CMS' 'doc fix' may need some repairs itself

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 merit-based 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 value-based 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.