[Senate Hearing 114-679]
[From the U.S. Government Publishing Office]
S. Hrg. 114-679
MEDICARE ACCESS AND CHIP
REAUTHORIZATION ACT OF 2015:
ENSURING SUCCESSFUL IMPLEMENTATION OF
PHYSICIAN PAYMENT REFORMS
=======================================================================
HEARING
BEFORE THE
COMMITTEE ON FINANCE
UNITED STATES SENATE
ONE HUNDRED FOURTEENTH CONGRESS
SECOND SESSION
__________
JULY 13, 2016
__________
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COMMITTEE ON FINANCE
ORRIN G. HATCH, Utah, Chairman
CHUCK GRASSLEY, Iowa RON WYDEN, Oregon
MIKE CRAPO, Idaho CHARLES E. SCHUMER, New York
PAT ROBERTS, Kansas DEBBIE STABENOW, Michigan
MICHAEL B. ENZI, Wyoming MARIA CANTWELL, Washington
JOHN CORNYN, Texas BILL NELSON, Florida
JOHN THUNE, South Dakota ROBERT MENENDEZ, New Jersey
RICHARD BURR, North Carolina THOMAS R. CARPER, Delaware
JOHNNY ISAKSON, Georgia BENJAMIN L. CARDIN, Maryland
ROB PORTMAN, Ohio SHERROD BROWN, Ohio
PATRICK J. TOOMEY, Pennsylvania MICHAEL F. BENNET, Colorado
DANIEL COATS, Indiana ROBERT P. CASEY, Jr., Pennsylvania
DEAN HELLER, Nevada MARK R. WARNER, Virginia
TIM SCOTT, South Carolina
Chris Campbell, Staff Director
Joshua Sheinkman, Democratic Staff Director
(ii)
C O N T E N T S
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OPENING STATEMENTS
Page
Hatch, Hon. Orrin G., a U.S. Senator from Utah, chairman,
Committee on Finance........................................... 1
Wyden, Hon. Ron, a U.S. Senator from Oregon...................... 3
.................................................................
ADMINISTRATION WITNESS
Slavitt, Andy, Acting Administrator, Centers for Medicare and
Medicaid Services, Department of Health and Human Services,
Baltimore, MD.................................................. 5
ALPHABETICAL LISTING AND APPENDIX MATERIAL
Hatch, Hon. Orrin G.:
Opening statement............................................ 1
Prepared statement........................................... 25
Slavitt, Andy:
Testimony.................................................... 5
Prepared statement........................................... 26
Wyden, Hon. Ron:
Opening statement............................................ 3
Prepared statement........................................... 32
Communications
Alliance of Specialty Medicine................................... 33
American College of Physicians (ACP)............................. 37
American Congress of Obstetricians and Gynecologists (ACOG)...... 44
American Hospital Association (AHA).............................. 48
American Society of Plastic Surgeons (ASPS)...................... 52
The Docs4PatientCare Foundation.................................. 53
Infectious Diseases Society of America (IDSA).................... 57
Medical Group Management Association (MGMA)...................... 61
(iii)
MEDICARE ACCESS AND CHIP
REAUTHORIZATION ACT OF 2015: ENSURING
SUCCESSFUL IMPLEMENTATION OF PHYSICIAN PAYMENT REFORMS
----------
WEDNESDAY, JULY 13, 2016
U.S. Senate,
Committee on Finance,
Washington, DC.
The hearing was convened, pursuant to notice, at 10:06
a.m., in room SD-215, Dirksen Senate Office Building, Hon.
Orrin G. Hatch (chairman of the committee) presiding.
Present: Senators Grassley, Crapo, Cornyn, Thune, Burr,
Isakson, Portman, Toomey, Heller, Scott, Wyden, Stabenow,
Nelson, Menendez, Carper, Bennet, Casey, and Warner.
Also present: Republican Staff: Chris Campbell, Staff
Director; and Brett Baker, Health Policy Advisor. Democratic
Staff: Joshua Sheinkman, Staff Director; Michael Evans, General
Counsel; Elizabeth Jurinka, Chief Health Advisor; and Beth
Vrabel, Senior Health Counsel.
OPENING STATEMENT OF HON. ORRIN G. HATCH, A U.S. SENATOR FROM
UTAH, CHAIRMAN, COMMITTEE ON FINANCE
The Chairman. I would like to welcome everyone to this
morning's hearing. Today, the committee will hear from the
Centers for Medicare and Medicaid Services on its initial
proposal for implementing the physician payment reforms
included in the historic Medicare Access and CHIP
Reauthorization Act of 2015, generally referred to as MACRA.
I would like to thank Acting Administrator Slavitt for
appearing today to testify on this important topic.
The passage of MACRA was a tremendous bipartisan
achievement that addressed longstanding and recurring problems
under Medicare. It was, I will note, one of the first of many
significant bipartisan accomplishments we have seen in the
114th Congress. Most notably, MACRA eliminated the flawed
Medicare Sustainable Growth Rate, or SGR, formula.
As everyone here will recall, the SGR mandated significant
cuts to Medicare physician payments that were, on a more or
less yearly basis, averted by legislation to, quote, ``patch''
the SGR. Between 2002 and 2014, Congress passed 17 different
laws to prevent the cuts from taking place. The perpetual SGR
cycle took up far too much of Congress's time and diverted
attention from other priorities. Getting rid of the SGR not
only resolved a vexing problem for lawmakers, it gave security
to Medicare beneficiaries who often had to wonder if they would
eventually lose access to their physicians.
In addition to repealing and replacing the SGR, the MACRA
law contains structural reforms to the Medicare program,
including increased means testing for Part B and Part D
premiums and limits on, quote, ``first dollar'' Medigap
coverage for new beneficiaries.
While these structural changes put Medicare on a more solid
fiscal footing, more needs to be done to ensure the program is
there for future generations.
I note these reforms today to reiterate what I have said on
several occasions. Despite the cries of naysayers, bipartisan
Medicare reform is possible, and the passage of MACRA proves
that to be the case.
I look forward to continuing the discussion on how to shore
up the Medicare program for the long term. But for today, let
me turn back to the stated purpose of this hearing, which is
MACRA's physician payment reforms.
The physician payment reforms are the result of years of
effort in the Finance Committee. Working with the House
committees of jurisdiction, this committee was able to craft a
legislative solution that garnered the support of nearly every
national and State physician organization.
This proved to be key to MACRA's enactment, as previous
efforts to eliminate the SGR had been stymied by the question
of what would replace it. These reforms were intended to
accomplish several things. Our most specific goals were to,
one, streamline disjointed incentive programs to reduce the
administrative burden on physicians; two, ensure that metrics
on which physicians are assessed are relevant to the patients
they treat; three, provide flexibility to physicians to
participate in a way that best fits their practice situation;
and, four, provide an incentive to consider and attempt
alternative payment models.
Now, we are here today to discuss and, hopefully, evaluate
how CMS has proposed to implement the law in order to achieve
these goals.
Let me say that I appreciate the extent to which CMS has
reached out to stakeholders to get their thoughts in advance of
the proposed rule the agency released in April. I understand
that CMS continued its outreach during the public comment
period to ensure that key groups would be informed on the
proposal and to hear their reactions. Consultation with
stakeholders, especially beneficiaries and physicians on the
front lines of providing care is precisely what we sought when
we drafted the statute.
I also appreciate the outreach that CMS has undertaken with
members of Congress and their staffs. Viewing implementation as
a partnership with Congress is the right way to go. Without
delving too far into my longstanding concerns about the
administration's lack of disclosure and cooperation with
Congress, I say that I wish this model would be used more
often.
The CMS proposal that resulted from this consultation and
outreach is hundreds of pages, and the details matter greatly
to our physicians and patients. This hearing will give CMS a
chance to describe its implementation efforts and give members
of the committee an opportunity to reflect and ask questions on
issues that are garnering significant comment and public
discussion.
It will also allow members to speak to Congress's intent
with regard to MACRA, share insights, and hopefully get answers
on the issues that are important to their constituents.
Before we hear from Mr. Slavitt on CMS's implementation,
though, I want to flag an important concern that I know is
shared by others, which is the plight of small and rural
physician practices. We recognized the inherent challenges of
these types of practices when we crafted the MACRA statute, and
I know CMS is aware of these issues, but we need to make sure
that the law is implemented in a way that works for these
physicians and ensures that these practice settings remain
viable options for Medicare beneficiaries.
So I look forward to a constructive dialogue here today and
to the committee's continued engagement with CMS through the
final rule in November and beyond.
With that, I want to recognize my partner and companion in
this effort, Senator Wyden, for his opening remarks.
[The prepared statement of Chairman Hatch appears in the
appendix.]
OPENING STATEMENT OF HON. RON WYDEN,
A U.S. SENATOR FROM OREGON
Senator Wyden. Thank you very much, Mr. Chairman. Thank you
for scheduling today's hearing.
It is my view that there are big opportunities ahead to
make substantial bipartisan progress when it comes to
protecting and updating the Medicare guarantee, and that is
what this committee will be discussing this morning.
The first is to implement the plan to throw in the trash
can the hopelessly broken, out-of-date Medicare reimbursement
formula known as the SGR. This was the source of uncertainty
and frustration for health-care providers and seniors, and it
has now been sent to the dustbin of history.
Today, the committee has a chance to talk about how its
replacement is going to be implemented.
Second, it is important to build on the new Medicare
payment system, and, in my view, the obvious place to start is
in the area of chronic care.
Seniors suffering from these chronic illnesses, such as
heart disease, cancer, diabetes, and stroke, now account for 93
percent of the spending in the Medicare program. I am very glad
that it is now a bipartisan focus of the committee.
By finally clearing the decks of the SGR debacle, the
Finance Committee has been able to get to work on developing
legislation that will empower families and Medicare to manage
and treat these debilitating illnesses.
I would like to especially thank the chairman, Senator
Warner, and Senator Isakson, who joined me in a special focus
on this issue. This effort has already begun paying dividends.
Last Thursday, for example, the Centers for Medicare and
Medicaid Services proposed to adopt, by rule, four of the
proposals developed by our chronic care working group. The four
areas relate to diabetes prevention, care coordination among
providers, mental health/substance abuse treatment, and
Alzheimer's care planning, which reflects the special priority
of our colleague from Michigan, who has done great work with
respect to Alzheimer's.
Obviously, there is still an enormous amount of work to be
done, but I just want to express to my colleagues my
appreciation for the good work that they have already done,
which, in my view, has been the spark behind what the Centers
for Medicare and Medicaid Services proposed last Thursday to do
by rule.
Now, when it comes to replacing SGR, Medicare payment
reform took the important step of engraving into stone the
principle of rewarding medical care that provides quality over
quantity. For the seniors who depend on the Medicare guarantee,
this ought to result in better, more thoughtful care. That is
the direction health care is headed across the country, and
Medicare ought to be leading the way.
I am going to wrap up by just making two quick points with
respect to implementing the Medicare Access and CHIP
Reauthorization Act the right way.
The first is to make sure all doctors who care for older
people get fair treatment under the new rule. As Chairman Hatch
and I have noted on many occasions, that is especially true for
the small or solo practitioners who have always been the
backbone of rural communities.
Second, the legislation supports efforts to strengthen
primary care--which I believe, once again, there has been
bipartisan support in this committee for--focusing there in
order to help people to be healthier and to hold down costs.
For example, the Comprehensive Primary Care Plus model allows
Medicare to partner with commercial and State health insurance
plans, so all parties are on the same page when it comes to
paying for value and quality care.
What it means is a primary care doctor who has business in
the commercial market and in Medicare does not have to find a
balance between a byzantine set of rules as she is trying to
serve as many people in her community as possible.
If done right, these kinds of innovative changes to the way
doctors are paid are going to improve care for seniors in the
program, and that is, of course, what the reform legislation
was all about.
Finally, I would like to thank Mr. Slavitt, Andy Slavitt,
Acting Administrator of the Centers for Medicare and Medicaid
Services, for joining the community. He has been committed for
a long, long time to doing right by the millions of Americans
who have to navigate our health-care system each day, and we
very much appreciate his push for more value and quality in
American health care.
Thank you very much.
[The prepared statement of Senator Wyden appears in the
appendix.]
The Chairman. Thank you, Senator.
Now, I would like to take a moment to once again introduce
today's witness, Acting Administrator Andy Slavitt.
Mr. Slavitt is the Acting Administrator for the Centers for
Medicare and Medicaid Services. He is responsible for
overseeing the coverage of 140 million Americans under
Medicaid, Medicare, the health insurance marketplace, and the
children's health insurance programs.
Prior to joining CMS in July 2014, Mr. Slavitt spent over 2
decades working in the private sector. Most recently, Mr.
Slavitt served as group executive vice president for Optum.
Prior to that and in reverse chronological order, Mr. Slavitt
served as CEO of OptumInsight, founded HealthAllies and served
as its CEO, assisted McKinsey and Company as a strategy
consultant, and, finally, worked as an investment banker for
Goldman Sachs.
Mr. Slavitt graduated from the Wharton School and the
College of Arts and Sciences at the University of Pennsylvania
and later received his master of business administration from
the Harvard Business School.
Mr. Slavitt, please proceed with your opening statement. We
are happy to have you here, and we welcome you to the
committee.
STATEMENT OF ANDY SLAVITT, ACTING ADMINISTRATOR, CENTERS FOR
MEDICARE AND MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN
SERVICES, BALTIMORE, MD
Mr. Slavitt. Thank you. Good morning, Chairman Hatch,
Ranking Member Wyden, and members of the committee. Thank you
for the opportunity to discuss CMS's work to implement the
bipartisan Medicare Access and CHIP Reauthorization Act of
2015.
We greatly appreciate your leadership in passing this
important law, which gives us a significant opportunity to move
away from the annual uncertainty created by the Sustainable
Growth Rate to a new system that promotes quality, coordinated
care for patients and sets the Medicare program on a more
sustainable path. You will hear this morning that we remain
open to alternative approaches that achieve these objectives.
Thanks to Congress, MACRA offers a new approach where every
physician and clinician will have the opportunity to be paid
more for providing higher-quality care for their patients.
In recognition of the diversity of the different practices,
Congress created two paths. The first allows physicians and
other clinicians to participate in a single simplified program
with lower reporting burden and new flexibility in delivering
quality care. The second recognizes the physicians and
clinicians who choose to take a further step toward care
coordination by participating in more advanced approaches, like
medical homes.
Our approach to this implementation rests on the belief
that physicians and their care teams know best how to provide
high-quality care to our beneficiaries, and we have taken an
unprecedented effort to draft a proposal that is based directly
on input from those on the front line of care delivery, and we
continue this dialogue with physicians and clinicians to help
us understand how the changes we are proposing may positively
impact care and allow us to reduce unnecessary burden.
In over 200 sessions throughout the country, we met with
64,000 attendees and have received nearly 4,000 formal comments
from a wide range of stakeholders, demonstrating, I believe,
the deep level of engagement from patients, physicians, and
other clinicians in working with us to build a system that is
more supportive of good patient care.
We have learned a lot in that process and continue to
engage directly with front-line physicians and patients.
I will now review five of the bigger themes that we
received input on.
First, we must make the patient the focus throughout this
program. Patients want to see policies that allow them to
participate in the overall vision of improving and coordinating
their care. Physicians want to see a program that supports them
in patient care, not a new compliance program. This committee's
leadership, in particular your focus on how we can best care
for those with multiple chronic conditions, as Senator Wyden
has discussed, has been instrumental in guiding us.
Second, we need to simplify the program and reduce burden
wherever and whenever possible so that physicians can focus on
patient care, not on reporting or scorekeeping.
Third, as new advanced approaches, like medical homes, are
established, we need to create pathways so that more and more
physicians and other clinicians can participate in these
models. We will continue to work with the physician community
to create more opportunities for physicians to participate in
tailored programs, like our recently announced oncology care
model, which provides a holistic coordinated approach to
supporting cancer treatment.
Fourth, we must design the program with special
consideration, as Chairman Hatch has said, for small and solo
independent practices. Small practices do not have the
resources that the large health systems do, and each new
administrative requirement takes time away from patient care.
Fifth and finally, commenters asked us to consider what
flexibility we have to allow the physician and clinician
community time to learn and prepare for these changes. While
the quality payment program builds on programs that should be
familiar to clinicians, such as the existing quality reporting
system, we understand that the new rules require adjustment and
preparation.
All of this input serves as a valuable guide as we
determine what adjustments are necessary in the final rule we
will release this year. We should acknowledge that physicians
have many frustrations and challenges with the current health-
care delivery system, and implementation of this law will not
resolve them overnight.
We will continue to need real and direct feedback from
physicians, clinicians, and beneficiaries, and from you and the
rest of Congress, on what is working and what should be
adjusted. The launch of this program is only the first step of
a larger process.
I will close by saying I have had the privilege of serving
as CMS's Acting Administrator as we celebrated the 50th
anniversary of Medicare and Medicaid last year, and I believe
that the foundations we are laying over the next several years
with the new patient-centered payment system will help set a
sustainable, higher-quality path for the next 50 years of
Medicare beneficiaries.
That is our clear focus in our implementation of MACRA, but
it will take continued work and high levels of engagement to
get it right.
I look forward to your perspectives about our
implementation and to answering your questions.
Thank you.
[The prepared statement of Mr. Slavitt appears in the
appendix.]
The Chairman. Thank you, Mr. Slavitt.
Physicians are concerned that they will not have enough
time to prepare to effectively participate in the new MACRA
incentive payment program when it starts on January 1, 2017.
Assuming that CMS releases their final incentive program
rule around November 1st, physicians would only have about 2
months before the program goes live.
I am sure there are pros and cons to any such start date,
but this seems to be, to me at least, a legitimate concern.
Considering that the MACRA law does give CMS flexibility as to
the start of the physicians reporting period, what options is
CMS considering to make sure this new program gets started on
the right foot?
Mr. Slavitt. You are exactly right. I want to begin where
you ended. We need to launch this program so it begins on the
right foot. That means that every physician in the country
needs to feel like they are set up for success.
So this has been a significant source of feedback we have
received as well, and I would start by saying we remain open to
multiple approaches.
Some of the things that are on the table--and we are
considering including alternative start dates--are looking at
whether shorter periods could be used and finding other ways
for physicians to get experience with the program before the
impact of it really hits them.
The Chairman. Your statement describes four principles that
guide the agency's implementation of the MACRA physician
payment reforms. While I agree with all four, I want to
highlight one here.
To paraphrase, you state that financial incentives should
work in the background and that the focus must be on patients
and not measurement. Now, this principle is consistent with one
of the main tenets of the MACRA reform: the streamlining of
disjointed programs for the disposition of administrative
burdens.
CMS has proposed a number of good steps to eliminate
redundancy, but I personally believe more needs to be done.
Can you describe opportunities for improvement in this area
to ensure that these programs support rather than detract from
patient care?
Mr. Slavitt. I think we all have a shared national goal to
simplify the health-care system, because there are really only
two tasks that physicians have to do every day. They are either
seeing patients, or they are doing some form of paperwork.
So the less time we can have them focused on the latter,
the more time they will have to take care of the people who
really need to be taken care of.
MACRA, as you have said, takes a big step in this direction
by taking three disjointed programs and streamlining them into
a single program. So even at the outset, there are some gains
for physicians.
But it is a long journey to continue to simplify the
health-care system, and we have solicited a lot of input in
this area and we are open to lots of ideas, such as figuring
out how to reduce the need for reporting at all. We have some
categories where we can get automatic data feeds from
physicians and do not need to ask them to report.
There are other areas where we know physicians are
performing well, so we do not need to have them report on this
at all.
We are looking at areas where we can exempt physicians or
look at thresholds for physicians who do not see lots of
Medicare patients.
So there are a variety of ideas that have been coming to
us, and they are all really on the table at this point.
The Chairman. Thank you. As I said in my opening statement,
I commend CMS for reaching out to stakeholders and members of
Congress as the agency crafted this initial proposal to
implement the MACRA physician payment reforms.
Now, such an inclusive approach is consistent with the
intent of the MACRA statute. I would also reiterate my
statement that we all need to work together on a continued
basis to ensure that implementation works for physicians and
beneficiaries.
My view is that this will be a multiyear process, and,
while we expect to see improvements from the proposed rule to
the final policy for 2017, there will be an ongoing need for
refinement. One step that CMS could take to ensure the
continuation of the iterative dialogue is to publish an interim
final rule this fall.
What is the plan to ensure that CMS is best positioned to
improve the programs on an ongoing basis?
Mr. Slavitt. I think that option, as well as other options,
are on the table for us to consider as we continue to keep the
feedback process open.
We know that this is a long-term process. We know that we
are only taking the first steps in the first years of
implementation. So we have to have processes that allow
physicians to continue to provide feedback to us.
From our perspective, CMS needs to really shorten the
window and close the gap between the actual practice of
medicine and policy implementation. That really is our job, and
I think this process has allowed us to get closer to that.
The Chairman. Thank you. My time is up.
Senator Wyden?
Senator Wyden. Thank you, Mr. Chairman.
Mr. Slavitt, of course, what our committee has learned is
that this is not our grandfather's Medicare program. Back when
I was with the Gray Panthers, we talked about Medicare when
somebody had a broken ankle or a really bad case of the flu.
Today, it is about chronic illness.
I noted 93 percent of the Medicare spending deals with
chronic illness, and 75 percent--75 percent--deals with seniors
who have four or more chronic illnesses.
Let us begin by getting your take on how the new MACRA law
would begin to start paying benefits for older people. I have
already described how going on to the next stage is something
that has been a priority for this committee, and we put it in
the context of this proposed rule that you announced last
Thursday.
But let us talk specifically about the law that has been
adopted by the Congress. How do you envision it dealing with
those seniors who generate 75 percent of the spend and have
four or more chronic illnesses?
Mr. Slavitt. Thank you, Senator Wyden.
Those statistics that you quoted and that you have
continued to remind us of over the years really ground us and
need to ground us in the implementation of both MACRA, as well
as, as you just covered, some of the other policy work that we
are doing.
New approaches to payment must emphasize the ability to
coordinate care for people who have multiple chronic conditions
and give physicians time to do that, and that needs to really
be part and parcel of every one of the advanced models that we
put forward.
We recognize that, as you say, the breadth of this issue
extends even beyond MACRA, and your longstanding leadership has
been instrumental to us, along with Chairman Hatch, in guiding
our principles here.
I would also add that the bipartisan working group chaired
by Senators Isakson and Warner has done the same as well, and I
thank them.
I think we can point to some recent successes in this area.
We have recently announced that we are going to be scaling the
prevention of diabetes. We have launched an oncology care model
for the treatment of cancer patients, which is directly a part
of the MACRA implementation.
We have a proposal now to better care for individuals
living with dementia, which I know has been a longstanding
commitment and priority of Senator Stabenow. And of course,
behavioral health and coordinated care become a part of all of
these pieces.
So really we have to bake this into the fabric of every
element of the models that are available to physicians under
the MACRA law, because as you say, we are not dealing with
people who are jogging and breaking an ankle. That is not the
burden on the Medicare program. The burden is helping people
who live with multiple chronic conditions.
Obviously, there are limits to what we can do
administratively, and we know you have other areas of focus and
ideas, such as expanding the independent home model.
So we stand ready to work with you in all of these efforts.
