- As the comment period for the proposed Medicare Access and CHIP Reauthorization Act (MACRA) came to a close earlier this week, the American Medical Association (AMA) expressed some concern with MACRA implementation and its specific Medicare payment reform programs.
In a letter to CMS Acting Administrator Andy Slavitt, the AMA explained that MACRA has made improvements to existing value-based care programs possible, but implementation of the new system will be a major undertaking for most providers.
“Throughout the years-long process of fighting to eliminate the deeply-flawed SGR, the AMA heard clearly from physicians that they want a new incentive system that reduces red tape, fosters flexibility and innovation in the delivery of care, and establishes a direct link between payments and quality of patient care," wrote AMA President Andrew W. Gurman, MD.
“While we believe CMS is expressing responsiveness to physician concerns in implementing the new law," he continued, "we urge Acting Administrator Slavitt and his staff to make changes to the program rules to ensure physician and patient needs are met.”
AMA listed several suggestions for ensuring a successful transition to the new payment system.
As part of its more general comments, AMA has urged CMS to delay the start date of MACRA from January 1, 2017 to July 1, 2017. According to the organization, the first year should act as a transitional period that would help physicians move away from current Medicare reporting requirements, learn about Medicare payment reforms, and develop workflows and system changes necessary for MACRA.
The delayed start date would also allow health IT vendors to update their systems to meet MACRA requirements and give CMS more time to change existing alternative payments models (APM) so that they can qualify under the Merit-Based Incentive Program (MIPS) or Advanced APMs track.
CMS should also facilitate MACRA implementation for small, rural, and health professional shortage area providers, stated the letter. AMA advised the agency to reduce reporting burdens for this population by implementing exemptions and lowering reporting thresholds, comparing this group to their peers, increasing the low-volume reporting threshold, and providing additional training and technical help.
In terms of the specific Medicare payment reform programs under MACRA, AMA voiced concern with MIPS because of its separate scoring categories, including cost, quality, clinical practice improvement activities, and Advancing Care Information.
“The AMA strongly urges CMS to work to establish a more holistic approach and not maintain the divide between different MIPS categories,” said Gurman. “A holistic approach would transform MIPS from a continuation of four distinct compliance programs to one in which physicians can identify a purpose to the reporting activities.”
AMA also called for better alignment of four MIPS categories by creating clear connections across the different scoring areas, such as streamlining scoring across categories, combining measures, developing new quality measures that bridge the categories, and emphasizing specialty designations.
The industry group likewise called for more flexibility with and simplification of MIPS reporting, such as allowing for more partial credit and removing some required measures or making them optional. Without more flexibility, providers may lose performance points and subsequently receive less reimbursement.
“In addition, infrastructure challenges may prevent physicians from having the ability to report on outcomes measures, such as having the appropriate data elements in the EHR as well as interoperability issues that may interfere with the exchange of needed information, and the inability to do longitudinal tracking due to the lack of uniform patient identifiers,” the letter stated.
As part of simplifying MIPS reporting, AMA has advised CMS to decrease reporting thresholds for quality measures from 80-90 percent to 50 percent to help reduce administrative burdens for providers.
CMS should also reconsider cost of care measures that were determined using hospital-level measurements, recommended AMA. These measures would not accurately assess cost performance for individual physicians or medical groups.
Other MIPS-related recommendations included the elimination of the pass-fail methodology in the advancing care information category, modifying EHR performance measures to differentiate them from current Stage 3 Meaningful Use requirements, decreasing the number of required Clinical Practice Improvement Activities measures, and improving risk adjustment and attribution methods for the resource category.
Additionally, AMA commented on the other pathway in the Quality Payment Program, the Advanced APM track. While the industry group applauded the flexibility provided to APMs, especially in terms of quality reporting, it still had concerns with the model.
“Other policies, especially the definition of financial risk requirements and the lack of a clear process and timeline for approving additional APMs, are a serious concern and must be changed if the APM pathway outlined in the MACRA legislation is to be a meaningful option for more than a handful of physicians,” the letter stated.
AMA has called on CMS to establish a percentage or dollar amount that defines the minimum requirement for financial risk to qualify for this payment track. This risk requirement should be based on physician practice revenues instead of Medicare expenditures, added the letter.
By calculating financial risk factors based on physician practice revenue, AMA claimed that providers would not have to take risks for healthcare expenses that are beyond their control, such as Medicare revenue.
AMA also suggested that CMS provide more opportunities for participation in APMs through the MIPS and Advanced APM tracks.
“CMS needs to develop a pathway and provide assistance to organizations that wish to develop and/or become participants in MACRA APMs. There also needs to be a pathway to help MIPS APMs transition to become Advanced APMs,” Gurman wrote.
AMA aims for its MACRA comments to help CMS recognize potential challenges that many providers could face once the new payment system launches.
“Under MACRA, high-quality, high-value care and improved health outcomes for patients will be rewarded, but ensuring a smooth transition away from SGR requires up-front work today,” said Gurman. “By working together with CMS and continuing an open dialogue, we believe we can make changes that allow physicians to achieve better care for their patients while reducing administrative burden or costs on practices.”