A Letter from CMS to Clinicians in the Quality Payment Program: We Heard You and Will Continue Listening

screen-shot-2016-10-14-at-8-43-48-amToday, we are finalizing policies to implement the new Medicare Quality Payment Program. Part of the bipartisan Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the Quality Payment Program aims to create a more modern, patient-centered Medicare program by promoting quality patient care while controlling escalating costs through the Merit-Based Incentive Payment System (MIPS) and incentive payments for Advanced Alternative Payment Models (Advanced APMs).

After issuing our proposal for how to implement the new program earlier this spring, we held a listening tour across the country to hear your thoughts and concerns first-hand about the Quality Payment Program. Whether you formally submitted one of the over 4,000 comments we received, or were one of the nearly 100,000 attendees at our outreach sessions, there have been record levels of clinician engagement. The interactions reflect the importance you place on serving the more than 55 million individuals that have Medicare coverage.

We found an eagerness to help the Medicare program improve and an interest in being engaged in how we address the challenges and opportunities ahead. We also heard concerns, which is not surprising, given the challenge of changing something as large and important as the Medicare program. But, we found that there is near-universal support for moving towards a future focused on patient care that pays for what works, reduces clinician burden, and better supports and engages the medical community.

The policy released today is the first step in a multi-year journey in which we are particularly focused on allowing clinicians to transition at their own pace, continuing to get feedback from the field, providing meaningful support, and improving the program over time. As we read your comments, engaged directly with many of you, sought guidance from Congress, and considered all the options, we identified these priorities for the design of the program.

Focus on the patient

Patients tell us they want and expect us to pay for what works and for higher-quality outcomes. Clinicians tell us that they want to focus on delivering the care that is best for their patients, not on reporting or paperwork. For example, one physician group in Texas urged us to concentrate on quality metrics “that are most meaningful to our practices and our patients.” For this reason, we have reduced the number of required measures and provided practices more flexibility to select the measures that they believe best represent their patients’ needs. And, to free up more time for clinicians to spend on patient care, we announced yesterday an initiative to reduce burden and improve physician engagement with CMS, including a regulatory review to begin reducing unnecessary documentation.

Start out gradually

Other than a 0.5 percent fee schedule update in 2017 and 2018, there are very few changes when the program first begins in 2017. If you already participate in an Advanced APM, your participation stays the same. If you aren’t in an Advanced APM, but are interested, more options are becoming available. If you participate in the standard Medicare quality reporting and Electronic Health Records (EHR) incentive programs, you will find MIPS simpler. And, if you see Medicare patients, but have never participated in a Medicare quality program, there are paths to choose from to get started. The first couple of years are aimed at getting physicians gradually more experienced with the program and vendors more capable of supporting physicians. We have finalized this policy with a comment period so that we can continue to improve the program based on your feedback.

More pathways to participate in Advanced Alternative Payment Models (APMs)

In listening to many of you and working with the Congress, we have heard strong interest in providing more opportunities for physicians to participate in Advanced APMs. Our goal over the next few years is to have more options that fit the diversity of practices and care across the nation, while maintaining robust models that actively encourage high-value care – the best care at the best price – for our Medicare beneficiaries.

In today’s rule, for both Medicare primary care clinicians and specialists, we are announcing our intent to explore testing a new Advanced APM in 2018 – ACO Track 1+ — which has lower levels of risk than other Accountable Care Organizations (ACO). Specifically for specialists, in addition to oncology and nephrology, we recently proposed allowing participants in new cardiac and orthopedic bundled payment models the possibility to qualify as Advanced APMs beginning in 2018. We are also reviewing the other models established through the CMS Innovation Center and are in the process of updating and possibly re-opening them to allow for more participation. And physicians can soon submit proposals for new models to the new Physician Focused Payment Model Technical Advisory Committee, which can now be designed with a lower level of risk than we had originally proposed, which may make more Advanced APMs available to small practices.

With these new Advanced APMs, we estimate that about 25 percent of eligible Medicare clinicians could be in an Advanced APM by the second year of the program.

Adapt for small and rural practices

We know that small practices deliver the same high-quality care as larger ones. Yet at every practice we visited or event we held, we heard from physicians in small and rural practices concerned about the impact of new requirements.

