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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.

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albertklausevitsmeltootsabraarkaranAllanWilliam Palmer MD Recent comment authors
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albertklausevits
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albertklausevits

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meltoots
Member
meltoots

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… Read more »

Allan
Member
Allan

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

ACA: “You can keep your doctor”

They lie like rugs.

Allan
Member
Allan

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.”

Margalit Gur-Arie
Member

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…

Abraar Karan MD
Member
Abraar Karan MD

“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.

William Palmer MD
Member
William Palmer MD

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… Read more »

Adrian Gropper, MD
Member
Adrian Gropper, MD

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… Read more »

Niran Al-Agba
Member

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… Read more »

Margalit Gur-Arie
Member

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

Niran Al-Agba
Member

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

Allan
Member
Allan

“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.

Margalit Gur-Arie
Member

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%..

Perry
Member
Perry

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.

Allan
Member
Allan

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.… Read more »

Niran Al-Agba
Member

“They want to hear surrender, not agreed upon compliance and they have the army of government behind them.” Some of us have no intention of surrendering ever… https://thehealthcareblog.com/blog/2016/10/16/dont-surrender-lets-fight-a-call-to-action/

Steven Findlay
Member
Steven Findlay

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… Read more »

Perry
Member
Perry

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?

Steve2
Member
Steve2

“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.

pjnelson
Member
pjnelson

And in what state did he receive “…near universal support…?”