Senator Wyden. Let me ask a question about the small
practices and the opportunity to really deal with the burden
and the complexity that the small practices and practitioners
bring to every single member of this committee.
I can just tell you, having talked to virtually all of the
members with respect to what they hear when they are home, this
is what comes up constantly with respect to the complexity and
the burden.
You all have proposed creating virtual groups--virtual
groups that would allow individual physicians to report
together. In effect, it might be a low volume threshold, and
then these providers in rural areas could report together. That
strikes me as pretty promising stuff.
Now, there are a lot of pieces to the puzzle, because we
have to make sure that they have good broadband connections and
the like.
But tell me a little bit about how you envision that
working, particularly giving the flexibility to these small
practices that they are asking for and that I think is in the
spirit of your proposal.
Mr. Slavitt. Yes. Thank you for asking that question,
because the focus on small, independent practices and their
ability to continue to practice independently is a very high
priority for us. And I would add, it is not just small
practices. It is also any physician who practices in a rural
location. They have a very different set of dynamics than other
physicians do, and many of our beneficiaries, of course, live
in those areas.
So we need every physician to be set up for success, and
the challenges in small practices are far greater. Oftentimes,
in a small practice, you will find it is a physician and his or
her spouse and that is it. That is all the work that they do.
So if we add additional paperwork, that paperwork comes out
directly from patient care.
So there are a number of areas where we receive feedback in
talking with small practices and visiting directly with small
practices, including, how do we compare the performance and
evaluate the performance of small physicians; how do we lessen
the reporting burden; how do we look at things like thresholds,
as you said.
We have solicited direct feedback on what the best way to
create virtual groups might be. So we remain very open in this
area. We think there are a number of steps that are available
to us, and we will continue to seek input in this area.
The Chairman. Senator Stabenow?
Senator Stabenow. Thank you very much, Mr. Chairman and
Ranking Member, for a very important hearing
Welcome, Mr. Slavitt. It is great to have you with us.
First, just a couple of comments. One, I want to thank you,
as I have done privately, for working with us and coming
forward with a number of proposals, certainly behavioral health
being incredibly important. But as it relates to dementia and
Alzheimer's, focusing on caregivers and being able to create a
system for payment incentives around caregiver planning
sessions is really, really important and is based on what we
have been working on, bipartisan legislation, for a number of
years, called the HOPE for Alzheimer's Act.
So we are very, very pleased that we have 57 members of the
Senate as cosponsors of this. So it is something that I am
anxious to work with you on as you move through the comment
period and so on, to be able to get this into practice as soon
as possible.
The other thing I want to mention as well, more of a
concern, is the home health demonstration project. Continue to
monitor that closely in terms of whatever is done, increasing
accountability to make sure it does not get in the way of
people being able to get home health care, which is critically
important.
The issue today, MACRA, is really a historic piece of
legislation. We all want very much for people to receive the
best health care possible, and we know that a health-care
payment system that rewards doctors for doing their job also
improves patient outcomes and saves taxpayer money. It is a
win-win, providing quality patient-centered care; we know that.
So the question is, how do we get there? We also know the
current fee-for-service model is outdated and less effective
than a value-based outcomes-oriented approach. But I also know
that if we surveyed everyone in the room, we would have
different ideas of what that meant, which is the challenge, I
think, for you and for all of us going forward.
But if we get it right with innovative approaches, we are
actually going to see patient outcomes and quality care go up
and costs go down. So it is important for doctors and seniors
and families and communities and hospitals and providers.
I want to ask for your comments on a couple of specific
issues, though, that I am hearing about from providers in
Michigan. They dovetail with what the chairman and ranking
member have talked about.
The first one is electronic health records. As we talk
about small practices, as we talk about rural communities, like
in northern Michigan and the upper peninsula of Michigan, that
may not have access to the technologies that APMs or the MIPS
program require, we know that in order for doctors to
participate in Alternative Payment Models to coordinate care,
it is really important that electronic health records be easy
and quickly able to operate, to be able to do what needs to be
done. Interoperability is critically important.
So what is CMS doing to make sure rural providers are able
to fully engage in these two models we are talking about: the
MIPS--the fee-for-service--and the Alternative Payment Models
reimbursement tracks, given their restrictions, especially as
it relates to electronic health records?
Mr. Slavitt. Thank you, Senator Stabenow. The good news, I
think, for all of us as a country, compared to where we sat 5
or 6 years ago, is today over 70 percent of physician practices
have electronic medical record technology in their office and
virtually all hospitals do today.
That is a significant step forward. However, we have more
work to do in that those electronic medical records, by most
reports, are not yet easy to operate and they are not yet able
to move information back and forth between one physician and
another or a physician and a hospital when a patient moves, and
that makes it much more difficult.
So we have attempted to focus in a couple of areas here.
First is really to lessen the requirements, and particularly
the requirements on the types of physicians that you refer to,
in terms of complying with the program that allows them to
qualify for use of electronic medical records.
We have increased flexibility. We have lessened the burden.
We have created more options, and we think that is going to be
helpful.
We have also focused virtually all of the measures now on
interoperability; that is, the ability of a technology to move
data between one system and another. Everyone has a role to
play in that. The vendors have to comply with this, and we
think that is going to ultimately be very beneficial to the
physicians.
Senator Stabenow. But I would just indicate that 10-12
years ago, as we were first talking about this--and I was very
involved in establishing this--I was very concerned there was
not one standard on interoperability at the time, because I
think it has added to the challenges that people have right
now.
Let me----
The Chairman. Senator, your time is up.
Senator Stabenow. Thank you, Mr. Chairman.
The Chairman. Senator Thune?
Senator Thune. Thank you, Mr. Chairman.
Mr. Slavitt, I want to come back for a minute to the issue
of virtual groups and talk a little bit about the timeline for
that.
I am disappointed that the final rule punts this decision
for another year, since the proposed rule indicates that
clinicians would have to elect to be in a virtual group by June
30th of the year before.
Could you provide us with a time frame for when CMS plans
to issue a proposed rule on these groups?
Mr. Slavitt. Thank you, Senator.
Virtual groups is an area that, going all the way back to
January, we have solicited feedback from physicians on
concerning how that might work, because we do agree with you
that it is a concept that has a lot of promise and a lot of
potential. But because it is a new concept, there are a lot of
details to work out, and we want to make sure that when we
launch it, we launch it right.
So in the first year, I think we have the opportunity to
launch a number of things that are helpful to small practices,
some of which I have talked about, including reporting
thresholds, including things that make it easier to report,
some performance improvements, and so forth, while we continue
to work with physician groups on the launch of virtual groups.
I think you are right. I think this is going to be a high
priority for us, and I think it is going to be something that
is going to need a lot more input from physicians to make sure
we get it right.
Senator Thune. Could you maybe specifically identify what
issues and barriers CMS has identified that are prohibiting
these groups from going live next year and how it plans to
overcome them next year?
Mr. Slavitt. It is just a whole new way of reporting, and
we need to make a number of decisions--and physicians would
need to make a number of decisions, and they are not yet used
to practicing that way.
So we have asked physicians, ``How might you want to go
about this?'' and we have gotten a lot of the sense that, yes,
this has promise, but we have to be able to make a whole lot of
decisions, let alone implement the operations and the
technology to support them.
So I do not think this is something that cannot be solved
with just a little bit more time, but it is certainly not
something that is ready to be launched in 10 months.
Senator Thune. Can you give us some sort of time frame,
though, when it might go live?
Mr. Slavitt. I think our aim would be to get it done within
the following year. That would be our aim. I want to make sure
we do everything we can to get it right and get the feedback.
The thing I want to also make sure to convey is the reason
why virtual groups are important. We think we are going to be
able to get them to small practices in the first year through
other means as well.
Senator Thune. I want to turn now to the issue of a low
volume threshold. Being from a rural state, I am always
contemplating how changes to reimbursement are going to impact
rural providers.
The proposed rule attempts to create a low volume
threshold, but I am not quite sure it provides enough
flexibility.
Clinicians eligible for the exemption must have Medicare
billing charges of less than or equal to $10,000 and provide
care for 100 or fewer beneficiaries. This dual requirement
seems especially low, especially the $10,000 threshold.
The question is, is there anything else that CMS can do to
ensure that rural providers have access to a meaningful low
volume threshold exemption?
Mr. Slavitt. Yes, Senator, that is an area where we have
received a lot of particular input. I think a lot of people
feel that the $10,000 number is too low. So we are currently
looking at that--that is very much on the table--to figure out
what is the right way to define that threshold.
But certainly, at some point, the juice has to be worth the
squeeze, and if a physician is not seeing enough Medicare
patients for this program to be meaningful, we should not
require them to go through the process.
Senator Thune. The recent Medicare trustees' report
estimates that the Independent Payment Advisory Board, or IPAB,
is going to be triggered in 2017 with implementation of these
cuts required in 2019.
How do you think that is going to impact MACRA
implementation?
Mr. Slavitt. I cannot speculate on that yet, because I
think we have not triggered IPAB, as you know, this year. So I
think that that is something that the next Secretary will face,
if they are in that position next year.
Senator Thune. Would you support repealing IPAB to protect
providers and beneficiaries who would be faced with these
arbitrary cuts?
Mr. Slavitt. No. I do not think that is the administration
position on IPAB.
Senator Thune. I know it is not the administration's
position.
Mr. Slavitt. Thank you. [Laughter.]
Senator Thune. As you know, there is going to be a new one
coming in, though. You could kind of go solo now, go rogue, and
actually give us your opinion.
Thank you, Mr. Chairman.
Mr. Slavitt. Thank you, Senator.
The Chairman. Thank you, Senator.
Senator Menendez?
Senator Menendez. Thank you, Mr. Chairman.
Thank you, Mr. Slavitt, for coming before the committee.
Let me say, thankfully, the days of being on the SGR doc
fix merry-go-round are behind us, and I, for one, want to make
sure that we do not find ourselves in the same position again,
a position that requires regular congressional intervention to
maintain consistency in Medicare payments and, ultimately,
consistency in access to care for seniors.
So with MACRA, we have a great potential to change the
paradigm around both payments and practice design with the
establishment of the alternative payment methods.
These models could ultimately end the fee-for-service model
once and for all, leading to a purely quality- and value-based
reimbursement system. However, to fully realize this goal
requires a substantial number of physicians moving into these
alternative practices and taking on some financial risks
associated with their quality resource use and outcomes.
While this two-sided risk provides a serious incentive to
achieve high quality, it is unclear how many physicians will
actually choose or have the ability to move their practice into
an advanced APM.
We have recently seen that this type of two-sided risk
arrangement has not had a lot of uptake--like the two-sided ACO
models, which have less than enthusiastic enrollment.
So what analysis has been done to take into consideration
providers' willingness or ability to move into two-sided risk
Alternative Payment Models in the near term, or, in another
sense, how many practices will, in essence, forego even trying
to get into an APM and just maintain fee-for-service through
the MIPS program in perpetuity?
Mr. Slavitt. Thank you, Senator. As you point out, we are
on the beginning of a journey to move toward a new set of
models that allow physicians more freedom to practice more
coordinated care, more team-based care, and give them the
flexibility to get rewarded for quality.
I think it is important to remind all of us that we are
very much in the early years of these programs, with just, I
think, the first and second generation models out today.
But the good news is, we are beginning to see these
approaches begin to work. We are seeing physicians increasingly
move into two-sided risk models. I do think we have to be
thoughtful and judicious about how we define two-sided risk, so
that it is not so intimidating to physicians, and make it
available to more physicians to join, which I think is your
suggestion.
Over the next several years, I think it is our task to work
with the PTAC, which is the physician advisory committee that
has been set up by the Congress, to get more and more models so
there are more and more options, such as our oncology model for
cancer and other specialties across the spectrum.
We have received meaningful feedback on this topic, both on
how to judge qualifications for more than nominal risk, as well
as how to get more advanced models in, and that is currently a
focus.
Senator Menendez. Can you quantify that for me at this
point?
Mr. Slavitt. Can I quantify----
Senator Menendez. The number of physicians who are actually
beginning to move in this direction.
Mr. Slavitt. Yes, and I think I can get you a more precise
number. But if I look at our largest population-based model,
which is called the ACO, I think we have 20 percent to a
quarter of those that are now in two-sided risk models, up from
a much lower number a year ago.
I am not sure that is the precise number, and I will follow
up with you. But that is pretty encouraging.
Senator Menendez. What other major changes to physician
practices, like the proposed Part B drug payment demonstration,
factored into the analysis that you have done about the
potential here?
Mr. Slavitt. Your question is, what has the Part B
demonstration----
Senator Menendez. What other major changes to physician
practices, like, for example, the proposed Part B drug payment
demonstration, factor into your view as to how the acceptance
is going to be among physicians in this regard?
Mr. Slavitt. I think there are two things. One is, I think
we will have a number of, and we will continue to have a number
of, limited demonstrations that come out of our Centers for
Medicare and Medicaid Services, because part of what we are
tasked with is figuring out what works and can be expanded upon
and what does not.
So that will continue to go on, and I think we will
ultimately create models and approaches that will allow us to
offer new, advanced Alternative Payment Models.
At the same time, I think we have to also be conscious of
the fact that we are putting an awful lot of change into the
system and on physician practices, and too much change on top
of an already-
burdened physician practice is just not where we should be
going.
One of the reasons we are interacting so heavily with the
physician community and the patient community is to reduce the
burden at the same time that we are working through some of
these changes, and then to modulate these changes in ways that
really make sense to physicians so they can support the
patient.
I think it is very important for all of us not to get
wrapped around the axle with these models and so forth. What we
have to continue to be focused on is the physician and the
patient and that these models need to work in the background so
that the physician can be successful.
The Chairman. Senator, your time is up.
Senator Isakson?
Senator Isakson. Thank you, Mr. Chairman.
Mr. Slavitt, I want to thank you for two things. One, first
of all, Senator Warner and I worked very much on care planning
for a couple years, and I want to compliment CMS on creating a
code and reimbursement for care planning, reimbursement for
physicians working with seniors to plan the kind of treatment
they want when they are capable of making those type of plans.
That was a great move on your part, and I appreciate your doing
it very much.
Also, on the chronic care working group, Senator Wyden and
Senator Hatch have been tremendously supportive of what Senator
Warner and I have been doing on care planning. As you know, we
have had 1,300 inputs now from stakeholders. We are about 18
months into that process, and we are at the point where CMS and
CBO are working together to come up with the scores that are
necessary for us to finish the product.
About 10 days ago, Senator Warner and I met with the staff,
who told us there were some difficulties getting a type of
information from CMS to CBO to get the final scoring done. But
I understand in the last 10 days, you all have done yeomen's
work doing that. I wanted to thank you for that and hope you
will continue to do so, because it is critical that we get that
score so we can finish that paperwork.
Mr. Slavitt. Yes, we agree. And I think our staff has been
very engaged in that.
Senator Isakson. Thank them, if you will.
Mr. Slavitt. I will, yes.
Senator Isakson. I was going to ask you a question about
small and rural practices, but if I am correct, every single
member, except Senator Menendez, has asked you that question,
and every time you have responded that you are aware of the
problem.
So let me just say on behalf of the Medical Association of
Georgia and all the rural doctors we have outside Atlanta,
anything you can do to help make this MACRA less burdensome for
them will be greatly appreciated.
Mr. Slavitt. Yes, Senator, absolutely.
Senator Isakson. I guess last, let me just say this. Under
the framework of the proposed MACRA rule, 87 percent of solo
physician practices face negative payment adjustments in 2019,
the first year of the merit-based incentive payment system, or
MIPS. Ending the cycle of possible Medicare premium cuts and
uncertainty in Medicare, which we accomplished by doing away
with SGR, was the goal of doing this.
The intent of the law was not to penalize physicians simply
because of being in a small practice or being in a certain
specialty, but MIPS was designed because CMS, at this point,
just seems to do that.
What are you doing to try to neutralize that effect?
Mr. Slavitt. Thank you. And that would not be an acceptable
outcome. What we have learned are a couple things. One is that
physicians in small and rural practices, when they report, can
do equally as well as larger-sized, mid-sized practices.
So that is the good news. I think what that tells us is
that we have to make the process of reporting easier. It is
relatively easy for large practices to report because they have
large staffs. So we have to make it much simpler for smaller
practices to be able to report.
We have a number of ideas for being able to do that, some
of which include being able to get information automatically,
some of which will allow us to work with places where
physicians are already submitting data, for example, to a
clinical registry, and just take that data from that registry.
So the aim is to not require a whole lot of paperwork and
data entry from physicians so they can focus on patient care.
I think if we do that--and the evidence has begun to show,
as physicians are able to report more, we are seeing that they
are not getting penalized. So over this comment period, we are
continuing to work through those ideas.
Senator Isakson. Thank you for the answer, but, in
particular, thank you for the support on what we are trying to
do on chronic care. We appreciate your cooperation.
Senator Menendez. Would the Senator yield just for a
moment?
Senator Isakson. Certainly.
Senator Menendez. I would be happy to invite my dear friend
and colleague to southwestern New Jersey, where we have
cranberry bogs, peach orchards, blueberries, and there are
rural parts of the State. So we have a concern that I share
with you in that regard.
Senator Isakson. And it is prettier than Newark, I can tell
you that. [Laughter.] Rural New Jersey is fantastic; I love it.
Thank you, Mr. Chairman.
The Chairman. Thank you.
Senator Casey?
Senator Casey. Thank you, Mr. Chairman.
Mr. Chairman, you know how many counties in Pennsylvania
are considered rural counties, with your roots in western
Pennsylvania. So let me add my voice to those concerns that
were raised.
I want to focus on one primary topic, though, for my one or
two questions--socioeconomic status, so-called SES, of
beneficiaries.
We are talking about low-income folks and the quality
rating impact that those folks have when those beneficiaries
are accounted for, the impact a high number of low-SES
beneficiaries would have on quality ratings.
I just want to read some of your testimony. On page 4, you
outline four principles that will guide implementation. The
second principle indicates as follows: ``Success will come from
adopting approaches that can be driven by a physician practice.
Quality measures need to accurately reflect the needs of a
diverse range of patient populations and practice types and
give physicians and other clinicians the opportunity to select
elements of the program in measures that are right for their
practice.''
So a diverse range of patient populations and practice
types and a focus on what would be right for their practice.
My basic question, with that predicate of your principles,
focusing on low-SES beneficiaries, is what steps have you taken
to help practices that treat a high number of these
beneficiaries achieve both fair and accurate quality ratings?
Mr. Slavitt. Thank you, Senator. You point to an important
priority for the agency, which is that the Medicare program's
biggest challenges are not 67-year-old joggers with three
Fitbits. They are people who live two bus stops away from their
dialysis appointment and have, as we talked about this morning,
four chronic conditions.
So it is very important to us to make sure we support the
physician who wants to treat those patients. We know that that
is a harder challenge.
So in everything we do, we have to figure out how to
account for that. Now, it is complicated, because there is no
straightforward way to do it always, but we just completed, I
think, a very significant piece of work in the Medicare
Advantage program to adjust how the Medicare Advantage program
pays so that we can essentially reimburse higher for taking
care of people in exactly the kind of situations that you
talked about.
We have to continue to make that march happen across the
entirety of the program. One vital step which is part of MACRA
is simply to do risk adjustment, which means that if two
patients come to see a physician and one of them has four
chronic conditions, that there will be a higher reimbursement
in acknowledgement of the fact that that is a more complex
situation.
That is baked into elements of MACRA. Do I think there is
more we can do? Yes. I think as we learn more and as we
understand more how these models work, we will be able to do
that.
We have a piece of work, a study that is being completed in
September around this very topic, coming out of the Assistant
Secretary for Planning and Evaluation's office. I am eagerly
awaiting that report, because I think we can incorporate those
themes into this and other pieces of our work.
Senator Casey. I appreciate that. I have been working for a
long time with Senator Portman on this. So we are grateful for
that work.
Let me end just by putting in a little bit of a commercial,
a commendation for the State Children's Health Insurance
Program, which we know here by the acronym S-CHIP. But it is
one of the most successful programs of any kind, not just
health-care programs, in our Nation's history--160,000
Pennsylvanian's were approaching the quarter-century mark in
our State for S-CHIP.
So I know you place a heavy emphasis on that program, and I
just urge you to keep doing that. We can follow up with
something for the record on the Children's Health Insurance
Program.
Thank you very much for your work.
Mr. Slavitt. Thank you, Senator.
The Chairman. Senator Warner?
Senator Warner. Thank you, Mr. Chairman.
Thank you for your good work on MACRA, Mr. Slavitt. It is
good to see you again.
The goals of MACRA are great. The complexity of getting it
right is going to be an enormous challenge, and I commend you
for your work so far.
I want to, first of all, follow up on a couple comments
that my friend, Senator Isakson, made. He is a real gentleman,
and he has been a great partner on a number of these projects.
I would like to nudge you a little more. The chairman and
the ranking member and Senator Isakson and I have been really
aggressively working on this chronic care package. We all know
the data. Over 90 percent of the Medicare costs arise from
these chronic care patients.
The challenge, if we are going to move this legislation,
hopefully in the early fall, is to get this scoring done, and
my hope is--you do not have to say it to me right now--that you
can get us a timeline on when we would get that scoring
completed so I can share it with the chairman and the ranking
member, because the chairman has expressed great interest in
moving forward on this as well.
So if I can get back to you in the next 24 hours and you
can get me some feedback on when that scoring will be done, I
would appreciate it.
Mr. Slavitt. You have our commitment on that.
Senator Warner. Thank you.
I also want to echo what Senator Isakson said on an issue
that I have been involved with since back when I was Governor,
and that is the whole question of advanced care planning.
Obviously, this is a challenge every family goes through. I
think, candidly, the public is way ahead of the elected
officials on sorting through this, and, again, I want to
commend you for putting in a CMS code on that kind of consult.
Senator Isakson and I have an Advanced Care Planning Act
that would move beyond that in terms of moving into this field
and making sure families make informed decisions based on their
values and choices.
Clearly, around Alzheimer's, you have made progress. But as
you think through the quality measures within MIPS, how do you
get it right to also reflect the priorities of the Medicare
beneficiaries and their families at that important stage of
life?
Mr. Slavitt. One of the things that is really important to
us is that we get out of the mode of just feeling like we are
paying physicians to cut, test, or prescribe, because as you
point out, if we do not also begin to pay physicians to have
conversations and talk about the cognitive issues, whether they
are advanced planning issues or whether they are issues of how
people are managing the chronic conditions that they are living
with, we are not going to make that kind of progress, both
short-term and long-term, that we need to make.
So models like medical home models--which provide a care
coordination fee within a small practice that could not
otherwise afford the resources to invest in things that allow
them to call patients at home, check on how they are doing,
make sure they are taking their medications, see what barriers
exist, whether they are social or clinical--are very, very
important.
I think the more and more of these advanced models that are
part of MACRA, the more successful we are going to be in this
whole array of both chronic topics, as well as other topics
that require physicians to spend their time the way they and
the patients really want them to spend it.
Senator Warner. I would simply say that part of this--the
chronic care and, also, the advanced care planning and trying
to make sure that if a family does sit down and create an
advance directive or a POLST--is that the docs and hospitals
are incented to actually follow that advance directive.
