Massachusetts Medical Society: MMS Comments on Proposed Rule for MACRA

MMS Comments on Proposed Rule for MACRA

Mr. Andrew Slavitt 
Acting Administrator 
Centers for Medicare & Medicaid Services 
Department of Health and Human Services 
Hubert H. Humphrey Building, Room 445-G 
200 Independence Avenue, SW 
Washington, DC 20201

Re: Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models; Proposed Rule (CMS-5517-P)

Dear Administrator Slavitt: 

On behalf of the 25,000 physician, resident and medical student members of the Massachusetts Medical Society (MMS) and our patients, I am pleased to submit the following comments in response to the notice of proposed rulemaking (NPRM) regarding the implementation of MIPS and APMs under the Medicare Access and Chip Reauthorization Act (MACRA).  At the outset I want to thank you for your personal commitment and genuine interest in making these regulations patient centered, physician focused and simple.   There are a number of improvements in the proposed rule which we support. In addition, we applaud your agencies outreach throughout the rulemaking process to inform and solicit comments from the physician community.  We at the MMS share your goals and hope our comments, which follow, will help CMS develop final rules which will achieve this end. 


I have appended the extensive and thoughtful comments submitted by the American Medical Association which we support.  The Massachusetts Medical Society was one of the many state and national medical organizations who worked with the AMA in development of these recommendations.   The AMA comments provide specific detailed recommendations for change where the proposed regulations are concerning as well as support for those provisions which we believe are consistent with Congressional intent and the law.  Our comments that follow will emphasize several overarching priority areas of concern to Massachusetts physicians and our Medicare patients. 


We join the AMA in asking the agency to issue an interim final rule as the next step which would allow more time for continued improvement and refinement of these requirements.  As our comments detail, we believe the current time frame is too compressed to either allow physicians or CMS to implement this critical program effectively. The stakes - the health care for America’s Medicare beneficiaries who depend on the viability of physicians practices - are too important for us to fail.  In addition, given the predilection of the private insurance industry to follow the lead of CMS, we suspect the final regulations will have a wider impact upon the practice of medicine in venues beyond those dominated by Medicare. 


The MMS looks forward to continuing to work collaboratively with you and your staff. The Society fervently wishes to make the implementation of MACRA a success for our physicians and the patients we serve.


Our specific comments follow.


I.        Amend the performance period to allow for sufficient time to prepare physicians to have a successful launch of MACRA.


The NPRM requires that both the MIPS and the APM performance periods begin January 1, 2017 for one year, with the first MIPS payment adjustments beginning in January of 2019 and the first incentive payments to Advanced APMs beginning mid 2019.  Given that final rules are not expected until the fall of 2016, we are gravely concerned that this abbreviated time frame would significantly undermine the ability of physician offices to understand, prepare for and implement a myriad of new requirements.  It is difficult to conceive how a physician’s office could feasibly learn and operationalize what we expect will be a voluminous and complicated final rule in a 60 day period.  We are obviously very worried about the impact on small practices, but even the more sophisticated PHOs, ACOs and physician networks in Massachusetts have expressed serious concerns about the time line.


Congress clearly stated in the MACRA law, that CMS should “make efforts” to align the performance period  in close proximity to the payment year – thus showing a correlation between the physician’s work and the resulting impact on quality, clinical integration, electronic health records and resource use.  A two year gap between the performance year and payment, particularly with a new program, fails to meet this test.


We urge CMS to move back the performance period to allow physicians adequate time to implement the new systems required by MACRA and to align the performance period with payment as defined by the impact on quality, clinical improvement, HIT, and resource use.  Nationally we understand that the majority of physicians’ organizations are recommending that the performance period begin in either July of 2017 or January of 2018 with a shortened performance period of less than one year (for example, 90 days to be determined by the physician practice).  We recommend physicians’ be given one year before the start of the performance period;  at a minimum we support moving the performance period back to July of 2017 with a possibility of additional time for small practices (see our recommendations under II Impact on small, solo and rural practices).   At the same time, it is critical that CMS provide feedback reports from the performance data to physicians in a timely manner so they can assess the veracity of the data and address underlying issues related to the data within a practice.  We know that the success of this law and, more importantly, physician’s ability to provide quality care to their patients, depends on our ability to ensure that both physicians and CMS have the opportunity to appropriately vet, test, evaluate and revise both the data and systems to meet our goals.  To be useful the data must be accurate, meaningful and actionable.  This will also take time.


