Republican Congressional Doctors Call for MACRA Rule Changes

Ken Terry

October 10, 2016

The GOP Doctors Caucus — a group of 18 Republican members of Congress who have healthcare credentials, including 8 physicians — is calling for significant changes in the proposed rule to implement the Medicare Access and CHIP Reauthorization Act (MACRA).

In an October 6 letter to Andrew Slavitt, acting administrator of the Centers for Medicare & Medicaid Services (CMS), and Shaun Donovan, director of the Office of Management and Budget (OMB), the GOP Doctors Caucus criticized the proposed rule as overly complex and burdensome and said that CMS should not implement the rule "in a manner inconsistent with Congressional intent." That language seemed to warn that Congress might intervene if it doesn't like CMS's final rule, which is expected by the end of this month.

The caucus's letter focused on the Merit-Based Incentive Payment System (MIPS), one of two Medicare reimbursement tracks that physicians can choose under MACRA. Most doctors are expected to participate in MIPS, the letter noted. CMS expects as few as 6% of physicians to join one of the advanced alternative payment models that constitute the other track, it pointed out.

Under CMS's proposed rule, the caucus said, MIPS would require even small practices to measure and monitor their performance on at least 22 measures, including 8 quality metrics, 2 resource use measures, 11 measures for Advancing Care Information (the successor to meaningful use), and 1 measure for clinical practice improvement activities. From the caucus's viewpoint, that is too much measurement.

"In order to be successful, MIPS must engage clinicians with a reporting system that is not overly burdensome, a scoring system that is simple and transparent, attained thresholds, and a short enough quality/payment feedback loop to allow physicians to learn and make necessary changes to avoid penalty," the letter said.

The latter point refers to the 2-year time lag that would exist between physician performance and its financial consequences under the CMS proposed rule. The initial performance reporting period starts January 1, 2017, but CMS would not use those data to adjust physician reimbursement until 2019.

90-Day Reporting Period

Like several medical societies, the caucus also believes that the January 1 start date and the length of the MIPS performance reporting period — a full calendar year — are unrealistic. The letter acknowledged that CMS recently made some significant changes in these aspects of the program, giving physicians more flexibility in when and how much they must report in 2017. However, CMS has not embraced a 90-day reporting period or a July 1, 2017, start date, as medical societies have urged. And its recent changes do not apply to 2018 or subsequent years.

The caucus called for CMS to establish a 90-day reporting period. While the group said the agency's recent policy shift is "a step in the right direction," it added, "We await further details to determine the extent to which this proposal and other provisions in the final rule alleviate potential problems raised by a 2017 start date."

The caucus also noted that MIPS is expected to contribute to the continued consolidation of small practices into larger units because of the administration burden imposed by the program. To help avoid this, it suggested that CMS should do the following:

  • Lower the patient minimum reporting thresholds from the proposed level of 90% of patients from all payers to the current threshold of 50% of Medicare patients that is used in the Physician Quality Reporting System. For physicians using a claims-based method to report quality data, the threshold should drop from 80% to 50% of Medicare patients, the caucus said.

  • Accelerate the introduction of "virtual groups" that small practices could use to measure and report on performance collectively. CMS plans to offer this option in 2018, but the caucus wants it to happen sooner.

  • Raise the low-volume threshold that would exempt some physicians from MIPS. Currently, this threshold applies to eligible professionals who have under $10,000 in allowed Medicare charges and see fewer than 100 Medicare patients per year. The caucus would raise this limit to $30,000 in allowed charges or under 100 Medicare patients per year. "This would exclude less than 30% of physicians while still subjecting more than 93% of allowed [Medicare] spending to MIPS," the letter said.

Finally, the caucus objected to CMS's use of resource measures that it says were developed for hospitals and may not provide an accurate or relevant assessment of physician performance. MACRA called for the development of new episode cost measures, but many CMS episode measures have not been adequately reviewed by physicians or tested for use in physician offices, the letter noted. Therefore, the caucus said, CMS should make the resource use category optional for at least a year while the resource use measures are refined and tested.

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