April 25, 2021
Liz Richter
Acting Administrator
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244-1850
Dear Acting Administrator Richter:
The Medicare Shared Savings Program (MSSP) and Quality Payment Program (QPP) are CMS initiatives that America’s Physician Groups (APG) appreciates and supports. Recently, the agency offered numerous changes to MSSP ACO quality policies that will have a significant impact particularly for physician practice ACOs. The sunsetting of CMS’ Web Interface reporting mechanism and move to all-payer reporting represent widespread change, requiring substantial investment and planning over a short amount of time. Combined with a smaller, more heavily weighted, measure set, pass/fail threshold for shared savings eligibility, and being measured across all MIPS reporters, the changes also introduce significant uncertainty. APG’s recommendations in response to these recent changes are intended to strengthen these programs and the overall movement from volume to value.
About America’s Physician Groups
APG is a national professional association representing over 300 physician groups that employ or contract with approximately 195,000 physicians that provide care for nearly 45 million patients. Our tagline, “Taking Responsibility for America’s Health,” represents our members’ vision to move away from the antiquated fee-for-service (FFS) reimbursement system where clinicians are paid “per click” for each service rendered rather than on the outcomes of the care provided. Our preferred model of accountable, risk based, and coordinated care avoids incentives for the high utilization associated with FFS reimbursement. APG member organizations are also working diligently to rise to the challenge presented by the COVID-19 pandemic, and we appreciate the flexibilities and waivers CMS has afforded us during this time of crisis.
Summary of APG’s Recommendations
• Extend the option for CMS Web Interface reporting until issues have been addressed
• Remove the all-payer requirement for measures reporting
• Set shared savings eligibility standards using a target that is established and published in advance
• Seek additional stakeholder input on the recent changes to quality measures
Comments
In the Calendar Year 2021 Revisions to Payment Policies under the Physician Fee Schedule, CMS proposed ceasing the use of its Web Interface reporting mechanism which has been used to support quality measure data collection and submission for ACOs. We have been consistent in sharing our numerous concerns over the removal of this reporting option which is heavily preferred by Medicare Shared Savings (MSSP) and Next Generation ACOs.
The costs and burden of the shift in reporting mechanisms is substantial for physician practice ACOs, and much of that burden will unfortunately fall on the physician practices themselves. Data extraction and aggregation across multiple EMRs is made more challenging by the fact that so many do not have the requisite access to these systems that makes integration feasible. This will likely require the creation of many interfaces and not all EMRs are constructed to accommodate this. This lack of the necessary infrastructure makes the switch to a new mechanism nearly impossible, especially given the relatively short period of time to develop, connect and test such reporting capabilities. The timeline presented by the agency could also have a negative effect on quality measurement, if implemented as planned. The new reporting mechanism is likely to measure EMR data entry and extraction rather than quality performance, if rushed through. Furthermore, the use of these reporting mechanisms could result in inaccurate evaluation of ACOs’ quality performance based on the total patient population instead of patients assigned to an ACO as the MSSP statute and prior regulations intend. ACOs have also expressed legal concerns around accessing data for patients not assigned to them from payers with whom they have no formal relationship.
CMS has publicly stated that it is seeking to align MSSP quality standards with the MIPS quality performance category, establishing a newly modified quality performance standard that requires ACOs to reach the 30th percentile at a minimum across all MIPS Quality performance category scores in order to qualify for shared savings, with the required performance level increasing to the 40th percentile beginning in the 2023 performance year. Because the 30th or 40th percentile could change dramatically year to year based on the broader MIPS rules and how all MIPS reporters perform under those rules, this approach does not provide sufficient transparency ahead of time for ACOs. In addition, such an all or nothing approach does not provide sufficient incentive for providers to pursue quality performance and improvement. While CMS has published quality performance benchmarks for the coming performance year, these benchmarks do not tell ACOs how they must perform in order to meet the quality performance standard. To assist ACOs in determining how they must perform in order to meet these standards, we ask that CMS set the standard for shared savings eligibility using a target that is established and published in advance. Doing so will allow ACOs to plan out their quality improvement activities and strategies to ensure their success in implementation.
Finally, many organizations have questions surrounding the new requirement that there must be reporting across all patients regardless of payer. The lack of clarity and specificity on what all-payer reporting entails for ACOs prevents providers from being able to adequately prepare for successful reporting. ACOs composed of multiple groups and multiple EMRs have added difficulty in attempting to comply with this requirement. We also worry this provision could inadvertently discourage some providers from expanding access to more complex, higher need patients, including Medicaid patients out of concern for their impact on the quality score.
Shifting from reporting on a sample of Medicare ACO patients to reporting on all-payer data may have unintended consequences. An ACO made up of practices serving predominantly commercial populations will likely have an easier time performing on these measures than an ACO that sees a heavily Medicare and Medicaid population. While we share CMS’ goal of improving quality of care for patients across all payer types, geographies, races, and socioeconomic status, this change could unfairly disadvantage ACOs that serve higher need populations and may discourage ACOs from including practices with a payer mix that is unfavorable from a quality performance perspective, thereby furthering inequities rather than addressing them. In light of these concerns, we ask that CMS pause this policy change until all potential issues are addressed and more clarity on the process is provided. At a minimum, the complete transition away from the Web Interface must be slowed to give ACOs sufficient time to implement a new reporting method.
The significant MSSP quality program changes described above would have wide-ranging effects on healthcare providers. While we have been supportive of some of these changes, such as reducing reporting burden, we feel that increased stakeholder input is still needed so that the reality of what these changes mean for physicians and their practices can be accounted for in implementation. We urge CMS to gather stakeholder input so that costs and burdens for ACOs and physician practices, potential effects on access, and clarity surrounding proposed changes can be discussed and accounted for. Open stakeholder forums or a stakeholder panel convened by the agency could both serve as viable venues for feedback that will ensure a smoother transition that is tenable for providers.
Conclusion
Thank you for your attention to the above comments. It is important that CMS continues to work with stakeholders to strengthen Medicare and incentivize the move toward value. Please feel free to contact Valinda Rutledge, Executive Vice President, Federal Affairs, (vrutledge@apg.org) if you have any questions or if America’s Physician Groups can provide any assistance as you consider these issues.
Sincerely,
Donald H. Crane
President and CEO
America’s Physician Groups
Please click here to download a copy of the letter.