II.      Provide more flexibility for solo physicians and small group practices, including raising the low volume threshold for small practices permanently exempted from MIPS reporting


a.      Impact on Small, Rural Health Professional Shortage Areas and Similarly Situated Practices


One of our most significant concerns with the proposed rules is the potential impact on small, solo, and rural practices.   We know that you share our interest in protecting the future of these practices under MACRA as well as the access to care for the patients they serve.  Even in Massachusetts, a number of our physician practices are considered small.  For these practices the costs of implementing new systems, procedures, hardware and software are disproportionately higher and more complicated than for larger integrated groups or employed physicians.  Congress understood this concern and included limited technical assistance funds to help small practices implement the new MACRA requirements.  


Simply put, small practices do not have the resources, whether financial or human, to invest in the new reporting systems and procedures to fulfill the administrative requirements that will be mandated by MIPs.  Physician practices will be required to learn and implement a myriad of new programs including, but not limited to new a) reporting, b) documentation and compliance measures, c) training of all relevant staff, d) reviews and verification of data, and e) additional costs involved with the installation, upgrade, or replacement of new software or EMRs. There are also the significant costs associated with lost productivity and time taken from patient care as physicians and the entire office learn new reporting programs.  Even small practices that are “affiliated” with larger systems are left to bear the burden of dealing with these issues.  Many of these costs are subject to economies of scale that place disproportionate financial stresses on these smaller practices.  Nor do they have a cash reserve that can keep them financially solvent while revenues decrease.   Some will be forced to leave the Medicare program; allowing practices more time to plan for and comply with the rules may help some stay in Medicare programs. 


The continued viability and sustainability of these small practices is critical to ensure that all patients – not just Medicare beneficiaries – have access to care.  MACRA was in part designed to help these small practices not only continue to survive but to transition successfully to new delivery and payment models. 


At a minimum we recommend the following changes to the proposal.


  • CMS should consider a phase in for small practices, depending on their size, over a several year period.  Small practices are defined as 15 clinicians and under. The phase in would be voluntary so that physicians in small groups would be given the choice of when to participate in the MIPS program.   A related recommendation is that CMS not penalize very small practices (for example, 5 and under) for a specified period of time – allowing them to implement and learn about MIPS reporting. These practices would be eligible for positive updates, without the risk of a penalty during the initial implementation period. 
  • Lower reporting burdens for small, rural and similarly situated practices.  CMS should provide explicit exemptions and lower thresholds throughout the rule for small practices.  For example, in the four MIPS reporting categories, small practices should be required to report on fewer measures as well as be exempt from reporting in certain categories (including the new ACI).  While the rule acknowledges that rural providers may have problems accessing the internet, there are a significant number of other variables that could make reporting in the ACI category a problem for such physicians.   Small practices should also be compared to each other in the scoring methodology. They should not be penalized because they do not have the resources or patient population of larger groups.

  • Provide training, education and technical assistance to small practices. CMS should provide specific, targeted training for small practices and those in rural areas to help them comply with the MIPS requirement.  The MMS worked closely with our Congressional delegation during the drafting of MACRA to support the $100 million in technical assistance funds for small practices. 


b)     Physicians Exempted from MIPS – Revised Definition of  Low Volume Threshold for small practices permanently exempted from MIPS reporting


The NPRM proposes to permanently exempt from the MIPS reporting several groups of physicians and health care professionals including those who are exempted by virtue of a low volume threshold, defined as treating 100 or fewer unique Medicare beneficiaries and $10,000 or less in Medicare allowed charges billed per year.  The statute allows the Secretary to choose among three criteria to define the low income threshold including number of patients, number of items and services provided and/or billable charges.  The AMA analysis of the 2014 “Medicare Provider Utilization and Payment Data: Physician and other Supplier” file found that 10% of physicians and 16% of all MIPs eligible clinicians would be exempted under this definition. This group accounts for less than 1% of the Medicare fee schedule.


