On Jan. 30, President Donald Trump signed an executive order(www.whitehouse.gov) titled "Reducing Regulation and Controlling Regulatory Costs."
Sensing a timely opening, the AAFP took full advantage of the opportunity to press CMS to make prudent and necessary changes regarding how the agency moves forward with implementation of the Medicare Access and CHIP Reauthorization Act (MACRA).
An April 26 letter(15 page PDF) to CMS Administrator Seema Verma, M.P.H., signed by AAFP Board Chair Wanda Filer, M.D., M.B.A., of York, Pa., serves as the introduction to an 11-page document that focuses on AAFP recommendations about how to "meaningfully improve and simplify" implementation of this law.
"Unfortunately, family physicians are facing a regulatory environment that is distracting them from their core purpose," said the AAFP -- and that is to provide the best possible health care to patients.
- On April 26, the AAFP sent a letter to CMS Administrator Seema Verma, M.P.H., urging the agency to immediately simplify the Medicare Access and CHIP Reauthorization Act (MACRA).
- The Academy acted on an opportunity presented by President Donald Trump's Jan. 30 executive order that called for reducing federal regulation and controlling regulatory costs.
- The AAFP asked CMS to eliminate a number of MACRA implementation components and modify others to make the rule better and easier for both CMS and physicians.
The letter cited a study(annals.org) published in the Annals of Internal Medicine in December 2016 that found physicians were spending about 50 percent of their time in the office on administrative tasks that included work related to electronic health records and only about 27 percent of their time on direct patient care.
Despite a number of earlier suggestions the AAFP gave CMS on how to make MACRA reporting requirements easier for physicians, "much more work remains to keep reporting and regulatory burdens to a minimum," said the letter.
For starters, keeping that big simplification umbrella in mind, the AAFP asked CMS to
- withdraw financial risk standards from its definitions of the medical home model,
- strip size restrictions that limit advanced alternative payment model (APM) participation in medical home models,
- discard all documentation guidelines for evaluation and management codes for primary care physicians in both the Merit-based Incentive Payment System (MIPS) and the advanced APM payment pathways,
- strike the complicated and "entirely uncalled for" MIPS APM category, and
- do away with the administrative claims population health measures.
Furthermore, the AAFP urged CMS to "use consistent terms" when writing proposed rules and final rules.
After laying out items that should be eliminated as MACRA is implemented, the AAFP offered a number of suggestions for modifying the rule to make it better and easier for both CMS and physicians -- many of whom are struggling to participate and comply.
For example, the AAFP urged CMS to improve payment for primary care services by making an immediate upward adjustment to the Medicare relative value units for common primary care services, increasing spending on services provided by primary care physicians to at least 15 percent of Medicare Part B physician spending (that percentage currently is no more than 6 percent), and defining small practices as "10 or fewer eligible clinicians."
The AAFP reiterated its strong support for MACRA and the advanced APM pathway. However, the letter noted the Academy's apprehension about the failure of that program and MIPS if they "are built upon the biased and inaccurate relative value data currently used in fee-for-service payments."
Unless that underlying flaw is remedied, "payments under MIPS and future actuarial calculations for advanced APMs will not adequately compensate primary care for the complexity of care provided," said the AAFP.
The Academy also called for a "more gradual MIPS transition period," to allow physicians and CMS to become familiar with the program and learn from 2017 results.
Among recommendations related to this topic was the AAFP's suggestion that CMS set the MIPS performance score threshold at a level that encourages "successful participation by ensuring a majority of physicians are held harmless from penalties."
The AAFP offered suggestions for simplifying MIPS scoring and asked CMS to develop tools to help physicians predict their scores, as well as generate physician feedback reports, at least quarterly, to provide them with actionable data.
Regarding the issue of virtual groups, the AAFP asked for an "interim pathway" in 2018 so that practices with 10 or fewer physicians who meet certain other qualifications would be exempt from negative payment adjustments until virtual groups are readily available.
The AAFP urged CMS to redirect funds to enable the disbursement of positive payment adjustments to "exceptional performers" and to "prioritize establishing virtual groups as envisioned in the law."
The letter pointed out that the virtual group option was established as a reasonable approach for solo and small-group physicians to begin building networks that would give them a boost toward participating in more sophisticated delivery models later.
"We are shocked and disappointed that this option is not available and implore CMS to get its act together and implement virtual groups for the 2018 performance period," said the AAFP.
Offering More Recommendations
In addition to the recommendations spelled out above, the AAFP gave CMS detailed suggestions related to
- advanced APMs,
- advancing care information (referred to in the letter as "ACI"),
- quality measures,
- CME relative to the improvement activities category,
- coding recommendations,
- the improvement activities scoring process,
- data completeness criteria and proposed percentage acceleration, and
- advanced APM incentive payment arrangements.
Regarding the last item, the AAFP argued that such payments should be made directly to eligible clinicians rather than to tax identification numbers associated with advanced APM entities.
In closing, the AAFP pointed out that "the implementation of MACRA will impact our health care system for years to come, and it must be done thoughtfully, carefully and as simply as possible.
"The AAFP sees a strong and definite need for CMS to step back and reconsider the current approaches to MACRA, which we view as overly complex and burdensome to physicians."
The Academy strongly encouraged CMS to follow the recommendations outlined in the AAFP's document to align the requirements of MACRA "with the goals and intent of the legislation."
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