Submitted to CMS August 2017
We appreciate the opportunity to provide comments on the proposed rule for the second transition year under the MACRA legislation. We provide practice management consulting services to small and mid-sized independent practices. For the past several years, we have assisted dozens of practices with Meaningful Use, PQRS, Value-Based Modifiers, and now the MIPS program. Our comments below focus on the MIPS pathway and reflect our learnings from working with many different types of practices.
Low Volume Exclusion
We appreciate CMS’s responsiveness to the difficulties faced by small practices and the many proposed changes designed to assist them with the transition to MIPS. However, we disagree with the expansion of the Low Volume Threshold and the resulting exclusion of another 10% (134,000) providers from this program. Under the MACRA legislation, the only mechanism by which most providers will receive an increase in payment rates during the six year period 2020-2026 is by performing well in the MIPS program. Small practices face increases to their costs every year, yet are increasingly unable to realize gains in revenue to offset these costs. We recommend that CMS retain the current low volume threshold for exclusion and make MIPS participation optional for providers with volumes between the current and proposed threshold. Providers who earn less than $90,000 or see less than 200 patients and choose not to report under MIPS should earn the standard physician fee schedule amount; those who do report data through any mechanism should be excluded only if they earn less than $30,000 or see less than 100 patients.
MIPS Threshold for 2018 Reporting Year
The proposed rule asked specifically for comments regarding the level of MIPS threshold that should be set for 2018. In selecting the appropriate threshold, it is important to set a level that is both attainable for all types of practices and encourages significant movement toward the legislatively mandated levels in the 2019 reporting year. We recommend that CMS use its best available data to estimate the likely mean and median MIPS score in 2017 as this will be the threshold for 2019. Selecting a 2018 threshold that is about halfway between the 2017 threshold of 3 and the estimated 2019 threshold would be reasonable.
Category Weights for 2018 Reporting Year
We are concerned about the proposal to maintain only three categories for 2018 and continue to weight the Resource Use category at 0%. In our experience, very few practices, most especially small practices, had any understanding of the cost component in the Value-Based Modifier. Based on the MACRA legislation, this category is scheduled to have a weight of almost one-third of the total MIPS score in 2019. If the weighting cannot be reduced in 2019, then it will be important to have a phased approach. One option is to maintain a 10% weighting for this category in 2018 as originally proposed but limit the measures to only those that are included in both the 2015 and 2016 QRUR reports. This would provide practices with two years of historical data to review and begin to understand the mechanics and data used in this category. Another option may be to exempt small practices from this category entirely and/or set minimum volume thresholds for each measure so that fewer practices are impacted by the Resource Use category in its initial year (2019). Regardless of when the Resource Use category is initiated, practices of all sizes need clear information about how patients are attributed, how measures are calculated and actions they can take to influence their scores in this area.
Facility-Based Scoring Option
The proposal to allow certain providers to elect to participate in MIPS themselves or to utilize the hospital’s VBP score in assessing performance is appropriate and helpful. We recommend expanding the proposal to include POS 22 (Hospital Outpatient on-campus) for Non Patient-Facing providers. Providers in specialties such as anesthesiology, radiology and pathology may provide more than 25% of their services in the outpatient hospital setting but contribute significantly to the hospitals VBP score and should be eligible to participate in this new scoring option.
Topped Out Quality Measures
We agree that a multi-year process for removing topped out measures is appropriate; however, we recommend delaying the implementation of this process for at least two years. The 2020 reporting year should be the first year of the process with identification of topped out measures, followed by two years of reduced value and then potential removal. With 45% of the current measures listed as topped out, moving forward with the proposed removal process at this time will provide a significant disincentive for participation. Practices have spent considerable time and effort selecting measures and developing processes and systems to collect and report on them. They need a reasonable level of consistency in the early years of the program as they adapt to new requirements and scoring mechanisms. When implemented, any removal or devaluation of a topped out measure should be restricted unless there is a new measure added to the same specialty set and that measure has been in place long enough that benchmarks are available prior to the beginning of the reporting year. This type of replacement process would help ensure that providers continue to have sufficient measures available that are applicable and appropriate for their specialty and patient population.
In attempting to build in flexibility to accommodate the wide variations in medical practices, the MIPS program as currently configured is more complex than necessary. We recommend the following steps to reduce the overall complexity of the program:
- Maintain the same timeframe for reporting periods across categories wherever possible. For 2018, a 90-day reporting period should be maintained for all categories rather than requiring a 12-month period for Quality and 90 days for the other categories.
- Use the same definition to identify who is eligible for the program (currently physicians, PAs, NPs, CNS and CRNAs), whose data is included in Group/Virtual Group reporting, who receives a payment adjustment, and who is counted in determining whether a practice is “small” (clarified in proposed rule that all providers billing Medicare are counted). When a provider (TIN/NPI) is determined to be eligible for MIPS, s/he should be counted in all determinations used in the program; if a provider is determined to be ineligible, then s/he should not be included in group reporting or determining practice size.
- Combine Hospital-Based and Ambulatory Surgery-Based designations into a single designation using the criteria of >75% of Medicare covered services are provided in POS 21, 22 on-campus, 23, or 24. This would also allow a provider who has < 75% in the current Hospital-Based designation and < 75% in the Ambulatory-Surgery based designation to qualify for ACI exclusion based on the combination of the two locations.
- Limit changes in the definitions and versions of clinical quality measures to those that are absolutely necessary. Many EHRs are not updating the eCQMs to the newest version because it is not required that they do so. As a result, providers cannot use the eCQMs which both limits their options for effective quality measures to report and increases the cost since they generally must pay for Registry reporting. Once providers understand and put systems in place to collect appropriate data for a specific measure, every change to that measure requires additional time and energy – often for very little differences in the data reported.
We appreciate your efforts to listen and respond to the provider community. Many of the changes proposed will indeed prove helpful to small practices who continue to operate in a fee-for-service world while trying to adapt systems and processes to also succeed in a new value-based model. We hope that these comments are useful and provide additional suggestions for revisions.