The MMS urges CMS to expand the definition of Low Volume threshold to $30,000 in Medicare allowed billable charges annually or fewer than 100 unique Medicare patients.  According to AMA data, the new definition would exclude approximately one quarter of physicians while subjecting more than 93% of Medicare spending to MIPS reporting.  Using the criteria from the rule, we believe this strategy is “value-oriented” as the preponderance of Medicare spending would be subject to the MIPS methodology.  Our concern is that that the current definition is too limited.  Small practices which treat few Medicare beneficiaries would be disproportionally impacted by the cost of complying with the MIPS reporting requirements.  Medicare beneficiary access to care could be significantly harmed should these practices decide to treat fewer Medicare patients or withdraw from the program completely.  Clearly Congress included the low volume exemption to help protect these small practices and the patients they serve.


  • Expand the definition of Low Volume threshold to $30,000 in Medicare allowed billable charges annually or fewer than 100 unique Medicare patients


c)      Virtual Groups


The MACRA statute envisioned the formation of virtual groups, which we believe hold promise for solo/small practices and the patients they serve.  It is important to understand that these practices are not limited to rural areas, but are critical to providing care throughout our state.  As we know, the increased consolidation of care is driving up the cost of care.  Small and solo practices are critical not only for patients’ access to care, but also to control costs and maintain a balance in the health care oligarchy. 


In MA several of our solo and small primary care practices are in the process of exploring the formation of virtual groups and virtual medical homes.  Unfortunately, there are a number of barriers and challenges.  The potential for these virtual practices to expand access to high quality care and reduce costs through small practices is significant.  In one model, the “virtual” medical home has focused on case management services for patients with the highest readmissions rate.  Through a consortium of services, these physicians and health care providers have significantly reduced the readmission rate, improved the quality of their patients care and reduced costs. Yet the legal barriers to actually forming a “virtual medical home” are significant.   Congress purposefully included language in MACRA creating virtual groups to overcome existing barriers as a way to help small and solo practices survive.  It is imperative that CMS work with the physician community expeditiously to develop regulations governing the formation of these models. We urge CMS to allow maximum flexibility with this new option.  The formation of virtual groups should not be limited by specialty, size or geographic region.


III.    Make Specific and Targeted Adjustments to Ensure that Patients with Health Care Disparities Receive High Quality Care


The MMS and all of our physician colleagues are extremely concerned about the inadvertent impact these rules - and the overall movement to quality, efficiency metrics and market consolidation – will have on our patients with health care disparities.   This is an issue about which the Acting Administrator also has expressed great concern.  Numerous studies have demonstrated conclusively that poverty and lack of education are correlated with poor health outcomes, even when health care is universally available.   Even in Massachusetts, where we pride ourselves on being the first in the nation to provide universal access to health insurance, we learned this painful lesson. 


The highest risk occurs at the intersection of health disparities and health care disparities.  Health disparities are defined as the prevalence or incidence of a disease population in a given ethnic or racial group.  Health care disparities are defined as poor access to or poor quality of care when referenced to the norm.  It is this risk driven by the social determinants of health care that makes so called “Population Health” more challenging in lower income communities.  Either disparity may result in poor outcomes. 


The analysis of the risk of managing these populations of patients has to be assessed prospectively allowing for adjustment in payment models and care management.  The quality metrics and outcomes would then be adjusted relative to the risk. 