We heard these concerns and are taking additional steps to aid small practices, including: reducing the time and cost to participate, excluding more small practices (the new policy will exclude an estimated 380,000 clinicians), increasing the availability of Advanced APMs to small practices, allowing practices to begin participation at their own pace, changing one of the qualifications for participation in Advanced APMs to be practice-based as an alternative to total cost-based, and conducting significant technical support and outreach to small practices using $20 million a year over the next five years, as well as through the Transforming Clinical Practice Initiative. Due to these changes, we estimate that small physicians will have the same level of participation as that of other practice sizes.

Simplified reporting and scorekeeping in MIPS

Many of you asked us for simplified scoring, better feedback, and clear rules. The policies finalized today begin that alignment and simplification process, which we intend to continue as the program matures.

First, we are simplifying requirements for the two quality components of the program – the quality measures and practice-specific improvement activities. Second, we are moving to align the measurement of certified EHR technology with the improvement activities. This will begin 2017 with a portion of the Advancing Care Information measures; we intend to align more of these measures with quality in later years, to further ensure that certified EHRs are being used to support high-quality care. We also narrowed the focus to those measures that support hospitals and physicians safely and securely exchanging information, and we expect both registries and certified EHRs to move to make reporting more “push button,” making such reporting easier for clinicians. Finally, we are rolling out the new Quality Payment Program website, which will explain the new program and help clinicians easily identify the measures and activities most meaningful to their practice or specialty.

Overall, we are deeply appreciative to everyone, from the Congress to practicing physicians, patient advocates, people with Medicare and their families, and technology companies, who provided input into the launch of the program. We listened and made changes based on your input.

There are a number of ways to learn more about the details and how you can get help in the Quality Payment Program: here. We want everyone to participate over time and will provide intensive support to clinicians through our new Quality Payment Program website, as well as directly through in-person and virtual educational sessions and webinars.

Through this process and the input you have given us, CMS is becoming even more open, transparent, and responsive. We are committed to paying close attention to the impact of our policies on care delivery and adjusting along the way. By working together, we can all make real progress in improving the delivery of care in our country.

21 replies »

  1. “I don’t know what to make of Andy S.”

    ACA: “You can keep your doctor”

    They lie like rugs.

  2. What I don’t like its the smoke and mirrors.
    In one breath, they want to reduce burden, reporting, computer clicking, screen time.
    In the other, here is your MACRA proposal with collecting all these measures, counting clicks, screen time, wasted effort, for nothing but reporting for dollars.
    Further, it appears that CMS/Andy wants to have us do quality measures on ALL patients, not just Medicare B, which is really wrong on many levels. First, its a herculean task to do these constant quality measures from just Medicare patients. From workflow changes, clicking, counting, reporting, all into a black box that you get zero feedback until you get either a bonus or penalty. Second, as far as I am concerned, I should not give CMS ANY data on non medicare patients.It is not their right to know, I contracted with Anthem, UHC, others and it is NOT in my contract to be sending info/data about their patients to CMS.Third, its an absurd, massive unnecessary change to include all patients not just Medicare B. It takes a significant amount of time to do these measures and to do them on all, would be a burden beyond measure.

    I don’t know what to make of Andy S.
    He is always talking about less burden, yet continues the burden and even states that we can limp into the program. Which means for beatings coming up, its the belt this year and the wrench next.

    I am bewildered that ANY policy maker thinks that ACI, MIPS, CPIA is anything but an exercise in data entry for already burned out MDs. What are they NOT hearing when they supposedly ask front line MDs about this? I do not know A SINGLE FRONT LINE MD that thinks any of this is a good idea, will add any value, nor improve a single thing about the care of patients in the US.

    What we need is a complete flushing of the program. NO counting ,measures, reporting, nothing. CMS can gather ALL the data they want, with their own employees and data checkers. There is enough in just claims and timing that they can gleam a significant amount of cost and info. Also NO more certification of EHRs. This is leading to just a few major players that only focus on the complex ever changing regulations. MDs would like to work with IT vendors for their needs, not the one size fits none that Washington DC thinks we need.

    I think Andy S is going to get out asap, go back to his cronies in the real world and use his inside knowledge to make even more bank. Like Marilyn Tavenner, who left CMS and now is the CEO of the American Insurance lobby. Nice move. Wasn’t that supposed to NOT happen? I guess not. Not unlike Farzad Mostashari, past ONC leader, who gave us MU, then left to be a venture cap guy that used his prior position of power to make regs that makes his business viable. He is a never-practice MD, never used EHR guy, that gave us this mess. And used his gov position to get favorable regulation in place for his post gov job.

    Its kind of a nightmare. I’m not sure when its going to end, but its going to end badly.
    The damage to physicians, nurses, and care givers has been beyond repair and they have lost most of us forever.