There are so many heartbreaking stories we have heard of
family members, oftentimes daughters, having to intervene to
make sure that mom's or dad's wishes are truly respected. It is
terribly important.
Let me move to another subject with my last minute,
something that has not been raised so far, but an area of
importance to me. That is the whole intersection--as we sort
through health care--of cybersecurity and protection of health-
care records.
Ninety-four percent of medical institutions have said their
organizations have been victims of a cyber-hack or cyber-
attack. Under the proposed rule, you do recognize this, and a
provider has to, quote-unquote, ``protect'' patient health
information through security risk analysis and effectively
check a box, and if they do not check the box, they do not get
credit here.
But in a field that is so dynamic and constantly evolving,
how do you make sure that that box checked, as cyber-threats
continue to evolve, is going to be able to be monitored on an
ongoing basis?
Mr. Slavitt. Well, I think we have to place the burden on
the people who can really do the most here, which is the
vendors and the technology community. I think physicians and
their willingness to attest to being careful with patient
data--I think physicians take that very, very seriously.
So that is probably not the largest concern. The largest
concern is to make sure that as we move to a world of
electronic medical records, they continue to update and qualify
for certification in the latest cybersecurity standards and
that they do not get certified unless they pass the latest
standard.
We are going to need to, to your point, continue to evolve
that, because, unfortunately, the state-of-the-art of
cybersecurity continues to move.
Senator Warner. Thank you, Mr. Chairman.
The Chairman. Thank you, Senator.
Senator Toomey?
Senator Toomey. Thank you, Mr. Chairman.
Mr. Slavitt, thanks for joining us again.
I would just like to briefly mention that the last time you
came before this committee, I think it was the last time, you
expressed your support and the administration's support for the
lock-in provision being provided to Medicare, a provision that
would allow Medicare to identify and then do something about
patients who are doctor-shopping for opioids, and I want to
thank you for that support.
As you may know, that provision is included in the
Comprehensive Addiction and Recovery Act bill that I think we
are going to vote on perhaps later today, and I am very hopeful
that that will pass, that the bill will pass. I think it has a
very, very strong combination of mostly modest steps that we
can take to deal with an enormously difficult and excruciating
problem.
So, thanks for your support on lock-in.
I also want to thank you for responding to what several of
us have observed, which is the previous policy, as I understand
it, of linking somewhat Medicare reimbursements to hospitals
based on the results of patient satisfaction questionnaires,
which included questions about pain management.
It may be somewhat indirect, but the result was to create a
financial incentive to over-prescribe opioids. My understanding
is that there is going to be a discontinuation of the link
between the response to the pain questions and the
reimbursement level. Am I correct in understanding that?
Mr. Slavitt. That is correct.
Senator Toomey. Has that gone into effect yet, or is it
about to go into effect?
Mr. Slavitt. It is a proposed rule. So we are seeking
comments on that right now.
Senator Toomey. Will reimbursement levels still be somewhat
a function of other questions on the patient satisfaction
questionnaire?
Mr. Slavitt. Absolutely.
Senator Toomey. They will. But no longer will the pain
management question----
Mr. Slavitt. That is correct.
Senator Toomey. I think that is exactly the right approach.
I want to thank you for that.
The question that I want to ask is about the CO-OPs. I
think just this morning, the latest CO-OP announced its
failure. We are now, I think, up to 16 of the original 23, I
believe, Obamacare CO-OPs having left the business.
I think in most cases, it is a simple bankruptcy, and I
think they failed financially. And along the way, of course,
their discontinued operation leaves hundreds of thousands of
people without health insurance.
Taxpayers have put $1.5 billion into the CO-OPs that have
failed. That money is just gone. And I am wondering about the
future of the remaining ones.
I guess my first question would be, has your staff advised
you to expect further failures, additional CO-OP failures over
the course of the remainder of this year?
Mr. Slavitt. We are just now at the point where, in July,
we are reviewing the June financials of the CO-OPs. I would say
kind of an overarching point in the way that at least I think
about the CO-OPs is that they are very small businesses
competing against very large businesses, with low amounts of
capital and, as a result, very low margins of error.
So we watch them month-to-month, and, more importantly, the
States and the State departments of insurance, which are really
responsible for having a bead on capital requirements, watch
them as well.
I think when we do this, our priorities are twofold. One is
to make sure that consumers are taken care of as best as
possible and to support the States which really make a lot of
those decisions.
Secondly, our job as a lender is to responsibly look after
the capital that has been committed and go through a process
with the Department of Justice to make sure that we recover
funds when possible.
Senator Toomey. I understand. But my question was, has your
staff advised you to expect further failures over the course of
this year, or do you think we are done, that the remaining CO-
OPs are mostly going to be fine? Do you have an opinion on
that?
Mr. Slavitt. I think it is a month-to-month focus for us
right now. I think we are working closely with the existing CO-
OPs. I think all of them, while successful in some measures,
all of them have pretty low margins of error, and I think we
need to watch them.
Senator Toomey. So something like 70 percent have already
failed. I am told to expect there will be more failures.
When I look at the big insurers who are well-capitalized
and extremely sophisticated, they are losing money hand over
fist in this space, and I am worried that this is a
manifestation of the adverse selection that some of us were
afraid was going to occur, that it is happening.
Premiums are rising enormously in response to that. Do we
not have a big problem in this whole space?
Mr. Slavitt. I think my characterization would be that we
have a wide variety across the entire spectrum, from some
health plans that are making a lot of money and very
successful, to some that are either at break-even or close, to
others that have been losing money and are going to be----
Senator Toomey. But a big majority are losing money, right?
A big majority of these plans are losing money.
Mr. Slavitt. I would say, as we sit here in 2016, that is
not necessarily clear. But I think what is important is that
this is a market that will evolve over the first 2 years. I
expect some new entrants to come in. I expect some people to
move out of markets. I think this is to be expected in a brand
new market with a new set of rules.
I think what is important to us is that we have a model
where people with preexisting conditions can get covered.
People have to make adjustments when they have to cover people
with preexisting conditions. We understand that. So we try to
compensate for that by risk adjustment and other approaches,
and we will continue to stay on top of it.
The Chairman. The Senator's time is up.
Senator Toomey. Thank you, Mr. Chairman.
The Chairman. We have a vote on, and Senator Carper will be
our last, as far as I know.
Senator Carper. Thank you.
The Chairman. I am going to go vote, and if you could wrap
it up, I would appreciate it.
Senator Carper. Yes, Mr. Chairman, I would be pleased to.
The Chairman. Mr. Slavitt, I am very grateful for your
testimony and grateful for you taking time to be with us. I
appreciate you being here.
Senator Carper. Mr. Chairman, before you go, I just want to
say Mr. Slavitt's nomination has been before the Senate, I
think, for about a month. He has, as you know, a very, very
hard job. I think he works hard for the money, he works hard
for our money, and I would just urge us to move his nomination.
The Chairman. I understand.
Senator Carper [presiding]. Having said that, I would say,
Mr. Slavitt, thanks. It is very nice to see you. I thank you
and your team very much for taking on a tough job and working
at it so hard.
I want to thank you, also, for your help with the first
Accountable Care Organization in our State and the work that
you and your staff did to give the doctors in Delaware and in
Maryland another chance to prove that they can deliver high-
quality care. I think we will ensure that these doctors remain
on the important path of moving away from fee-for-service and
toward performance-based models, for which we also want to
thank you.
In your testimony, I believe you noted that 30 percent of
Medicare payments were already linked to Alternative Payment
Models and that we soon hope to reach 50 percent of payments
with these alternative models.
My question is, what type of Alternative Payment Models do
you consider to be the most promising for improving health-care
outcomes and lowering costs? And related to that, what
obstacles prevent Accountable Care Organizations from
shouldering more risk for their patients?
Mr. Slavitt. Thank you, Senator. I think we are just in the
first and second generation of seeing what new approaches work,
that work better than fee-for-service. I think we all agree
that the fee-for-service program is not the applicable system,
and we have spent the last few years, as you pointed out,
testing several different approaches.
I will name four really quickly. The first is a bundled
approach where someone will come in for a procedure, and the
entirety of their experience--inpatient, outpatient,
rehabilitation, everything--can be covered under one payment.
That, of course, encourages teamwork.
The second would be a team-based model, as you pointed out,
like an accountable care model, where physicians are
essentially incentivized to work together as part of a team to
look at an entire populations' health. Those models, I think,
have begun to show some real progress.
Third are models that are primary care-focused, like a
medical home, where physicians can essentially take the time
and have investments into care coordination.
Then, finally, I think a very promising development and
maybe a more recent development is prevention models. We just
launched and announced that we are going to be scaling a model
that is a prevention model for diabetes. I think that is very
exciting, very promising.
All of those four domains and possibly others, I think,
will emerge over the next few years to hopefully provide a next
generation of care for patients across the country.
Senator Carper. Good. I would concur with you on the last
one, because the prevention model is very encouraging. Thank
you.
My other question relates to CMS stakeholder meetings. The
new physician payment system is, as you know, fairly
complicated to explain and for physicians to understand, for us
to understand.
I am encouraged that you and your colleagues have held
literally hundreds of stakeholder meetings, I think, throughout
the country to collect feedback for implementing this new
Medicare payment system.
Could you just share with us--not today, but in the days
ahead--the schedule for future meetings so that we can let our
own constituents know when they can participate, how they can
participate?
The other thing I would ask is, what other types of
outreach and interface are you considering to help physicians
navigate this new payment system?
Mr. Slavitt. To your first question, we absolutely will.
To your second question, we find with a law of this
importance, almost the worst place for us to write the policy
is here in Washington, and the best place is to get out in the
field and visit physician offices.
So the types of places and the ways we have been conducting
outreach range from sitting down in physician offices and
having physicians share with us their experience with the
programs that they have to deal with today, to focus groups, to
day-long workshops and working sessions. And then what we have
to do is engage the people whom physicians trust the most to
help them educate about this.
That is not necessarily going to be the Federal Government,
it might surprise us. It is going to sometimes be the specialty
society or the State medical society or some other organization
that will be very knowledgeable about the program and that the
physician can rely on for some advice in this area.
So part of our stakeholder engagement includes making sure
that the people the physicians trust become as knowledgeable as
they need to be and have a direct pipeline to us to get
information.
Senator Carper. Thanks. Thanks so much.
My staff just gave me this. The chairman has asked me,
given my strong support for your confirmation, to ask unanimous
consent that you be--no, just kidding. [Laughter.]
We are here on an otherwise dull Wednesday morning. No, not
dull. Not dull at all.
I want to thank you for your testimony. We want to thank
you for your testimony today.
We also want to thank our colleagues for their
participation. This is, for all of us I think, a highly
important meeting, and we hope that we can continue working
with you and your folks as we seek to further improve the
Medicare system.
I was with some folks from another industry today, and I
said, ``You have a really hard job,'' trying to improve
quality, quality outcomes, with value systems and prevention
and so forth, and it is not easy. So we thank you for that.
I would ask that any written questions be submitted by
Wednesday, July 27, 2016.
With that, this hearing is adjourned.
[Whereupon, at 11:19 a.m., the hearing was concluded.]
A P P E N D I X
Additional Material Submitted for the Record
----------
Prepared Statement of Hon. Orrin G. Hatch,
a U.S. Senator From Utah
WASHINGTON--Senate Finance Committee Chairman Orrin Hatch (R-Utah)
today delivered the following opening statement at a hearing to examine
the Centers for Medicare and Medicaid Services' (CMS) implementation of
the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA):
I'd like to welcome everyone to this morning's hearing. Today, the
committee will hear from the Centers for Medicare and Medicaid Services
on its initial proposal for implementing the physician payment reforms
included in the historic Medicare Access and CHIP Reauthorization Act
of 2015, generally referred to as MACRA.
I would like to thank Acting Administrator Slavitt for appearing
today to testify on this important topic.
The passage of MACRA was a tremendous bipartisan achievement that
addressed long-standing and reoccurring problems under Medicare. It
was, I'll note, one of the first of many significant bipartisan
accomplishments we've seen in the 114th Congress.
Most notably, MACRA eliminated the flawed Medicare Sustainable
Growth Rate, or SGR, formula.
As everyone here will recall, the SGR mandated significant cuts to
Medicare physician payments that were, on a more or less yearly basis,
averted by legislation to ``patch'' the SGR. Between 2002 and 2014,
Congress passed 17 different laws to prevent the cuts from taking
place.
The perpetual SGR cycle took up far too much of Congress's time and
diverted attention from other priorities.
Getting rid of the SGR not only resolved a vexing problem for
lawmakers, it gave security to Medicare beneficiaries who often had to
wonder if they would eventually lose access to their physicians.
In addition to repealing and replacing the SGR, the MACRA law
contained structural reforms to the Medicare program, including
increased means testing for Part B and Part D premiums and limits on
``first dollar'' Medigap coverage for new beneficiaries. While these
structural changes put Medicare on a more solid fiscal footing, more
needs to be done to ensure the program is there for future generations.
I note reforms today to reiterate what I have said on several
occasions: despite the cries of naysayers, bipartisan Medicare reform
is possible, and the passage of MACRA proves that to be the case.
I look forward to continuing the discussion on how to shore up the
Medicare program for the long-term, but, for today, let me turn back to
the stated purpose of this hearing, which is MACRA's physician payment
reforms.
The physician payment reforms are the result of years of effort in
the Finance Committee. Working with the House Committees of
jurisdiction, this committee was able to craft a legislative solution
that garnered the support of nearly every national and State physician
organization. This proved to be key to MACRA's enactment as previous
efforts to eliminate the SGR had been stymied by the question of what
would replace it.
These reforms were intended to accomplish several things. Our most
specific goals were to:
(1) Streamline disjointed incentive programs to reduce the
administrative burden on physicians;
(2) Ensure that metrics on which physicians are assessed are
relevant to the patients they treat;
(3) Provide flexibility to physicians to participate in a way
that best fits their practice situation; and
(4) Provide an incentive to consider and attempt alternative
payment models.
We're here today to discuss and hopefully evaluate how CMS has
proposed to implement the law in order to achieve these goals.
Let me say that I appreciate the extent to which CMS has reached
out to stakeholders to get their thoughts in advance of the proposed
rule the agency released in April.
And I understand that CMS continued its outreach during the public
comment to ensure that key groups would be informed on the proposal and
to hear their reactions. Consultation with stakeholders--especially
beneficiaries and physicians on the front lines of providing care--is
precisely what we sought when we drafted the statute.
I also appreciate the outreach that CMS has undertaken with Members
of Congress and their staff. Viewing implementation as a partnership
with Congress is the right way to go.
Without delving too far into my long-standing concerns about the
administration's lack of disclosure and cooperation with Congress, I
will say that I wish this model would be used more often.
The CMS proposal that resulted from this consultation and outreach
is hundreds of pages. And the details matter greatly to our physicians
and patients.
This hearing will give CMS a chance to describe its implementation
efforts and give members of the committee an opportunity to reflect and
ask questions on issues that are garnering significant comment and
public discussion. It will also allow members to speak to Congress's
intent with regard to MACRA, share insights, and, hopefully, get
answers on issues that are important to their constituents.
Before we hear from Mr. Slavitt on CMS implementation though, I
want to flag an important concern that I know is shared by others,
which is the plight of small and rural physician practices.
We recognized the inherent challenges of these types of practices
when we crafted the MACRA statute and I know CMS is aware of these
issues, but we need to make sure that the law is implemented in a way
that works for these physicians and ensures that these practice
settings remain viable options for Medicare beneficiaries.
I look forward to a constructive dialogue here today and to the
committee's continued engagement with CMS through the final rule in
November and beyond.
______
Prepared Statement of Andy Slavitt, Acting Administrator, Centers for
Medicare and Medicaid Services, Department of Health and Human Services
Chairman Hatch, Ranking Member Wyden, and members of the committee,
thank you for the invitation and the opportunity to discuss the Centers
for Medicare and Medicaid Services' (CMS's) work to implement the
Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). We
greatly appreciate your leadership in passing this important law, which
provides a new opportunity for CMS to partner with physicians and
clinicians to support quality improvement and develop new payment
models to further our nation's shared goals of a health care system
that achieves better care, smarter spending, and healthier people and
puts empowered and engaged consumers at the center of their care. As we
take our initial steps to implement this important law, we have and
will continue to work closely with you and listen to the physicians and
clinicians providing care to Medicare beneficiaries, with the goal of
creating a new payment program that is focused on the needs of patients
and responsive to the day-to-day challenges and opportunities within
physician practices. As we continue to transform the Medicare program,
we are working to move beyond ``one size fits all'' measurements to an
approach that recognizes and supports the diversity of medical
practices that serve Medicare beneficiaries and offers multiple paths
to value-driven care. To inform this effort, CMS is meeting with
practicing physicians across the country, including those in big
practices and small practices, specialists and primary care providers,
and those in new payment models and in traditional fee-for-service.
CMS is committed to finding ways, to deliver better care at lower
costs. Today, over 55 million Americans are covered by Medicare \1\--
and 10,000 become eligible for Medicare every day.\2\ For most of the
past 50 years, Medicare was primarily a fee-for-service payment system
that paid health care providers based on the volume of services they
delivered. In the last few years, we have made tremendous progress to
transform our nation's health care system into one that works better
for everyone and rewards value over volume. Key to this effort is
changing how we pay physicians and other clinicians, so they can focus
on the quality of care they give, and not the quantity of services they
deliver or order. Already, we estimate that 30 percent of traditional
Medicare payments are tied to alternative payment models (APMs).
Generally speaking, an APM is a model that puts the outcome of the
patient at the center and holds care teams accountable for the quality
and cost of the care they deliver to a population of patients by
providing a financial incentive to coordinate care for their patients.
This can help patients receive the clinically appropriate care for
their conditions and reduces avoidable hospitalizations, emergency
department visits, adverse medication interactions, and other problems
caused by inappropriate care or siloed care. Hospital and physician
participation in APMs is a major milestone in the continued effort
towards improving quality and care coordination. We expect this
progress to continue, and we are on track to meet our goal of tying 50
percent of traditional Medicare payments to APMs by 2018--especially in
light of MACRA.
---------------------------------------------------------------------------
\1\ https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-
releases/2015-Press-releases-items/2015-07-28.html.
\2\ http://www.medpac.gov/documents/reports/chapter-2-the-next-
generation-of-medicare-beneficiaries-(june-2015-report).pdf?sfvrsn=0.
The enactment of MACRA, which replaced the Sustainable Growth Rate
(SGR) formula with a more consistent way for paying physicians and
other clinicians, provided new tools to modernize Medicare and simplify
quality programs and payments for these professionals. Currently,
Medicare measures the value and quality of care provided by physicians
and other clinicians through a patchwork of programs. Some clinicians
are part of APMs such as Accountable Care Organizations (ACOs), the
Comprehensive Primary Care Initiative, and the Bundled Payments for
Care Improvement Initiative--and most participate in programs such as
the Physician Quality Reporting System, Physician Value-based Payment
Modifier (``Value Modifier Program''), and the Medicare Electronic
Health Record (EHR) Incentive Program. Thanks to Congress, MACRA
streamlined these various programs into a single framework where
clinicians have the opportunity to be paid more for providing better
value and better care for their patients. CMS has proposed to implement
these changes through the unified framework called the Quality Payment
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Program.
The Quality Payment Program gives physicians and clinicians the
flexibility to participate in one of two paths. First, the Merit-based
Incentive Payment System (MIPS) streamlines three existing CMS programs
into a single, simplified program with lower reporting burden and new
flexibility in the way clinicians are measured on performance. MIPS
allows Medicare clinicians to be paid for providing high value care
through success in four interrelated performance categories: Quality,
Advancing Care Information, Clinical Practice Improvement Activities,
and Cost.
For physicians and clinicians who take a further step towards care
transformation, the Quality Payment Program rewards physicians and
clinicians through a second path, participation in Advanced APMs. Under
Advanced APMs, physicians and clinicians would accept more than a
nominal amount of risk for providing coordinated, high-quality care for
a set portion of their practice, such as through Tracks 2 and 3 of the
Medicare Shared Savings Program and the Next Generation ACO model.
Since the enactment of MACRA a little over a year ago, CMS has been
developing our approach toward implementation of the new law, and on
April 27, 2016, CMS issued a Notice of Proposed Rule Making (NPRM).\3\
In our efforts to draft a proposal that would be simpler and meaningful
for physicians and clinicians, we reached out and listened to over
6,000 stakeholders before we published the proposed rule, including
state medical societies, physician groups, consumer groups, and federal
partners. We asked for comments \4\ from the stakeholder community on
key topics related to how to develop the measurements, scoring, and
public reporting for the Quality Payment Program. We conducted multi-
day workshops and visited with physicians in their communities
individually and in groups to understand how the changes we considered
may positively impact care and how to avoid unintended consequences.
Just as stakeholder input has been instrumental in the development of
the proposed rule, the feedback we have received will be essential in
our development of final regulations. Since proposing the rule, CMS has
conducted extensive outreach to providers and other stakeholders to
ensure that we get their feedback on our proposal. These efforts have
stretched across the country and have been both large and small, with
more than 200 outreach events. We have also hosted numerous webinars
that have seen more than 64,000 participants. We received 3,875
comments during the public comment period.\5\ We are currently
reviewing the comments and feedback we received and expect to issue
final rulemaking after this review is complete.
---------------------------------------------------------------------------
\3\ http://federalregister.gov/a/2016-10032.
\4\ http://federalregister.gov/a/2015-24906.
\5\ https://www.regulations.gov/document?D=CMS-2016-0060-0068.
The input we have received from stakeholders throughout the process
has been very valuable: physicians and clinicians want support for a
care system that focuses on quality, but too many unaligned quality
programs, measures, and technology requirements can hinder their best
efforts to accomplish these goals. Based on what we learned, our
approach to implementation has been guided by four principles. First,
patients are, and must remain, the key focus. Financial incentives
should work in the background to support physician and clinician
efforts to provide high quality services, and the needs of the patient,
not measurements, need to be the focus of our approach. Second, success
will come from adopting approaches that can be driven by the physician
practice. Quality measurement needs to accurately reflect the needs of
a diverse range of patient populations and practice types and give
physicians and other clinicians the opportunity to select elements of
the program and measures that are right for their practice. Third, in
everything we do, we must strive to make care delivery as simple as
possible, with more support for collaboration and communication through
delivery system reform. Fourth and finally, we must focus on the unique
concerns of small independent practices, as well as rural practices and
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practices in underserved areas.
We relied heavily on stakeholder input we received over the last
year to inform our proposal of a scoring methodology for MIPS that aims
to improve upon and streamline existing measures in the quality, cost,
and advancing care information categories, which are based in part upon
current CMS programs. In particular, we have been working side-by-side
with the physician and consumer communities to address needs and
concerns about the Medicare EHR Incentive Program, often known as
Meaningful Use for physicians, as we transition it to the Advancing
Care Information category in MIPS. The new approach heightens focus on
the patient, increases flexibility, reduces burden, and concentrates on
aspects of health information technology, such as health information
exchange, that are critical for delivery system reform and improving
patient outcomes. We also used this feedback when proposing the new
clinical practice improvement activities category, which the statute
created. When developing the proposed activities for this category, we
listened closely to specialty societies and associations when creating
options to allow clinicians to select activities that match their
practices' goals.