Data have already shown hospitals that disproportionately care for minority or poor patients score poorly on HQA process measures, efficiency, costs and HCAHPS patient experience.   We know that minority patients and patients with health care disparities have a much higher readmissions rate.   Consequently we know that physicians and hospitals that treat these patients will score lower on all MIPS metrics.  The value based modifier, which is the basis for the resource use category, is, in our opinion, a significantly flawed formula.   CMS does not have a method to account for these socio economic issues, difficult issues which negatively impact a patient’s ability to seek preventive care, comply with treatment plans and follow up – issues which a physician cannot change or control.   


The current CMS methods that fail to risk adjust accurately for socioeconomic status and the resultant impact on health care penalize physicians who care for fragile, high risk patients (whose high costs are negatively reflected in expenditure scores).   We urge CMS to consider several recommendations to address this potential problem:


  • Make specific adjustment for the number of Dual Eligible Medicare beneficiaries in a physician’s practice as part of the determination of the MIPS Resource Use Calculation.


  • Analyze the risk of managing these populations of patients prospectively allowing for adjustment in payment models and care management.  The quality metrics and outcomes would then be adjusted relative to the risk


  • Provide bonus points/payments to physicians treating a certain threshold of dual-eligible Medicare beneficiaries to ensure that physicians and health care providers are not penalized for treating fragile, high risk, costly patients.


  • Significantly revise the Resource Use Category specifically with respect to the physician attribution methodology, subspecialty physician comparisons, and most importantly include adjustment for race, ethnicity, income and socioeconomic status of the patient.


  • With respect to APMs, we recommend CMS risk adjust for patient characteristics in determining benchmarks


  • Monitor programs for de facto avoidance of “at risk” patients.


  • Mandate quality indicators by race/ethnicity within the APM.


  • Examine the distribution of patients by race/ethnicity between APMs when assessing quality of care.


  • Lower financial risk requirements for Medicaid and other Medical Homes which treat a significant percentage of patients with health care disparities.


  • Merit Based Incentive Payment – MIPS


The AMA Comments detail critical changes that should be made to each of the reporting categories under MIPS.  We strongly support these recommendations.  Our main point is to simplify the MIPS program into one streamlined entity that has relevance to quality and patient care. 


Specific recommendations include:




  • Align the different components of MIPS so that it operates as a single program rather than four separate parts.


  • Simplify reporting burdens and improve chances of success by creating more opportunities for partial credit and fewer required measures within MIPS.


  • Test and demonstrate the reliability before any mandated measures are used for accountability, payment or public reporting.  New measures need to be risk adjusted, tested and released for comment prior to implementation.


Feedback and Reporting Mechanisms


Physicians’ access to timely, valid, meaningful information is critical to the success of the MIPS program and improved health care.  Too often access to these data have been delayed, the information itself upon which the data are based has been flawed, and the validity of the result is in question.  We are very concerned about the Agency’s ability to correctly attribute data to the correct physician – an issue which CMS acknowledges in the proposed rule.   We would welcome the opportunity to work with CMS and other stakeholders to help develop the best format for sharing meaningful information and allowing actionable feedback with physicians and practices.  It is critical that CMS:


  • Provide ongoing real-time feedback on performance.

  • Clearly outline methods used to calculate any benchmarks or attributes for a particular measure.


  • Make available web-based dashboard and paper reports.


  • Develop a fair and transparent process for physicians to appeal findings in the feedback reports and lengthen the review timeline to at least 90 days.


  • Release feedback reports in a timely manner.


  • Quality Measures


  • Reduce the thresholds for reporting on quality measures from 90% to 50%.


  • Reduce the number of required quality measures.


  • Eliminate the mandate for outcome and cross-cutting measures requirement; provide bonus points for those who report on these measures.


  • Provide a three year phase out of any measures that are being proposed for removal.


  • Allocate the $75 million (over 5 years) for the development of physician led quality measures.


  • Simplify the scoring process; ensure scoring does not favor large practices.


  • If population health measures are retained, develop benchmarks by specialty and region.