  3. Those who promote rules and regulations regarding climate change tend to use large private airplanes to transport themselves between international airports, and then are driven in big fat SUVs from one fully lit and massively air conditioned mansion to another.
    Same thing in health care. These corrupt exploiters of humanity will not be availing themselves of anything remotely similar to “value-based care”. Ever.
    Rules and regulations are for little people…

  4. Steve Findlay writes: ” It’s akin to climate change.”

    Right, and remember those promoting “specific rules and regulations regarding climate change lied about the work being done. We all know that the healthcare system needs a lot of improvement, but once again those involved with the rules and regulation lie and steal “You can keep your own doctor”, “everyone will save money” while they destroy the best healthcare system (though financially inept) in the world.”

  5. “For this reason, we have reduced the number of required measures and provided practices more flexibility to select the measures that they believe best represent their patients’ needs.” This is very important, and the reason that many QI efforts have not done well. We need to allow for this flexibility because the meaning of “quality” is different for all.

  6. “You have shown us the guillotine and now instead are planning to chain us,”

    Let’s not confuse niceness from Medicare with being personable. Like frogs, Medicare has placed physicians into a pot of water that is being heated up with care. A little money here, a little relaxation of rules there, but that is just to keep the docs in the pot. Eventually, the water will boil and like the frogs, the docs will not be able to jump out.

  7. Margalit: “to appear as if you “listened” to your opponents (yes, opponents) and made a magnanimous compromise.”

    You used the word opponents because you are a nice individual, but to be truthful “enemies of the state” would be more appropriate. They want to hear surrender, not agreed upon compliance and they have the army of government behind them.

    It wasn’t that long ago that, though for some it might be, that a federal decision permitted physicians to sue Medicare in a federal court. Before that Medicare (or its agency) was prosecutor, judge, and jury. Look at the forms sent out. They frequently don’t even use a physician’s name. They say provider instead of doctor. They knowingly go on witch hunts to intimidate physicians. They break rules of judicial process.

    They are not interested in what we think. They want us to function as drones and the only problem they have is medicine requires too much knowledge to quickly change the dynamics. Instead, they are trying to dummy down medical care.

    After writing this I will probably have my taxes audited. The government has done that to many people that disagree with their policies. After all almost half the nation are considered deplorables and from the recent emails we might find that Bernie Sanders was considered deplorable as well.

  8. Yes, we’re still going to chop your head off, but instead of today it will be next week, and instead of a saw we’ll use a guillotine.

  9. The price/cost/spending trajectory may not be sustainable but we have also reached certain benchmarks in civilization upon which we cannot go backwards…that have priority over spending trajectories. One of these is freedom to sell our own work at any price and volume and quality that we want. But, you will say that the buyer also has freedoms in what he buys in any form and quantity an price he wants. If we did not have these freedoms we would still have slavery and masters.

    Indeed, and the idea is that there is always a mutual agreement before the sale is completed and the market is cleared.

    But the larger and more monopsonic the purchaser and the more he prices and constrains what and how he buys, the less freedom for the seller….just as if the seller became a monopoly and he priced and controlled what and how much he sold.

    So it is easy to say that the market has beome asymmetrical and that there is too much buyer power. We know the buyer has to buy from us so that we do not have to please him.
    We are also not trying to please many buyers. Thus we feel we do not have to compete with each other to try to enlarge our number of buyers=market share. We also focus upon trying to figure out ways to get the most money we can from the one buyer.

    These are hardly recipes for reducing the costs of health care.

  10. Payment reform needs to be supported by practice reform. Practice reform is dependent on the ability to innovate. Meaningful innovation is not possible when the largest of incumbent institutions control the flow of patient information through control of EHRs, health information exchanges, and the standards themselves. The HITECH incentives for health IT consolidation are now the pricipal barrier to practice innovation.

    The solution to this aspect of transitioning volume to value is plain and simple regulation to prevent data blocking. Institutions and their EHR vendors must be required to offer ALL of the patient information they hold at zero cost and zero delay to any destination, practice, or app that the patient or the patient’s physicians specify. Then, and only then, will information truly follow the patient and practice innovators will have a fair chance to compete. The fundamentals of this were clarified and well reported by this summer’s API Task Force.

