The proposed federal regulations to implement the MACRA health care reforms are too complex, too onerous on small and solo practices, lack opportunities for many to participate in alternative payment models, and should be delayed for a full year, at least.
That was the message that emerged from hundreds of comments regarding the proposed rule that were submitted by physician organizations and other stakeholders.
“The intent of [the Medicare Access and CHIP Reauthorization Act of 2015] was not to merely move the current incentive program into [the Merit-based Incentive Payment System], but to improve and simplify these programs into a single more unified approach,” the American Medical Association said in its comments, noting that “numerous changes” will be needed in the way cost and quality are measured.
AMA also called for a better, faster way for physicians to develop alternative payment models. “We strongly urge CMS to vigorously pursue this objective and establish a much more progressive and welcoming environment for the development and implementation of specialty-defined APMs than proposed in the [proposed rule].”
AMA also suggested that CMS provide more flexibility for solo and small practices, align the four components of MIPS so it operates as a single program, simplifying and lowering the financial risk for advanced APMs, and providing more timely feedback to physicians.
The organization also called for CMS to “create an initial transitional performance period from July 1, 2017, to December 31, 2017, to ensure the successful and appropriate implementation of the MACRA program. In future years, for all reporting requirements, CMS should allow physicians to select periods of less than a full calendar year to provide flexibility.”
In its comments, the American Medical Group Association questioned whether the proposed rule actually would lead to improved quality of care and reward value.
In the proposed rule, “CMS will measure and score quality and resource use or spending separately,” AMGA wrote in its comments. “CMS will not measure outcomes in relation to spending. CMS will not measure for value. If value is left unaddressed in the final rule, it will be difficult at best for the agency to meet MACRA and the [HHS] secretary’s overarching goals.”
While expressing support for MACRA conceptually, officials with the American Academy of Family Physicians wrote that they “see a strong and definite need and opportunity for CMS to step back and reconsider the approach to this proposed rule which we view as overly complex and burdensome to our members and indeed for all physicians. Given the significant complexity of the rule, we strongly encourage CMS to issue an interim final rule with comment period rather than to issue a final rule.”
Specifically, AAFP criticized the proposed rule for allowing small and solo practices to form “virtual groups” in order to earn bonuses, despite it being mandated by law.
Solo and small group practices who participate in MIPS to should “be eligible for positive payment updates if their performance yields such payments, but would be exempt from any negative payment update until such a time that the virtual group option is available,” AAFP officials wrote.
They also called for medical home delivery models to be included in APMs, in an effort to improve on the limited opportunities for family practices in particular to participate in alternative payment models.
The American College of Physicians also called for safe harbors for small and solo practices until virtual group options can be established.
ACP, like other groups, questioned that medical homes are not recognized as alternative payment models and argued that Congress intended medical homes to qualify as APMs “without bearing more than nominal financial risk.”
Despite the flexible approach to the overall quality payment program, CMS has “created a degree of complexity” and must “continue to seek ways to further streamline and simplify” the move to quality payments, according to comments from the American College of Cardiology.
The ACC also expressed concerns that the reporting requirements under MIPS and some of the APMs will limit the ability for cardiologists to report the most meaningful measures, particularly if they are part of a multi-specialty group, and suggested changes in scoring methodology or to allow more than one data file to be submitted in multi-specialty situations.
It also expressed concerns that the rule as proposed could adversely effect small practices, rural practices, and practices in health professional shortage areas, and “in the absence of other solutions such as virtual groups in 2017, CMS should monitor policies and provide effective practice assistance to these practices.”
The proposed rule provides no support for small practices, according to the American Gastroenterological Association.