  • Ensure that data are accurate – hold physicians harmless from vendor errors.


  • Develop more specialty based quality measurements (note that specialty societies may have such measurements and bench marks already established).


  • Resource Use


As noted previously, the MMS has serious questions about the resource use category which continues to include components from the fatally flawed value based modifier.  We are very concerned about the agency’s ability to attribute accurately claims information (as noted by the CMS).  CMS should risk adjust the data for socioeconomic, health status, and geographic cost differentials.  We are also very concerned about the status of “episode groups” which are very much a work in progress.  We strongly recommend CMS conduct a pilot on the resource use category and exempt physicians from reporting until the program has been appropriately tested. 


Specific recommendations include:


  • Improvement of risk adjustment and attribution methods before moving forward with the resource use category.


  • Replacement of current cost measures that were developed for hospital-level measurement and refine and test new episode measures prior to widespread adoption. 


  • Collaboration such that CMS works with medical specialties to identify and refine episode groups that seem most promising, piloting their use on a voluntary basis. No resource uses should be mandated until Care Episode Groups, Patient Condition Groups and Patient Relationship categories have been developed, tested and supported by professional societies treating the majority of patients in those groups.


  • Recommendation that CMS reweight the resource performance category to all available MIPS categories (not just quality) for the case of physicians for whom there are no resource use measures.


  • Pairing of Quality and Resource measures – to make sure that high cost physicians are not penalized for treating rare, costly conditions which might concentrate in their practices because of their special expertise.


  • Elimination of Part A and Part B drug costs from resource use.


  • Calculation of resource use on a baseline period closer to the payment period rather than the performance period.


  • Clinical Practice Improvement (CPIA)


The MMS supports the broad range of CPIAs included which allow physicians to report based on their region, specialty, and patient mix and practice characteristics.  We support the proposed rule’s flexibility in providing lower thresholds for small rural and non- patient facing physicians as well as not requiring lengthy documentation for this category.  We also support giving physicians who practice in medical homes, and APMS full credit in this category. 


Specific recommendations include:


  • Decrease the number of required CPIAs – rule currently requires 6 categories. We support AMA recommendation to decrease the number depending on the weighting of the category.


  • Increase credits for medical home and expand entities that qualify to include similar specialty recognition programs, including state based payer sponsored groups, such as the Blue Cross Blue Shield ACQ.


  • Expand the list of CPIA activities to include more high weighted activities.


  • Advancing Care Information ( ACI)


As the Administrator is well aware, physician frustration with the former Meaningful Use program has been one of our biggest concerns and problems.    We were extremely pleased when CMS announced that the meaningful use (MU) would be significantly revised to make it more aligned with patient care. The MMS appreciates a number of the critical changes that have been incorporated into this rulemaking including reducing the number of categories that need to be reported,  eliminating the all or nothing scoring (with one significant exemption) and streamlining the reporting process.  But in the big picture, we remain extremely concerned that the measurements that the physicians will be required to report under the proposed plan have not been revised to reflect patient care or to be useful to medical practices.  We strongly urge CMS to convene working groups from the medical specialty organizations to significantly overhaul the MU reporting categories, to simplify the system and more importantly to align the new ACI program with issues that are in concert with the best patient care.   The concept of the MIPS program can work if the program is coordinated, simple and meaningful.   ACI reporting that includes timely communication of test results, closing a referral loop and updating care plans would be valuable.   


  • Simplify and revise ACI measures to make them relevant for physician’s practices and patient care. CMS should invite proposals for the development of these measures from national medical organizations which would replace the current MU 3 platform. Ideally the ACI measures would connect back to the quality and clinical use categories.


  • Eliminate the pass-fail approach for reporting the base score. Success in performance scoring should be based on the physicians/practices’ improvement year to year – not by static comparison to other practices of varying sizes, location and specialty.  This diminishes the effect of care disparity on score, as improvement rather than absolute score demonstrates continuous movement towards higher quality care.


