced Primary Care Alternative Payment Model.

    "The AAFP's APC-APM was approved by the PTAC in December 2017, receiving one of the strongest recommendations by the PTAC to date," the Academy wrote. "The AAFP remains fully supportive of the PTAC's role in evaluating physician-focused payment models."

    And last month's announcement of the CMS Primary Cares Initiative, which draws in part on the AAFP's APC-APM, marks "a critical step toward recognizing the importance of primary care by developing payment models that value primary care," the Academy added. "We look forward to working with CMS and the Center for Medicare & Medicaid Innovation on testing and developing these models, so they are available, attractive and workable for all primary care practices, including those that are small and/or rural."

    But, the Academy's testimony also advocated for the following five key improvements to the MACRA framework.

    Correcting Undervaluation of Primary Care Fee-for-service

    "Congress should direct CMS to aggressively address inequities in the Medicare fee schedule that undervalue primary care services -- especially the office-based evaluation and management codes for new and established patients," the Academy wrote.

    "Specifically, Congress should urge CMS to increase the relative value of ambulatory E/M and other primary care services to rebalance the Medicare physician fee schedule," the Academy added, citing a June 2018 report by the Medicare Payment Advisory Commission that warned trickle-down effects of mispricing could include a less robust physician pipeline.

    Reducing MIPS Complexity

    "The implementation of MIPS has created a burdensome and extremely complex program," the Academy wrote -- a stumbling block for primary care practices trying to deliver high-quality care.

    "CMS continues to struggle to provide timely and clinically actionable data because the MIPS cost category measures are flawed and hold primary care physicians more accountable for total cost of care than other sub-specialties. We urge Congress to extend CMS's authority to weigh the MIPS cost category below 30% to allow time to overhaul existing measures."

    The Academy's testimony detailed further opportunities to improve MIPS, including:

    • congressional repeal of meaningful use requirements;
    • eliminating health IT utilization measures, as well as others that hinder physicians' flexibility;
    • holding health IT vendors accountable(8 page PDF) for interoperability before physicians are measured on EHR use;
    • reconsideration of the CMS mandate of 2015 edition Certified Electronic Health Record Technology (CEHRT), in favor of score-based incentives; and
    • cross-category credit for measures and activities that span multiple performance categories.

    Eliminating the MIPS APM Category

    The AAFP is concerned that clinicians who participate in the MIPS APM category of the Quality Payment Program will choose to stay there even if they are eligible to progress to the Advanced APM category, which will unfairly skew MIPS against clinicians who are not eligible to progress.

    The written testimony pointed out that the MIPS APM option can be eliminated because it was created by CMS -- not by the MACRA law -- and that the 2017 performance period demonstrated an imbalance that was particularly hard on numerous small and rural practices.

    Extending the Advanced APM Bonus

    "Given the limited availability of AAPMs to date, we strongly urge Congress to extend the 5% AAPM bonus for three to five years beyond the current statutory restriction and include language giving the secretary of HHS discretion to extend the bonus further," the Academy wrote.

    Creating a Culture Focused on Patient Care

    Emphasizing that prior authorization tops the list of physician complaints about administrative burden, the testimony cited AMA data reporting that interactions with insurers cost $82,975 annually per physician.

    "In coalition with 16 other medical organizations, the AAFP has called for the reform of prior authorization and utilization management requirements that impede patient care," the Academy wrote.

    The written testimony also quoted a Health Affairs study that found that staff and physicians in four specialties -- family physicians, general internists, cardiologists and orthopedists -- spend, on average, 785 hours per physician and a combined total of more than $15.4 billion annually to report quality measures.

    "So that family physicians can devote more time to patient care, we urge Congress to influence action by all payers to reduce the administrative complexity," the Academy wrote.

    Additional Recommendations

    The Academy's written testimony also proposed that Congress direct Medicare payment systems to

    • extend the 0.5% baseline conversion factor update until 2026,
    • focus on outcomes and patient-reported outcome measures that truly matter for practices and patients, and
    • reward practices that achieve significant year-over-year improvement rather than those at the upper levels of annual performance.

    Cullen, in his testimony, emphasized the need for the latter bonus structure and the extension of 0.5% annual payment increases.

    "It is our belief that additional positive payment adjustments would be better used if they were focused on rewarding the hard work of practices that achieve year-over-year improvements," he told the committee.

    "We should ask physicians to focus on our patients, not checking boxes," Cullen said. "That is how to improve patient satisfaction, outcomes and overall Medicare cost reductions."

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