Advocacy in Action: Quality Payment Program – The New SGR

Carter L. Alleman, J.D.

One year ago, the House of Medicine celebrated the end of the sustainable growth rate (SGR). No more yearly trips to Capitol Hill to ask for a “patch,” no more waiting for the eleventh hour bill to avoid penalties, no more of the constant discussions on when would be the best time to end the SGR. Everyone billed Medicare Access and Children’s Health Insurance Program Reauthorization Act of 2015 (MACRA) with its Merit-based Incentive Payment System (MIPS) and alternative payment models (APMs) to be the best payment model for physicians. Now when it is time to implement MACRA through the Quality Payment Program (QPP), the true picture of the next payment model comes in focus.

The recent ACOS Brief outlined the QPP as it stands today. This is important to note because the parts of the proposed rulemaking can change between June 27, the end of comments, and Centers for Medicare & Medicaid Services (CMS) estimated publication of the final rule on November 1, 2016. This is a major concern of not only ACOS, but other surgical specialty association. There would be only two, possibly three, months to educate our members and get them prepared to be successful. It also limits the ability to use legislative means to modify the QPP if it does not align with MACRA.

Meetings with CMS have not shed enough light on the proposed rulemaking to what the final rule will look like. When CMS is asked about specifics or why they went a certain direction, the responses were comment on that or think how we were thinking. CMS is stressing that the rule is to be flexible, simplistic, and less burdensome, however CMS is not following the rules while saying they are going to be flexible, the rules as written are rigid.

CMS envisions that most physicians will be participating in MIPS the first payment cycle. This means that many physicians will have to sink thousands of dollars to get ready for the MIPS program even though they may later enter into an APM or advanced alternative payment model (AAPM).

Beginning January 1, 2017, 50% of the total MIPS score will be based on quality. This means that if physicians are not participating in the Physician Quality Reporting System and the quality component of the Value Modifier Program, they will need to start. Within the rule there is a specialty set of measurements that would allow specialists to report on their practice, however not all specialty types are included in the rulemaking. Other concerns are a lack of risk adjustment methodologies and the lack of information on how this section will be scored. The other 50% of the MIPS score is broken across Resource Use, Advancing Care Information, and Clinical Practice Improvement Activity categories. Each of these have their flaws including unclear methodologies, repacked versions of current programs such as Meaningful Use, and the reliance on any measure not met can be readjusted by raising the Quality portion higher.

Through a recent briefing, it became apparent that the way CMS is implementing the APM section of MACRA was incorrect by placing the nominal risk on the physician instead of the entity. This results in an inordinate amount of financial risk for a physician attempting to practice in an AAPM. Another issue with the APM portion of the QPP are that the current CMS approved AAPMs and MIPS APM are for primary care, with no models available for specialist. This becomes troubling because the only other route to get APMs approved is through the Physician Technical Advisory Committee, whose rules are part of the proposed rules, thus it will not be completely up and running until the final rule.

As with all proposed rules, what is in it today can completely change. The ACOS is tirelessly working with other specialty associations to get CMS to listen and make changes that will make this payment model work. The ACOS will be submitting comments on the rule as well. If you have any questions or comments, please do not hesitate to contact us.