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How Can CMS Improve MACRA’s Quality Payment Program, MIPS?

Full implementation of MIPS, more Advanced APMs, and administrative burden reductions are among the Quality Payment Program improvements suggested by providers.

MACRA, Quality Payment Program, and the Merit-Based Incentive Payment System (MIPS)

Source: Thinkstock

By Jacqueline LaPointe

- While providers commend CMS for replacing the Sustainable Growth Rate with MACRA and its Quality Payment Program, many still have some reservations about the Medicare program.

After completing the first Quality Payment Program performance year in 2017, providers are expressing concerns to policymakers and healthcare leaders regarding the program and its two payment tracks: the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (Advanced APMs).

Representatives from leading healthcare organizations and industry groups recently participated in a House Subcommittee on Health hearing to discuss their challenges with the Quality Payment Program and offer recommendations on how to improve the Medicare program.

Reduce the administrative burden on providers

Industry experts at the hearing agreed that the Quality Payment Program would more effectively transition providers to value-based care if there were less administrative burdens associated with the program.

CMS promised to simplify Medicare value-based purchasing initiatives by consolidating them into a single program. The Quality Payment Program uses elements from the Physician Quality Reporting System (PQRS), meaningful use, and the Value-Based Payment Modifier (VM).

READ MORE: Understanding the Quality Payment Program’s Advanced APM Track

However, providers are still facing quality reporting and administrative burdens under the consolidated value-based purchasing program. About 82 percent of providers in a 2017 MGMA survey viewed the Quality Payment Program as very or extremely burdensome.

The majority of respondents (80 percent) also had concerns about the clinical relevance of MIPS and its quality measures, which was a challenge the American College of Surgeons (ACS) stressed during the subcommittee hearing.

Frank Opelka, MD, FACS, ACS’ Medical Director of Quality and Health Policy, explained that primary care and population health-focused quality measures increase the reporting burden on specialists.

“For example, surgeons are frequently being evaluated based on a patient’s immunizations. This is not relevant to the care surgeons provide, and therefore is seen as unnecessary and burdensome,” he stated. “This in turn reflects poorly on MIPS and its intention, causing a lack of buy-in on the part of many surgeons.”

CMS should implement quality reporting that does not overburden providers and detract the focus from patient care. “To accomplish this, CMS needs measures that accurately and meaningfully target the episode of care being assessed, providing useful information to physicians and patients. This is not currently the case,” he said.

READ MORE: Key Ways to Succeed Under MACRA’s Quality Payment Program

The American Medical Association’s (AMA) immediate past president David O. Barbe, MD, MHA, also provided a list of suggestions for decreasing administrative burden in the Quality Payment Program. His recommendations included:

  • Reducing the number of measures a physician must report for the MIPS Quality performance category
  • Permitting providers to report for a minimum of 90 days in all MIPS performance categories
  • Expanding facility-based definition to include providers in all settings, such as post-acute care and long-term care facilities

“Our recommended changes would reduce physicians’ administrative burden, allowing them to spend more time with their patients,” Barbe stated.

Modify the MIPS Promoting Interoperability category

MIPS in general may increase the administrative burden on providers, but eligible clinicians are particularly troubled by the Promoting Interoperability performance category.

Through the Promoting Interoperability performance category (formerly known as Advancing Care Information), CMS intends to advance certified EHR use as the federal agency did through provider-focused meaningful use initiatives.

However, the ACS finds the MIPS performance category’s scope too limited.

READ MORE: 4 Strategies for Merit-Based Incentive Payment System Success

For many providers, Promoting Interoperability (PI) remains the most frustrating aspect of the MIPS program,” Opelka stated. “The category is focused too narrowly on the EHR and less on the advancement of broadly applied patient digital health information from all data sources as the original name of ‘Advancing Care Information’ implies.”

The industry group explained that CMS should “refocus to the original goals of using technology, and more specifically digital health information at the patient level, to improve care and lessen the focus on EHRs alone.”

More specifically, the Promoting Interoperability category should reward providers who use health IT tools to create a more complete patient record that is available to patients and other providers at the points of care.

The AMA also called on CMS to modify the reporting requirements of the MIPS performance category.

