AMGA: Drop Transition, Add MSSP Track for MACRA Implementation
AMGA recommended several MACRA implementation improvements, including the elimination of the transition year and a new MSSP track by 2018.
By - With the Quality Payment Program set to launch on Jan. 1, 2017, the American Medical Group Association (AMGA) provided CMS with several MACRA implementation suggestions, including transition year elimination by 2018 and Medicare Shared Savings Program (MSSP) Track 1+ development.
In a letter to CMS Acting Administrator Andy Slavitt, the industry group listed several recommendations to improve the Quality Payment Program’s two value-based reimbursement tracks.
For the Merit-Based Incentive Payment System (MIPS), AMGA advised CMS to only use 2017 as a transition year, stratify quality measure benchmarks by practice size, implement virtual groups, and use the MSSP as a model for benchmarking methodologies.
According to the final MACRA implementation rule, 2017 will act as a transition year. As long as eligible clinicians submit data to MIPS on one quality, improvement, or advancing care information measure, they will avoid a negative payment adjustment in 2019.
The flexible MIPS attestation tracks, however, will prevent some eligible clinicians from earning the maximum 4 percent value-based incentive payment in 2019, AMGA argued. By implementing the transition year, total positive MIPS adjustments went from $1.333 billion in the proposed MACRA implementation rule to $699 million in the final rule.
Flexible MIPS participation would, therefore, unfairly penalize providers who have prepared for the Quality Payment Program.
“The agency's decision to define 2017 as a ‘transition year’ is a step backward as it penalizes providers that have taken steps to improve care and population health and reduce spending growth in order to effectively subsidize providers that have not yet to date chosen to do so,” wrote the group. “AMGA hopes CMS will fully implement the MIPS program in performance year 2018.”
MIPS would also benefit from quality measure benchmark stratification by practice size, rather than submission mechanism, added AMGA.
The final MACRA implementation rule contained five MIPS data submission mechanisms for individual eligible clinicians and six for groups. For each submission mechanism, CMS plans to develop separate quality measure benchmarks as well as lower data completeness to 50 percent in 2017.
However, AMGA claimed that benchmarks by submission mechanism would not work because of the following:
• No rationale or logic for giving mean or benchmark scores by submission mechanism
• Different benchmark scores would promote gaming, especially since providers can submit quality data based on the mechanism with the lowest benchmarks
• 50 percent data completeness threshold is not consistent with the federal agency’s group practice reporting option’s requirement of 248 consecutively ranked and assigned beneficiaries
• Quality would be assessed and rewarded on “its own merits,” causing quality scores to be skewed, especially for accountable care organizations (ACOs) that may have higher measurement scores
AMGA also recommended that virtual group implementation start before the 2018 performance year to help solo eligible clinicians and group practices participate in MIPS. The final MACRA implementation rule called for MIPS virtual groups, which would allow groups of no more than 10 eligible clinicians to report to MIPS as a single entity.
But AMGA stated that the federal agency should not develop “minimum standards” for how virtual groups organize and design their MIPS reporting processes. Flexible standards would allow for more peer-to-peer learning.
In terms of MIPS, AMGA also suggested that CMS use MSSP ACO methodologies as models for topping out MIPS measures and scoring year-over-year quality improvement. Incorporating MSSP methodologies would improve consistency across federal alternative payment models.
Additionally, AMGA provided several recommendations for the Advanced Alternative Payment Model (APM) track, such as developing MSSP Track 1+, more ramping up of financial risk, and eliminating provider submission of Other Payer model information.
The final MACRA implementation rule mandated CMS to explore a new MSSP ACO option that would include less financial risk than Tracks 2 and 3, but more than Track 1. The two-sided financial risk option would also qualify as an Advanced APM.
To help MSSP Track 1+ development, the industry group recommended the following:
• Make Track 1+ available to all current MSSP ACO participants
• Allow current ACOs and demo ACO participants to participate in the track in any performance year
• Expand participation restrictions to indefinite participation, participation beyond six years, or two three-year agreement periods
• Use a regional financial benchmarking methodology
• Offer higher value-based incentives or shared savings percentages than Track 1
• Allow either preliminary prospective or prospective beneficiary assignment
• Permit beneficiary attestation
• Adjust risk for health status for continuously assigned beneficiaries
• Offer participants the option to apply for payment waivers, such as those for home health, skilling nursing, and telehealth
“AMGA is eager to work with the incoming administration to develop the Track 1+ model,” Donald W. Fisher, PhD, CAE, AMGA’s President and CEO, stated in a press release. “The vast majority of ACO participants are excluded from the Advanced Alternative Payment models, but if done correctly, Track 1+ will serve as an on ramp for providers to move toward increased risk sharing.”
In addition, the industry group expressed support for financial risk ramp-ups in Advanced APMs, including MSSP Track 1+ and medical home models.
Under the final MACRA implementation rule, CMS plans to set the revenue-based risk standard at up to 15 percent of revenue or at 10 percent as long as risk is at least equal to 1.5 percent of expected spending for which an Advanced APM participation is responsible under the model.
While the industry group supported the 15 percent standard, it also pushed for stop loss provisions, like in the MSSP ACO benchmarking methodology, and the buildup of risk over time. Like MSSP ACOs, Advanced APM participants should be able to gradually increase financial risk to ensure success.
Although, AMGA added that eligible clinicians or groups that are part of a larger healthcare organization should be individually evaluated for APM financial risk standards.
CMS proposed to assess the organization rather than the provider groups, but AMGA argued that providers within the organization may have different organizational capacities, patient populations, and financial risk capabilities.
AMGA also called on CMS to eliminate provider requirements to submit information on Other Payer Advanced APMs.
The federal agency will approve alternative payment models from other payers if the model follows MACRA requirements. To qualify, providers will have to submit information on the model to CMS.
However, submitting information on other payers may cause providers to “compromise their ability, or violate their obligation, to keep confidential contractual insurance plan information.”
While the comment period on the final MACRA implementation rule closed on Monday, CMS still plans to start the Quality Payment Program in the new year.
Dig Deeper:
• CMS Timelines for Stage 3 Meaningful Use, MACRA Implementation
• What We Know About Value-Based Care Under MACRA, MIPS, APMs