  • Measure the majority of patients, not total patient population.

  • Allow physicians to continue to use 2014 CEHRT, if so they so choose.


  • Continue existing hardship and exemptions – expand to include low volume practices and small practices (see specific recommendations in Section II).


  • Establish a 90 day reporting period – requiring one year will hinder the ability to test and implement technology.


  • MIPS Composite Scoring Methodology


Overall the proposed MIPS composite scoring method is too complex.  The AMA’s comments detail how to revise the formula and calculations to streamline the process and make it more relevant and comprehensible for physicians. We strongly urge CMS to revise this process.


  • Third Party Data Submission


As noted earlier in our comments, physicians cannot be held responsible for errors or delays by third party vendors.


  • Require testing and provide data validation on data submitted to EHR vendors and Qualified Clinical Data Registries (QCDR) to CMS. Inform physicians about errors.
  • Notify physicians when a third party data submission entity is on probation.
  • Provide flexibility for QCDRs – to encourage the use of QCDRs and to focus on specialty specific measurements (vs cross cutting) measurements not applicable to a designated specialty or QCDR.


  • All Payers Claims Data


CMS proposes to require all payer claims data through qualified registries, QCDR and EHR mechanisms, but only Medicare Part B data for claims and web interface reporting. Given that the quality benchmarks are based on the Medicare population, we are concerned that mixing the patient base will result in inaccurate and misleading assessments of quality performance.  We recommend CMS make reporting consistent and limit it to Medicare patients.


  • Non patient Facing Clinicians


CMS proposes to define non-patient facing groups as 25 or fewer patient facing encounters for the entire group to be exempted from MIPs reporting.  Rather we would encourage CMS to broaden the definition to apply to individual members of the group. If more than 51 % of the members meet the criteria, the group would be considered non-patient facing. Also recommend that CMS revise the criteria to designate clinicians as hospital based to include care provided in hospital outpatient settings – excluding evaluation and management codes.  Recommend that CMS designate this group as facility based as opposed to hospital based.


V.     Alternative Payment Models: Simplify and Lower Financial Risk For APMs, Expand Options


As the AMA comments detail, there are a number of provisions in the proposed rule regarding Alternative Payment Models (APMs) which we support – most notably those which allow APMs flexibility in determining quality measurements and other metrics.


Our overarching concern is that the proposed definition of an Advanced APM is overly restrictive and could hinder ongoing progress in practice transformation.   The corollary is that because the bar is set so high in these rules to become an advanced APM there is a missed opportunity to help physicians who want to transition to value based payment models without fear of insolvency.   The financial risk requirements in the proposed regulations are unattainable for most organizations and effectively limit the 5% bonus payments to the 5 existing CMS innovation Center models, as noted by CMS. This is occurring at a time when national medical specialty organizations are developing unique specialty-centric payment models and at the state level, organizations are successfully developing ACOs, APMs and a variety of value based risk bearing organizations which will not qualify for the 5% bonus incentives as currently proposed.  It is critical that the new MACRA regulations support innovative efforts at the federal and state level and not create new challenges or misaligned incentives for physicians that impair the growth of these organizations.


We strongly urge CMS to expand the definition of APMs to support both the maturation of existing models and to create a series of options which will help other physician practices transition gradually and successfully to risk bearing value based payment models.  


Setting aggressive risk requirements for inclusion into the APM program is counter to the clear message that the Massachusetts legislature sent to physician organizations in their cost containment bill (Ch. 224 of the Acts of 2012). In it, the legislature created a “Risk-bearing Provider Organization” certification program to ensure that physician organizations were taking downside financial risks commensurate with their ability to maintain fiscal solvency. The program acknowledges that the appropriate risk, that is, sufficient risk to help incentivize clinical change without undue risk of financial insolvency, depends on the size, structure, and organization of a given physician operation. Creating arbitrary, unduly high inclusion requirements will accomplish only two things: 1) drive out smaller provider organizations that are taking downside risk appropriate to their size and structure, or 2) drive certain physician organizations to enter into contracts with risk that puts their entire practices in jeopardy for insolvency. If the goal is to promote physician organizations of various sizes to move towards appropriate risk-bearing contracts, then the current APM formula is not the appropriate solution.  The proposed APM policies should not create new challenges and barriers for physicians who are successfully participating in high quality value based programs or misalign incentives between the existing programs and future APMs.


