Reaction to CMS's proposed rule includes a claim from MGMA that the proposal "provides almost no opportunities for medical groups to begin the shift away from fee-for-service reimbursement."
Physicians may not despise (MACRA) as much as they did the sustainable growth rate (SGR) formula, but the Centers for Medicare & Medicaid Services' proposed rule for implementation of the Medicare Access and Children's Health Insurance Program Reauthorization Act isn't winning any popularity contests.
Emblematic of how physicians responded were the comments left by Charles A. Adams, Jr., MD. "While anything that did away with the flawed and completely ineffective SGR should be an improvement, adoption of MACRA will likely not have the desired effect that it hopes to realize," he wrote.
In all, more than 1,200 comments were submitted by individuals, hospital and physician groups, and consumer advocates.
The American Hospital Association
"The AHA is extremely disappointed that few of the models in which hospitals have engaged will qualify as advanced alternative payment models (APMs); we urge CMS to adopt a more inclusive approach," said the American Hospital Association in its comments.
"Specifically, we are concerned that CMS's proposed approach fails to recognize the significant resources providers invest in the development of APMs, because under the proposal, an APM generally must require participating entities to accept significant downside risk to qualify as an advanced APM."
Major physician organizations, including the American Academy of Family Physicians (AAFP), voiced concerns about the proposed pace of implementation.
"While our support for MACRA remains strong, we must state that we 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," the AAFP wrote in a 107-page letter to CMS Acting Administrator Andrew Slavitt.
"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."
The American Medical Association also called for an interim final rule.
"Under MACRA, high-quality, high-value care and improved health outcomes for patients will be rewarded, but ensuring a smooth transition away from SGR requires up-front work today," said AMA president Andrew W. Gurman, MD.
The rule's timing and complexity are key complaints among specialty groups as well.
The American College of Rheumatology (ACR), for example, argued that most rheumatologists wouldn't be able to comply with the law's requirements under the proposed timeline.
In a joint statement, the American Association of Neurological Surgeons (AANS) and Congress of Neurological Surgeons (CNS) called the timeline to implement MACRA "overly ambitious" and recommended the initial performance period be delayed from January 1 to no earlier than July 1, 2017, "but ideally not until Jan. 1, 2018."
AANS and CNS also called for participation in a qualified clinical data registry to automatically satisfy multiple Merit-based Incentive Payment System (MIPS) categories, including quality, clinical practice improvement activities, and advancing care information—the MACRA replacement for the meaningful use program for physician practices.
The majority of physician practices with fewer than 25 clinicians, which reflect most neurosurgical practices, will receive negative payment adjustments under the proposed rule, AANS and CNS said.
The two organizations suggested CMS raise the MIPS low-volume exclusion threshold to $30,000 in charges allowed by Medicare, or for practices seeing fewer than 100 Medicare patients.
MIPS and APMs
As for the reporting mechanisms themselves, groups generally decried the bars set by both the Merit-Based Incentive System (MIPS) and Alternative Payment Models (APM) as being unrealistically and unnecessarily high.
"Unfortunately, the MIPS/APM proposed rule strays significantly from Congress's intent to simplify quality reporting and provide new value-based opportunities for physicians in Medicare," Halee Fischer-Wright, MD, president and CEO of the Medical Group Management Association (MGMA), said in an media statement.
"The rule's proposed MIPS scoring system is nothing short of a mathematical marvel. Its narrow definition of APM provides almost no opportunities for medical groups to begin the shift away from fee-for-service reimbursement," she said.
Suggestions for Improvement
Among the scores of public comments urging CMS to halt MACRA, MIPS, and APMs altogether, physicians did offer straightforward suggestions for improvement.
"Establish objective and timely measurement and reporting systems that are simpler and less costly than those required under current programs like PQRS and meaningful use," wrote Texas physician John Ghiodi.
"The focus should be improving care for all Medicare patients, not creating yearly physician winners and losers with payment affected two years after care has been delivered."
Perhaps the most often-recurring theme is summed up by Ghiodi's first suggestion: "Keep it simple."
CHIME Chimes In
The College of Healthcare Information Management Executives (CHIME) also urged CMS to simplify the MACRA rules as proposed.
In particular, CHIME suggested that requirements for providers to attest that they are being compliant to exchange information in standard ways with each other be relaxed until such standards are more clearly defined.
"Because the work underway at the Office of the National Coordinator for Health IT (ONC) to tackle these challenges is not yet complete, CMS is inadvertently asking providers to attest to more than they reasonably can at this time," CHIME stated. "The attestations in the final rule should be modified to recognize this."
CHIME also expressed concern that hospitals and clinicians "are on separate trajectories for pathways to achieve meaningful use… the pass/fail construct and full-year reporting period... [do] not advance interoperability enough to achieve the goals of a value-based delivery system."
Consumer Advocates React
A coalition of consumer groups applauded the proposed rule. The Consumer Partnership for eHealth, representing consumer, patient and labor organizations, did recommend changing the single-patient requirement for e-prescribing, patient electric access and secure messaging, to 5% of all patients in 2019.
Premier, a healthcare performance improvement alliance of approximately 3,600 U.S. hospitals and 120,000 other providers, proposed modifications related to APMs, including adding Comprehensive Care for Joint Replacement and Bundled Payment for Care Improvement as Advanced APMs.
By statute, the final rule for MACRA must be issued no later than November 1.