Excluding such a significant percentage of
otherwise eligible clinicians has several negative consequences. Most notably, given the budget-neutral nature
of the MIPS, excluding so many otherwise eligible clinicians reduces the potential payment adjustments for
those left in the program. With fewer participants, there
will be fewer negative MIPS adjustments, which are
needed to offset positive MIPS scores. As a result, CMS
estimated that the aggregate MIPS adjustment would
be 0.9%, far below the maximum possible 5% for the
2018 performance year.
These Part B updates, which will grow to 9% in
2022 and beyond, factored into how physician practices and medical groups, including AMGA members,
prepared to compete and provide care under MIPS.
These clinicians and groups invested in the necessary
infrastructure with the reasonable expectation they
would be competitive under MIPS. If finalized as
proposed, even those that perform well under MIPS
will receive updates that do not keep pace with medical
inflation, effectively resulting in a loss.
It appears that those working to improve care
and outcomes, and reduce spending growth are now
engaged in what amounts to a compliance exercise.
In addition, the proposal ultimately harms those
clinicians whom it purports to protect. Those groups
and clinicians participating in MIPS will have gained
experience in participating in a value-based system.
Lacking this experience will put those excluded at a
competitive disadvantage once they are required to
participate in MIPS.
Beyond the low-volume threshold, CMS also
proposed for 2018 to set the CPS too low to be an
effective gauge of performance. As proposed, a minimal
amount of MIPS reporting would be sufficient to reach
the proposed threshold of 15 points, and receive either
a neutral or positive update. This is particularly true
for small-sized providers, which CMS is proposing to
automatically award five bonus CPS points.
The proposed low-volume exclusion levels, combined with the CPS threshold, fail to acknowledge the
significant investments in health information technology,
staffing, training, and clinical practice innovation efforts
that are needed to deliver care in a value-based reimbursement system. AMGA members have been preparing
for these reforms, and it is disappointing their efforts will
again be diminished under this proposed rule.
Based on these and other concerns, AMGA concluded that a MIPS program that does not challenge or
engage the medical community would not approach the
desired quality improvement and spending reduction
goals MACRA intends.
Blocking the APM Pathway
AMGA also has concerns with CMS’ proposals
for the alternative payment model (APM) pathway.
In a switch from last year’s final MACRA rule, CMS
now proposes to conduct qualifying practitioner (QP)
determinations for the All-Payer Combination Option
at the individual clinician level, rather than at the APM
entity level. Intended to avoid including clinicians with
minimal participation in an APM, the proposal fails
to account for the nature of group practices. Group
practices are measured and evaluated at the group
level, not at the individual clinician level. This proposal
appears to take a different approach and shifts away
from acknowledging that clinicians in advanced APMs
are working together toward a common goal and that
this collaboration is the hallmark of superior patient
care. AMGA is opposed to this change in policy and
recommended that CMS conduct QP determinations at
the APM entity level.
In an effort to facilitate APM participation, we also
encouraged CMS to allow providers that have contracts
with Medicare Advantage (MA) plans that meet the
risk, quality, and certified electronic health information
technology requirements to be considered for advanced
APM status before performance year 2019. CMS has
the discretion under MACRA to include such contracts
by including MA beneficiaries in the beneficiary threshold test. This recognizes the risk providers take under
MA contracts and provides another option for providers to participate as advanced APMs.
Move to Value Now
MACRA was intended to shift the Medicare
program away from a fee-for-service system based on
volume and intensity to a reimbursement system based
on value. By revising its proposed MACRA rule based
on our recommendations, CMS can help providers
realize Congress’ vision for a Medicare program that is
rooted in performance and value.
David Introcaso, Ph.D., is senior director, regulatory
and public policy ( email@example.com), and Darryl
M. Drevna, M.A., is director, regulatory and public
policy ( firstname.lastname@example.org), at AMGA.