While we expect that most clinicians will participate in MIPS for
the first years of the Quality Payment Program, we will continuously
search for opportunities to expand and refine our portfolio of payment
models in order to maximize the number of physicians and other
clinicians who have the opportunity to participate in Advanced APMs. It
is our intent to allow as much flexibility as possible for clinicians
to switch between MIPS and participation in Advanced APMs based on what
works best for them and their patients. The proposed rule is the latest
step in our efforts to work in concert with stakeholders on the front-
line of care delivery to draw upon their expertise and incorporate
their input into the policies for the Quality Payment Program so that
together, we can achieve the aim of the law.
notice of proposed rule making (nprm)
In our proposed rule, we provide details and descriptions of the
proposed policies that will allow us to implement the important new
provider payment provisions included in MACRA.
Merit-based Incentive Payment System (MIPS)
Currently, Medicare measures physicians and other clinicians on how
they provide quality care and reduce costs through a patchwork of
programs, with clinicians reporting through some combination of the
Physician Quality Reporting System, the Value Modifier Program, and the
Medicare EHR Incentive Program. Through the law, Congress streamlined
and improved these reporting programs into the Merit-based Incentive
Payment System. Under MIPS, eligible physicians and clinicians will
report their performance under four categories and will receive a
payment adjustment based on their overall performance, or composite
performance score.
Consistent with the goals of the law, the proposed rule would
improve the relevance of Medicare's value and quality-based payments
and increase clinician flexibility by allowing clinicians to choose
measures and activities appropriate to the type of care they provide.
Under our proposed rule, performance measurement under the new program
for physicians and other eligible clinicians would begin in 2017, with
payments based on those measures beginning in 2019. MIPS allows
Medicare clinicians to be paid for providing high quality, efficient
care through success in four performance categories:
1. Quality (50 percent of total score in year 1; replaces the
Physician Quality Reporting System and the quality component of the
Value Modifier Program): Clinicians would choose to report six measures
versus the nine measures currently required under the Physician Quality
Reporting System. This category gives clinicians reporting options to
choose from to accommodate differences in specialty and practices.
2. Advancing Care Information (25 percent of total score in
year 1; replaces the Medicare EHR Incentive Program for physicians,
also known as ``Meaningful Use''): Clinicians would choose to report
customizable measures that reflect how they use health information
technology in their day-to-day practice, with a particular emphasis on
interoperability and secure information exchange. Unlike the existing
Meaningful Use program, this category would not require quality
reporting, which would be assessed within the Quality category.
3. Clinical Practice Improvement Activities (15 percent of
total score in year 1): Clinicians would be rewarded for clinical
practice improvement activities such as activities focused on care
coordination, beneficiary engagement, and patient safety. Clinicians
may select activities that match their practices' goals from a list of
more than 90 options. In addition, clinicians would receive credit in
this category for participating in APMs and in Patient-Centered Medical
Homes.
4. Cost (10 percent of total score in year 1; replaces the
cost component of the Value Modifier Program, also known as Resource
Use): The score would be based on Medicare claims and require no
reporting by physicians or other clinicians. This category would
integrate more than 40 episode-specific measures to account for
differences among specialties.
The law requires MIPS to be budget neutral. Therefore, physicians'
and clinicians' MIPS scores would be used to compute a positive,
negative, or neutral adjustment to their Medicare Part B payments. In
the first year, depending on the variation of MIPS scores, adjustments
are calculated so that negative adjustments can be no more than 4
percent, and positive adjustments are generally up to 4 percent; the
positive adjustments will be scaled up or down to achieve budget
neutrality. Also, in the first 6 years of the program, additional
bonuses are provided for exceptional performance.
Advanced Alternative Payment Models (APMs)
For clinicians who take a further step towards care transformation,
the law creates another path. Physicians and clinicians who participate
to a sufficient extent in Advanced APMs would qualify for incentive
payments. Importantly, the law does not change how any particular APM
rewards value. Instead, it creates extra incentives for participation
in Advanced APMs. For years 2019 through 2024, a physician or clinician
who meets the law's standards for Advanced APM participation in a given
year is excluded from MIPS payment adjustments and receives a 5 percent
Medicare Part B incentive payment. For years 2026 and later, a
clinician who meets these standards is excluded from MIPS adjustments
and receives a higher annual fee schedule update than those clinicians
who do not significantly participate in an Advanced APM.
Under the law, Advanced APMs are those in which clinicians accept
risk and reward for providing coordinated, high-quality, and efficient
care. As proposed, Advanced APMs must generally:
1. Require participants to bear a certain amount of financial
risk. Under our proposal, an Advanced APM would meet the financial risk
requirement if CMS would withhold payment, reduce rates, or require the
entity to make payments to CMS if its actual expenditures exceed
expected expenditures, consistent with parameters we specified in the
rule.
2. Base payments on quality measures comparable to those used
in the MIPS quality performance category. To meet this statutory
requirement, we propose that an Advanced APM must base payment on
quality measures that are evidence-based, reliable, and valid. In
addition, at least one such measure must be an outcome measure if an
outcome measure appropriate to the Advanced APM is available on the
MIPS measure list.
3. Require participants to use certified EHR technology. To
meet this requirement, we propose that an Advanced APM must require
that at least 50 percent of the clinicians use certified EHR technology
to document and communicate clinical care information in the first
performance year. This requirement increases to 75 percent in the
second performance year.
In addition, under the statute, medical home models, which are a
popular and patient-centered approach for primary care practices to
coordinate care, that have been expanded under the Innovation Center
authority qualify as Advanced APMs regardless of whether they meet the
financial risk criteria. While medical home models have not yet been
expanded, the proposed rule lays out criteria for medical home models
to ensure that primary care physicians have opportunities to
participate in Advanced APMs.
The rule proposes a definition of medical home models, which focus
on primary care and accountability for empaneled patients across the
continuum of care. Because medical homes tend to have less experience
with financial risk than larger organizations and limited capability to
sustain substantial losses, we propose unique Advanced APM financial
risk standards, consistent with the statute, to accommodate medical
homes that are part of organizations with 50 or fewer clinicians.
The proposed rule includes a list of models that would qualify
under the terms of the proposed rule as Advanced APMs. These include:
Comprehensive ESRD Care (Large Dialysis Organization
arrangement);
Comprehensive Primary Care Plus (CPC+);
Medicare Shared Savings Program--Track 2;
Medicare Shared Savings Program--Track 3;
Next Generation ACO Model; and
Oncology Care Model--Two-sided risk (available in 2018).
Under the proposed rule, CMS would update this list annually to add
new payment models that qualify. CMS will continue to modify models in
coming years to help them qualify as Advanced APMs. In addition,
starting in performance year 2019, clinicians could qualify for
incentive payments based in part on participation in Advanced APMs
developed by non-Medicare payers, such as private insurers, Medicare
Advantage plans, or State Medicaid programs.
We recognize the substantial time and money commitments in which
APM participants invest in order to become successful participants.
Under the proposed rule, physicians and clinicians who participate in
Advanced APMs but do not meet the law's criteria for sufficient
participation in Advanced APMs, and those who participate in certain
non-Advanced APMs, would be exempt from the Cost category in MIPS,
would be able to use their APM quality reporting for the MIPS Quality
category, and would receive credit toward their score in the Clinical
Practice Improvement Activities category. We want to make sure that in
addition to encouraging physicians and other clinicians to improve
quality of care by participating in APMs that best fit their practice
and patient needs, physicians and clinicians are not subject to
duplicative, overly burdensome reporting requirements.
physician-focused payment model technical advisory committee (ptac)
To help spur innovation for models that meet the needs of the
physician community, MACRA established a new independent advisory
committee, the Physician-
Focused Payment Model Technical Advisory Committee (PTAC). The PTAC
will meet at least quarterly to review physician-focused payment models
submitted by individuals and stakeholder entities and prepare comments
and recommendations on proposals that are received, explaining whether
models meet CMS criteria for physician-focused payment models. The 11
members of the PTAC, who were appointed by the Comptroller General, are
experts in physician-focused payment models and related delivery of
care, including researchers, practicing physicians, and other
stakeholders. The PTAC has met twice and presentations from the meeting
are available online.\6\ We encourage physician specialists and other
stakeholders to engage with the PTAC to suggest well designed, robust
models. CMS is committed to working closely with the PTAC and are
looking forward to reviewing their recommendations for new physician-
focused payment models.
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\6\ https://aspe.hhs.gov/meetings-physician-focused-payment-model-
technical-advisory-committee.
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technical assistance
We know that physicians and other clinicians may need assistance in
transitioning to the MIPS, and we want to make sure that they have the
tools they need to succeed in a redesigned system. Congress provided
funding in MACRA for technical assistance to small practices, rural
practices, and practices in medically underserved health professional
shortage areas (HPSAs).
Last month, CMS announced the availability of $20 million of this
funding for on-the-ground training and education for Medicare
clinicians in individual or small group practices of 15 clinicians or
fewer. These funds will help provide hands-on training tailored to
small practices, especially those that practice in historically under-
resourced areas including rural areas, HPSAs, and medically underserved
areas. As required by MACRA, HHS will award $20 million each year for 5
years, providing $100 million in total to help these practices
successfully participate in the Quality Payment Program.
In addition to MACRA implementation efforts, last month, CMS
launched the second round of the Support and Alignment Networks under
the Transforming Clinical Practice Initiative. This opportunity will
provide up to $10 million over the next 3 years to leverage primary and
specialist care transformation work and learning that will catalyze the
adoption of APMs on a large scale. Support and Alignment Network 2.0
awardees' activities, coaching, and technical assistance will help
practices transform the way they deliver care. The ultimate goal is for
these practices to participate in APMs and Advanced APMs. Critical to
this approach is the capacity for awardees to accurately identify large
numbers of clinicians and practices in advanced states of readiness
through sound data analytics capabilities, to enroll them into the
Transforming Clinical Practice Initiative, to provide them with
tailored technical assistance, and to align them with the most suitable
Alternative Payment Model options. Further, awardees will need to
customize direct technical assistance and support services that are
tailored to these clinicians' and practices' needs.
conclusion
MACRA will help move Medicare towards more fully rewarding the
value and quality of services provided by physicians and other
clinicians, not just the quantity of such services. For it to be
successful--in other words, for MACRA to improve care delivery and
lower health care costs--we must first demonstrate to clinicians and
patients both the value of these new payment programs established by
MACRA and the opportunity for these participants to shape the health
care system of the future. The program must be flexible, practice-
driven, and person-centered. It must contain achievable measures; it
must support continued and improved information sharing through
innovations and advancements in interoperability and the health IT
infrastructure; it must engage and educate physicians and others
clinicians; and it must promote and reward improvement over time.
Our proposed rule incorporates valuable input received to date, but
it is only a first step in an iterative process for implementing the
new law. Moving forward, we will continue to gather feedback from our
stakeholders, to inform an implementation approach that leads to better
care, smarter spending, and improved patient outcomes. We will continue
partnering with Congress, physicians and other providers, consumers,
and other stakeholders across the Nation to make a transformed and
improved health system a reality for all Americans. We look forward to
working with you as we continue to implement this seminal law.
______
Prepared Statement of Hon. Ron Wyden,
a U.S. Senator From Oregon
There are big opportunities ahead to make substantial, bipartisan
progress when it comes to protecting and updating the Medicare
guarantee, and that's what the committee will be discussing this
morning.
The first is implementing the plan to throw in the trash can the
hopelessly broken, out-of-date Medicare reimbursement formula known as
the SGR. This was the source of endless uncertainty for health-care
providers and seniors, and it's now in the dustbin of history. Today,
the committee will talk about how its replacement will be implemented.
Second, it's important to build on the new Medicare payment system,
and in my view the obvious place to start ought to be in the area of
chronic care. Seniors suffering from these chronic illnesses, such as
heart disease, cancer, diabetes and stroke, now account for 93 percent
of spending in the program. I'm glad that's now a bipartisan focus of
this committee.
By finally clearing the decks of the SGR debacle, the Finance
Committee has been able to get to work on developing legislation that
will empower families and Medicare to manage and treat these
debilitating diseases. I'd like to thank Chairman Hatch, along with
Senators Isakson and Warner especially, for their continued dedication
to this issue. This effort is already paying dividends; last week, in a
rule released by the Centers for Medicare and Medicaid Services (CMS),
they proposed adopting four policies the chronic care group has
developed and putting them in place administratively. There's still
more work to be done, but that was a promising start.
Now when it comes to replacing the SGR, Medicare payment reform
took the important step of engraving in stone the principle of
rewarding medical care that provides quality over quantity. For the
seniors who depend on the Medicare guarantee, that ought to result in
better, more thoughtful health care. That's the direction that
healthcare is headed in across the country, and Medicare should be
leading the way.
I'll make two key points about what it's going to take to implement
this legislation the right way.
First is to make sure all doctors who care for our seniors get fair
treatment under these new rules. That's particularly important for the
small or solo practitioners who are truly the backbone of rural
communities.
Second, this legislation supports efforts to strengthen primary
care, which in my view is key to making people healthier and bringing
down costs. For example, the ``Comprehensive Primary Care Plus'' model
allows Medicare to partner with commercial and State health insurance
plans so everyone is on the same page when it comes to paying for value
and quality care.
That means a primary care doctor who has business in the commercial
market and in Medicare doesn't have to find a balance between many
different sets of rules as she's trying to serve as many people in her
community as possible. This is just one promising example, if done
right, of innovative changes to the way doctors are paid that will
improve care for seniors in the program--exactly what these reforms
were designed to do.
I'd also like to thank Andy Slavitt, Acting Administrator of the
Centers for Medicare and Medicaid Services, for joining the committee
this morning. Andy has always been committed to doing right by the
millions of Americans who have to navigate the health-care system every
day. His role in pushing for more value and quality in healthcare is a
big part of making that a reality.
______
Communications
----------
Alliance of Specialty Medicine
3823 Fordham Road, NW
Washington, DC 20016
Chairman Hatch, Ranking Member Wyden, and members of the committee, the
Alliance of Specialty Medicine (the Alliance) would like to thank the
Senate Committee on Finance for the opportunity to provide feedback on
implementation of the Medicare Access and CHIP Reauthorization Act of
2015 (MACRA). The Alliance strongly supports your involvement in
ensuring that the Centers for Medicare and Medicaid Services (CMS)
follows the legislative intent of MACRA as CMS undergoes rulemaking to
implement its provisions. The Alliance is a coalition of medical
specialty societies representing more than 100,000 physicians and
surgeons from specialty and subspecialty societies dedicated to the
development of sound federal health care policy that fosters patient
access to the highest quality specialty care.
Member organizations of the Alliance have continuously sought out and
developed robust mechanisms (including clinical decision support,
clinical data registries, and other tools) aimed at improving the
quality and efficiency of care specialty physicians provide. In
addition, Alliance member organizations have analyzed and heavily
scrutinized data related to the services they provide, looking for ways
to improve how they diagnose, treat, and manage some of the most
complex health care conditions in their respective specialty areas.
With those sentiments in mind, the Alliance is eager to engage in
programs that would further these efforts with incentives and technical
assistance.
However, despite the considerable and often overwhelming effort the
Alliance put into helping shape provisions in the MACRA legislation, as
well as the ongoing feedback provided during the many pre-rulemaking
comment and feedback opportunities, we are concerned that several of
the principles we have long supported and conveyed to the agency were
largely ignored. This is particularly true when it comes to proposals
associated with the use of electronic health records (EHRs), the
application of socioeconomic risk factors in quality and cost metrics,
and most importantly, substantial disparities in Quality Payment
Program (QPP) requirements that significantly disadvantage specialty
care providers and the patient populations they serve. We hope that our
comments herein will move CMS to address some of the most pressing
issues facing specialty medicine, removing barriers that limit
meaningful specialty physician engagement, and offering all specialists
and non-specialists equal opportunities to demonstrate quality in a
relevant manner.
Our written testimony below will detail some concerns regarding the
proposals in the CMS proposed rule titled ``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.''
As discussed in more detail below, the Alliance has the following
recommendations:
CMS should modify the initial start date of MIPS so physicians
and practices have adequate time to prepare for the new program. MIPS
should start no earlier than July 1, 2017, allowing CMS to establish a
shorter performance period in the first year of the QPP program--such
as a 6-month performance period, with an optional ``look-back'' to
January 1 in 2017.
CMS should minimize the reporting burden, particularly during
the initial transition period, by maintaining the current PQRS
reporting thresholds. Additionally, CMS should retain measures groups.
The cost and resource use measures are completely flawed and
inadequate. As such, CMS should use its authority under MACRA to re-
weight this category to zero.
There are very few activities that create a pathway for
specialists to earn credit for their engagement in clinical practice
improvement activities, and it is essential that CMS expand its list of
recognized activities for this MIPS category.
CMS should eliminate the ``all or nothing'' scoring in the
electronic health record (now known as ``advancing care information'')
category.
The proposed QPP largely retains the flawed siloed approach of
Medicare's current quality improvement programs and its scoring system
is extremely complex. CMS should, therefore, rethink its scoring
methodology and make modifications that would standardize, streamline,
and maintain consistency so that MIPS eligible clinicians are able to
understand and respond appropriately.
We continue to be frustrated by the lack of APM participation
options available to specialty physicians.
CMS must establish a mechanism for distinguishing subspecialties
to ensure that smaller subspecialties are not disadvantaged by the QPP
and its scoring methodology.
Proposals for the Merit-Based Incentive Payment System (MIPS)
The MIPS Performance Period
Given the breadth of proposed changes to CMS's quality and performance
improvement programs, we are very concerned about the timeframe in
which the agency expects to begin evaluating specialty physician
performance. We are sympathetic to the administrative challenges CMS
faces in operationalizing the new program. However, Alliance member
organizations are concerned that specialty physicians will not be able
to successfully adapt under the proposed rigorous schedule.
Even before MACRA was signed into law, specialty societies were
educating their members on the anticipated changes. Unfortunately, and
not unlike with other CMS programs, the challenge of educating
physicians on these new programs has been difficult. We find that many
of our specialty society staff are still educating members on CMS's
long-standing quality programs, including the Physician Quality
Reporting System (PQRS) and Value-Based Payment Modifier (VM)/Physician
Feedback Program. As you know, PQRS continues to have relatively low
participation rates, and those facing adjustments under the VM do not
understand exactly from where those penalties stem. As a significant
portion of the MIPS is based on the PQRS, which continues to suffer
from critical measure gaps in regards to specialty medicine, as well as
the flawed VM and problematic Quality and Resource Use Reports (QRURs)
distributed under the Physician Feedback Program, we are deeply
concerned about the impact this will have on specialty physicians.
As most specialty physicians will not be ready on January 1, 2017 to
begin MIPS, CMS should modify the initial start date of the MIPS
program and provide a shorter reporting/performance period in 2017--
e.g., 6 months, with an optional ``look-back'' to January 1 in 2017.
CMS should maintain this shorter reporting/performance period in future
years of the program (with an optional ``look-back'' to January 1), in
addition to any year-long reporting requirements, beginning in 2018.
This shorter reporting/performance period will provide a necessary
``on-ramp'' for many specialty physicians who will be new to the
program. And, it is consistent with approaches CMS has taken previously
with the Medicare EHR Incentive Program, which currently utilizes a 90-
day reporting period.
The MIPS Quality Performance Category
For the quality performance category, CMS proposes to adopt
requirements similar to those under the existing Physician Quality
Reporting System (PQRS). We are concerned with this approach, because,
as you know, PQRS continues to have relatively low participation rates,
and it has been difficult educating our members on the complexities of
the PQRS. Furthermore, some of CMS's proposals under the quality
performance category would make it more difficult for specialty
providers to be successful under the MIPS. Specifically:
The Removal of Measures Groups: CMS proposes to no longer
include Measures Groups as a data submission method for purposes of the
quality performance category. In its place, CMS is proposing specialty-
specific measure sets, which CMS believes will address confusion in the
quality measure selection process. Some of the specialties represented
in the Alliance heavily rely on Measures Groups to meet quality
reporting requirements under the current PQRS program and would
appreciate the opportunity to continue meeting the quality reporting
requirements under the quality performance category in the same way. By
proposing to do away with this reporting mechanism, CMS is severely
limiting meaningful quality reporting options available to many
specialists, particularly those in small practices. Similarly, in many
instances, the proposed removal of measure groups will either leave no
meaningful measures for certain specialties and subspecialties or
greatly diminish the value of the measures that CMS proposes to retain
as stand-alone measures.
Increasing the Data Completeness Threshold: CMS also proposes to
revise its data completeness thresholds such that individual MIPS
eligible clinicians submitting via Part B claims would need to report
on 80 percent of his/her Medicare Part B-only patients; whereas
individual MIPS eligible clinicians and groups submitting via Qualified
Clinical Data Registry (QCDR), qualified registry, and EHR would need
to report on 90 percent of their Medicare and non-Medicare patients. We
very much oppose this proposal and request that CMS lower the reporting
thresholds for all reporting mechanisms to 50 percent, which is
consistent with the current PQRS reporting requirements. As an
alternative, CMS could consider simply requiring reporting on 20
consecutive patients, which would be consistent with CMS' current
threshold for Measures Groups under the PQRS program.
The MIPS Resource Use Performance Category
We are deeply concerned about the use of the VM measures in the MIPS
program, particularly in the initial years. A CMS report on the result
of the 2016 VM program (based on 2014 performance) showed that only 128
groups exceeded the program's benchmarks in quality and cost efficiency
and earned a 2016 payment incentive. In contrast, physicians in 5,418
groups that failed to meet minimum reporting requirements saw a
``-2.0%'' decrease in their Medicare payments in 2016 and physicians in
59 groups saw a decrease in their Medicare payments based on their
performance on cost and quality measures under the VM. The disparity in
groups earning an incentive or receiving a negative adjustment for the
2016 VM is great. It is clear these measures are not ready for prime
time, and the need to further refine and evaluate episode-based cost
measures is essential.
Furthermore, in calculating the performance under the resource use
performance category, CMS proposes to include several clinical
condition and treatment episode-based measures that have been reported
in Supplemental Quality and Resource Use Reports (sQRURs) or were
included in the list of the episode groups developed under section
1848(n)(9)(A) of the Act published on the CMS website. We are concerned
about the premature application of these cost measures, which have not
been adequately vetted by specialty care providers given their limited
use. Most of the cost measures are new, only recently having been put
forward for comment as part of CMS's Episode Groups Request for
Comment. The remaining measures may have been included in sQRURs,
however, very few clinicians understood (or understand) how to access
or interpret their QRURs or sQRURs.
For these reasons, we strongly urge CMS to use its authority under
MACRA to re-weight this category to zero.
The MIPS Clinical Practice Improvement Activity (CPIA) Category
Despite the inclusion of 94 unique activities in the Clinical Practice
Improvement Activity (CPIA) inventory, the vast majority of activities
are focused on activities more appropriate for primary care providers.
