The AAFP recently weighed in on CMS' 2018 updates to the Quality Payment Program (QPP) regulation with an Aug. 18 letter(95 page PDF) to CMS Administrator Seema Verma, M.P.H.
The 95-page comment letter, signed by AAFP Board Chair Wanda Filer, M.D., M.B.A., of York, Pa., gave CMS a meticulous review of the agency's work. Some of the issues that are of critical importance to family physicians -- many of them related to the Merit-based Incentive Payment System (MIPS) -- were highlighted.
MIPS Performance Period, Measures, Cost Weighting
The AAFP expressed concern that CMS is prematurely requiring a full year of quality reporting for the 2018 performance year, especially because CMS gave MIPS-eligible clinicians an opportunity to use the so-called Pick Your Pace strategy for the 2017 performance period.
The letter pointed out that even though many AAFP members are gaining experience in reporting quality measures, "CMS is not yet adept in providing prompt and actionable feedback reports to these practices," leaving some practices struggling to correct inadvertent reporting mistakes.
- The AAFP let CMS know what it likes -- and what needs to be fixed -- in the agency's proposed rule that would update the 2018 Quality Payment Program (QPP).
- In its comments, the AAFP focused on issues that matter most to family physicians, such as the Merit-based Incentive Payment System performance period, quality measures and cost weighting.
- The comment letter also addressed physicians' use of certified electronic health record technology, the complexity of the QPP and the administrative burden primary care physicians bear.
The AAFP urged CMS to
- continue to allow 90-day reporting periods for the quality, advancing care information and improvement activities performance categories in the 2018 MIPS performance period;
- offer flexibility to practices so physicians do not need to choose the same continuous 90-day period for the three categories; and
- grade a practice's performance on the highest scoring period if a practice reports for more than a 90-day period.
The AAFP also encouraged CMS to use the 2018 performance period as a continuous learning process both for physicians and for CMS as it learns how to process data coming in from physicians and strives to "improve the clinical utility and promptness of feedback reports sent to MIPS-eligible clinicians."
Regarding CMS' proposal to reweight the cost category to zero percent for the 2018 performance period, the AAFP noted its support but strongly urged CMS to "continue a gradual introduction of cost into the MIPS final score and increase it to 10 percent beginning with the 2019 performance period," eventually ending at 30 percent some years later.
Furthermore, the AAFP told CMS that holding individual clinicians and small practices accountable for cost "introduces disparities" into the program.
"Therefore, when cost is weighted and added to the final score, we ask that CMS not assess clinicians in small practices (defined as 15 or fewer clinicians) on cost at least until valid and reliable measures are developed," wrote the AAFP.
"It is incredibly difficult (impossible at times) for clinicians in these practices to have a significant impact on health care costs. Large practices and those participating in advanced payment models (APMs) are in a better position to have a meaningful impact on costs," said the AAFP.
CEHRT, Complexity and Administrative Burden
The issue of certified electronic health record technology (CEHRT) -- particularly as it relates to the advancing care information performance category -- also drew a response from the AAFP.
The letter noted that many eligible clinicians are upgrading to 2015 edition CEHRT, and some physicians who are dissatisfied with their current CEHRT functionality are switching vendors "in an attempt to minimize multiple significant clinical workflow disruptions."
The AAFP was supportive of CMS' proposal to offer MIPS-eligible clinicians an exception on using certified technology, but strongly suggested that physicians should be held harmless if their CEHRT becomes decertified mid-stream.
"We have concern about the vagueness of (phrases such as) 'made a good faith effort' and 'through supporting documentation,' in regard to the application process for this exception," said the AAFP. The letter urged CMS to provide further guidance that "better defines these terms."
The AAFP noted it was "highly unlikely" that a physician would have the funding or time to purchase other CEHRT within the year in the case of decertification.
The overwhelming complexity of the QPP also prompted a high level of concern from the AAFP.
For instance, the AAFP reiterated its "steadfast opposition to the entire MIPS APM category," and said it introduced an "unnecessary level of complexity to an already complex program."
"The AAFP strongly encourages consistency and equal reporting standards among all MIPS-eligible clinicians," said the letter.
Another area of frustration for the AAFP is that "CMS continues to create new terminology, not based on statute, and that serves only to confuse clinicians and make this program more complicated. We object to the MIPS APMs. We object to the new term, 'Other MIPS APMs,' due to the inconsistent use of this term in the proposed rule and the confusion this leads to when interpreting requirements for clinicians," said the AAFP.
"A goal of this administration, which the AAFP supports, is administrative simplification," the AAFP said; however, the continuous generation of new terms "introduces complexity and undermines that overall goal."
Regarding the administrative and financial burdens that physicians bear in implementing QPP elements -- whether it's submitting quality performance data or setting up a virtual group -- the AAFP told CMS its estimates are unrealistic.
"CMS assumes that all practices have an office manager, IT support, licensed practical nurse and billing clerk to assist physicians in carrying out reporting requirements. In reality, for many small offices, this work is done by the clinicians themselves, at a higher cost than CMS estimates," said the AAFP.
Furthermore, when submitting data via an EHR, CMS does not recognize the time it takes to design templates, train personnel in data capture, complete documentation, review data submission reports and work with vendors to correct submissions, said the AAFP.
"CMS also doesn't include IT consulting fees for small groups that lack internal IT departments and fails to consider direct fees from the EHR vendors submitting on behalf of clinicians (approximately $300/physician)," the letter added.
The AAFP addressed a number of other issues related to CMS' proposed updates to the QPP. For instance, the Academy urged CMS to
- offer a MIPS opt-in pathway for practices excluded from MIPS on the basis of the low-volume threshold exclusions in the 2018 performance year -- a concern recently addressed in a separate letter;
- monitor MIPS participants who could intentionally avoid progressing to advanced APMs;
- consider that not all states have expanded Medicaid eligibility, and in light of that fact, review the use of dual-eligible status as an indicator of patients' complexity as it could severely underestimate the number of "truly complex patients";
- ensure that all specialists and subspecialists are required to meet the same MIPS program expectations as primary care physicians;
- consolidate and simplify the QPP wherever possible;
- remove the term "primary clinician" and replace it with "physician" or "primary care physician;" and
- consider that requiring physicians to maintain submitted records for 10 years for auditing purposes is unreasonable.
Despite its lengthy commentary to CMS, the AAFP said it was pleased overall with the proposed rule because "CMS took significant steps to improve the ability of family physicians to participate successfully in payment reforms envisioned by the bipartisan Medicare Access and CHIP Reauthorization Act (MACRA)."
The AAFP's recommendations are intended to support two of MACRA's key goals: to strengthen primary care for Medicare beneficiaries and to encourage more physicians to participate in APMs, said the AAFP.
Indeed, CMS already has considered and incorporated a number of previous AAFP recommendations.
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MACRA: The Medicare Access and CHIP Reauthorization Act
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