ASH Comments on MACRA Final Rule

Summary of ASH MACRA Comments v MACRA Final Rule

On October 14, 2016, the Centers for Medicare and Medicaid Services (CMS) released its final rule outlining the new payment system for Medicare clinicians, implementing the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) payment provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), collectively called the Quality Payment Program (QPP). CMS will accept public comments on this final rule until December 19, 2016 at 5:00pm EDT. An overview of final rule’s provisions on which ASH commented follows in the paragraphs below.

Unit of Accountability

ASH supported allowing physicians to choose to report at either the individual physician or group level. ASH also advocated for having the unit of accountability chosen being applied to all four elements of the MIPS system.

CMS finalized its proposal that clinicians be able to report as individuals or at the group level and that the same identifier be used for all four performance categories. If information is submitted at the group level in one MIPS performance category, then it must be measured at the group level for all four categories (quality, cost, clinical practice improvement activities, and advancing care information).

Quality Measures

ASH supported CMS’s proposals to reduce the number of measures physicians will report from nine to six. However, ASH did advocate that the agency switch from the proposed increase in the reporting threshold (80% for claims-based reporting and 90% for EHR, clinical registry, QCDR, or CMS Web Interface mechanisms, up from 50% in the previous system, regardless of the type of mechanism) to a more graduated approach that would raise the reporting threshold over a period of years.

In its final rule, CMS finalized its proposal requiring MIPS eligible clinicians or groups to report at least six measures, including at least one outcome measure if available, for a minimum of a continuous 90-day performance period. CMS did not finalize its proposed 80%/90% reporting thresholds after feedback from ASH and other stakeholders. Instead, for the 2017 transition year, CMS finalized a 50% reporting threshold for claims, clinical registry, EHR, and QCDR mechanisms; consistent with the current PQRS requirements. For the 2018 performance year, CMS finalized a 60% reporting threshold for EHR, clinical registry, and QCDR mechanisms, consistent with ASH’s request for graduated implementation of the higher thresholds.

Specialty Specific Measure Sets

ASH did express appreciation for CMS’ attempt to provide more flexibility and to simplify the measure selection process for physicians to whom many measures apply by developing specialty specific measures sets. There are no measures sets for hematology or clinical oncology. However, the Society suggested in its comments that it would be simpler to require six measures from all physicians who have eligible patients within the denominators of the approved measures and require everyone to meet the same standards.

CMS did finalize a proposal requiring MIPS eligible clinicians or groups to report at least six measures for a continuous 90-day performance period at a minimum. The agency also finalized a proposal allowing MIPS eligible clinicians or groups to report one specialty-specific measure set, or the measure set defined at the subspecialty level, if applicable. The final rule did state, however, that if the measure set contains fewer than six measures, MIPS eligible clinicians will be required to report all available measures within the set. If the measure set contains six or more measures, the MIPS eligible clinicians can select six measures or more. Clinicians reporting on a measure set will be required to report at least one outcome measure or, another high priority measure (appropriate use, patient safety, efficiency, patient experience, and care coordination measures) within the set if no outcome measures are available.

Resource Use

In its comment letter, ASH expressed support for CMS’ proposal to adjust the resource use measure based on a provider’s specialty and requested that the agency continue to examine and refine the risk adjustment methodology. ASH also supported CMS’ proposals to set the benchmark for resource use assessment on the measurement year as opposed to the prior year’s benchmark and to add episode measures, but not the deep vein thrombosis measure until it received further feedback from stakeholders.

For the 2017 transition year, CMS reduced the weight for the cost performance category in the final score to 0, with MIPS scoring based only on the other three performance categories. Beginning with performance year 2018, the cost performance category weight in the MIPS final score will gradually increase from 0 to the 30 percent by 2021 as required by MACRA.

This performance category will not require MIPS eligible clinicians to report any data to CMS. A clinician’s score will be calculated by CMS based on cost measures, and the agency will provide performance feedback to clinicians. CMS also finalized 10 episode based measures that were previously reported in the 2014 supplemental Quality and Resource Use Reports (QRURs) and were found to meet the agency’s reliability thresholds. Because it was not included in the 2014 QRUR, the deep vein thrombosis measure was not finalized for the MIPS CY2017 performance period, as was recommended by ASH.

Cost of Drugs

ASH requested that CMS rescind its proposal to continue to exclude the cost of Medicare Part D drugs from resource use measures. The Society instead recommended that the cost of Medicare Part D drugs be included, despite the technical challenges to doing so.

