MACRA responses hit CMS for short timeline, high reporting burden

The public comment period on proposed rules for implementing the Medicare Access and CHIP Reauthorization Act of 2015, better known as MACRA, closed Monday at 5 p.m. Eastern time.

MACRA, which many called the “doc fix,” replaces the hated Medicare Sustainable Growth Rate, among other things. It also creates the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APM) programs to consolidate the Physician Quality Reporting System, Meaningful Use and the Medicare value-based payment modifier. (The Meaningful Use framework accounts for 25 percent of the MIPS score, so the electronic health records incentive program isn’t really going away.)

Lots of groups had lots to say on the plan, which the Centers for Medicare and Medicaid Services proposed in late April. In fact, acting CMS Administrator Andy Slavitt tweeted that more than 3,700 comments came in.

#MACRA comment period:

Over 200 physician meetings
Over 64,000 attendees
3,772 submitted comments at last count

More = better. TY all.

— Andy Slavitt 🇮🇱 🇺🇦 (@ASlavitt) June 28, 2016

The Medical Group Management Association (MGMA) filed its comments last Friday. The 54-page document reflects the fact that the MGMA has had problems with the Sustainable Growth Rate formula and the Meaningful Use programs that MACRA is superseding. The Englewood, Colorado-based organization said:

MGMA believes the MIPS and APMs proposed rule strays significantly from the terms and themes of MACRA. Further, as proposed, the framework of these programs would not achieve CMS’ overarching goal of promoting high-value healthcare through patient-centric, flexible and streamlined payment incentives. During a recent MGMA webinar about the proposed MIPS program, 65% of the nearly 500 participants responded that this proposed rule would not only fail in achieving its goal of improving clinicians’ ability to deliver high-value care, it would actually detract from it. MGMA and our members recognize proposed MIPS criteria are so onerous that, when coupled with an almost non-existent Advanced APM pathway, they would consume clinicians’ time and resources in collecting and reporting what are essentially government-mandated data points rather than spending time with patients.

The Healthcare Information and Management Systems Society (HIMSS) and the Association of Medical Directors of Information Systems (AMDIS) offered comments jointly in a 17-page letter:

The NPRM reflects CMS’s intention to develop value-based payment policies that encourage maximum participation in both the Merit Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs) tracks, while allowing opportunity for customization, streamlining requirements, and flexibility.

However, we are concerned that this flexibility has created a level of complexity that increases the burden for eligible clinicians (ECs), particularly in the proposed Quality Payment Program.

The College of Healthcare Information Management Executives (CHIME) took issue with the attestation period, with monitoring of “data blocking” and with proposed EHR surveillance requirements. Among CHIME’s concerns:

While we appreciate ONC’s efforts to oversee [certified EHR technology] to ensure products are performing as intended, we have three major concerns with the provision as proposed. First, we are concerned that this requirement could pose a security threat unless implemented with adequate precautions. Our members do not agree that the federal government, or their designees, should be provided unlimited access to the CEHRT itself. Second, it could be very hard to monitor such access. Maintaining access or creating generic accounts to facilitate such access is laborintensive and extremely costly. Third, while we recognize the proposed rule indicates that ONC-ACBs would be considered “health oversight agencies” per the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, our concerns go beyond HIPAA violations. Providers work daily to protect their systems from attacks and granting unrestricted access to a provider’s EHR could introduce more security threats depending upon how this is operationalized.

The American Medical Informatics Association (AMIA) fell in line with other provider-focused groups in wanting CMS to shorten the reporting period, at least in 2017.  The organization said:

AMIA members express doubt over the ability of MIPS ECs to successfully participate in a full-year reporting period beginning January 1, 2017. Despite our support for much of this NPRM, the level of complexity inherent in these programs has no equal in Medicare, and we suspect it rivals any federal program in aggregate complexity. This complexity will necessitate tremendous amounts of education and dialogue, despite most EC’s familiarity with certain aspects of MIPS.

The American Medical Association, which has a history of fighting any change that may affect its members’ pocketbooks, did not disappoint this time. In a 70-page document, the AMA, whose new president seems to be proud of the fact he doesn’t use an EHR, said:

To improve upon the current proposal, we urge CMS to adopt the following high-level recommendations:

• Establish a transitional period to allow for sufficient time to prepare physicians to have a successful launch of MACRA.

• Provide more flexibility for solo physicians and small group practices, including raising the low volume threshold.

• Provide physicians with more timely and actionable feedback in a more usable and clear format.

• Align the different components of MIPS so that it operates as a single program rather than four separate parts, such as creating a common definition for small practices.

• Simplify reporting burdens and improve chances of success by creating more opportunities for partial credit and fewer required measures within MIPS.

• Reduce the thresholds for reporting on quality measures.

• Reward reporting of outcome or cross-cutting measures under a bonus point structure rather than a requirement in order to achieve the maximum quality score.

• Improve risk adjustment and attribution methods before moving forward with the resource use category.

• Replace current cost measures that were developed for hospital-level measurement and refine and test new episode measures prior to widespread adoption.

• Permit proposals for more relevant measures, rather than keeping the current MU Stage 3 requirements.

• Remove the pass-fail component of the Advancing Care Information (ACI) score.

• Reduce the number of required Clinical Practice Improvement Activities (CPIAs) and allow more activities to count as “high-weighted.”

• Simplify and lower financial risk standards for Advanced APMs.

Hospital purchasing cooperative Premier Inc. was perhaps the most bullish among major commenters. Still, the organization did have some concerns. Premier said:

We appreciate the efforts by CMS and ONC to support an interoperable HIT infrastructure; however we are concerned that oversight activities are too focused on providers. In our experience data is locked in proprietary software systems, preventing providers from being able to connect and exchange information. We ask that CMS oversight include monitoring EHR systems and understanding barriers (financial or other) clinician face in implementing EHR functions that support interoperability.

CMS now will consider all the comments as it finalizes MACRA regulations. The agency has promised a final rule by early fall.

It probably won’t consider this one:

https://twitter.com/MWFriedberg/status/747779447248556033

Photo: YouTube user U.S. Department of Health and Human Services