Society Comments on MACRA Proposed Rule

July 1, 2016
Policy Snapshot
Centers for Medicare and Medicaid (CMS), Pain Management, Payment, Alternative Payment Models (APM), Coding, Reimbursement, & Documentation, Current Procedural Terminology (CPT) codes, Practice Management, Physician Quality Reporting System (PQRS)

This week AMDA - The Society for Post-Acute and Long-Term Care Medicine submitted comments on the Centers for Medicare & Medicaid Services (CMS) Proposed Rule on Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models.

The proposed rule was the first since the passage of the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA). The MACRA makes three important changes to how Medicare pays those who give care to Medicare beneficiaries. These changes create a Quality Payment Program (QPP):

  • Ending the Sustainable Growth Rate (SGR) formula for determining Medicare payments for health care providers’ services.
  • Making a new framework for rewarding health care providers for giving better care, not just more care.
  • Combining our existing quality reporting programs into one new system.

These proposed changes, which CMS named the Quality Payment Program, replace a patchwork system of Medicare reporting programs with a flexible system that allows clinicians to choose from two paths that link quality to payments: the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models.

The Society was encouraged by CMS’ transparency in the rulemaking process to try and improve upon the prior programs. “We believe, if properly implemented, the new physician payment framework will promote improvements in the delivery of care for patients and residents in PALTC settings,” the Society said.

The Society focused on several principles they believed CMS should follow to ensure these programs work for all clinicians and, more importantly, serve the needs of the population in PALTC settings. They included:

  • Provide an equitable payment system that incentivizes quality health care for a diverse patient population.  As policies continue to transition payment from fee-for-service into a value-based system where clinicians and health care settings are evaluated on quality and resource use metrics, CMS must ensure that these measures target the appropriate populations, and that quality and cost scores are evaluated in appropriate comparison groups. 
  • Promote workforce development and competencies to care for the PALTC population. Although payment models have the opportunity to drive clinician behavior that improves the quality of care, we believe, ultimately, that increasing the quality and quantity of the workforce to care for an exponentially growing number of frail elderly, and building clinician competency to care for them, is more likely to succeed in achieving these results.
  • Reduce administrative burden. Administrative burdens must be limited and reporting tasks streamlined. For the many physicians who practice in multiple facilities spanning the PALTC sector, it means having to track and gather data on a patient population that comes from multiple facilities that may have difference electronic health record (EHR) vendors.
  • Take into account differences in practice sizes, settings, specialties, and availability of measures. Throughout the MIPS framework, CMS should identify exceptions or include greater flexibility to address the unique concerns of small, SNF based, rural, and other specific practices.
  • Adopt virtual groups. The MACRA statute included the concept of virtual groups to help assist small practices; however, CMS proposes not to implement such groups until the 2018 performance period.
  • Work with medical societies and provide transparency promptly (ahead of reporting periods) to determine how to reweight performance categories. CMS should not overemphasize the quality category when determining how to reweight a missing MIPS component. Rather, the rule should allow for flexibility in how to redistribute the different performance weights, and CMS should work with affected physicians and medical societies to determine a more appropriate approach.

Specifically, the Society also commented on CMS’ proposal to modify attribution methodology for the total per capita cost measure and uses a two-step attribution methodology that focus on the delivery of primary care services by both primary care clinicians and specialists. The Value-Modifier currently defines primary care services identified by the following codes: 99201-99215, 99304-99340, 99350, G0402 (welcome to Medicare visit) and G0438 and G0439 (annual wellness visits). For MIPS, CMS proposes the following changes:

  • Include transitional care management codes (99495 and 99496) and the chronic care management code (99490) and
  • Exclude SNF services billed under 99304-99318 when the claim includes the POS 31 modifier.

The Society was supportive of this proposal but “remain[s] concerned that it does not solve the issue of comparing clinicians who treat similar populations. Resources necessary to take care of patients in the long-term custodial nursing facility (NF) setting defined by place of service (POS) 32 modifier are very different from internal/family medicine clinicians seeing patients in office-based or other outpatient/ambulatory or long-term care (e.g., domiciliary/assisted living) settings. Most long-term custodial (POS 32) nursing home residents have limited life expectancy and multiple morbidities, and are likely to have higher resource utilization. We strongly urge CMS to study risk adjustment methodologies that would ensure a more equitable comparison groups.”

The Society also urged CMS to expand the number of Advanced APMs by providing more flexibility on what it defines as an advanced APM. Currently, there are no APMs in the Advanced APM category that would allow clinicians who practice in PALTC setting to qualify. To read all of the Society’s comments click here.