“CMS should also change Promoting Interoperability reporting requirements to attestation alone and develop new measures that utilize not only certified electronic health records (EHRs), but also technology that builds on certified EHRs,” Barbe said on behalf of the AMA.

Add more Advanced APM options

Most eligible clinicians participate in MIPS, but a select few have opted to go down the Advanced APM pathway.

The Quality Payment Program payment track offers the greatest incentive payments to providers who successfully and sufficiently participate in approved risk-bearing alternative payment models. A goal of the Quality Payment Program is to encourage more eligible clinicians to participate in the risk-bearing alternative payment models.

At the time of this publication, CMS has approved nine Advanced APMs, which are primarily accountable care organizations (ACOs) and bundled payments.

However, experts at the American Academy of Family Physicians (AAFP) told policymakers that nine models are not enough to truly transition providers to risk-based value-based care.

“MACRA placed a priority on the transition of physician practices from the legacy fee-for-service payment model towards alternative payment models (APM) that promote improved quality and efficiency. To date, the number of available APMs is not sufficient to achieve this goal,” AAFP Board Chair John Meigs, Jr., MD, FAAFP, wrote in a letter entered into the record at the subcommittee hearing.

Particularly, more Advanced APMs that cater to specialists would help to promote risk-bearing alternative payment model participation, ACS added.

ACS’ understanding at the time of passage of MACRA was that surgeons and other physician specialties would be evaluated based on measures related to the care they provide and would have access to APM options suitable to their practice,” Opelka said.

“If these were unavailable at the time of passage, opportunities were built in by Congress to allow specialties to develop them. However, these new models and measures have not materialized, and not for lack of effort on the part of the physician community.”

Opekla specifically criticized HHS’ lack of action with approving and testing models physician-focused payment models.

HHS designed the physician-focused payment model option to expand the number of approved Advanced APMS. But the federal department has yet to implement or even test any of the physician-focused payment models approved by a technical advisory committee.

America’s Physicians Groups (AGP) also explained that expanding Advanced APMs to other alternative payment methods besides ACOs and bundled payments is key to advancing value-based care.

Continue to look at care models outside of traditional FFS Medicare, most notably capitation, in which groups assume financial risk and responsibility,” advised the group’s Chairman of the Board Kurt N. Ransohoff, MD, FACP. “The care given in that model, when the activities of doctors are measured, should count towards the value-based care Congress is trying to promote.”

Implement MIPS as originally intended

Industry experts testifying at the subcommittee hearing also agreed that CMS should implement MIPS as originally intended by the Medicare Access and CHIP Reauthorization Act of 2015. Specifically, the federal agency should encourage greater participation as intended.

We believe that CMS has bypassed the intent of MACRA by excluding 58 percent of providers from MIPS requirements for performance year 2019 in the recently proposed Quality Payment Program (QPP) or MACRA rule (CMS-1693-P),” said AMGA’s Chairman of the Board Ashok Rai, MD.

“This exclusion will result in negligible payment adjustments for high-performers that have made meaningful investments to improve quality of care for the communities they serve. This action effectively collapses the MIPS payment adjustment distribution curve,” continued Rai, who is also the President and CEO of Prevea Health.

The limited participation in MIPS significantly modified the payment adjustments for AGP’s Ransohoff, who is also the CEO of the Sansum Clinic in California.

High-performers were eligible for a four percent payment adjustment under the original MACRA implementation plan. However, the clinic will only receive a 2.02 percent payment adjustment despite scoring 100 points during the first MIPS performance period.

“This is still meaningful, but the costs of doing well are considerable, and the reduction of incremental payment reduced our margin significantly,” Ransohoff reported.

While CMS intended for greater exclusions to give providers more time to prepare for the new program, stakeholders are asking the federal agency to finally implement the program as intended to ensure providers get paid for their investments in high-value care.

The federal agency can also help small, rural providers, who struggle with aligning their processes with MIPS, by offering them a new pathway within MIPS, APG recommended.

“In recognition of the fact that smaller groups have fewer resources, MIPS for smaller groups may need to look different from MIPS for larger groups,” the group advised.

“In other words, give smaller groups a different test, more suitable for their resources, instead of excluding them entirely. Doing so will help move more doctors from volume to value and allow more to participate, while acknowledging that smaller groups have more limited resources to comply with an overly burdensome test.”


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