Specific recommendations include:


  • Expand the definition of MACRA Advanced Payment Models to allow wider physician and medical group participation. Consider including all Track I ACOs, NCQA Patient Centered Medical Homes and new evolving models that allow different levels of financial risk. 


  • Encourage CMS to create a process to review various APM models in a transparent and expeditious manner that includes input and feedback from all physicians and health care professionals involved in the model. CMS should take steps to ensure that primary care physicians and specialists have equal opportunities to participate in Advanced APMs.


  • Include physician’s investment and uncompensated costs as potential financial losses.  This is a critical point if new APMS are going to be created and succeed. The costs of developing and organizing an APM are significant. These include a) hiring of a wide variety of staff including medical and health care professionals and care coordinators; b) training for new staff; c) initiating new systems for data analytics and a variety of communication vehicles to follow up with patients routinely; and d) purchasing new HIT systems and communication systems which are critical to care redesign.  Many of these costs are not reimbursed by Medicare. In addition, there is a significant lag time between the formation of a new ACO and when the organization can realistically begin to recoup investments.  CMS provided funding for the initial start of early Pioneer ACOs and has recognized the need for ACOs to have to have a sustainable business model in the “ACO investment Model request for Application Form.” 


  • Modify the definition of “more than nominal risk” for advanced APMs. The current definition of “more than nominal risk” is extremely confusing and complicated. Physicians need to clearly understand how much money they will need to set aside in the event repayments or reductions are required. A process of zero-interest loans from the government, with a reasonable time to repay, would facilitate this.


  • Base the risk requirements on Physician Practice Revenues instead of Medicare revenues:  MACRA does not require that risk be defined solely in terms of losses to CMS.  A physician practice will bear “financial risk for monetary losses in excess of a nominal amount” regardless of how large or small are the losses to CMS.


  • Physicians should not be at risk for costs beyond their control. Although the term APM benchmark is not defined, the requirement that financial risk be tied to total costs of care – including inpatient and outpatient, post-acute care, drugs and other costs – means physicians would be held accountable for costs beyond their control.  Expand the proposed financial risk standard of loss of guaranteed payments for medical homes to all other APMs. The rationale for counting loss of guaranteed payment as losses under financial risk is relevant for all APMs.  Most organizations creating APMs pay physicians an additional amount of money, such as a monthly case management fee, in recognition of the expanded activities required to meet quality and resource goals.  Medicare does not pay for these services. If the APM does not reach its financial goals, it may be forced to reduce the payments to physicians, who have now experienced a financial loss for those services which are not reimbursed. Regardless of the entity, these dollars should count towards the calculation of financial risk.


  • Set MACRA Alternative Payment Model Benchmarks at national average of Medicare expenditures so that efficient physician organizations are not penalized.  A number of Massachusetts physicians have participated in the Pioneer ACOs and other successful programs over the past several years. These physicians have already found the economies and cost efficiencies in their programs and should not be penalized for being ahead of their peers.  On a related note, several of our Pioneer programs were forced to leave the CMMI program because of the continued resetting of the benchmark to extract more money out of the system.  If physicians and hospital have successfully met their goals of slowing the rate of the growth in the program and improved quality then CMS should not continuously revise benchmark which completely eliminates any revenue over costs.  Ultimately these systems and programs will not have the necessary funds to continue to invest in quality improvement and care management services critical to patient care.