There are very few activities that create a pathway for specialists to
earn credit for their engagement in clinical practice improvement. The
list of proposed CPIAs neither includes the vast majority of activities
we suggested for inclusion nor did CMS acknowledge that it had at least
considered these activities for inclusion. We urge CMS to reconsider
including these activities in the proposed rule. They include:
Attendance and participation in Accreditation Council for
Continuing Medical Education (ACCME)-accredited continuing medical
education (CME) and non-CME events, such as the specialty and
subspecialty society conferences and events, including those that are
web-based, that exceed certification requirements;
Fellowship training or other advanced clinical training
completed during a performance year;
Participation in morbidity and mortality (M&M) conferences;
Taking emergency department (ED) call as part of Expanded
Practice Access,
Voluntary practice accreditation, such as accreditation achieved
by the National Committee on Quality Assurance (NCQA), Accreditation
Association for Ambulatory Health Care (AAAHC), The Joint Commission
(TJC), or other recognized accreditation organizations;
Demonstration of incorporation of evidence-based practices and
appropriate use in clinician practices, using evidence-based clinical
guidelines, appropriate use criteria, ``Choosing Wisely''
recommendations, etc.;
Engagement in state and local health improvement activities,
such as participation in a regional health information exchange or
health information organization;
Engagement in private quality improvement initiatives, such as
those sponsored by health plans, health insurers, and health systems;
and
Participation in other federally sponsored quality reporting and
improvement programs not already affiliated or considered under the
MIPS program.
CMS intends, in future performance years, to begin measuring CPIA data
points for all eligible clinicians and to award scores based on
performance and improvement. We strongly oppose this proposal,
particularly given there are no baseline or benchmark data available
for comparison. In addition, we believe that requiring this diverts
from the Congressional intent of including this proposal in the first
place.
The MIPS Advancing Care Information Performance Category
We are sorely disappointed in the proposals included in the Advancing
Care Information performance category. The implementation of programs
established under MACRA afforded CMS a unique opportunity to
drastically change the direction of the meaningful use program for
physicians. Since the fall, CMS promised a more flexible program in
response to physician concerns heard around the country. Instead, the
measures that CMS has retained are every bit the same and even more
difficult with the proposed removal of most exclusions. Under CMS's
base scoring proposals, they must still report on at least one patient
for each of the measures in the objectives that require reporting a
numerator/denominator. MIPS eligible clinicians will continue to be
forced to report on measures that are not meaningful to their practice
and patient populations. While CMS touts these modifications as a
departure from the previous ``all-or-nothing'' approach to the Medicare
EHR Incentive Program, specialty physicians observe little change in
how they can approach the new requirements and be successful.
The MIPS Composite Performance Score Methodology
We are deeply concerned about the scoring methodology for MIPS.
Alliance member organizations have reviewed the proposals in great
detail, yet we continue to find the proposals extremely complex and
confusing. We recognize that, to provide flexibility, the scoring will
be more difficult. However, if our most sophisticated and knowledgeable
volunteer physician leaders are struggling to understand the scoring
proposals, how does CMS expect the vast majority of physicians in
practice to understand?
The proposed methodology also maintains the current silos of
performance scoring, despite the fact that scoring is all rolled up
into a composite performance score. To move toward a more value-driven
health care system, it seems that the scoring should provide physicians
with meaningful and actionable information that leads them toward that
goal.
We request that CMS rethink its scoring methodology and make
modifications that would standardize, streamline, and maintain
consistency so that MIPS eligible clinicians are able to understand and
respond appropriately.
Alternative Payment Models (APMs)
Specialty physicians are at a disadvantage as the proposed Advanced
Alternative Payment Models (APMs) remain primary care-focused, leaving
specialty physicians with few APM participation options. Despite its
Request for Information (RFI) on Specialty Practitioner Payment Model,
the Center for Medicare and Medicaid Innovation (CMMI) has not made a
concerted effort to ensure specialists have a pathway toward engaging
in APMs. Only two models currently cover specialty medicine--the
Oncology Care Model and the Comprehensive Care for Joint Replacement
Model, the latter of which CMS did not propose to qualify as an
Advanced APM.
We continue to be frustrated by the lack of APM participation options
available to specialty physicians given the intent of MACRA to move
physicians away from traditional fee-for-service and into payment
models that better focus on cost and quality. We urge CMS to offer
guidance on how APMs that did not meet the proposed Advanced APM
criteria could be altered to meet the criteria. It seems as if in many
cases, it is simply a lack of quality metrics or concerted use of
certified electronic health record technology (CEHRT) that limit those
models from Advanced APM status. If that is the case, we request that
CMS work with the developers and participants of those models to make
modifications that lead to Advanced APM designation.
Distinguishing Specialty Care Physicians
Finally, member organizations in the Alliance represent a broad array
of specialty and subspecialty organizations. However, CMS' current
proposals do not recognize the intricacies of all of these specialties
and subspecialties. For example, Mohs micrographic surgeons are
identified in claims and other datasets as relatively low-quality and/
or high-cost providers because they are being compared to the whole of
dermatology. Mohs surgeons focus their practice on skin cancer
diagnosis and treatment, unlike a lot of other dermatologists who may
be focused on other conditions, such as acne.
Individually, many of these subspecialty providers have urged CMS to
use ``Level III, Area of Specialization'' codes from the Healthcare
Provider Taxonomy code set to develop quality and cost benchmarks for
these providers to at least somewhat level the playing field. We
request that CMS begin the process for developing appropriate
benchmarks for these providers using the aforementioned ``third-tier''
taxonomy codes. Without being able to more accurately define the role
of a provider, it would be difficult for CMS to truly measure
performance.
Thank you again for taking into consideration our written comments. The
Alliance of Specialty Medicine looks forward to working with the
committee on addressing these issues to ensure the successful
implementation of MACRA and we would be happy to discuss our concerns
with you, as well as any other questions you may have going forward.
______
American College of Physicians (ACP)
25 Massachusetts Avenue, NW, Suite 700
Washington, DC 20001-7401
Statement for the Record
The American College of Physicians (ACP) applauds Chairman Hatch and
Ranking Member Wyden for holding this hearing on the implementation of
the Medicare Access and CHIP Reauthorization Act (MACRA). The College
appreciates the opportunity to provide a statement to the Senate
Finance Committee that includes our recommendations to improve the
implementation of MACRA. These recommendations are based on a comment
letter that ACP sent last month to the Centers for Medicare and
Medicaid Services (CMS) Acting Administrator Andy Slavitt that provides
our ideas for improvements to the proposed rule that was released
earlier this year by CMS to implement MACRA.
ACP has developed three principles that Congress should use to ensure
that this law is implemented in a manner that truly improves care for
Medicare beneficiaries and thus the policy that is developed to guide
these new value based payment programs must be thoughtfully considered
in that context. We believe that these principles are also consistent
with the manner that Congress intended the law to be implemented. These
principles are:
That the new payment systems should reflect the lessons from
current and past programs and effectively allow for ongoing innovation
and learning. The agency must constantly monitor the evolving
measurement system to identify and mitigate any potential unintended
consequences.
CMS should work to ensure that patients, families, and their
relationships with their physicians are at the forefront of thinking in
developing the new payment systems.
CMS should collaborate with specialty societies, frontline
clinicians, and Electronic Health Records (EHRs) vendors in the
development, testing, and implementation of measures with a focus on
integrating the measurement of and reporting on performance with
quality improvement and care delivery and decreasing clinician burden.
We ask Congress to not only use these principles to guide the oversight
process, but also offer a series of concrete recommendations to CMS
that we believe will help ensure that the law is implemented in a
manner that serves the interests of our patients and also follows
Congressional intent. We look forward to working with Congress to
ensure that these recommendations are implemented as our physicians
prepare to move toward a new value-based payment system.
Among the detailed suggestions, we have outlined a set of top priority
tasks for CMS, including the following:
Implement an alternative Merit-Based Incentive Payment System
(MIPS) scoring methodology, developed by ACP, which combines,
simplifies, aligns, and reduces the complexity of the four reporting
categories.
Provide better opportunities for small practices to succeed,
including via the creation of virtual groups for assessment under MIPS,
while holding practices of nine or fewer eligible clinicians harmless
from any potential downward adjustments until such time that a virtual
groups option is made available.
Make significant improvements to simplify, harmonize and reduce
the burden of quality measurement and reporting for MIPS both over the
short and longer term.
Simplify reporting requirements within CMS's Advancing Care
Information (ACI) program that is to replace the current Meaningful Use
program.
Change the start date for the First Performance Year in the
Quality Payment Program (QPP) to July 1, 2017.
Improve the opportunities for Patient-Centered Medical Homes
(PCMHs) and PCMH Specialty Practices in MIPS and for PCMHs as advanced
Alternative Payment Models (APMs).
Implement changes that would make more advanced APMs available
for physicians in all specialties, especially including those in
internal medicine and its subspecialties.
At this time, we believe that CMS is sincerely open to making
improvements from its proposed rule, and do not believe that it is
necessary or desirable for Congress to make any legislative changes to
MACRA. Rather, we encourage the Senate Finance Committee, and the House
Medicare committees of jurisdiction, to exercise oversight over CMS's
implementation, and specifically, to be supportive of the following
recommendations in ACP's comment letter on the NPRM.
Implement an Alternative Scoring Methodology for MIPS
ACP recommends that CMS simplify and clarify performance scoring in the
final rule to allow physicians to better assess the scoring and
weighting within each category. The scoring approach included in the
proposed rule had different points systems and scales for each of the
four reporting categories, making it unnecessarily complicated; ACP's
alternative would put the points all on the same scale, combining them
into one simplified and harmonized program as Congress intended.
ACP proposed to CMS a more simplified alternative that would make all
available points within the quality component add up to a total of 50
points, not 80--which then counts for 50 percent; the points within
resource use would add up to a total of 10 or less; the points within
Clinical Practice Improvement Activities (CPIA) would add up to 15; and
the points within ACI would add up to 25 (and not 131, with only 100 of
those points actually ``counting,'' as currently proposed).
By simplifying the scoring to allow the maximum points for each measure
or activity to directly translate to its contribution to the overall
CPS, the scoring will be streamlined to better account for MIPS as one
comprehensive program rather than silos for each performance category.
This will allow physicians to better focus their efforts on the
activities and measures that are most meaningful to their patients and
practice.
Provide Better Opportunities for Small Practices to Succeed
Section 1848(q)(5)(I) of the Act establishes the use of voluntary
virtual groups for certain assessment purposes. The statute requires
the establishment and implementation of a process that allows an
individual MIPS eligible clinician (EC) or a group consisting of not
more than 10 MIPS ECs to elect to form a virtual group with at least
one other such individual MIPS EC or group of not more than 10 MIPS ECs
for a performance period of a year. While the rule recognizes this
requirement, it proposes to delay the onset of this provision until the
2018 performance year based on identified significant barriers
regarding the development of a technological infrastructure required
for successful implementation and the operationalization of provisions
that would make this a conducive option for MIPS ECs or groups.
The College believes that the implementation of the virtual groups'
provision is an important step towards establishing a viable and
effective quality payment program. It will allow small practice
clinicians to aggregate their data to allow for more reliable and valid
measurement as well as serve as a platform to facilitate shared
accountability and collaborative efforts. While we recognize and
appreciate the barriers mentioned towards implementation in time for
the 2017 performance period, ACP is not supportive of the planned delay
in implementation. It places small practices in a situation in which
payment adjustments based upon the 2017 performance year will likely be
based upon suspect data.
Therefore, ACP strongly urges CMS to include in the final rule for the
2017 performance period a policy that allows small practices to join
together as virtual groups for the purposes of MIPS assessment in the
initial performance period. This is a critical option that small
practices should be permitted in order to allow greater assessment
opportunities under MIPS. To accomplish creating a virtual group option
for the first performance period, the College notes that CMS can
utilize Interim Final Rulemaking processes.
If the Agency is unable to provide a virtual group option through
rulemaking for the first year, then as a backup, ACP recommends that
CMS treat small practices in a manner similar to how they were treated
in the phase-in of the Value-based Payment Modifier (VBM) program.
Under this option, CMS would allow solo clinicians and groups of 2-9
ECs who report under MIPS to be held harmless from any potential
downward adjustments until such time that a virtual groups option is
made available. They should still be eligible for upward adjustments.
Make Significant Improvements to Quality Measurement and Quality
Reporting for MIPS and Over the Longer Term
In our comments on the quality component of MIPS, it seems imperative
to reiterate our call for CMS to use the opportunity provided through
the new MACRA law to actively build a learning health and healthcare
system. It is critically important that the new payment systems that
are designed through the implementation of MACRA reflect the lessons
from the current and past programs and also effectively allow for
ongoing innovation and learning. Overall, quality measurement must move
toward becoming more relevant and accurate, and toward effective
approaches of measuring patient outcomes.
We provide these specific recommendations for CMS to properly implement
the new Quality Performance Category:
1. The College recommends that CMS collaborate with specialty
societies, frontline clinicians, and EHR vendors in the development,
testing, and implementation of measures with a focus on integrating the
measurement of and reporting on performance with quality improvement
and care delivery and on decreasing clinician burden.
It is critically important to constantly monitor the evolving
measurement system to identify and mitigate any potential unintended
consequences, such as increasing clinician burden and burn-out,
adversely impacting underserved populations and the clinicians who care
for them, and diverting attention disproportionately toward the things
being measured to the neglect of other critically important areas that
cannot be directly measured (e.g., empathy, humanity).
2. We recommend that ideally any measures CMS proposes to use
outside of the core set identified by the Core Quality Measures
Collaborative be endorsed by the Measure Application partnership.
ACP is appreciative that CMS has proposed to reduce the overall number
of measures required for reporting from nine measures to six, as well
as removing the requirement that these measures fall across all of the
National Quality Strategy domains. However, the College would like to
reiterate our overall concerns with the performance measures that are
currently in use within the Physician Quality Reporting System (PQRS)
program, as well as many of those proposed for use within MIPS. To
begin to address this issue in the short term, in our comments on the
draft Measurement Development Plan (MOP), ACP called on CMS to utilize
the core set of quality measures identified by the Core Quality
Measures Collaborative.
3. CMS should consider the recommendations made by ACP's
Performance Measurement Committee with regard to measure selection
within MIPS.
These recommendations, as listed on the ACP website (with a thumbs up,
down, or sideways), are based upon a scientific review process that
involves four domains: purpose and importance to measure, clinical
evidence base, measure specifications, and measure implementation and
applicability.
4. CMS should take concrete actions to provide clear options for
those specialties and subspecialties that may be most impacted by too
few appropriate measures.
Many of these specialties may already be impacted under the current
proposal--particularly by a lack of outcomes and/or high priority
measures--and certainly would be affected if a number of the measures
available were to be reduced through a more focused and needed approach
of ensuring measure validity, clinical relevance, and ability to
implement. These actions should include:
Developing a process to determine, in advance of the
reporting year, which quality measures are likely applicable to each
EC--and only holding them accountable for these relevant measures
(i.e., weighting performance on the remaining measures higher, rather
than penalizing them with a score of zero on unreported measures).
Putting a process in place, for the short term, to address
the significant issues of validity and ability to implement associated
with using measures that are not endorsed by the National Quality Forum
(NQF), and/or ACP recommended.
Establishing safe harbors for entities that are taking on
innovative approaches to quality measurement and improvement and also
provide clear protections for individual clinicians who participate in
these types of activities--this could be done by having the entities
register certain measures as ``test measures.''
Ensuring that the flexibility for Qualified Clinical Data
Registries (QCDRs) to develop and maintain measures outside of the CMS
selection process is protected.
Simplify Reporting Requirements for the ACI Program
ACP proposed significant improvements to simplify the reporting
requirements for the ACI program that is to replace Meaningful Use in
the new law. ACP has been a consistent advocate of physicians and other
clinicians leveraging EHRs and other health information technology (IT)
to improve care. As such, ACP was a strong supporter of the goals of
the HI-TECH Act and of the Meaningful Use program, although we have
expressed concerns regarding the implementation of the Meaningful Use
program, specifically due to the uniform (or one-size-fits-all) and
overly prescriptive approach taken by CMS, which turned what should
have been an incentive program towards specialty-specific optimization
of the emerging health IT infrastructure into a ``check the box''
compliance exercise. That said, the ACP believed that the Meaningful
Use program accomplished many of its objectives, and with the coming of
Medicare's QPP via MACRA, CMS had a golden opportunity to fix
Meaningful Use into something truly meaningful for physicians,
clinicians, and patients.
Instead, what is proposed for Meaningful Use inside of MIPS is even
more complicated than what was proposed for Stage 3, and with even
higher thresholds. This legacy--if not significantly changed in the
MACRA/MIPS final rule, will not be one of using the enabling
infrastructure of health IT to improve quality and value--but rather
using it to satisfy regulatory compliance. What doctors, clinicians,
and clinical informatics leaders should be doing now--analyzing and
improving workflows and targeted use of health IT for specific quality
and value purposes--will not happen. Instead, just as has occurred with
each stage of Meaningful Use, they will be taking significant time to
understand the rules and the FAQs that are certain to follow and
continuing to develop workarounds and configuration ``gimmicks,''
particularly where the metric is not consistent with workflow.
In summary, the ACP believes that there is a place for Meaningful Use
within MIPS, but it is one that plays a supportive role to improving
care quality and value, and not one that promotes care information over
patient care. Please see our specific recommendations and comments
below, as well as an alternate proposal for Meaningful Use within MIPS,
which we believe is responsive to the legislative requirements of
MACRA.
1. We urge CMS to simplify the reporting requirements and scoring
methodology within the proposed ACI Category and not require the volume
and complexity specified in the base and performance scores.
In the new ACI system offered in the proposed rule, each practice will
be challenged to track and manage so many activities of so many people
and systems if it is to successfully complete the ACI component. The
likelihood of a costly error will be high. Further, the amount of
effort that will be required to perform, manage, and report all the
measures that make up ACI is more than would have been required under
the Meaningful Use Stage 2 modification rule for 2017. The number of
required activities greatly exceeds the numbers for the other
components of MIPS.
2. For the 2017 performance period, ACP recommends that the ACI
measurement period be 90 days instead of the full calendar year as done
previously with the EHR Incentive Program performance period.
It is extremely unlikely that all ECs will be prepared to report
measures in the new system on January 1, 2017. Therefore, many ECs will
be required to report on CMS's alternate ACI proposal of modified
objectives for the 2017 performance period. CMS should acknowledge this
in the final rule. Assuming a best case scenario, most practices will
spend the 2017 MIPS performance period converting from a 2014 Certified
Electronic Health Record Technology (CEHRT) system to a 2015 CEHRT
system that will negatively impact their ability to perform all ACI
measures for the full calendar year.
3. The College urges CMS to modify the base score component of ACI
and remove the threshold requirements of 1 or ``yes'' for all proposed
base measures except for the protecting patient health information
attestation which ACP believes is integral to the use of Health IT.
This modification will support CMS's public statements and those of its
Acting Administrator, Mr. Slavitt, outlining goals that give ECs the
ability to select measures that are relevant and that move them forward
in using health IT to improve value of care. ECs are going to need
health IT capabilities that they do not yet have, and the ACI program
should be used as a vehicle to help them make the needed transitions.
The proposed base measures, which are the same measures that physicians
have already found to be cumbersome and inappropriate, do little to
help ECs move forward.
Change the Start of the Initial Performance Period Under the QPP to
July 1, 2017
The College urges CMS to delay the initial performance period under the
OPP to July 1, 2017 rather than the proposed January 1, 2017 start
date. The performance period should remain as 1 year in length overall,
ending on June 30, 2018. ACP believes that this later start date for
the performance period better matches Congressional intent that the
performance period be as close to the payment adjustment period as
possible, while still allowing for the related payment adjustments to
take place in 2019 as mandated by MACRA.
Given that the final rule implementing the initial performance period
for MACRA will likely not be issued until October 2016 at the earliest,
CMS, physician organizations, ECs, and other affected parties would
have less than three months to prepare for implementation of an
entirely new Medicare payment system, OPP. While it may be feasible for
the physician fee schedule to be issued and implemented in a short time
frame, the MACRA rule is different because it is not simply issuing
revisions to a rule that has previously been implemented. Rather the
MACRA rule entails digesting long, complex policies on MIPS and APMs
that have never been in existence. Significant efforts will be required
by CMS, physician organizations, and others to prepare educational
materials and tools and provide practices opportunities to learn how
they can succeed in OPP and best meet the needs of their patients. CMS
should also use the time between the issuance of the final rule and the
later July 1, 2017, start date to refine the feedback mechanisms that
will be utilized for OPP performance and allow for appropriate user
feedback and end-to-end testing.
Improve the Opportunities for PCMHs and PCMH Specialty Practices in
MIPS and for PCMHs as Advanced APMs
PCMHs and PCMH Specialty Practices in MIPS
The College sincerely appreciates CMS' active implementation of this
component of the law--as it is critically important to facilitate
movement by all clinicians toward care that is truly patient-centered,
coordinated, and comprehensive. ACP has been a leader in supporting the
medical home model, particularly in light of the plethora of currently
available research linking the model to higher quality and lower costs.
ACP recognizes that there will be a significant number of clinicians in
PCMH practices that will be included in the MIPS pathway, even if CMS
establishes a deeming process that would allow clinicians in medical
home practices participating in programs run by states, other non-
Medicare payers, and employers to become qualified advanced APM
participants. These MIPS PCMH practices have taken significant steps to
improve care for their patients through ongoing, meaningful, practice
improvement approaches and therefore should be given the opportunity
for full credit within the CPIA performance category. A number of these
practices will, in fact, fall within the proposed definition from the
agency (as outlined above); however, ACP believes that a number of
clinicians in truly innovative PCMH practices could be left out of this
opportunity and will therefore have the burden of documenting
additional CPIA.
ACP recommends that CMS broaden its definition of the PCMH for the
purposes of full CPIA credit to specifically be inclusive of programs
that have a demonstrated track record of support by non Medicare
payers, state Medicaid programs, employers, and/or others in a region
or state (but that do not yet meet all of the requirements to be deemed
an advanced APM):
The programs to be included should be clearly articulated by CMS
in advance, along with transparent criteria and methodology for the
addition of new PCMH programs. With regard to ``comparable specialty
practice,'' ACP also recommends that CMS broaden its definition to not
only include those practices recognized by National Committee for
Quality Assurance (NCQA), but also those practices that may be
certified in some manner by other nationally recognized accreditation
bodies or programs implemented by non-Medicare payers, state Medicaid
programs, employers, and others in a region that may become available.
Additionally, the College recommends that specialty practices
should be able to attest directly to CMS and document that they meet
standards comparable to those for primary care medical homes as
recognized through an accreditation body, other certification process,
or direct application to CMS or one of its carriers.
PCMHs as Advanced APMs--There Should Be Multiple Pathways Available
The College commends CMS for its recognition within the proposed rule
regarding the unique status of the medical home within the advanced APM
portfolio. However, we are greatly concerned that CMS did not meet
Congress's intent that medical homes be able to qualify as [advanced]
APMs without being required to bear more than nominal risk (even via
the less stringent Medical Home Model Standard for financial risk and
nominal amount). The following explains our interpretation of the
Congressional intent of the law and proposes specific steps that should
be taken to modify the proposed rule to meet this intent.
A reasonable reading and interpretation of the statute provides what we
believe to be the clear congressional intent--that CMS should allow a
medical home to qualify as an [advanced] APM, without bearing more than
nominal financial risk; if it is a medical home that meets criteria
comparable to medical homes expanded under section 1115A(c). While this
language is included in the discussion of the all-payer option that
begins in 2021 (which is when other payer payments can be counted
toward the threshold to determine if one is a qualifying APM
participant), it makes clear that the intent of the law is to
incentivize medical homes that are aligned with Medicare initiatives--
and therefore ACP sees no reason to unnecessarily limit the initial
opportunities for practices to become advanced APMs that are clearly
meeting comparable criteria.
