July 4, 2016
SCAI and ACC Submit Comments to CMS on Proposed MACRA Structure
July 5, 2016—The Society for Cardiovascular Angiography and Interventions (SCAI) and the American College of Cardiology (ACC) have separately submitted comments to the US Centers for Medicare and Medicaid Services (CMS) on the proposed regulations to implement the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).
SCAI President Kenneth Rosenfield, MD, submitted a letter to CMS Acting Administrator Andrew M. Slavitt noting that interventional cardiologists should be separately recognized from general cardiologists in terms of their cost and quality. Dr. Rosenfield's letter is available online here, as well as joint society letters joined or endorsed by SCAI to CMS regarding the MACRA proposed regulations.
ACC President Richard A. Chazal, MD, on behalf of ACC Advocacy, submitted extensive comments to CMS based on the feedback of key member groups, including ACC’s Health Affairs Committee, Partners in Quality Subcommittee, MACRA Task Force, NCDR Management Board, the Health Information Technology (Health IT) and Informatics Task Force, and several member sections and workgroups.
On April 27, the US Department of Health and Human Services announced that it was issuing a Notice of Proposed Rulemaking to implement key provisions of MACRA, bipartisan legislation that replaced the flawed Sustainable Growth Rate formula with a new approach to paying clinicians for the value and quality of care they provide. The proposed rule would implement these changes through the unified framework called the Quality Payment Program, which includes two paths: the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). The CMS Fact Sheet on the proposed program is available online here.
CMS will release the final regulations by November 1, 2016, and they will go into effect on January 1, 2017, which is the proposed start of the reporting period under the new payment program.
The SCAI's Dr. Rosenfield noted that in 2014, CMS recognized interventional cardiology as a separate specialty of medicine, however, the proposed rule doesn’t seem to recognize this new specialty, perhaps because most of the data it relied on were from 2014 or earlier. SCAI is requesting to meet with CMS staff to discuss the appropriate quality measures for interventional cardiology.
SCAI stated that although the society understands CMS’s desire to see a greater use of patient registries, the agency should understand that most registries are focused on patients with particular procedures or conditions. There are no useful one-size-fits-all patient registries available nor are they likely to be developed. Therefore, SCAI recommends that CMS not raise the required registry participation rate from 50% and that the agency recognize that most useful registries do not include all types of patients and the enrollment requirement should be limited to eligible patients only.
As noted by the ACC, the flawed SGR formula focused on fee-for-service payment, where higher performing physicians had no ability to earn more for outcomes. Replacing the SGR with MACRA will pave the way for a new payment system that places importance on quality care. MACRA also creates stability for Medicare payments by mapping out payment updates for 10 years and beyond—stability that was severely lacking under the SGR formula. These regulations will establish rules for clinician participation in MIPS and qualifying for incentive payments based on participation in Advanced APMs beginning with the 2019 payment year.
In the comments to CMS, ACC acknowledged the complexity of implementing a new payment model like MACRA and agreed that simplified education and assistance from CMS will be needed to ensure that members are prepared for implementation. The ACC encouraged CMS to revise policies to allow clinicians reporting data as a group to report and be scored on the most relevant measures to their clinical practice. Additionally, ACC recommended that clinicians be “held harmless” from penalties if it becomes apparent that clinicians are having trouble transitioning to the new policies.
ACC’s other key comments to CMS include:
- Refining the “low volume” MIPS exemption threshold to make it more available to cardiologists, particularly those in small practices and those treating a primarily pediatric or non-Medicare population.
- Refining the “nonpatient facing” clinician definition to ensure that the flexibility offered under this category is available to cardiologists, particularly imaging specialists. The ACC also advocated that quality improvement initiatives performed as part of laboratory accreditation be recognized as clinical practice improvement activities under MIPS.
- Recommending how CMS should provide clinicians with clear and actionable feedback to ensure that they understand their reporting requirements and whether or not they are successfully meeting criteria.
- Recommending that CMS increase flexibility for the Advancing Care Information component of MIPS (formerly Medicare Electronic Health Record [EHR] Incentive Program, also referred to as Meaningful Use) to provide opportunities for success, including a delay in requiring the 2015 Edition EHR certification.
- Strongly opposing the proposal to substantially increase the successful reporting threshold from 50% to 80% or 90% of all applicable patients, despite ACC’s support of the collection of all-payer data to improve the sample size for quality reporting.
- Recommending a cautious approach to the implementation of new episode groups for measuring clinician cost and resource use. The ACC warned CMS of the complexity of measuring clinician cost performance, especially when treating patients with chronic conditions.
- Supporting a process in which clinicians and groups can request that CMS review their MIPS data if they believe that the agency has assigned an incorrect score or penalty.
- Supporting CMS’s recognition of the role of registries in quality improvement, including proposals to have Qualified Clinical Data Registries such as NCDR’s PINNACLE Registry and the Diabetes Collaborative Registry accepted as a MIPS reporting mechanism and clinical practice improvement activity.
- Highlighting the need to make participation in APMs recognized under the MIPS APM and Advanced APM pathways more available to cardiologists, including recommendations to consider models such as the Bundled Payments for Care Improvement program as a MIPS or Advanced APM.