    Unfortunately, ONC is dragging its feet (Dr. Washington, at a recent Health 2.0 Town Hall, took pains to point out that the API Task Force report vote was only 13 to 10). CMS is still designing Blue Button on FHIR with innovation-killing rent-seekers like DirectTrust in the middle. And, the VA looks like it’s moving away from open source to proprietary IT that depends on vendor lock-in as a core strategy.

    Data blocking is absolutely obvious to any patient that is struggling with a dozen separate and very different patient portals, any patient or physician that cannot access independent decision support for quality or cost at the point of care, and any innovator that is forced to deal with a growing cartel of middlemen and rent-seekers to get information about services that their patients have already paid for at the highest rates in the world. This is not rocket science. It’s regulatory capture resulting directly from years of HITECH and it needs to end.

  11. Well that gives a lot of us 10 years to figure out an exit strategy, a Drexit if you will.
    Then the s*** will really hit the fan.
    By the way Steve, how would you like to be paid this way?

  12. Thanks 🙂 There should be a post later tonight on here that goes with it!

  13. “No Regulation without Representation!” I absolutely love this….

  14. In reality, it does not sound like you are listening or maybe it is your hearing that needs aid. Exempting those with 100 Medicare patients or less does not help those of us in rural areas. I have 400 Medicaid patients right now and a waiting list of more than 50 that will take more than 6 months to go through. These are human beings who need care, yet I will not be able to feed my family if I do the work for “free/CMS rates.”

    “We know that small practices deliver the same high-quality care as larger ones.” Try as you might, you are not getting it. The small practices deliver BETTER quality, lower hospitalization rates, and are far more cost effective. What you are doing will bankrupt the system.

    Margalit is absolutely correct. You have shown us the guillotine and now instead are planning to chain us, while viewing your work as benevolent compromise. The poor and disabled in this country will be without ANY care in the future you are envisioning unless they are paying cash. Please remember what I said. You will wish you had thought more about your plans.

    Those of us involved in the Transformation of Care grants have already stumped the administrators in the first weeks of data distribution. They have no answers for the questions I and other physicians are asking…. they did not anticipate such issues, but reality is dawning on them slowly.

    Please allow an “exempted group and a “control” group of physicians to remain in the pool. They will stem the tide of early retirements (aka Drexit) that is coming. They will also be able to bail you out when you and patients need it most. Do not insist on imposing these regulations on us all. No Regulation without Representation!

  15. This is like a page from the art of the deal. Knowingly propose something outrageous and then “compromise” a bit around the edges to appear as if you “listened” to your opponents (yes, opponents) and made a magnanimous compromise.
    MACRA is part of the ACA thinking and it will just amplify and expedite the original intent: impoverished populations served by unqualified teams of “health workers”, managed by few and far in between retrained, reeducated and underpaid “doctors”, supervised by an artificially intelligent, centralized politburo, or simply put: Medicaid for all but the 1%..

  16. Andy and CMS will, of course, have to steel themselves for another round of criticism as they seek to implement a law that was inherently going to be tough to implement. Many front-line docs simply don’t want to be micromanaged by the government. Who can blame them, after some of the failures to date. But we find ourselves in a bad situation. It’s akin to climate change. There is no getting around the fact that the price/cost/spending trajectory for U.S. healthcare is unsustainable, with the proverbial s**t starting to hit the fan in about a decade. In addition, the quality of care in the U.S. remains woefully suboptimal by almost every measure.
    My sense is that many in the medical community are still in denial about these two facts, and the urgency needed to address them. And many still seem to deny that government (taxpayers) pay half the healthcare tab!
    MACRA, in my view, represents one of the most meaningful bipartisan acts a broken Congress has taken in the past five years. Lawmakers actually seemed to recognize the need for action. (They also had to kill SGR.) Congress essentially embraced a batch of mechanisms that have arisen organically and evolved over the past 10 to 15 years. Yes, I concur, some of these mechanisms (quality reporting, PFP, payment incentives, bundled payment, etc) lack conclusive evidence of long-term effectiveness. But it’s not as if there’s no evidence they can work. So we find ourselves, with MACRA and these final rules, at a juncture. Lacking other coherent ideas, the medical community either gives this a big push and tries in all good faith to make it work, with whatever adjustments are necessary along the way…..or it continues to complain, resist, and undermine, based in part on philosophical/ideological opposition to government regulation. My crystal ball guess is that if there’s failure this time, after a decade or so, we’ll be on our way to single payer–and providers are sure not going to like that.

  17. “Due to these changes, we estimate that small physicians will have the same level of participation as that of other practice sizes.”

    Short people got no reason to live.