Criteria ``comparable to medical homes expanded under section
1115A(c)'' means:
(1) the Secretary determines that such expansion is expected to--
(A) reduce spending under applicable title without reducing the
quality of care; or
(B) improve the quality of patient care without increasing
spending;
(2) The Chief Actuary of the Centers for Medicare and Medicaid Services
certifies that such expansion would reduce (or would not result in any
increase in) net program spending under applicable titles; and
(3) The Secretary determines that such expansion would not deny or
limit the coverage or provision of benefits under the applicable title
for applicable individuals. In determining which models or
demonstration projects to expand under the preceding sentence, the
Secretary shall focus on models and demonstration projects that improve
the quality of patient care and reduce spending.
In sum, the Congressional intent and even the statutory language and
criteria clearly do not require medical homes to bear more than nominal
financial risk in order to qualify for payments as [advanced] APMs.
Nor does it require that the Secretary and the Chief Actuary determine/
certify that medical homes would reduce net program spending--rather,
the applicable standard is that the Secretary determines they would
``reduce spending . . . without reducing the quality of care'' or
``improve the quality of patient care without increasing spending'' and
the Chief Actuary certifies they ``would reduce (or would not result in
any increase in) net program spending.'' The College believes that
there is abundant evidence that medical homes, at the very least, can
improve the quality of care without increasing spending (although there
is growing evidence from the many PCMH programs around the country that
can also bring about reductions in costs).
Therefore, ACP recommends that CMS take the following steps to provide
multiple pathways for medical homes to be included in the advanced APM
pathway, in addition to the Comprehensive Primary Care Plus pathway
proposed by CMS:
1. Immediately initiate plans to undertake an expedited analysis
of the results of the Comprehensive Primary Care Initiative (CPCi) to
determine whether the statutory requirements for expansion by the
Secretary are met.
2. Establish a deeming program or process to enable practices
enrolled in medical home programs run by states (including state
Medicaid programs), other non-Medicare payers, and employers as being
deemed to have met criteria ``comparable to medical homes expanded
under section 1115A(c).''
3. Allow inclusion of medical home programs as advanced APMs that
meet the Medical Home Model Standard for financial risk and nominal
amount as outlined in the proposed rule.
Implement Changes That Would Make More Advanced APMs Available for
Physicians in All Specialties, Especially Including Those in Internal
Medicine and its Subspecialties
The College expresses significant concern regarding the limited number
of opportunities currently available for non-primary care specialists/
subspecialists to participate in recognized APMs and Advanced APMs.
ACP makes the following specific recommendations to address this
problem:
1. Provide priority for consideration through the Physician
Focused Payment Models Technical Advisory Committee (PTAC) and for
Center for Medicare and Medicaid Innovation (CMMI) testing for models
involving physician specialty/subspecialty categories for which there
are no current recognized APMs and Advanced APM options available. We
further recommend that CMS provide a clear pathway for models
recommended by PTAC to be implemented as APMs under MACRA.
2. Reduce the nominal risk requirement for potential advanced APMs
other than the Medical Home model. The current nominal risk requirement
for these models is onerous--essentially requiring a maximum risk of 4
percent of total health expenditures for the attributed population.
3. Create a platform to expedite the testing for APM recognition
of bundled payment and similar episodes of care payment models.
4. The College recommends the addition of a new Track within the
Medicare Shared Savings Program (MSSP) that helps bridge the transition
for one-sided to two-sided risk. The feedback we have received from our
members currently involved in Track One MSSP is that despite their
ability presently to stay within Track One for a second 3-year
contractual term, few of the participating physician-led entities
currently feel they would be able--even after that 6-year period--to
assume the currently required downside risk of Tracks 2 and 3.
Therefore, as a means of addressing this issue, the College has
recommended that CMS add a Track to the MSSP program that includes two-
sided risk, but at a level that would not place the participating
practices at unreasonable financial jeopardy .
Summary and Conclusion
We look forward to working with the Congress to ensure that the new
MACRA law is implemented in a successful manner that is consistent with
the intent of Congress. The recommendations we offered to CMS in our
letter, as summarized above, would serve to ensure the law truly
improves care for Medicare beneficiaries. With these improvements, the
QPP could go a long way to achieving Congress' goal of aligning
payments with high quality care without imposing more unnecessary
administrative burden on physicians.
______
American Congress of Obstetricians and Gynecologists (ACOG)
409 12th Street, SW
Washington, DC 20024-2188
Phone: 202-638-5577
Internet: http://www.acog.org/
On behalf of the American Congress of Obstetricians and Gynecologists
(ACOG), representing over 57,000 physicians and partners in women's
health, please accept our statement for the record for your hearing
titled ``Medicare Access and CHIP Reauthorization Act of 2015: Ensuring
Successful Implementation of Physician Payment Reforms.'' We thank the
Senate Finance Committee for its leadership and crucial role in
repealing the flawed Medicare Sustainable Growth Rate formula, and for
its work enacting the bipartisan Medicare Access and CHIP
Reauthorization Act (MACRA). Your continued partnership during the next
phase of this process is highly valued and will make certain that the
law is implemented as you intended and that the new program meets the
needs of patients and physicians.
ACOG was, and continues to be, very supportive of MACRA, truly landmark
legislation that holds the promise of improving our Nation's health. We
applaud your work in getting MACRA passed into law and especially
appreciate that you ensured that physicians would be integrally
involved in determining the specifics of implementation, rather than
having to struggle under a top-down, bureaucratically designed program.
This aspect of the legislation, as many others, is a tremendous
improvement.
Successful implementation of MACRA should ensure that women's unique
health needs are being met. It is with that goal in mind that we
provide the following comments regarding the Centers for Medicare and
Medicaid Services' (CMS) proposed rule establishing the Quality Payment
Program.
Low-Volume Threshold
ACOG remains incredibly appreciative that Congress included a statutory
requirement allowing low volume Medicare providers to be excluded from
reporting in the Merit-based Incentive Payment System (MIPS).
Wisely, the law is written in a way that doesn't specify the threshold,
but leaves it up to CMS to determine the threshold after consultation
with the physician community. CMS has proposed a threshold of 100
patients and $10,000 in submitted charges. Under this threshold, many
ob-gyns, particularly those who deliver surgical care, would be
required to invest in reporting infrastructure, but may not meet the
20-case minimum for measures to be scored, making them ineligible for
positive payment adjustments.
While 92 percent of obstetrician-gynecologists (ob-gyns) participate in
Medicare, many do not have a significant proportion of Medicare
beneficiaries in their patient panels.\1\ The low-volume threshold
proposed by CMS assesses volume based on the number of patients seen
and the submitted charges associated with caring for Medicare patients.
However, the specific threshold proposed by CMS does not accurate ly
reflect ob-gyn practice. Ob-gyns often provide surgical care for female
Medicare beneficiaries. The cost of surgery may cause ob-gyns to exceed
CMS' proposed financial cap even if they see few Medicare patients
during a performance period. To ensure that ob-gyns are not required to
report without the ability to be scored due to too few cases for
measures, the financial cap should be raised from the proposed $10,000
to $30,000.
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\1\ American Congress of Obstetricians and Gynecologists. (2013).
2013 Socioeconomic survey of ACOG Fellows. Retrieved from: http://
www.acog.org/-/media/Departments/Practice-Management-and-Managed-Care/
2013SocioeconomicSurvey.pdf.
In addition, CMS should align the patient cap with the Comprehensive
Primary Care Plus (CPC+) program's patient panel requirement of 150
Medicare Part B patients, as opposed to the proposed 100 patient
threshold. While ob-gyns are currently excluded from participating in
CPC+, it is inappropriate to hold any practice to two different low-
volume thresholds. Two different thresholds will cause confusion and
keep practices that fall in the gap between programs from making the
needed investments to move to comprehensive, coordinated, value-based
care. This change to a consistent 150 patient threshold will help
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improve the program for all physician types, including ob-gyns.
Furthermore, the definition of low-volume providers should only apply
to individual clinicians. CMS should develop a new, separate definition
if the agency decides that groups should also have a lowvolume
threshold. Low-volume ob-gyns should be able to choose whether to
report individually or with a group if practice partners do not meet
the low-volume threshold.
We believe proper implementation of this provision would establish a
threshold of 150 patients and $30,000 in charges. Our proposed
threshold would help those practices, as well as ob-gyn surgeons who
provide high-cost services, but see few Medicare beneficiaries.
We were pleased to hear during his remarks before the Senate Finance
Committee that CMS Acting Administrator Slavitt is open to alternative
proposals to help low-volume and small practices. We hope that you
would encourage CMS to strongly consider our suggested change.
MIPS Performance Period
Consistent with many of our colleagues in the physician community, ACOG
is deeply concerned with the proposed start date of January 1, 2017 for
the first performance period. We feel strongly that the first
performance period should begin no earlier than July 1, 2017 and be
shortened to 6 months to ensure that there is a greater opportunity to
educate ob-gyns on the Quality Payment Program. Delaying the start date
for the first performance period will increase the odds that CMS has
the appropriate systems and technical assistance in place to support
ob-gyns and other providers as they begin reporting on performance.
ACOG is committed to partnering with CMS and our members to enable ob-
gyns to thrive under MACRA. However, few ob-gyns will be able to
succeed under the currently proposed timeline, especially since many
ob-gyns are not currently participating in the core components of
MIPS--the Physician Quality Reporting System (PQRS), Value-based
Payment Modifier (VM) program, and the Medicare Electronic Health
Record (EHR) Incentive Program. In order to successfully participate in
the program, ob-gyns need several months to put into place the data
collection systems needed to facilitate reporting. The short timeframe
between the finalization of the rule and January 1 is not enough time
to ensure successful participation.
Setting the performance year too soon will also compromise the ability
of vendors, registries, EHRs, and others to update their systems to
meet program requirements. The MIPS program asks that these entities
incorporate a significant number of new measures, including an entirely
new category of clinical practice improvement activities (CPIAs). We
are concerned that, given the proposed performance period start date,
there will be inadequate time to not only include new measures but also
to test and ensure the data submitted is accurate and reliable. The
time frame proposed does not allow for these entities to validate new
data entry and testing tools, which can also exacerbate usability
issues and add to the existing problems with this technology.
Furthermore, EHRs are expected to undergo a significant overhaul of
their systems to comply with the 2015 certification requirements. To
date, however, there are no 2015 certified products available and most
expect that physicians will not have this updated technology by January
2017, requiring physicians to use alternatives to meet the ACI
requirements and limiting those in alternative payment models (APMs)
from utilizing the benefits of the new technology.
The statutory language for the MIPS and APM categories does not require
the use of a full calendar reporting period. The MIPS definition simply
uses the term ``performance period,'' avoiding the word ``year'' to
allow CMS flexibility. Indeed, CMS recognizes this authority to set a
shorter reporting period for the CPIA category and proposes a minimum
90-day reporting period. The APM statutory language also includes
language noting that the reporting period ``may be less than a year.''
\2\ We urge the Committee to encourage CMS to take advantage of this
flexibility and allow for a shorter initial performance period, in
addition to a delayed start date.
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\2\ Merit-based Incentive Payment System (MIPS) and Alternative
Payment Model (APM) Incentive under the Physician Fee Schedule, and
Criteria for Physician-focused Payment Models. 81 FR 28382. (May 9,
2016). At Sec. 1833(z).
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Composite Performance Score Methodology
ACOG appreciates the Congressional intent of MACRA to, among other
things, streamline incentive programs, reduce the administrative burden
on physicians, and ensure that metrics are relevant to each physician's
patients. We believe a large part of physician acceptance and
satisfaction with MACRA will be determined by how easily an individual
doctor can understand and comply with the performance scoring
methodology.
MACRA is an enormous improvement over previous law in many ways,
including that it reduces the reporting requirement from three programs
to one. We very much support this important change in the law, but it
is important that we remember that many ob-gyns, especially those not
in large group practices, do not currently participate in the existing
programs that will make up MIPS. These ob-gyns face a steep learning
curve, lacking experience in the previous programs.
Successful implementation must ensure a simplified, user-friendly
system that is transparent and predictable. Instead, CMS's
implementation proposal, in particular, the proposed calculation
methodology for the composite performance score, is overly complex and
lacks transparency. The calculation will be difficult to replicate
without an intimate knowledge of the minutia of the formula,
potentially resulting in a lack of trust in the scores that ob-gyns
receive from CMS.
Ob-gyns and other providers need to know how their performance will be
measured and assessed prior to the performance period. Instead, we find
CMS's proposal lacking in detail of how the benchmarks will be scored.
We are also troubled that the benchmark year 2015 may not have high-
quality data available due to the transition from International
Classification of Diseases--(ICD) 9 to ICD-10 midway through the
calendar year. While 2016 data may still reflect that transition and
may not be of the highest quality, its consistent use of codes makes it
the preferable approach.
ACOG is encouraging CMS to exercise flexibility where Congress allowed
it, including when determining scoring thresholds. The proposed rule
was unclear as to whether CMS intends to use a single numerical
threshold or a range of scores to determine the MIPS adjustment
factors. We recommend using a range of scores as opposed to a single
number that would create arbitrary cutoffs for the physicians that
cluster around the mean or median performance level. In that case those
above the performance threshold would still receive a positive
adjustment factor and those below would receive a negative adjustment
factor, as outlined in the statute, but the cluster of physicians
around the mean/median would be held harmless. This represents a more
accurate way to judge performance and will avoid both subjective
penalties and incentives for those whose performances are very similar
to one another.
Simultaneously, we suggest that CMS delay incorporating improvement
into the composite scoring methodology at this time. MIPS is an
entirely new reporting program with new measures, new requirements, and
new categories that will take significant education for physicians and
other participants to understand. CMS should take advantage of the
flexibility Congress built into the statute and delay factoring
improvement into scoring until at least the second year, to ensure a
successful launch of the program prior to evaluating future
improvement.
Finally, ACOG has requested that CMS provide individual clinician and
group feedback for eligible clinicians reporting as part of a group to
help providers determine whether to continue reporting with the group
or change to individual reporting. ACOG recommends that CMS aim to
display feedback and performance measurement information in graphic
form with additional details displayed elsewhere. In addition, the
reports should include high-level overall performance information and
drill down tables with individual patient information. There have been
ongoing problems with physicians' ability to access their feedback
reports due to the overly complicated log-in process. ACOG recommends
that CMS improve the log-in process for accessing reports to ensure it
is simple and user-friendly. It should also be possible for individual
physicians within a group practice to access their own reports directly
rather than through a group. Additionally, ACOG has requested that CMS
develop a portal so that ob-gyns are able to accurately estimate how
their current performance will affect their payment adjustment. This
will allow for ongoing feedback throughout the performance period, not
just when reports are released to providers.
Medical Home Model and Medicaid Medical Home Model
ACOG has a strong history of support for medical homes, as a way to
ensure continuity and coordination of care for women from adolescence,
through the reproductive years and pregnancy, menopause and beyond. Ob-
gyns are trained to provide primary care services to women throughout
their life course, not just during their reproductive years. Ob-gyns
play a critical role in providing primary and preventive care to women
in the United States, and an ob-gyn is often the only provider a woman
sees on a regular basis.\3\
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\3\ Undem, T., and Stewart, E. (2014). Perception is everything:
How women view their OB/GYN providers. Congressional Leadership
Conference. Mandarin Oriental, Washington, DC. March 2, 2014.
CMS proposes to allow pediatric medicine, but not obstetrics and
gynecology, to participate in the Medical Home Model and Medicaid
Medical Home Model demonstrations, an exclusion that makes no sense to
us since most pediatric providers care for very few Medicare
beneficiaries. MACRA is silent on which provider types should qualify,
leaving it up to CMS and physician input. We believe the decision of
which doctors should be included should be based on qualifications, not
specialty designation. But certainly if specialties are going to be
designated, obstetrics and gynecology must be on the approved list. As
the population ages, there will be a greater need for ob-gyns to care
for older women, including in a primary care capacity. Many ob-gyn
generalists are able to meet the other criteria laid out in the Medical
Home Model definition. It is important that CMS also include ob-gyns in
multi-payer models to ensure that ob-gyns and the women they care for
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are fully included in alignment efforts.
CMS's overly narrow interpretation of primary care is a detriment to
women's health. To correct this, CMS should add Physician Specialty
Code ``16 Obstetrics and Gynecology'' to the list of eligible specialty
types that can participate in both Medical Home Models. Including ob-
gyns would accurately reflect the training received by ob-gyns in
residency and the care they provide every day. Ob-gyns do not just
focus on the reproductive system. Rather, they are trained to provide
primary care services to women throughout their life course. Preventive
counseling and health education are essential and integral parts of the
practice of ob-gyns as they advance the individual and community-based
health of women of all ages.\4\ During the annual well-woman
examination, ob-gyns provide screening, evaluation, counseling, and
immunizations, among other services. They provide nutritional and
exercise counseling; cardiovascular disease screening; diabetes
screening, diagnosis, and management; risk counseling and discussion of
psychosocial topics, including mental health issues and substance use
disorders; and cancer screening, including colon and lung, as well as
breast, cervical, endometrial, and ovarian.
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\4\ American College of Obstetricians and Gynecologists. The scope
of practice of obstetrics and gynecology. Approved by the Executive
Board on February 6, 2005.
In the same vein, it is important that CMS add code ``16 Obstetrics and
Gynecology'' to the eligible list of specialties that can participate
in a Medicaid Medical Home Model. As the payer for more than half of
births in the country, Medicaid is integral to the delivery of women's
health care.\5\ Women of reproductive age, including Medicaid
beneficiaries, are a unique patient population and many of their
primary care needs can effectively be met and managed by ob-gyns.
Dismissing the care delivered to this significant portion of the
population and foreclosing ob-gyns' opportunity to improve their
practice infrastructure and invest in care coordination activities is a
disservice to the millions of women enrolled in Medicaid and is a lost
opportunity for aligning the health system and realizing potential
cost-savings to the Medicaid program.
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\5\ Markus, A.R., Andres, E., West, K.D., Garro, N., Pellegrini, C.
(2013). Medicaid covered births, 2008 through 2010, in the context of
the implementation of health reform. Women's Health Issues. 23(5):e273-
e280.
Advancing Care Information and 2014-edition Certified Electronic Health
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Record Technology (CEHRT)
ACOG has long espoused the potential of electronic health records to
help ob-gyns improve the quality, safety, and efficiency of the care
they provide patients. Yet the proposed CMS requirement that ob-gyns
and other providers must report using the 2015 edition of certified
electronic health record technology (CEHRT) starting in 2018 is just
not practical. Of course, using the most up-to-date technology is
ideal. Today, though, no certified software meets the 2015 edition
criteria, and widespread access to and adoption by all providers of the
2015 edition is not likely before 2018. Instead, CMS should allow
physicians to continue to use the 2014 edition technology, or a
combination of 2014 and 2015 technology, until it confirms that 2015
edition technology is readily available and cost-effective to
practices. In the interim, we hope the Committee will encourage vendors
to incorporate new MIPS measures into their systems to ensure
physicians can report via those tools.
Thank you again for the opportunity to submit a written statement for
the record. ACOG looks forward to our continued partnership with the
Senate Finance Committee to ensure that MACRA is implemented as
Congress intended. Please do not hesitate to contact me or ACOG's
Director of Federal Affairs Rachel Tetlow at [email protected] or 202-
863-2534 should you have any questions.
______
American Hospital Association (AHA)
800 10th Street, NW
Two CityCenter, Suite 400
Washington, DC 20001-4956
(202) 638-1100 Phone
http://www.aha.org/
On behalf of our nearly 5,000 member hospitals, health systems and
other health care organizations, and our 43,000 individual members, the
American Hospital Association (AHA) appreciates the opportunity to
submit comments on ensuring the successful implementation of the
physician quality payment program (QPP) mandated by the Medicare Access
and CHIP Reauthorization Act of 2015 (MACRA).
The implementation of the MACRA's QPP will have a significant impact,
both on physicians and the hospitals with whom they partner. According
to the AHA Annual Survey, hospitals employed more than 249,000
physicians in 2014, and had individual or group contractual
arrangements with at least 289,000 more physicians--a significant
portion of the 800,000 clinicians the Centers for Medicare and Medicaid
Services (CMS) estimates will be impacted by the MACRA. Hospitals that
employ physicians directly will help defray the cost of the
implementation of and ongoing compliance with the new physician
performance reporting requirements under the Merit-based Incentive
Payment System (MIPS), as well as be at risk for any payment
adjustments. Moreover, hospitals may participate in advanced
alternative payment models (APMs) so that the physicians with whom they
partner can qualify for the bonus payment and exemption from the MIPS
reporting requirements.
Given its significance to the hospital field, the AHA is carefully
monitoring the implementation of the QPP. CMS's recent Notice of
Proposed Rulemaking includes a number of policies we support, including
a reduction in the number of required quality measures in the MIPS,
movement towards greater flexibility in meeting meaningful use in the
advancing care information (ACI) category of the MIPS, and a flexible
approach to the certified electronic health record (EHR) and quality
measurement criteria in the APM track. However, we believe significant
changes must be made to policies that may impinge upon the ability of
hospitals and physicians to successfully participate in the QPP.
Specifically, we believe the QPP should include:
An expanded definition of advanced APMs that recognizes the
substantial investments that must be made to launch and operate APM
arrangements;
A quality and resource use measure reporting option in which
hospital-based physicians can use CMS hospital quality program measure
performance in the MIPS;
A socioeconomic adjustment in the calculation of performance as
needed; and
Alignment between the hospital meaningful use program and the
ACI category of the MIPS, and simplified ACI requirements.
In addition, we urge Congress to consider changes to the fraud and
abuse laws to allow hospitals and physicians to work together to
achieve the important goals of new payment models--improving quality,
outcomes and efficiency in the delivery of patient care.
Detailed information about our suggestions for improvement to the
implementation of the QPP mandated by MACRA are below.
DEFINITION OF ADVANCED APMS
The MACRA provides incentives for physicians who demonstrate
significant participation in APMs. The AHA supports accelerating the
development and use of alternative payment and delivery models to
reward better, more efficient, coordinated and seamless care for
patients. Many hospitals, health systems and payers are adopting such
initiatives with the goal of better aligning provider incentives to
achieve the Triple Aim of improving the patient experience of care
(including quality and satisfaction), improving the health of
populations and reducing the per capita cost of health care. These
initiatives include forming accountable care organizations, bundling
services and payments for episodes of care, developing new incentives
to engage physicians in improving quality and efficiency, and testing
payment alternatives for vulnerable populations.
Despite the progress made to date, the field as a whole is still
learning how to effectively transform care delivery. There have been a
limited number of APMs introduced so far, and existing models have not
provided participation opportunities evenly across physician
specialties. Therefore, many physicians may be exploring APMs for the
first time.
As a general principle, the AHA believes the APM provisions of the
MACRA should be implemented in a broad manner that provides the
greatest opportunity for physicians who so choose to become qualifying
APM participants. Particularly in the early years of MACRA
implementation, the QPP should reflect an expansive approach that
encourages and rewards physicians who demonstrate movement toward APMs.
