“Upon release of the proposed rule, we were disappointed to see that not only will APMs be essentially closed off to small practices in the first years of implementation, but the MIPS program will significantly harm practices with less than 25 eligible clinicians,” AGA noted, citing data presented by CMS that 87% of solo practitioners will receive a negative adjustment with an aggregate negative impact of $300 million and for all practices with less than 25 eligible clinicians, the aggregate negative adjustment will total $649 million.
“Any system in which smaller practices are so heavily disadvantaged is unacceptable,” AGA said. CMS has previously stated that the regulatory impact statement would likely change and reflect a smaller impact for small and solo practices once more updated information can be modeled when the rule is final.
Additionally, AGA expressed concern over the limited engagement in APMs that will be possible under the proposed rule. “Given the importance of APM participation to both the practice and reimbursement of Medicare physicians, access to advanced APMs should be provided to all physicians.”
The association also expressed concern that the definition of APM is not broad enough and suggested that it be widened in scope so that it can capture payment models that have been created using the AGA’s Roadmap to the Future of GI Practice. It recommended a number of models be classified as APMs, including the colonoscopy bundled payment, gastroesophageal reflux disease episode payment, obesity bundled payment, Project Sonar (a chronic disease management program for IBD), and the Medical Home Neighbor.
The American College of Rheumatology called for a delay in the implementation of any final MACRA regulations, noting in its comments that with requirements set to begin in 2017, the current implementation schedule “does not provide enough time for providers to implement the required changes,” though ACR does not recommend a specific start time.
ACR also questioned how the criteria for APMs was set up, noting expressly that Physician Focused Payment Models may not meet the APM requirements. The group is seeking clarification on whether these models will qualify as an APM.
“Medical home APMs should also permit specialty physicians to participate, including small group and multispeciality groups, in keeping with the need for APMs to be flexible with their criteria and the role of specialty physicians in providing chronic care.
The American Academy of Dermatology Association echoed a number of concerns voiced across the medical profession and is calling for a delay in the implementation of MACRA’s regulations.
In particular, AADA noted that the regulations are not friendly for small and solo practices in general and little is contained within the proposal to “meaningfully engage specialist physicians in APMs.”
The association also is calling for broader mechanisms to allow for the development and recognition of APMs, including recognizing specialty-focused medical homes.
The group also is calling for pilot programs to test the validity of the measures that will form the basis of quality payment incentives and penalties.
In an effort to protect small and solo practices, AADA is calling for an exemption from MIPS or APM requirements until a virtual group option is developed, tested, and is fully operational.
The American Psychiatric Association echoed a number of broad concerns raised across the physician spectrum, including calling for a to the first year of implementation to July 1, 2017, and lasting through Dec. 31, 2017, as well as enabling the formation of virtual groups at the onset of implementation in its comments.
But APA also noted that mental health presents a variety of unique issues that need to be addressed.
For example, the association notes that psychiatrists work across a number of practice settings, including academic health centers, hospitals, clinics, nursing homes, and private practices, as well as offering services via telemedicine.
“This makes it difficult for psychiatrists to capture all the work they do, because of the combination of settings that utilize multiple, and potentially differing reporting programs and methods,” APA noted.
It added that psychiatrists generally have limited time and resources that can be devoted to Medicare quality reporting, which would make participation in MIPS and APMs more challenging, particularly because many operate in small or solo practices that do not own electronic health record systems, which would complicate reporting requirements to qualify for MIPS or APMs.
In addition to concerns with reporting in general, APA said that psychiatrists “also have limited choices in outcome quality measures.”