Medical Industry Groups Comment on Proposed MACRA Rule

Ken Terry

August 22, 2017

Healthcare industry groups sent the Centers for Medicare and Medicaid Services (CMS) a wide array of comments on its 2018 proposed rule for the Quality Payment Program (QPP). The deadline for those comments was Monday.

The most surprising comments came from the American Medical Association (AMA) and the American Medical Group Association (AMGA), both of which sought more flexibility for eligible clinicians and group practices to take part in the Merit-Based Incentive Payment System (MIPS).

The AMA and most other industry groups praised CMS for raising the threshold for exclusion from MIPS to $90,000 or less in Part B-allowed Medicare charges or 200 or fewer Part B Medicare beneficiaries. But the AMA said it wanted CMS to allow excluded eligible clinicians (ECs) and groups to opt into the program if they wished to. While recognizing that it may be too late for CMS to do this in 2018, the AMA asked the agency to investigate an opt-in plan for future years.

The AMA also asked CMS to exclude low-volume ECs from MIPS payment adjustments if they're reporting performance data to CMS as part of group practices. Conversely, the Medical Group Management Association (MGMA) requested that CMS exempt groups from MIPS if 75% or more of their ECs fell below the low-volume threshold.

AMGA, which represents large group practices, criticized CMS for raising the threshold for MIPS participation and recommended that it maintain the current threshold of $30,000 or less in Part B revenues or 100 or fewer Medicare beneficiaries. If the proposed threshold is adopted and an EC or group falls below it, AMGA wants CMS to let that EC or practice voluntarily participate in MIPS.

Both the AMA and the MGMA requested that CMS notify ECs and their practices about whether they have met the threshold for MIPS participation well in advance of the performance measurement period. In 2017, the first performance year for MIPS, physicians were not notified of their status until May, although this was mainly a problem for those who chose to report a full year's worth of data. Other ECs were allowed to report for shorter periods this year.

The MGMA asked CMS to permanently shorten the reporting period for quality measures from the calendar year to 90 consecutive days. This is the same period used for practice improvement activities and Advancing Care Information, the successor to the meaningful use program. The MGMA said it was unrealistic to expect practices to be ready for full-year reporting by January 1, just a couple of months after the final QPP rule is expected to be released.

CMS' proposal to factor improvement in the MIPS performance categories into an EC's or a practice's final score came under fire in the industry comments. The MGMA argued that it was premature to measure improvement in MIPS, partly because of the 18-month lag time between performance and feedback on MIPS scores. The association urged CMS to analyze a few years of MIPS performance data and test the proposed methods of measuring improvement in the field before implementation.

The AMA similarly said, "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."

Applaud Virtual Groups

Both the AMA and the MGMA embraced virtual groups, which, under the QPP proposal, would provide a way for small independent practices to report data to MIPS collectively. But the MGMA advised CMS to relax its definition of virtual groups to allow them to be linked with independent practice associations and management organizations. The AMA, similarly, asked that virtual groups have "maximum flexibility."

Besides MIPS, QPP includes another track for advanced alternative payment models (APMs). Currently, the requirements for advanced APMs — participation which exempts doctors from MIPS and gives them 5% annual bonuses — are very restrictive. The MGMA would expand the list of qualifying APMs to include accountable care organizations in Track 1 of the Medicare Shared Savings Program and participants in CMS' Bundled Payments for Care Improvement initiative.

The AMA's main concern about advanced APMs is that CMS not raise the "nominal risk standard" for qualifying APMs. Currently, CMS requires that 8% of the estimated total Medicare revenues of an APM be at financial risk for the organization to qualify as an advanced APM.

Both the AMA and the MGMA lauded CMS for allowing ECs to use either 2014 Edition or 2015 Edition electronic health records (EHRs) in Advancing Care Information next year. But the MGMA asked the agency to extend that flexibility through 2020.

Other industry groups praised CMS for proposing a bonus for those providers who adopt 2015 Edition EHRs next year. However, the American Medical Informatics Association sought to have CMS state that it will require QPP participants to use 2015 Edition EHR starting in 2019.

Health IT Now, a coalition of patient groups, provider organizations, employers, and payers, complained that CMS was missing an opportunity to drive change in healthcare by allowing providers to use either type of software in 2018.

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