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Advocacy Action Center: Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models

Jun 18, 2016

Template Letter:

Andy Slavitt

Acting Administrator

Centers for Medicare & Medicaid Services

Department of Health and Human Services

Attention: CMS–1645–P

Mail Stop C4–26–05

7500 Security Boulevard

Baltimore, MD 21244–1850

 

RE: Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models

 

Dear Mr. Slavitt:

As a member of the American Academy of Physical Medicine and Rehabilitation (AAMP&R), the society that represents more than 9,000 physiatrists, I appreciate the opportunity to submit comments to the proposed rule referenced above  that was published in the Federal Register on May 9, 2016. Physical medicine and rehabilitation (PM&R) physicians, also known as physiatrists, treat a wide variety of medical conditions affecting the brain, spinal cord, nerves, bones, joints, ligaments, muscles, and tendons. PM&R physicians evaluate and treat injuries, illnesses, and disability, and are experts in designing comprehensive, patient-centered treatment plans. Physiatrists utilize cutting‐edge as well as time‐tested treatments to maximize function and quality of life.

I submit the following comments in support of AAPM&R’s more extensive comment letter and to express my concerns with several of the Agency’s proposals.

II. Provisions of the Proposed Regulations

4. MIPS/APM Performance Period

In this proposed rule, there are a number of significant changes put forward for FY 2017.These changes and new aspects of the Quality Payment Program take time for physicians to understand and implement. CMS will not issue the final rule until the fall of 2016, yet with a proposed start date of January 1, 2017. Due to the extensive nature of the proposed changes, this does not provide sufficient time to prepare physicians for a successful launch of MACRA. Therefore, I strongly urge CMS to amend the performance period for 2017 to start well after January 1, 2017. At a minimum, a six-month performance period (starting June 1, 2017) would allow physicians, like myself, to better understand MACRA and implement changes in my practice.

5. MIPS Category Measures and Activities

b. Quality Performance Category

The proposed rule increases the thresholds for reporting on quality measures from 50% of Medicare Part B beneficiaries to 90% of all patients if through a registry (QCDR) and electronic health record (EHR), or 80% of Medicare Part B beneficiaries if reporting via claims. This considerable increase in reporting thresholds is a huge burden on my practice. I recommend that CMS reduce that burden by decreasing the threshold to 50%. 

While it was appreciated that CMS introduced specialty measure sets in the proposed rule, the PM&R measure set is not something that any PM&R physician would find helpful when looking for quality measures to report. The measures in this set have a number of issues:

  1. They are all process measures so I would still need to find an outcome or high priority measures;
  2. The only way one can report on six out of seven measures is via a registry;
  3. Although the measures could be applicable to some PM&R physicians, this set is not applicable to ALL PM&R physicians.

I urge CMS to remove this specialty measure set and work with AAPM&R on identifying better measures for our specialty.

e. Resource Use Criteria

The resource use category for FY 2017 is by far the most concerning category for physicians. Physiatrists urge CMS to focus on methodological improvements within the resource use category. This includes replacing the current hospital-intended cost measures, as well as use of more sophisticated risk-adjustment, more granular specialty comparison groups, and use of attribution methods that are relevant across specialties. It is especially important that efforts are directed at eliminating flaws that have made practices with the most high-risk patients more susceptible to penalties than other physicians.

f. Clinical Practice Improvement Activity (CPIA) Category

In the proposed rule, CPIA is a new category that physicians have not yet reported on. There are a number of resource-intensive and high-quality activities that are listed as a medium weight activity in the proposed rule. CMS should consider the time commitment, effort and patient benefit to all activities when weighting them. I recommend that CMS increase the number of high-weight activities for FY 2017.  By increasing the number of high-weighted activities, I will have the opportunity to select activities that are meaningful while not sacrificing time and energy that should otherwise be spent on treating the patient. 

g. Advancing Care Information (ACI) Performance Category

I was/were disappointed to learn that CMS has removed exclusions that were part of the Meaningful Use program in the new ACI category for FY 2017. It is my belief that all existing exclusions should remain available for physicians.

I would also like to see CMS allow for alternative ACI measures that are more meaningful and relevant. This would ensure that practices like mine could select and use health IT tools in innovative ways.

F. Overview of Incentives for Participation in Advanced Alternative Payment Models (APM)

4. Advanced APMs

The proposed rule is full of perplexing criteria for Advanced APM participation. As practicing physicians, trying to determine the conditions for Advanced APM participation is extremely confusing. CMS has stated on numerous webinars that they, in fact, do not believe there will be a high number of eligible clinicians in Advanced APMs during the first few years once this rule is final. I urge CMS to simplify the criteria, make it more flexible, and allow time for new APMs to be implemented and existing APMs to be modified.

(1) Use of Certified EHR Technology

In FY 2017, Advanced APMs must require at least 50% of participating clinicians to use certified EHR technology to document and/or communicate clinical care to their patients or other health care providers.  CMS discusses raising the requirement to 75% in FY 2018, but I recommend that this policy not be adopted.  Instead, regulations should keep the requirement at 50% unless and until experience indicates it is practical to move to a higher threshold.  There is still too much uncertainty about the value EHR use adds to the equation – in fact, in the proposed rule, it is stated that “At present, evidence on EHR benefits in either improving quality of care or reducing health care costs is mixed.” 

(4) Nominal Amount of Risk

In the proposed rule, the definition of how one meets nominal risk needs to be simplified and set at a level that is more realistic, appropriate and attainable.  With multiple components including total risk, marginal risk and minimum loss rate, it would be difficult for physicians contemplating participation in Advanced APMs to understand their financial risks or know how much to set aside to cover potential repayments. Most physician offices, especially smaller offices, do not have actuaries to calculate their risk. In addition, many of them do not have the data on which to calculate risk or the IT infrastructure to support it. They also do not have the number of lives under their care to facilitate spreading the risk that one or two patients will have much higher than expected medical issues.

The Department of Health and Human Services’ definition of “significant impact” is a loss of 3% of physician revenue. Therefore, I believe the minimum amount of losses needed to be considered “more than nominal” should be tied to a percentage of physician revenues, not a percentage of Medicare expenditures in the APM.  Total costs of care are beyond a physician’s control.

I appreciate the opportunity to comment on this proposed rule.