MSOC Comments on Proposed Rule (File Code CMS-5517-P)
Medicare Program: Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models
Thank you for the opportunity to provide comments on this proposed rule that greatly impacts how physicians are paid for the services they provide to Medicare patients. We are a small business that provides medical practice consulting and billing services to many small independent medical practices, including most specialties and both urban and rural settings. For the past 6 years, we have worked with our clients to assist them in meeting the requirements of the current Medicare Quality Programs (PQRS, VBM and Meaningful Use). We have provided education on these topics through numerous seminars to specialty organizations and State/Local MGMA chapters as well as national webinars. We continue to be surprised by the number of small practices that have little understanding of the current programs, and we have great concerns for their future under these proposed rules.
We believe that the MACRA legislation and the complexity of the proposed MIPS program will ultimately force many providers to join large groups, leave rural underserved areas, or become non-participating with the Medicare program. We believe that this type of payment system will result in providers turning away patients that are non-compliant so that their practice is deemed ‘high-value’ and they can receive a reasonable reimbursement for their services. All of these outcomes will significantly impact access to care for Medicare beneficiaries.
Most physicians in small practices provide excellent, high quality and personalized care. Their time, effort and resources are directed to that task; the MIPS program as proposed will require practices to redirect their limited resources to proving value according to ever-changing government definitions.
If we desire to build a truly patient-centered system then it is the patient’s definition of value that should be forefront in efforts to “pay for value”. Under the current MIPS proposal, CAHPS for MIPS surveys are one option for a portion of the Quality component but the cost is prohibitive for small practices. In future iterations of the Quality Payment Program, we would urge CMS to fund these types of surveys for all practices and base a larger portion of the Composite Performance Score on the results.
In addition to these general comments regarding the MIPS program, we have several comments, suggestions and questions on specific aspects of the proposed rule.
The reporting period should be reduced from 12 months to any continuous 90 day period during the calendar year. Requiring a 12-month reporting period is unduly burdensome for small practices and does not provide any better information about the quality and value of care they provide to patients. While we suggest that the shorter reporting period be incorporated for all reporting years, it is especially critical that it be reduced in the first reporting year. With final rules scheduled for November 1, a January 1 start date is unreasonable. By reducing the reporting period, practices will have until October 1, 2017 to understand the complex requirements of this new program and implement the necessary changes to succeed.
Low Volume Threshold
The low volume threshold should be changed to 250 Medicare patients OR $25,000 in Medicare allowables. A typical primary care provider will care for 2500 to 3500 patients. Under the current proposal, a provider is required to invest in infrastructure to prove value to CMS when less than 4% of his patients are Medicare beneficiaries. A target around 10% is more reasonable and would not significantly increase the number of providers excluded from the program. Depending on specialty, an individual clinician may meet the allowable threshold and not the patient threshold or vice versa. Requiring both thresholds to be met is unnecessarily burdensome.
If the practice chooses to report as a group, the low volume threshold should be multiplied by the number of eligible clinicians in the group. Under the proposed rule, groups with some low-volume providers are virtually required to report all data as individual clinicians, creating additional and unnecessary work.
A clinician should be exempt from MIPS based on meeting the low volume threshold in the year prior to the reporting period. As currently proposed, a provider with low volumes would not know until the end of the reporting period whether they had met the low volume threshold and therefore would be required to expend the resources needed to meet the program’s requirements, regardless of the volume of patients or allowables.
The proposed rule does not address how payment adjustments are applied for eligible clinicians who are non-participating with Medicare. We request clarification on this issue and would suggest that only Medicare’s portion of the allowable amount should be adjusted. Patients should continue to pay 20% of the standard Medicare allowable. This approach would facilitate practices being able to accurately calculate and collect the portion owed by patients at the time of service, and would allow supplemental insurance plans to have a consistent baseline to calculate their premium rates.
Reporting rate should be reduced to 50% of Medicare patients. If CMS retains the proposal to require 90% of all patients, we request clarification on how CMS will verify that this requirement is met. Many providers are now familiar with the current reporting requirements under the PQRS program. Increasing the reporting rate to 90% of all patients is unreasonably burdensome and does not provide more information about the quality of care provided. Achieving a 90% reporting rate will require all clinicians to be actively collecting data for all selected measures on January 1 of each year and is especially problematic if final rules regarding quality measures are not published until November.
Measure Groups should be included as a reporting option and should be expanded by creating Measure Groups for more clinical conditions or specialties. Many providers in small practice have used this reasonable and cost-effective approach to report quality data under the PQRS program. Removing this option dramatically increases the reporting burden for small practices and provides the minimum number of cases required for a statistically valid analysis.
“Topped Out” measures should be treated the same as all other measures. The proposed rule specifies that when a measure reaches a specific average performance rate, the scoring mechanism will be changed to provide less points to high-performing providers. This proposal essentially penalizes clinicians for performing well on a selected measure. In addition, providers will not know which measures are considered ‘topped out’ until November prior to the reporting period, leaving them little opportunity to change plans and implement data collection efforts on an alternative measure by January 1.
Scoring for new measures should be the same as measures with < 20 eligible cases. The proposed rule specifies that new measures will be scored based on benchmarks from the reporting year. This approach puts the clinician in the unfortunate position of reporting a measure and having no understanding of the target performance required. It is likely to discourage providers from reporting on a new measure and may result in a long lead-up time until reasonable benchmarks are available for that measure. The current policy of excluding new measures from calculation of the overall Quality Score is preferable.
Resource Use Component
The practice of attributing providers to specialist clinicians is inherently unfair and inaccurate. While there is some justification for attributing the full costs of patients to primary care clinicians, beneficiaries should not be attributed to specialists for the per capita cost measure. Such attribution may unfairly assign the full costs for a beneficiary to a provider who has no responsibility for the treatment choices of the patient or other providers. A per-capita cost measure should not be calculated for specialist clinicians.
Advancing Care Information Component
We agree with the proposal to remove the CPOE and Clinical Decision Support measures from the Modified Stage 2 and Stage 3 requirements.
Clinical Practice Improvement Activities Component
We request that CMS clarify the documentation requirements for each of the 90 activities provided in the list of possible activities. Many of the proposed activities included in Table H are vague statements without definitions. The proposed rule includes proposals for how clinicians will be audited to ensure they have provided accurate and complete information in attestations and data submissions. Clinicians must know prior to the reporting year, exactly what documentation will be required for this component should they be audited. They are likely to make their selection of which improvement activities to implement at least partially based on these documentation requirements.
We greatly appreciate the opportunity to provide input into the final rules and regulations that will govern payment to medical practices that serve Medicare beneficiaries. The size and complexity of the proposed rules severely limits the ability of providers and managers in small practices from taking part in this important discussion. We hope that our insights from over 20 years working with these groups is useful as you strive to create an equitable, fair, and transparent payment system.