For this reason, the AHA is extremely disappointed that few of the
models in which hospitals have engaged will qualify as advanced APMs as
defined in CMS's proposed rule. We urge the Administration adopt a more
inclusive approach. Specifically, we are concerned about CMS's proposed
generally-applicable financial risk standard, under which an APM must
require participating entities to accept significant downside risk to
qualify as an advanced APM. We recommend the expansion of the
definition of financial risk to include the investment risk borne by
providers who participate in APMs, and the development of a method to
capture and quantify such risk. We also urge CMS to update existing
models, such as the Bundled Payments for Care Initiative and the
Comprehensive Care for Joint Replacement, so that these models would
qualify as advanced APMs.
We believe it is fair, as well as important, that the QPP recognize the
significant resources providers invest in the development of APMs. For
example, to successfully implement an APM, providers must acquire and
deploy infrastructure and enhance their knowledge base in areas, such
as data analytics, care management and care redesign. Further, one
metric for APM success--meeting financial targets--may require
providers to reduce utilization of certain high-cost services, such as
emergency department visits and hospitalizations through earlier
interventions and supportive services to meet patient needs. However,
this reduced utilization may result in lower revenues. Providers
participating in APMs accept the risk that they will invest resources
to build infrastructure and potentially see reduced revenues from
decreased utilization, in exchange for the potential reward of
providing care that better meets the needs of their patients and
communities and generates shared savings. This risk is the same even in
those models that do not require the provider to repay Medicare if
actual spending exceeds projected spending.
Although the clinicians participating in shared savings-only models are
working hard to support the Administration's goals to transform care
delivery, under CMS's proposal they will not be recognized for those
efforts. We believe this would have a chilling effect on
experimentation with new models of care among providers that are not
yet prepared to jump into two-sided risk models.
RECOMMENDED CHANGES TO THE MIPS
The MACRA sunsets three existing physician quality performance
programs--the physician quality reporting system, Medicare EHR
Incentive Program for eligible professionals and the value-based
payment modifier--and consolidates aspects of those programs into the
MIPS. The MIPS will be the default QPP track for eligible clinicians.
The MIPS must assess eligible clinicians on four performance
categories--quality measures, resource use measures, clinical practice
improvement activities and ACT, a modified version of the historical
meaningful use program. Based on their MIPS performance, eligible
clinicians will receive incentives or penalties under the Medicare
physician fee schedule of up to 4 percent in calendar year (CY) 2019,
rising gradually to a maximum of 9 percent in CY 2022 and beyond.
The AHA urges the adoption of a MIPS that measures providers fairly,
minimizes unnecessary data collection and reporting burden, focuses on
high-priority quality issues, and promotes collaboration across the
silos of the health care delivery system. To achieve this, we believe
the QPP should encompass the following characteristics:
Streamlines the focus of the MIPS measures to reflect national
priority areas;
Allows hospital-based physicians to use their hospital's quality
reporting and pay-for-performance program measure performance in the
MIPS;
Employs risk adjustment rigorously--including sociodemographic
adjustment, where appropriate--to ensure providers do not perform
poorly in the MIPS simply because of the types of patients they care
for; and
Moves away from an ``all-or-none'' scoring approach for the ACI
category, and ensure that programmatic changes for eligible clinicians
are aligned with those of the EHR Incentive Program for eligible
hospitals.
The AHA agrees with several CMS proposals that are aligned with these
recommendations, including a reduction in the number of required
quality measures. However, we urge significant changes to policies
discussed below to reduce unnecessary burden, address technical
problems, and maximize the ability of the MIPS to compare performance
fairly.
Use of Hospital Quality Measures for Hospital-Based Clinicians
The AHA urges adoption of a CMS hospital quality program measure
reporting option for hospital-based clinicians in the MIPS as soon as
possible. A provision in the MACRA allows CMS to develop MIPS-
participation options for hospital-based clinicians so they can use
their hospital's quality and resource use measure performance for the
MIPS. We believe using hospital measure performance in the MIPS would
help physicians and hospitals better align quality improvement goals
and processes across the care continuum, and reduce data collection
burden.
While we are disappointed that the agency does not formally propose
such an option for the CY 2019 MIPS, we look forward to working with
all stakeholders in the coming months to make hospital-based physician
reporting in the MIPS a reality.
Socioeconomic Adjustment
The AHA strongly urges the robust use of risk adjustment--including
socioeconomic adjustment, where appropriate--to ensure caring for more
complex patients does not cause providers to appear to perform poorly
on measures. It is a known fact that patient outcomes are influenced by
factors other than the quality of the care provided. In the context of
quality measurement, risk adjustment is a widely accepted approach to
account for some of the factors outside the control of providers when
one is seeking to isolate and compare the quality of care provided by
various entities. As noted in the National Quality Forum's 2014 report
on risk adjustment and sociodemographic status, risk adjustment creates
a ``level playing field'' that allows fairer comparisons of providers.
Without risk adjustment, provider performance on most outcome measures
reflect differences in the characteristics of patients being served,
rather than true differences in the underlying quality of services
provided.
The evidence continues to mount that sociodemographic factors beyond
providers' control--such as the availability of primary care, physical
therapy, easy access to medications and appropriate food, and other
supportive services--influence performance on outcome measures. For
example, in January 2016, the National Academy of Medicine (NAM)
released the first in a planned series of reports that identifies
``social risk factors'' affecting the health outcomes of Medicare
beneficiaries and methods to account for these factors in Medicare
payment programs. Through a comprehensive review of available
literature, the NAM's expert panel found evidence that a wide variety
of social risk factors may influence performance on certain health care
outcome measures, such as readmissions, costs and patient experience of
care. These community issues are reflected in readily available proxy
data on socioeconomic status, such as U.S. Census-derived data on
income and education level, and claims-derived data on the proportion
of patients dually eligible for Medicare and Medicaid. The agency also
recently proposed to adjust several measures in the Medicare Advantage
Star Rating program for sociodemographic factors. Yet, to date, CMS has
resisted calls to incorporate sociodemographic adjustment into the
quality measurement programs for physicians, hospitals, and other
providers.
Unfortunately, failing to adjust measures for sociodemographic factors
when necessary and appropriate can harm patients and worsen health care
disparities by diverting resources away from physicians, hospitals and
other providers treating large proportions of disadvantaged patients.
It also can mislead patients, payers and policymakers by blinding them
to important community factors that contribute to poor outcomes.
Physicians, hospitals and other providers clearly have an important
role in improving patient outcomes and are working hard to identify and
implement effective improvement strategies. However, there are other
factors that contribute to poor outcomes. If quality measures are
implemented without identifying sociodemographic factors and helping
all interested stakeholders understand their role in poor outcomes,
then the nation's ability to improve care and eliminate disparities
will be diminished.
MIPS Advancing Care Information Category
CMS proposes a new framework for the Medicare EHR Incentive Program for
MIPS-eligible clinicians. The AHA supports changes to the meaningful
use program for physicians that begin to offer flexibility in how
physicians and other eligible clinicians are expected to use certified
EHRs to support clinical care. As these changes are implemented, it
will be essential to ensure that program requirements are aligned
across all participants, including physicians, hospitals, and critical
access hospitals. This alignment is essential to ensuring the ability
of providers to share information and improve care coordination across
the continuum.
CMS proposes two pathways for provider participation in the ACI
performance category with base requirements and an additional
performance score. The AHA appreciates the movement toward flexibility
in the measures, but we remain concerned that the reporting burden will
remain high. The AHA recommends that CMS simplify the ACI requirements
by permitting eligible clinicians to use objectives and measures
derived from the EHR Incentive Program Modified Stage 2. We also
recommend a delay in the introduction of Stage 3 until a date no sooner
than CY 2019.
In addition, the AHA supports the elimination of an all-or-nothing
approach that makes clear that attainment of 70 percent of the
objectives and measures in meaningful use afford full credit in this
performance category. Prior experience has demonstrated that the
complexity of the measures, the length of the reporting period and
immature standards and technology present challenges to successfully
meeting program requirements.
The AHA strongly supports the goals of information sharing to improve
care, engage patients, and support new models of care. The proposed
rule would require all hospitals, CAHs and physicians that participate
in the meaningful use program to attest that they did not ``knowingly
and willfully take action to limit or restrict the compatibility or
interoperability'' of their certified EHR. Additionally, the proposed
rule would require two additional attestations:
(1) How the technology is implemented to conform with standards,
allow patient access and support secure and trusted bi-directional
exchange; and
(2) That hospitals, CAHs or physicians responded in good faith and
in a timely manner to requests to retrieve or exchange electronic
health information, including from patients, health care providers, and
other persons, regardless of the requester's affiliation or technology
vendor.
The AHA is concerned that proposals that physicians attest to not
participating in information blocking--and cooperate with EHR
surveillance activities--do not focus on the core issues at hand. The
AHA recommends that the Administration, including CMS and the Office of
the National Coordinator for Health IT, consider the extent to which we
have the standards, technology and infrastructure in place to
facilitate information exchange with a focus on mechanisms to ensure
the availability of efficient and effective trusted exchange in
practice, and robust testing of products used to support exchange.
Without those building blocks in place, providers are challenged to
efficiently and effectively exchange and use health information.
The AHA also recommends adoption of only one of the three proposed
attestations about information blocking--that hospitals and CAHs
participating in the meaningful use program and clinicians
participating in the Medicare quality program attest that they have not
``knowingly and willfully taken action (such as to disable
functionality) to limit or restrict the compatibility or
interoperability of their certified EHR.''
LEGAL IMPEDIMENTS TO IMPLEMENTATION OF
NEW PAYMENT MODELS
By tying a portion of most physicians' Medicare payments to performance
on specified metrics and encouraging physician participation in APMs,
the MACRA takes another step in the health care field's movement to a
value-based paradigm from a volume-based approach. To achieve the
efficiencies and care improvement goals of the new payment models,
hospitals, physicians and other health care providers must break out of
the silos of the past and work as teams. Of increasing importance is
the ability to align performance objectives and financial incentives
among providers across the care continuum.
Outdated fraud and abuse laws, however, are standing in the way of
achieving the goals of the new payment systems, specifically, the
physician self-referral (Stark) law and Anti-Kickback statute. These
statutes and their complex regulatory framework are designed to keep
hospitals and physicians apart--the antithesis of the new value-based
delivery system models. A recent AHA report, Legal (Fraud and Abuse)
Barriers to Care Transformation and How to Address Them, examines the
types of collaborative arrangements between hospital and physicians
that are being impeded by these laws and recommends specific
legislative changes.
Congress should create a clear and comprehensive safe harbor under the
Anti-Kickback Law for arrangements designed to foster collaboration in
the delivery of health care and incentivize and reward efficiencies and
improvement in care. Arrangements protected under the safe harbor would
be protected from financial penalties under the Anti-Kickback civil
monetary penalty law. In addition, the Stark Law should be reformed to
focus exclusively on ownership arrangements. Compensation arrangements
should be subject to oversight solely under the Anti-Kickback Law.
CONCLUSION
Thank you for the opportunity to share our views on the implementation
of the MACRA. The AHA looks forward to working with Congress, CMS and
all other stakeholders to ensure successful implementation of physician
payment reforms enhances the ability of hospitals and physicians to
deliver quality care to patients and communities.
______
American Society of Plastic Surgeons (ASPS)
Executive Office
444 East Algonquin Road
Arlington Heights, IL 60005-4664
847-228-9900 Fax: 847-228-9131
https://www.plasticsurgery.org/
July 13, 2016
U.S. Senate
Committee on Finance
Dirksen Senate Office Building
Washington, DC 20510
Chairman Hatch, Ranking Member Wyden, and the honorable members of the
Senate Committee on Finance (Committee), on behalf of the American
Society of Plastic Surgeons (ASPS), we submit this testimony regarding
the July 13, 2016 Committee hearing reviewing the Medicare Access and
CHIP Reauthorization Act of 2015 (MACRA) implementation process. ASPS
is grateful for your continued attention to the MACRA rulemaking
process.
ASPS is the largest association of plastic surgeons in the world,
representing more than 7,000 members and 94 percent of all American
Board of Plastic Surgery board-certified plastic surgeons in the United
States. Plastic surgeons provide highly skilled surgical services that
improve both the functional capacity and quality of life of patients.
These services include the treatment of congenital deformities, burn
injuries, traumatic injuries, hand conditions, and cancer. ASPS
promotes the highest quality patient care, professional and ethical
standards, and supports education, research and the public service
activities of plastic surgeons.
As mentioned above, plastic surgeons perform a wide array of procedures
and surgeries. This diversity makes defining quality care a difficult
task. As surgical specialists, plastic surgeons have unique issues with
the MACRA implementation process, and today we address the Committee
regarding three specific areas where the Centers for Medicare and
Medicaid Services (CMS) has deviated from Congressional intent:
1. SECTION 101(e) of the law creates a new Physician-Focused
Payment Technical Advisory Committee (PTAC) to provide recommendations
to the Secretary of Health and Human Services on the development of new
physician-focused alternative payment models. Late in 2015, CMS staff
stated in public forums that it is ``under no statutory obligation'' to
follow the recommendations of the PTAC. This clearly disregards
Congress's desire to ensure that the design of these models is heavily
influenced by the practitioners that form their foundation.
Additionally, ASPS is concerned that the review criteria employed by
the PTAC will not result in sufficient engagement with specialty
medicine providers in the evaluation of proposed new specialty-focused
payment models.
2. SECTION 102 of the law directs the Secretary to provide $15
million annually to support the development of physician quality
measures, beginning in FY15. FY15 came and went without these funds
being released, FY16 is nearing its end, and CMS has given no
indication of when they will be made available. Furthermore, ASPS has
heard troubling indications that CMS may determine that medical
specialty societies will not be eligible to apply for this funding.
Because they play a significant role in the development of evidenced
based clinical guidelines and provide a great deal of time and
resources measuring specialty-specific quality, medical specialty
societies are uniquely positioned to develop quality measures for
physician specialists. If CMS enacts this provision as suspected, it
will disadvantage specialist physicians and undermine efforts to
develop useful measures.
3. SECTION 105(b) of the law directs CMS to share Medicare claims
data with Qualified Clinical Data Registries (QCDR) to support quality
improvement and patient safety. Earlier this year, CMS stated that it
intended not to implement this provision. This month, CMS released a
Final Rule partially implementing this section in a manner that does
not respect the law as written, and will not permit QCDR's to access
real-time Medicare claims data.
Thank you very much for this opportunity to address the Committee and
for your consideration of our comments. CMS should not be allowed to
repeat the mistakes of the past, and we implore Congress to ensure that
its statutory will is respected in the design of MACRA. Additionally,
ASPS is happy to work with you and CMS to ensure CMS implements the law
appropriately. Please do not hesitate to contact Patrick Hermes, ASPS
Senior Manager of Advocacy and Government Affairs, if you have any
comments, questions, or concerns. He can be reached at phermes@
plasticsurgery.org or (847) 228-3331.
______
The Docs4PatientCare Foundation
The Medicare Access and CHIPS Reauthorization Act of 2015 (MACRA) is
the largest body of legislation affecting health care since the passage
of Obamacare in 2009. It is also the most expensive since Obamacare,
costing billions of dollars per year to implement and maintain. The
Docs4PatientCare Foundation is pleased to submit the following comments
regarding MACRA to the Senate Committee on Finance.
Introduction and Overview
To fully understand the nature of the MACRA rule and our comments
regarding the same, it is necessary to review the historical context in
which MACRA was passed. MACRA consolidates several existing programs
including the Meaningful Use health information technology program, the
Value-Based Purchasing Program and the PQRS quality reporting program.
In the past these programs existed in separate bodies of legislation/
regulation and thus were never considered together in their entirety
until now. This brings many previously discussed yet still unresolved
issues regarding health care delivery to the surface for conversation
and review.
This legislation brings back into the spotlight many issues regarding
the four major components of the proposed rule. The first issue is the
role of third party quality measurement in the practice of medicine.
The ``quality movement'' in medicine has been in existence for at least
10 years since the first version of the Physician Quality Reporting
System (PQRS) was issued in 2006. Since then the ``quality movement''
has enjoyed increasing momentum based on little more than its own
propaganda. The biggest single body of information regarding the
alleged lack of quality in U.S. health care is based on a study issued
by the World Health Organization in 2000, the World Health Report 2000.
This has led to other misguided reports from similarly inclined
institutions that compare infant mortality rates and life expectancies
across a large number of countries including the United States. When
compared against per capita health-care spending it becomes clear that,
although the United States spends the most per capita on health care
(currently about $8,750 per individual), the ranking of the United
States regarding life expectancy and infant mortality are generally in
the mid-30s and are even lower among industrialized nations. These data
are routinely used to construct an intellectual ``shell game'' based on
the assumption that infant mortality and life expectancy are valid
measures of a health-care system's performance. The misguided
conclusion is that the United States is not getting its money's worth
from its health-care system.
A significant body of information demonstrates that these assumptions
regarding the relationship of infant mortality and life expectancy to
overall health-care system performance are untrue. Japan, for example,
is usually touted as the nation with the highest life expectancy while
spending less than half the amount per capita for health care as does
the United States. If life expectancy were truly a measure of health-
care system performance then one would expect people of Japanese
ancestry who live in the United States to have a lower life expectancy
because they are ``victims'' of a poor health-care system. In fact the
opposite is true: people of Japanese ancestry have the same life
expectancy whether they live in the United States or Japan. A truly
objective analysis of the data clearly demonstrates that there is no
statistical relationship between life expectancy and per capita
spending on health care. Life expectancy has instead been shown to be
associated with factors independent of the health-care system--such as
cleanliness of living conditions, income, literacy rate, diet,
lifestyle and genetics.
Using infant mortality as a measure of overall health-care system
performance suffers from different yet equally significant
shortcomings. The methods of measuring infant mortality differ greatly
among countries. The United Nations Statistics Division defines a live
birth as an infant, once removed from its mother, which is breathing or
shows other evidence of life such as a heartbeat, pulsation of the
umbilical cord or movement of voluntary muscles regardless of
gestational age. However, Switzerland's definition also stipulates the
infant must be at least 30 cm long at birth to be considered living.
Italy has three different definitions of infant death depending on
region within the nation. Japan, Finland, France and Norway all have
different approaches to counting births from citizens living outside
the host nation. In addition, infant mortality also is affected by
parental behavior including marital status. No health-care system has
any control over issues such as these.
Perhaps most telling is that the Editor-in-Chief of the original World
Health Report 2000, Philip Musgrove, Ph.D., opined in the New England
Journal of Medicine in 2010 that the data from the report were being
used improperly for the purpose of ranking health-care systems and that
``it is long past time for the zombie number(s) to disappear from
circulation.''
Why do supporters of big government-based health-care reform continue
to cite these numbers as evidence that America is not getting value
regarding health-care spending? Here's where the intellectual shell
game occurs. The rhetoric regarding ``not getting one's money's worth''
is used to shift the health-care reform conversation from a paradigm of
cost and access to one of quality and value. This serves two purposes
for those who endeavor to control the narrative on health-care reform.
First, the shift from a cost/access argument to one involving quality/
value moves the conversation from easily measurable elements (cost and
access) to elements which are impossible to measure (quality and
value). Indeed quality and value do not even possess objective units of
measurement. Thus, any health-care reform measures implemented in the
name of quality and value cannot be proven to fail based on objective
measurement. In such an intellectual vacuum a perception of success can
be created by an effective narrative. There is no need whatsoever for
the measures in question to actually succeed.
The second purpose is equally sinister. A conversation based on cost
and access will by its nature distribute responsibility for rising
health-care costs appropriately across all competitive stakeholders
within the health-care system. It is intuitively obvious that in a
cost-based conversation, blame is shared among insurance plans,
government regulations, hospitals/health systems, and physicians
themselves. Conversely, a value/quality conversation allows the
predominance of blame to be placed upon physicians and others who touch
patients for a living.
Into such a ``fertile'' environment the proposed MACRA rule has been
introduced. A conversation based on quality/value makes a 962 page rule
which proposes over 450 quality measures appear reasonable. And no
matter what the outcome, its supporters will claim success and support
that claim with well constructed rhetoric. But once the quality/value
vs cost/access shell game has been recognized, the proposed rule looks
quite different. It has been estimated that the cost of reporting
quality measures alone is over $15 billion per year. Since quality
reporting is one of four major components to the proposed rule one can
roughly estimate the total cost of the proposed rule to be at least $60
billion per year. Thus when the proposed rule is evaluated in the
appropriate cost/access paradigm, MACRA must save $60 billion per year
before the first penny of benefit is realized. In this framework the
proposed MACRA rule quickly collapses under its own weight.
Comments Regarding Specific Parts of the Rule
1. Quality reporting. ``Eligible clinicians'' must report on six
quality measures chosen from a list of 465 options. These must include
at least one ``cost-cutting measure'' and one ``outcomes measure.''
Supporters of the proposed rule point out that this is fewer than the
nine quality measures that were originally required under the
Meaningful Use guidelines. However, it is widely recognized that, with
rare exceptions, such quality measures have never been shown to improve
outcomes. Under the Meaningful Use program such quality measures have
generated huge amounts of data reported to CMS that have never been
read or analyzed. Continuing such a practice ensures that the $15
billion a year that is currently spent on quality reporting will
continue to be wasted.
Respected leaders within the health IT and government communities have
criticized quality measures. Former CMS Administrator Donald Berwick in
December 2015 proposed nine steps to enter the ``moral era'' of health
care. These included stopping excessive measurement and abandoning
complex incentives. He proposed a 50% reduction in number of the
quality metrics reported. This would support a reduction from nine
quality measures--beyond the proposed six--down to four. John Halamka,
Chief Information Officer at Beth Israel Deaconess Medical Center and
one of America's leading health information technology experts, has
recommended replacing all EMR and quality reporting requirements with 3
outcome-based measures chosen by each medical specialty. We would
therefore suggest that the number of quality measures required be
reduced further from 6 to 3.
2. Advancing care information. This is the section of the proposed rule
which carries most of the requirements previously included in the
Meaningful Use program. There is, however, one important addition to
the proposed health IT/EHR requirements which is based on potentially
deliberate misuse of supporting information and which carries very
frightening implications. This section requires that the eligible
clinician complete a three-part attestation that (1) one did not take
action to knowingly restrict compatibility or interoperability, that
(2) implemented technologies and electronic medical record systems are
configured in a compliant manner, and that (3) one responded in good
faith and in a timely fashion to medical information requests. This is
part of the commitment of CMS to enhance interoperability and suppress
``data blocking.'' On pages 41 and 42 of the proposed rule, the
requirement for clinicians to make such attestations is supported by
evidence that ``health-care providers'' have engaged in data blocking.
The source of this evidence is a report to Congress entitled Report on
Health Information Blocking delivered to Congress in April 2015 by the
Office of the National Coordinator of Health Information Technology. A
careful review of that report reveals on pages 15-18 a discussion of
anecdotal evidence of ``potential information blocking.'' However, in
this discussion the term ``providers'' refers to large hospitals and
health-care systems, not the individual physicians to whom the
attestation requirements of the proposed rule are directed. The
deception here is clear; whether such a deception was borne of
``advantageous negligence'' or malevolence is academic.
