CMS’ ‘doc fix’ may need some re­pairs it­self

Modern Healthcare - - NEWS - By Shan­non Much­more

Hos­pi­tal and physi­cian groups, fac­ing a loom­ing dead­line on ma­jor changes to re­im­burse­ment, say the CMS needs bet­ter mea­sures and re­port­ing meth­ods be­fore it ties physi­cian pay to qual­ity and out­comes.

The Amer­i­can Hos­pi­tal As­so­ci­a­tion, the Amer­i­can Med­i­cal As­so­ci­a­tion and other provider groups wrote let­ters pro­vid­ing feed­back on how the CMS should struc­ture the new physi­cian pay­ment pol­icy that was in­cluded in the Medi­care Ac­cess and CHIP Reau­tho­riza­tion Act (MACRA) passed this year.

The com­ment pe­riod ended last week, with 252 com­ments at last count. The CMS did not im­me­di­ately of­fer a re­sponse to the com­ments, but it’s ob­vi­ous the agency has a rough road ahead as it tries to come up with a way to mea­sure per­for­mance that’s work­able, fair, ac­cu­rate and po­lit­i­cally vi­able.

MACRA elim­i­nated the sus­tain­able growth-rate for­mula in fa­vor of the Merit-based In­cen­tive Pay­ment Sys­tem (MIPS), which takes into ac­count re­port­ing of qual­ity mea­sures and providers’ im­ple­men­ta­tion of elec­tronic health records that com­ply with mean­ing­ful-use re­quire­ments. MIPS also in­cor­po­rates the value-based pay­ment sys­tem that was part of the Af­ford­able Care Act. That sys­tem re­wards or pe­nal­izes providers de­pend­ing on how they score. The new pay­ments are slated to start in 2019.

In offering feed­back on the pol­icy, or­ga­ni­za­tions gen­er­ally called for flex­i­bil­ity and re­spect for vary­ing pa­tient pop­u­la­tions and spe­cialty prac­tice con­sid­er­a­tions.

The AMA, which out­lined 10 prin­ci­ples it wants the CMS to con­sider, said cur­rent pro­grams for gath­er­ing data and mea­sur­ing Medi­care qual­ity should not sim­ply be com­bined to form the ba­sis for the new mer­it­based sys­tem.

“Th­ese cur­rently sep­a­rate pro­grams must be care­fully as­sessed, re­vised, aligned and stream­lined into a co­her­ent and flex­i­ble sys­tem that is truly rel­e­vant to high-value care,” they wrote.

The Amer­i­can Med­i­cal In­for­mat­ics As­so­ci­a­tion said it sup­ports pay­ment based on out­comes, but is con­cerned that elec­tron­i­cally spec­i­fied clin­i­cal qual­ity mea­sures are not ac­cu­rate and com­plete enough. “As we tran­si­tion away from fee-for-ser­vice pay­ment, (we must) move away from the qual­ity mea­sure­ment par­a­digm un­der­ly­ing that sys­tem,” the com­ment read. “De­spite earnest ef­forts, qual­ity mea­sure­ment has not be­come ‘a byprod­uct of care de­liv­ered,’ as en­vi­sioned, and we are con­cerned the cur­rent mode is in­suf­fi­cient to en­able this.”

Premier, the Char­lotte, N.C.-based group pur­chas­ing or­ga­ni­za­tion, dis­agreed. It said the CMS should con­tinue to use the value-based pay­ment ap­proach, with some im­prove­ments, be­cause it is well un­der­stood and tested.

The Med­i­cal Group Man­age­ment As­so­ci­a­tion, how­ever, wrote that the new pro­gram should re­place the cur­rent val­ue­based pay­ment cal­cu­la­tion with episode-based mea­sures that have a solid ev­i­dence base. The group also said the CMS should elim­i­nate the Physi­cian Qual­ity Re­port­ing Sys­tem cri­te­ria when es­tab­lish­ing MIPS be­cause they would con­tinue to cause un­due ad­min­is­tra­tive bur­dens and be­cause there is no ev­i­dence to jus­tify those cri­te­ria.

“MIPS should not carry on the tra­di­tion of flawed qual­ity and cost as­sess­ments un­der a dif­fer­ent name,” it wrote. “We re­mind the CMS that the in­tent be­hind cre­at­ing MIPS is to hit the re­set but­ton and put an end to the bro­ken el­e­ments of cur­rent qual­ity pro­grams.”

In its com­ments, the Amer­i­can Acad­emy for Fam­ily Physi­cians said that pri­mary-care ser­vices are cur­rently un­der­val­ued, and rel­a­tive value data as used in the fee-for-ser­vice sys­tem are bi­ased and should not be the ba­sis for the new sys­tem.

Mul­ti­ple physi­cian groups and med­i­cal or­ga­ni­za­tions have pre­vi­ously re­quested that the fed­eral gov­ern­ment de­lay im­ple­men­ta­tion of EHR re­quire­ments that will help de­ter­mine physi­cian qual­ity un­der MACRA. They con­tin­ued to rail against the re­quire­ments in com­ments to the lat­est re­quest for in­for­ma­tion, and many or­ga­ni­za­tions said they should not be in­cluded in the new model. “The CMS will only guar­an­tee con­tin­ued fail­ure should Stage 3, as it is cur­rently writ­ten, be in­cor­po­rated into MIPS,” ac­cord­ing to MGMA com­ments.

Health­care groups also dis­cussed the Con­sumer As­sess­ment of Health­care Providers and Sys­tems (CAHPS) sur­veys, which are pub­licly re­ported and can af­fect pay­ment. The Amer­i­can So­ci­ety of Clin­i­cal On­col­o­gists said CAHPS should not be used as a qual­ity mea­sure and should in­stead be a clin­i­cal prac­tice im­prove­ment ac­tiv­ity, while Premier said CAHPS should be op­tional be­cause it may not be suited for all providers.

The CMS will take the com­ments into con­sid­er­a­tion be­fore it is­sues a pro­posed rule, which is ex­pected next spring.

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