Some worry that a new approach would recreate the “black box” physician-quality determinations that are made by commercial insurers.

Feb. 16—The Trump administration is pushing to scrap quality reporting for most physicians who are paid under Medicare’s new payment system.

Specifically, the administration this week proposed to end quality reporting under one of two tracks of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The vast majority of physicians paid under MACRA will fall under the Merit-based Incentive Payment System (MIPS), which the administration wants changed.

The administration’s proposed budget for the U.S. Department of Health and Human Services (HHS) includes removing two MIPS performance categories (the budget does not specify which categories) and evaluating performance only based on “meaningful quality and cost measures.”

For those measures, “Performance would be assessed by [the Centers for Medicare & Medicaid Services] without requiring any reporting from clinicians, thereby leaving more time for clinicians to focus on patient care,” the budget states.

The administration would simplify MIPS through the use of broader claims-based measures and beneficiary survey-calculated measures that assess clinician performance on quality and cost during each performance period only at the group (the budget does not specify which type of group) level. Additionally, MIPS cuts would be limited to payments made under the Physician Fee Schedule rather than all Part B payments. MIPS cuts go as high as 9 percent of a physician’s annual Medicare payments.

A separate proposal would change the second part of MACRA, which pays physicians who are part of advanced alternative payment (APM) models. The budget would remove the thresholds (the budget does not specify if this was referring to revenue and patient-volume thresholds) that clinicians must meet to receive a bonus for participating in APMs and instead would pay bonuses to all clinicians participating in such models.

HHS Secretary Alex Azar told the Senate Finance Committee on Feb. 15 that the proposal was among many regulatory relief initiatives that the administration was advocating.

“What we we’re doing is taking a whole host of physicians who will have not only reduced reporting burdens but maybe none under the MIPS part of the program,” Azar said. Under the proposal, “We would be able to look at data ourselves to determine their compliance with the quality programs, rather than their having to report anything.”

Differing Views

The MACRA changes followed the call of many physician advocates to reduce or eliminate the quality-reporting requirements. And some praised the administration’s proposal.

“The administration's goal of reducing reporting burden for MIPS-eligible clinicians is spot on,” said Cybil Roehrenbeck, an attorney for Polsinelli and a former lobbyist for the American Medical Association. “That goal should be balanced with the use of data that appropriately reflects clinicians' efforts to improve care and accurately attributes costs, which may be difficult using [CMS] internal data sources alone.”

Brian Outland, PhD, director of regulatory affairs for the American College of Physicians (ACP), said his organization supports efforts to reduce the administrative burden of quality reporting and performance measurement.

“Measures that are calculated via administrative claims and require no additional data submission by the physician are one way of reducing the burden on physicians,” Outland said.

However, because ACP has concerns with many quality measures used by CMS, the organization “would need to evaluate new measures under consideration to ensure that they are properly designed and measuring outcomes that are high-value and important to physicians and their patients,” he said.

The administration’s proposal followed CMS delays over the last two years in fully implementing MACRA amid provider group requests to be given flexibility. Provider groups have sought an additional three years of flexibility in fulfilling the law’s requirements.

Others were dubious about the benefits of the proposal.

Jennifer Searfoss, founder and chief solutions strategist of healthcare consulting firm SCG Health, said the proposal fails to simplify the MACRA program or alleviate the burden on clinicians.

“There is no specialty-specific thought or autonomy permitted where clinicians can choose what quality aspects are appropriate for them and their practice,” Searfoss said.

The proposal “silos clinician rating to only claims data and to quality measures assessed as valuable to Medicare officials,” and eliminates the anticipated participation benefits of moving to APMs by removing the thresholds, she said.

A Feasible Approach?

Some have questioned whether CMS is capable of undertaking such an internal quality compliance assessment of physicians.

“The question is, How robust are the CMS data capabilities?” said Anders Gilberg, senior vice president of government affairs for the Medical Group Management Association (MGMA). “They can’t really even share information within a year with providers to help them improve quality.”

He doubted CMS would have the same ability as commercial insurers to analyze claims-based quality measures to determine MIPS bonus payments or cuts.

Other alternative approaches that CMS could take with MIPS include the use of qualified clinical data registries, which pull data directly from the electronic health record, Outland said.

“These should also be considered in burden reduction [efforts] within quality improvement, as the information that they collect can be valuable to other areas such as clinical research,” Outland said.

Jennifer McLaughlin, senior associate director for MGMA, said the administration’s proposal echoes the concerns and approach urged by the Medicare Payment Advisory Commission (MedPAC). In January, MedPAC voted to urge Congress to replace MIPS with a new voluntary value program, which would compare clinicians in voluntarily formed groups based on the quality of care provided to patients.

McLaughlin raised concerns that an internal assessment by CMS would create the same lack of transparency that physicians face in quality assessments by commercial insurers.

“A similar concern that many practices across the country express with a lot of the private-payer quality-cost metrics that are calculated in a ‘black box’ is that the outcomes are just reported to the practice later on, and there really isn’t any transparency or predictability,” McLaughlin said.

She also doubted that such a change is likely this year since the statutory requirements of MACRA would necessitate an act of Congress.

“There’s not much political appetite to make wholesale changes” to MACRA, she said, noting that Congress limited itself to technical corrections to MACRA as part of the recently enacted budget deal—which included a broad range of healthcare policy changes in many other areas.

Rich Daly is a senior writer/editor in HFMA’s Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare

Publication Date: Friday, February 16, 2018