  • Medical Homes: Eliminate Requirement to Accept Additional Risk, Expand Definition of Advanced Medical Homes


The Patient Centered Medical Home is an important component in our health care delivery system and one which has proven to reduce costs and provide high quality care. In MA, our Health Policy Commission has created a voluntary certification process for Patient Centered Medical homes.  In addition, a number of our medical homes are certified through the NCQA accreditation process.  There is a significant body of evidence that shows these models drive reductions in health care costs and/or unnecessary utilization, such as emergency department visits, inpatient hospitalizations and hospital readmissions.   In its recent Annual Review of PCMH, the Patent Centered Medical Home Collaborative found that 21 of 23 programs reporting on cost measures found reductions in one or more measures and that 23 of 25 reporting on utilization measures found reductions in one or more measures.


As the medical home concept is expanded and developed through MACRA and other payers, we believe that it is imperative that multiple pathways be available to clinicians to form and participate in medical homes which align with the goals of value based quality care.  In keeping with our recommendation that the MACRA rules not distract from innovations in the field, we recommend that CMS remove the requirements that medical homes must assume additional risk.    We also oppose the requirement that medical homes be limited to 50 practitioners or less.  We believe this is an arbitrary limit that was not contemplated by Congress.  At the same time, we support including CPCI Plus as Advanced Medical Homes which would automatically qualify for the 5% bonus.  We understand that there is discussion as to whether existing CPC s should be considered advanced medical homes.   Should CMS need additional analysis on this topic, we urge them to move expeditiously to determine whether the statutory requirements have been met.  Our goal is eliminating barriers to models which have been successful under the APM methodology. 


I.        Physicians Technical Advisory Committee


MACRA creates the Physicians Technical Advisory Committee which is charged with recommending new physician focused payment models.  We believe these models will provide innovative solutions to value based care and urge CMS to expedite the rulemaking process to allow these models to qualify as APMS.  In particular we believe CMS should provide priority for testing of models involving physician specialty/subspecialty categories for which there are no current recognized APMs and Advanced APM options available.


II.      Surveillance and Information Blocking


The proposed rule requires that physicians attest that they have complied with surveillance of CEHRT and demonstrate that they did not knowingly or willfully take action to block interoperability.  We oppose both provisions as currently drafted.  The latter requires a technical understanding of IT systems well beyond what any physicians could or should be expected to know and equally importantly, beyond what IT vendors have established.  CMS is well aware of the problems and frustrations within the physician’s community over the lack of interoperability between health care systems and EHRs.  Our recommendation is for CMS to focus on the barriers to interoperability that are outside the physician’s control. These barriers continue to thwart achieving the true promise of health information exchange and improved quality care.


III.    Potential Impact on Pediatric Population


Obviously most of the proposed rule will have little impact on the pediatric population. Nevertheless Medicare payment policies will often impact Medicaid and other payers.  In that light we join our colleagues in pediatrics in urging CMS to consider the following recommendations:


  • Develop a more realistic application of the APM standards for pediatrics.

  • Expand the definition and standards for medical home to include the special needs of children.

  • Recognize that in most states, Medicaid prohibits risk sharing, and

  • Consider including more streamlined and robust measures for pediatric quality care and health care in the quality metrics.


These concerns are particularly relevant to the Medicaid medical home concept.  The proposed rules requirements for a Medicaid Medical home to qualify as an Advanced APM are overly restrictive and not necessarily designed for the pediatric population.  We urge CMS to consider broadening the requirements and tailoring quality measures to include the pediatric populations - not only for Medicaid Medical homes, but for all payer Medical homes as envisioned by this proposed rule.  The American Academy of Pediatrics has submitted detailed comments on this issue which we urge the agency to consider.


We also urge CMS to eliminate the nominal risk requirements for Medicaid Medical Homes.  By definition physicians who treat Medicaid and dual eligible patients are assuming more than nominal financial risk, given very low reimbursement rates.  Our policies should encourage physicians to treat these patients – not provide additional barriers to their care.


The Massachusetts Medical Society looks forward to working with you on this important initiative.



James S. Gessner, MD


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