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Physician Organizations Voice Concerns About Complexity, Timing of MIPS/APMs Proposed Rule

June 27, 2016
by Heather Landi
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Numerous physician organizations have submitted comments to the Centers for Medicare & Medicaid Services (CMS) calling for the agency to reconsider the timing and complexity of a massive proposed rule that implements Medicare’s new physician payment system.

Comments, which can be posted here, are due today by 5 pm on the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models outlined in the Medicare Access and CHIP Reauthorization Act (MACRA).

In a letter to U.S. Department of Health and Human Services (HHS) CMS Acting Administrator Andy Slavitt, Halee Fischer-Wright, M.D., president and CEO of the Medical Group Management Association (MGMA), which represents more than 33,000 administrators and executives, stated that the MIPS/APM proposed rule “strays significantly from Congress’ intent to simplify quality reporting and provide new value-based opportunities for physicians in Medicare.”

And, she referred to the rule’s proposed MIPS scoring system as “nothing short of a mathematical marvel.”

“Its narrow definition of APM provides almost no opportunities for medical groups to begin the shift away from fee-for-service reimbursement. MGMA appreciates the significant outreach from CMS leadership in recent weeks and is hopeful the agency will take our feedback and implement a simplified system that offers significantly more choices for physicians and supports their ability to provide high quality patient care,” Fischer-Wright wrote in the letter.

MGMA also “strongly opposes” the “overly-narrow and restrictive Advanced APMs criteria proposed by CMS."

“While MACRA established a requirement that APMs bear more than nominal financial risk, CMS would establish a rigorous risk standard that requires strict repayment of losses—a criterion that excludes the vast majority of legitimate APMs, such as Track 1 MSSP ACOs and the Bundled Payments for Care Improvement models.

“Setting a soaring hurdle that physician practices must clear to qualify for the incentives that Congress envisioned to promote practice transformation is taking a step backward, rather than forward. We believe CMS should not only amend its proposed definition of eligible APM to conform to congressional intent in MACRA, but also adopt private payer and PFPMs to fill the void,” MGMA stated.

MGMA also offered a number of recommendations to “improve the proposed regulatory framework of MIPS and APMs,” including beginning the first MIPS performance period “no sooner than Jan. 1, 2018.” “Following publication of the final rule and ahead of the start date, the agency must devote significant resources to educate practices about this complex program. Most importantly, beginning Jan. 1, 2018, would bring the measurement period closer to the payment year.”

MGMA also recommends that CMS shorten the quality and advancing care information (ACI) performance periods to any 90 consecutive days using sampling and attestation methodologies that ensure statistical validity. “Ninety days would align quality and ACI with the proposed 90-day clinical practice improvement activity (CPIA) performance period,” MGMA stated.

The American Academy of Family Physicians (AAFP), which represents close to 125,000 family physicians, stated in its comments to CMS that it continues “to support the core reforms set forth in MACRA” and supports the idea that the law, “at its core, is designed to strengthen primary care and make primary care a strong foundation for payment and delivery reform for physician services under Medicare.”

AAFP says it supports numerous provisions included in the regulation and “applauds CMS for identifying and adhering to the fundamental provisions of the law.”

Specifically, AAFP supported CMS's effort to "simplify the program and to eliminate the pass/fail evaluation processes.”

However, the organization also stated, “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.”

And, AAFP stated, “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.”

The organization also gave a number of recommendations, including that the initial performance period start no sooner than July 1, 2017.

The proposed rule has garnered 2,393 comments so far, including numerous comments from individual physicians who also voiced concerns and frustrations with the proposed rule.

One physician commented, “I am a Texas physician who is extremely disappointed and disillusioned with the Centers for Medicare & Medicaid Services' draft rule to implement the Medicare Access and CHIP Reauthorization Act (MACRA). Physicians as a profession and individually are dedicated to constantly improving the quality of care we provide. But as I read it, this rule will wreak havoc with my practice while offering absolutely no evidence that it will do anything to improve patient care.

Further the physician stated, “Here is how you can help his this problem: Since you won't finalize the rules until on or around Nov. 1, 2016, the Jan. 1, 2017, start date is completely unreasonable. Physicians need at least a six-month deferment to prepare our practices and processes for all the changes MACRA is demanding. Please begin the first period on July 1 and end it on Dec. 31. This deferment will be particularly critical for small practices.”

The American College of Rheumatology (ACR) also stated, in its comments, that while it supports the MACRA law, “the complexity and timing of the requirements are daunting.” “We are concerned that the proposed timeline will impede rheumatologists’ ability to prepare and comply with the extensive new requirements.”

ACR also wrote that, as currently written, the requirements for qualifying participation in APMs are formidable, and “establish too high of an administrative burden.” “There are few existing APMs that are feasible for rheumatologists. Workable alternatives should be developed with attention to facilitating participation of small and solo practices.”



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