After receiving comments both for and against this proposal, in its final rule, CMS stated that to the extent possible, it will continue to investigate methods to incorporate this component of healthcare spending into its cost measures in the future.

Clinical Practice Improvement Activities

ASH expressed support for CMS’ broad and flexible approach to this new category which allows for the reporting of many different types of improvement activities. Because this is the only completely new MIPS performance category, ASH requested that the agency make education a focus so providers would understand their responsibilities and requirements to succeed in this category. Also, ASH requested that CMS be as inclusive as possible in considering what is categorized as a clinical improvement activity.

CMS finalized the definition of clinical practice improvement activities to include an activity that a relevant MIPS eligible clinician, organization, or other relevant stakeholders identify as improving clinical practice or care delivery, and that the Secretary determines is likely to result in improved outcomes when effectively executed. CMS included an improvement activities inventory in Table H in in the Appendix of the final rule which includes a description of the specifications for how to satisfy the qualifications for each project (activity) in order to earn points. Table H may be read from pages 2189-2204 in the final rule.

Advancing Care Information

ASH expressed support for CMS’ move away from the “all or nothing” measurement standard used in the current Meaningful Use program to one that awards partial credit for certain components of EHR use.

CMS finalized its proposal to move away from the all-or-nothing approach as advocated for by ASH. Certain measures under the final policy remain required measures for the base score in the advancing care information performance category, including e-Prescribing, Send Summary of Care, Request/Accept Patient Care Record, and Security Risk Analysis. CMS reduced the total number of required measures from eleven in the proposed rule to five in the final rule in this category.

Alternative Payment Models

ASH highlighted the need for CMS to work on issues related to rare diseases and focus its efforts on approving APMs in areas where there is a clear need. Populations such as those that suffer from sickle cell disease can at times be ignored by the healthcare delivery system and require significant investment by APM entities.

In its final rule, CMS acknowledged that while it may already have an APM addressing a specific disease, condition, or episode, there may still be unique, valuable payment approaches for similar conditions. The agency finalized the criterion for Physician-focused Payment Models (PFPM) to require that they aim to broaden or expand the CMS APM portfolio by addressing an issue in payment policy in a new way or include APM Entities whose opportunities to participate in APMs have been limited. CMS asserted that will further its goal to promote participation in APMs.

Transition Year Reporting Basics (2017 Reporting, 2019 Payment)

• Eligible clinicians will have three flexible options to submit data to MIPS and a fourth option to join Advanced APMs in order to become QPs
• Option 1: Clinicians can choose to report fully on MIPS for the entire year or a full 90-day period to maximize their chances to qualify for a bonus payment.
• Option 2: Clinicians can choose to report on MIPS for less than the entire year, but for a full 90-day period at a minimum, and report more than one quality measure, more than one improvement activity, or more than the required measures in the advancing care information performance category in order to avoid a penalty under MIPS and possibly receive a bonus.
• Option 3: Clinicians can choose to report one measure in the quality performance category, one activity in the clinical practice improvement activities performance category, r report the required measures of the advancing care information performance category and avoid a negative MIPS payment adjustment
  • If MIPS eligible clinicians choose to not report even one measure or activity, they will receive the full negative 4% adjustment. CMS leadership has said that the only negative MIPS scores will go to those “not submitting one piece of data.”
• Option 4: Clinicians can participate in an advanced APM
• Clinicians who achieve a final MIPS score of 70 or higher will be eligible for the exceptional performance adjustment.
• MIPS eligible clinicians must submit measures and activities in Quality, Improvement Activities, and Advancing Care Information categories for full participation and highest possible scores
• The weighting of the cost performance category has been lowered to 0 percent for the transition year
• Full participation in the quality performance category requires reporting on six quality measures, or one specialty-specific or subspecialty-specific measure set
• Full participation in the Advancing Care Information performance category (Meaningful Use): MIPS eligible clinicians report on five required measures
  • Reporting on all five of the required measures would earn MIPS eligible clinicians 50%
  • Reporting on optional measures would allow MIPS eligible clinicians to earn a higher score
• Full participation in the Clinical Practice Improvement Activities performance category: Clinicians can engage in up to four activities (Highest possible score of 40)
  • Down from six in the proposed rule
  • For the 2017 transition year, CMS will award a bonus score for activities that utilize CEHRT and for reporting to public health or clinical data registries