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AMA to CMS: Work to Simplify Quality Payment Program Regulations

By: Andis Robeznieks

American Medical Association   (AMA)

August 21, 2017

The AMA told the Centers for Medicare and Medicaid Services (CMS) that it supported many of the proposals it offered for the second year of the Medicare Quality Payment Program (QPP), but it also encouraged the agency to do more to simplify the evolving regulations for value-based payments.

“We are committed to working with CMS to provide feedback on the QPP and highlight ways to improve successful participation,” AMA Executive Vice President and CEO James L. Madara, MD, wrote in a letter to CMS Administrator Seema Verma. “With respect to the 2018 program year, while we believe CMS has included many improvements, we continue to urge the agency to seek ways to simplify and further streamline the program.”

Physicians’ QPP participation in 2018 will affect their Medicare payment levels in 2020.

CMS released its proposed rule on June 20 and it suggested that the second year of the program, which was created by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), would serve as another transition year for physicians adjusting to a value-based payment system.

“When physicians are asked to move to a new program, we expect some bumps along the way,” AMA President David O. Barbe, MD, MHA, said in a statement. “CMS has been a good partner in smoothing out the bumps but the program still needs to be more understandable and less burdensome. The complexity is an obstacle to the goal of promoting innovative approaches to encourage higher value care. We applaud CMS’ decision to allow for another transition year for MIPS, recognizing the challenges physicians face both bureaucratic and technological. The willingness to compromise will help physicians and patients alike.”

Proposals benefit small practices

This would be especially true for small practices as CMS proposed exempting more physicians from the QPP’s Merit-based Incentive Payment System (MIPS) in 2018.

The AMA submitted its comments to CMS in Dr. Madara’s Aug. 21 letter to Verma, in which the Association registered its support for the proposal to raise the Medicare-patient-level and Medicare Part B-charge thresholds for requiring MIPS participation. The AMA also noted its appreciation for allowing small-group and solo practices to work together in virtual groups under MIPS and to not be limited by geography or specialty.

If the rule is implemented as proposed, CMS estimates 94 percent of eligible clinicians will receive either a positive or neutral adjustment to their Medicare payments in 2020, based on the success of their MIPS participation next year.

The AMA recommends CMS maintain a slow pace to developing its methodology for measuring and rewarding performance improvement.

“CMS should continue to seek feedback and analyze data before adopting an approach to measure and score improvement, which may add complexity to the program and, once implemented, may be difficult to change,” Dr. Madara warned in his letter.  “The AMA strongly supports many of CMS’ proposals that will create stability within the quality-performance category for physicians—including not increasing the number of quality measures a physician is required to report.”

The letter also called on CMS to let physicians use the number of Medicare Advantage patients they see in beneficiary counts that determine whether they qualify as participants in Advanced Alternative Payment Models (APMs)—noting that this could affect 2020 payment adjustments.

Madara reminded CMS of the AMA’s continued opposition to including Part B drug costs in its calculations for determining MIPS eligibility, applying the MIPS payment adjustment, and in comparing physician costs. If the costs of these drugs are included in those calculations, certain specialists—such as oncologists and rheumatologists—who purchase and dispense medications will be subject to penalties that will lower their reimbursement to a figure below their expenses.

“Many physicians who provide these critically important drugs will have little choice but to refer their patients to hospital outpatient departments where Medicare and its beneficiaries will face higher costs,” Dr. Madara wrote.

Registry concerns registered

The AMA also called on CMS to allow more flexibility on the use of Qualified Clinical Data Registries (QCDRs) for quality reporting, noting that medical specialty societies “are spending millions of dollars” on registries that provide timely and relevant feedback information.

“QCDRs enable physicians to report on quality measures that are robust, outcome oriented, and more applicable to a physician’s patient population compared to traditional MIPS measures,” Dr. Madara wrote.  “We are therefore concerned with CMS’ recent direction related to the approval of QCDR measures since it severely limits their flexibility.”

The AMA also called for greater flexibility in allowing specialty practices to qualify as medical home APMs. The letter described regulations requiring Medicare and Medicaid medical homes to use primary-care physicians and to deliver primary care services as “unnecessarily and inappropriately restrictive.”

Oct. 2 reporting deadline nears

The highlight of the 2017 QPP rule released last year was the roll out of the pick-your-pace scoring methodology that included three options. The first allowed full adoption of the MIPS reporting system under which participants could be eligible for a Medicare bonus of four percent or more in 2019.

There is still time for physicians to select the partial-reporting “pace.” Physicians seeking  a bonus of up to four percent have until Oct. 2 to start reporting on more than one quality measure, more than one improvement activity or four Advancing Care Information measures for at least 90 days.

Physicians who are less prepared can test their readiness by reporting one measure, from one patient, at any time before Dec. 31. While this method wouldn’t qualify for a bonus, the physicians who use it avoid receiving a penalty in the form of a negative Medicare payment adjustment.

The AMA has launched an education campaign, “One patient, one measure, no penalty,” to help guide physicians through that process. The campaign includes a video and a step-by-step guide to help physicians complete the requirement and avoid a penalty. To learn more about CMS’ “pick your pace options,” listen to this recent ReachMD interview with Kate Goodrich, MD, CMS’ chief medical officer and director of its Center for Clinical Standards and Quality.

A new customizable resource, the MIPS Action Plan, helps physicians choose and implement a practice QPP strategy, fulfill regulatory requirements, avoid federal penalties and have an opportunity for performance-based incentive payments.

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