Individual physicians have absolutely no vested interest in ``blocking
data'' or any other behavior which impairs the exchange of health
information between any entities that are legally or morally entitled
to such information. The notion that physicians need to complete
attestations that they do not engage in such behavior is both punitive
and useless. It also initiates a ``slippery slope'' of progressively
ratcheted attestations over time to develop a quasi-legally binding
culture of ``allegiance'' to CMS. This is morally and ethically
bankrupt. The attestation requirement of the Advancing Care Information
section must be removed.
With few exceptions (mostly cardiology and surgery), none of the 465
options for reporting measures in the proposed rule are based on
scientific method. We propose that each of the 465 options must meet
three criteria. First, it must be based on scientific method. Second,
there must be a plan to review and act on the data that is reported to
CMS through the guideline. Third, the reporting of such quality
measures must be an automated function of the electronic medical record
system and not impair, slow down or distract physicians participating
directly in patient care.
3. Calculation of performance scores. For each eligible clinician
Medicare payments will be adjusted upward (bonus) or adjusted downward
(penalty) based on a performance score. The score has four components:
Advancing Care Information, quality measures, resource use, and
clinical practiceimprovement. When fully implemented payments may be
adjusted upward or downward by as much as 9% based on the performance
score. Although CMS portrays this payment method as an improvement over
the current ``all or nothing'' incentive/penalty system currently in
use, further analysis reveals this proposed method to be worse than the
current method. The problem lies in the requirement that the program is
revenue neutral. There must be enough penalties assessed to fund the
bonuses. This means there will never be a state in which all eligible
clinicians achieve an acceptable level of compliance to avoid a
penalty. Simply, performance scores must be ``graded on the curve'' to
meet the revenue neutral requirements. This is unacceptable. All
physicians should have the opportunity to comply with the program at an
adequate level to avoid penalty.
Within the proposed rule the now infamous Table 64 offers chilling
statistics for physicians in small practices (defined as less than 100
physicians). For practices of nine clinicians or less the odds are
approximately 85% that they will receive a penalty rather than a bonus.
Only for practices of 100 or more eligible clinicians do the odds of a
bonus exceed the odds of a penalty. Although CMS is quick to point out
that this is based on 2014 data and that smaller practices have
significantly better reporting in subsequent years, the revenue-neutral
nature of this portion of the program still mandates that performance
thresholds be raised every year to ensure that there are enough losers
to finance the winners. Small practices have no chance of competing
against the far greater aggregate resources of the 100+ clinician
practices. We therefore propose that the revenue-neutral nature of this
portion of the program be eliminated and that penalty-performance
threshold scores be fixed for a number of years to give practices with
less than 100 clinicians enough incentive to improve compliance and
avoid penalties.
4. Obligations of eligible clinicians regarding documentation of usage
of certified EMR technology. After 6 years of Meaningful Use
implementation it is not possible for any eligible clinician to meet
all of the requirements under MACRA without having a certified EMR
system. Thus the notion that every eligible clinician must go through
an elaborate series of steps through the CMS website to obtain a
certification number for the EMR system is no longer valid. We propose
that the documentation requirements regarding use of certified EMR
technology be eliminated for providers and that all activity regarding
EMR certification take place only between CMS and the EMR vendors. It
should suffice that the eligible clinician provides only a short
statement from the EMR vendor documenting that an EMR is in use and
that licensing fees are current.
5. Expansion of EMR surveillance by ONC under MACRA. Beginning on page
40 of the proposed rule CMS makes the argument that the Office of the
National Coordinator has been authorized by the Office of Civil Rights
to act as a ``health oversight agency'' under HIPAA to conduct ongoing
surveillance of any and all EMR systems in use by eligible clinicians
including access to patients' protected health information in the name
of quality monitoring. This has been widely and sternly criticized by
physicians as a violation of our obligations under the Hippocratic Oath
to patient privacy and is a violation of the Fourth Amendment of the
U.S. Constitution. Furthermore, CMS offers no examples of past
incidents of quality issues which would have been improved or events
prevented by such surveillance. We therefore side with the opinions of
a great number of concerned physicians that there is no ethical or
quality driven justification for such practices. We therefore propose
that this expansion of EMR surveillance by ONC be eliminated.
6. Alternative Payment Models (APMs). A detailed commentary regarding
Alternative Payment Models is beyond the scope of this document.
However, it is interesting to note an article in the current issue of
the New England Journal of Medicine (June 16, 2016) entitled ``Early
Performance of Accountable Care Organizations and Medicare.'' The
article concludes that contracts with ACOs under the Medicare Shared
Savings Program showed reductions in Medicare savings that were either
trivial ($144 per beneficiary) or statistically insignificant ($3 per
beneficiary)
Conclusions
Although the Docs4PatientCare Foundation is pleased to submit these
comments regarding the proposed MACRA rule, our participation in the
commentary process should not be interpreted to mean that we support
the existence of MACRA or the spirit of this law. MACRA was passed last
year with bipartisan support; however, this bipartisan support came
only because of the widespread need to eliminate the SGR model of
calculating Medicare payments to physicians. Congress and organized
medicine were so focused on this issue that the remainder of MACRA,
including the Merit Incentive Payment System and Alternative Payment
Models, was largely ignored during its passage. The notion that quality
can be measured by a third-party long after a health-care transaction
event is deeply flawed and has never been demonstrated to be effective
in improving patient care outcomes. The idea that such flawed quality
measurements should be used to financially punish physicians is
extremely unethical. At the legislative level we support delaying the
implementation of MACRA from 2017 to 2019 to allow further time for
study and enough time for physician practices to prepare after the
final MACRA rule is issued. We also support legislation that would
eliminate future Medicare penalties to physicians based on reporting
behavior in 2016, similar to the Patient Access and Medicare Protection
Act of 2015.
It is appropriate to conclude with two insightful quotes from John
Halamka:
When you remodel a house, there comes a point when additional
improvements are not possible and you need to start again with
a new structure.
And finally,
It's time to leave the profession if we stay on the current
trajectory.
References:
Marty Stempniak, Don Berwick Offers Health Care 9 Steps to End Era of
``Complex Incentives'' and ``Excessive Measurement,'' http://
www.hhnmag.com/articles/6798-don-berwick-offers-health-care-9-steps-to-
end-this-era-of-greed-and-excessive-measurement, December 11, 2015.
``Health Care System Rankings,'' N. Engl. J. Med., 2010, 362:1546-1547,
April 22, 2010, DOI: 10.1056/NEJMc1001849.
Early Performance of Accountable Care Organizations in Medicare, J.
Michael McWilliams, M.D., Ph.D., Laura A. Hatfield, Ph.D., Michael E.
Chernew, Ph.D., Bruce E. Landon, M.D., M.B.A., and Aaron L. Schwartz,
Ph.D., N. Engl. J. Med., 2016, 374:2357-2366, June 16, 2016, DOI:
10.1056/NEJMsa1600142.
David Hogberg, Ph.D., Don't Fall Prey to Propaganda: Life Expectancy
and Infant Mortality are Unreliable Measures for Comparing the U.S.
Health Care System to Others, http://www.nationalcenter.org/
NPA547ComparativeHealth.html July 2006.
John Halamka, A Deep Dive on the MACRA NPRM, May 5, 2016, http://
thehealthcareblog.com/blog/2016/05/05/a-deep-dive-on-the-macra-nprm/.
John Halamka, Rethinking MACRA Part II, May 15, 2016, http://
thehealthcareblog.com/blog/2016/05/15/rethinking-macra-part-ii/.
Philip Musgrove, editor et al., The World Health Report 2000, The World
Health Organization, http://www.who.int/whr/2000/en/whr00_en.pdf?ua=1.
______
Infectious Diseases Society of America (IDSA)
1300 Wilson Boulevard, Suite 300
Arlington, VA 22209
TEL: (703) 299-0200
FAX: (703) 299-0204
E-mail address: [email protected]
Website: http://www.idsociety.org/
The Honorable Orrin Hatch The Honorable Ron Wyden
Chairman Ranking Member
Committee on Finance Committee on Finance
U.S. Senate U.S. Senate
104 Hart Senate Office Building 221 Dirksen Senate Office Building
Washington, DC 20510 Washington, DC 20510
Dear Chairman Hatch and Ranking Member Wyden:
Thank you for scheduling the hearing entitled, ``Medicare Access and
CHIP Reauthorization Act (MACRA) of 2015: Ensuring Successful
Implementation of Physician Payment Reforms'' on Wednesday, July 13,
2016. IDSA greatly appreciates the Committee's leadership in repealing
the Medicare Sustainable Growth Rate (SGR) formula and in overseeing
MACRA implementation. IDSA continues to provide input to the Centers
for Medicare and Medicaid Services (CMS) on key implementation issues
and to work with our members to prepare for payment reforms.
We are pleased to share with the Committee some of our recommendations
for MACRA implementation and hope you will raise some of these issues
with CMS Administrator Slavitt during the upcoming hearing. We provided
detailed comments to CMS and below highlight some specific issues that
we believe will be of interest to the Committee--such as the need for
new infectious diseases (ID) quality measures and ways to better align
new physician quality improvement programs with antibiotic stewardship
and public health emergency preparedness. Given the Committee's
interest in physician reimbursement issues, we also want to highlight a
related concern regarding the current undervaluation of the infectious
diseases (ID) specialty, which is leading to a steep decline in the
number of physicians pursuing ID specialization, at a time when our
nation urgently needs ID physician expertise.
The Value of ID Physicians
ID physicians make significant contributions to patient care,
biomedical research, and public health. Their leadership and services
save lives, prevent costly and debilitating diseases, and drive
biomedical innovation. ID physician involvement in patient care is
associated with significantly lower rates of mortality and 30-day
readmission rates in hospitalized patients, shorter lengths of hospital
stay, fewer intensive care unit (ICU) days, and lower Medicare charges
and payments. Some of the specific important contributions of ID
physicians include:
Providing life-saving care to patients with serious infections
(such as HIV, sepsis, infections caused by antibiotic resistant
bacteria, Clostridium difficile, and hepatitis C);
Leading public health activities to prevent, control, and
respond to outbreaks in healthcare settings and the community, and
emerging infections such as Ebola and Zika virus infections;
Leading antibiotic stewardship programs to optimize the use of
antibiotics to achieve the best clinical outcomes while minimizing
adverse events, limiting the development of antibiotic resistance and
reducing costs associated with suboptimal antibiotic use;
Monitoring and managing highly complex patients with or at risk
of serious infections (including organ and bone marrow transplant
patients, chemotherapy patients, and others); and
Conducting research leading to breakthroughs in the origin and
transmission of emerging and re-emerging diseases, factors that make
these virulent, and the development of urgently needed new
antimicrobial drugs and other therapies, diagnostics, and vaccines.
MACRA Implementation: Opportunities and Challenges
IDSA is excited for the opportunities that MACRA implementation
presents to realign physician payment to truly incentivize high quality
care. We are hopeful that the new Quality Payment Program (QPP), which
incorporates both the Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) options, will offer significant
improvements over the existing quality programs that it will replace.
However, we are concerned that the APM option, which offers significant
incentives, will not be accessible to physicians in small or mid-sized
practices; and that the MIPS program, as currently structured, misses
many opportunities to provide quality-based incentives.
The implementation of the new QPP will have a profound impact on ID
physicians. CMS estimates that approximately 5,544 ID physicians will
be participating in the MIPS program. Approximately 43% (2,300) of
those physicians will experience a negative payment adjustment,
equaling a $12 million loss in Medicare allowed charges across the
specialty. Given this projection, IDSA has offered CMS a series of
recommendations to strengthen the MIPS program geared toward providing
the highest quality ID physician services.
Additional ID Quality Measures
Current Physician Quality Reporting System (PQRS) measures are not
well-aligned with infectious disease practices. This is due in part to
the overwhelming proportion of ID clinical services being delivered in
the inpatient setting while most of the PQRS measures developed apply
to face-to-face encounters in the outpatient setting. Aside from HIV,
HCV, pneumonia vaccination and influenza immunization, there are no
truly ID-specific measures on which ID specialists can report.
IDSA continues to propose relevant and meaningful ID measures for CMS
to consider within the QPP. Earlier this year, we submitted two
additional measure concepts (Appropriate Use of anti-MRSA Antibiotics
and 72-hour Review of Antibiotic Therapy for Sepsis) into the CMS
Measures Under Consideration (MUC) process, both related to advancing
quality measurement of antimicrobial stewardship at the physician-
level. We hope the Committee will encourage CMS to advance these into
inclusion on the list of applicable measures under the quality
component of MIPS. Antibiotic stewardship is critical to prevent the
misuse and overuse of antibiotics that drive the development of
antibiotic resistance--a serious and growing public health crisis that
claims at least 23,000 lives in the U.S. a year according to the
Centers for Disease Control and Prevention (CDC) and complicates a host
of other medical services that rely upon safe and effective
antibiotics, including the care of preterm infants and
immunocompromised patients, solid organ and bone marrow transplants,
cancer chemotherapy, and many surgeries.
IDSA is also pleased that MACRA provides CMS with additional funding
for measure development. We believe the lack of relevant ID measures
within the MIPS is partly due to the time and cost of measure
development, and the additional funding from the MACRA offers an
invaluable opportunity for CMS to assist in the development of measures
where gaps exist. We urge the Committee to encourage CMS to use part of
this funding towards the development of ID measures.
Clinical Practice Improvement Activities (CPIAs) Under MIPS
It is within this component of the MIPS where we believe ID physicians
will have the most impact and will be able to participate in a
meaningful way within the QPP. However, we offer several
recommendations to help ensure that the robust array of appropriate ID
activities is reflected in the available CPIAs.
IDSA is pleased that CMS is proposing the implementation of an
antibiotic stewardship program (ASP) as a CPIA, and we recommend that
CMS strengthen this approach by establishing leadership of an ASP as a
high weight CPIA while maintaining participation in an ASP as a medium
weight CPIA. The CDC has recommended that all ASP have a single leader
who will be responsible for the program's outcomes and have noted that
physicians--particularly those with formal training in infectious
diseases--have been highly effective in this role. Further, the Joint
Commission's Prepublication Standards for Antimicrobial Stewardship
specifically cites the involvement of an infectious diseases physician
in ASPs. CMS has issued two proposed rules to require ASPs in acute
care hospitals and long term care facilities, aligned with the goals
and objectives of the National Action Plan for Combating Antibiotic
Resistant Bacteria (CARB). The growing need for stewardship activities
and expert leaders to ensure their success underscores the importance
of making leadership of ASP a high weight CPIA.
IDSA is also pleased that CMS has included some emergency preparedness
and response activities in the CPIA list. However, we strongly believe
preparedness should go beyond volunteering for domestic and
international humanitarian work and emergency response and disaster
assistance. It is critical that our hospitals and health systems
prepare and build the capacity to respond to public health emergencies,
including outbreaks such as Ebola Virus Disease, Zika, MERS-CoV,
pandemic influenza and others. ID physicians are heavily involved in
these intensive efforts, which often involve coordination across
multiple departments in a hospital or health system and with public
health entities, needs assessments, development of protocols,
communications plans and other activities. IDSA recommends that CMS add
additional CPIAs to encompass leadership and participation in a wide
array of health care facility preparedness and response activities.
CMS has appropriately recognized the need to develop and include
additional CPIAs, allowing for greater participation in MIPS. IDSA has
recommended that CMS consider the following CPIA concepts: development,
implementation, and oversight of infection prevention and control
programs; development, implementation and oversight of infectious
diseases protocols for solid organ and stem cell transplant procedures;
implementation and ongoing leadership of a hospital avoidance and
timely discharge program enabled through outpatient parenteral
antibiotic therapy; leadership of activities related to hospital or
health system engagement with local, state or federal public health
entities (such as surveillance, immunization programs, or outbreak
response).
Undervaluing ID: Jeopardizing the Next Generation of ID Physicians
It is important for policymakers to understand that MACRA
implementation is occurring against a complex backdrop for physicians
and our healthcare system in which compensation issues are driving
young physicians away from the field of infectious diseases. Data from
the National Residency Match Program (NRMP) indicate a disturbing
decline in the number of individuals applying for ID fellowship
training, with 342 applicants in the 2010-2011 academic year and only
221 in 2016-2017. For 2016-2017, only 65% (or 218 out of 335) of
available ID fellowship positions filled. In many specialty areas, all,
or nearly all, available fellowship positions are typically filled.
These data indicate a broader problem--the undervaluation of ID.
In 2014, IDSA surveyed nearly 600 Internal Medicine residents about
their career choices. Very few residents self-identified as planning to
go into ID. A far higher number reported that they were interested in
ID but chose another field instead. Among that group, salary was the
most often cited reason for not choosing ID. Average salaries for ID
physicians are significantly lower than those for most other
specialties and only slightly higher than the average salary of general
Internal Medicine physicians, even though ID training and certification
requires an additional 2-3 years. Young physicians' significant debt
burden ($200,000 average for the class of 2014) is understandably
driving many individuals toward more lucrative specialties.
Over 90% of the care provided by ID physicians is accounted for by
evaluation and management (E&M) services. These face-to-face, cognitive
encounters are undervalued by the current payment systems compared to
procedural practices (e.g., surgery, cardiology, and gastroenterology).
This accounts for the significant compensation disparity between ID
physicians and specialists who provide more procedure-based care, as
well as primary care physicians who provide similar E&M services but
who have received payment increases simply because of their specialty
enrollment designations as ``primary care physicians.'' Cognitive E&M
services comprise a higher percentage of services provided by ID
specialists than those provided by primary practice specialists such as
Internal Medicine, Family Medicine or Pediatrics, based on CMS data.
Current E&M codes fail to reflect the increasing complexity of E&M
work, which covers the vast majority of ID as discussed above. Without
updated, accurate E&M codes, the payment reform activities included in
MACRA will have only a limited impact on improving ID patient care and
will fail to address the underlying problem of undervaluing ID that is
driving fewer young physicians to enter the specialty. ID physicians
often care for more chronic illnesses, including HIV, hepatitis C, and
recurrent infections. Such care involves preventing complications and
exploring complicated diagnostic and therapeutic pathways. ID
physicians also conduct significant post-visit work, such as care
coordination, patient counseling and other necessary follow up.
IDSA urges the Committee to direct CMS to undertake the research needed
to better identify and quantify the inputs that accurately capture the
elements of complex medical decision making. Such studies should take
into account the evolving health care delivery models with growing
reliance on team-based care, and should consider patient risk-
adjustment as a component to determining complexity. Research
activities should include the direct involvement of physicians who
primarily provide cognitive care. Specifically, this research should:
(1) Describe in detail the full range of intensity for E&M services,
placing a premium on the assessment of data and resulting medical
decision making;
(2) Define discrete levels of service intensity based on observational
and electronically stored data combined with expert opinion;
(3) Develop documentation expectations for each service level;
(4) Provide efficient and meaningful guidance for documentation and
auditing; and
(5) Ensure accurate relative valuation as part of the Physician Fee
Schedule.
Once again, we thank the Committee for its attention to physician
payment and health care quality, and we look forward to continuing to
work with you in order to meet the evolving needs of our patients.
Sincerely,
Johan S. Bakken, M.D., Ph.D., FIDSA
President, IDSA
______
Medical Group Management Association (MGMA)
1717 Pennsylvania Ave., NW, #600
Washington, DC 20006
T 202-293-3450
F 202-293-2787
http://www.mgma.org/
The Medical Group Management Association (MGMA) applauds the U.S.
Senate Committee on Finance (Committee) for continuing to show
leadership on the implementation of the Medicare Access and CHIP
Reauthorization Act of 2015 (MACRA) and is committed to working with
the Committee, Congress, and the Administration to ensure a successful
implementation of MACRA.
MGMA helps create successful medical practices that deliver the
highest-quality patient care. As the leading association for medical
practice administrators and executives since 1926, MGMA helps improve
members' practices and produces some of the most credible and robust
medical practice economic data and data solutions in the industry.
Through its national membership and 50 state affiliates, MGMA
represents more than 33,000 medical practice administrators and
executives in practices of all sizes, types, structures and specialties
in which more than 280,000 physicians practice.
MGMA strongly supported MACRA, which was a significant legislative and
policy achievement that replaced the failed sustainable growth rate
formula with stable Medicare physician payment updates and incentives
to innovate and participate in new care delivery models that have the
potential to reduced Medicare waste while improving patient outcomes.
However, we are concerned that CMS' notice of proposed rulemaking
(NPRM) implementing the new Merit-Based Incentive Payment System (MIPS)
and alternative payment models (APMs) strays from the key terms and
themes of MACRA to simplify quality reporting and reward the move from
fee-for-service to value-based payment and delivery models. Instead,
the NPRM would create a complex web of administratively burdensome
reporting requirements in MIPS while limiting opportunities for
practices to utilize the transitional APM payments to support their
care delivery redesign.
MGMA is pleased to have the opportunity to offer this statement for the
record at this critical juncture in MACRA implementation and to share
with the Committee our concerns and recommendations for improving the
proposed framework for MIPS and APMs. In our comment letter to CMS in
response to the NPRM, we made recommendations to assist CMS and the
Administration in implementing MACRA in a manner that supports
physician group practices as they transform their payment and delivery
approaches from fee-for-service toward value-based models. Our key
recommendations include:
Beginning the first MIPS and APM performance period no sooner
than January 1, 2018. Beginning January 1, 2018 would bring the
measurement period closer to the payment year and provide practices
with more opportunities to participate in eligible APMs by giving more
time to CMS's Centers for Innovation to develop Medicare payment models
and the Physician-Focused Payment Models Technical Advisory Committee
to shepherd private sector models into the eligible APM track.
Shortening the quality and advancing care information (ACI)
performance periods to any 90 consecutive days using sampling and
attestation methodologies that ensure statistical validity.
Accommodating claims-based reporting with a longer submission period,
such as 6 months. Ninety days would align quality and ACI with the
proposed 90-day CPIA performance period.
Finalizing the MIPS group practice assessment option, which
recognizes the fundamental advantage the group practice model offers by
coordinating a wide range of physician and related ancillary services
in a manner that is seamless to patients.
Reducing the reporting requirements across MIPS. As proposed,
physician group practices' finite resources would be spread across at
least 20 measures and objectives, including a minimum of eight measures
in the quality category, two measures in resource use, nine measures in
ACI, and at least one measure in the CPIA category. CMS should
structure MIPS to allow practices to prioritize effective and impactful
improvements to patient care, rather than comply with sprawling
reporting mandates.
Awarding credit across MIPS performance categories. Whenever
possible, CMS should award credit in multiple categories to streamline
the program and reduce redundancies.
Overhauling the eligible APM criteria and expanding the list of
qualifying APMs to include legitimate CMS Innovation Center models such
as Medicare Shared Savings Program (MSSP) Track 1 ACOs and the Bundled
Payment for Care Improvement (BPCI) models.
Seeking opportunities to adopt private sector payment models and
patient-centered medical home (PCMH) models as eligible APMs.
Conclusion
We appreciate the opportunity to submit this statement for the record
to the Committee. MGMA remains committed to helping group practices and
CMS understand the best way to implement MACRA in order to streamline
and harmonize quality reporting programs into MIPS and develop
meaningful APMs. We look forward to continuing to work with the
Committee, Congress and the Administration to ensure that the rollout
of these new programs is successful. We would be happy to provide you
with a full copy of our comments to CMS's MIPS and APMs NPRM as well as
any additional resources (www.mgma.org/MACRA).
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