For the better part of this year, efforts to repeal and replace the Affordable Care Act have dominated the political arena and public discourse. But with all eyes on what ultimately proved to be a complete mess, the Centers for Medicare & Medicaid Services (CMS) released its critical and much-anticipated plan to update the Medicare payment program for physician reimbursement.
While it was certainly hard not to watch the repeal-and-replace debacle unfold—even if it proved to be arguably a waste of time—the CMS proposal is much more important in terms of actual impact on physicians and their ability to provide patient care.
Proposed updates to QPP in year two
On June 30, CMS released the long-awaited proposed rule to update Medicare’s Quality Payment Program (QPP) for the 2018 performance period. Coming in at just over 1,000 pages, the extensive proposal continues the overall “pick-your-pace” trend established in the QQP implementation policy for 2017, while also amending some existing requirements and establishing new policies.
According to CMS, the proposal’s goal is to continue “building and improving Quality Payment Program policies that will be familiar to stakeholders and are designed to integrate easily across clinical practices” while also addressing “elements of MACRA that were not included in the first year of the program, including virtual groups, facility-based measurement, and improvement scoring.”
The proposed rule estimates that in year two (2018) of the QPP, 8,590 urologists will be eligible to receive payment under MACRA's Merit-based Incentive Payment System (MIPS) in 2020.
Physicians talked, CMS listened
Through the rulemaking process and other initiatives, CMS has engaged in extensive outreach with physicians and other stakeholders to solicit feedback on QPP implementation, and that was evident in its proposal for year two.
In a press release announcing the proposed rule, CMS Administrator Seema Verma reaffirmed the agency’s commitment to working with physicians and other health care providers to improve policies and reduce clinician burden: “We’ve heard the concerns that too many quality programs, technology requirements, and measures get between the doctor and the patient. That's why we're taking a hard look at reducing burdens. By proposing this rule, we aim to improve Medicare by helping doctors and clinicians concentrate on caring for their patients rather than filling out paperwork.”
The American Association of Clinical Urologists (AACU) has been quite vocal about the burden of MACRA on urologists and the many implementation difficulties they face. As such, it has submitted extensive comments voicing these concerns on past MACRA-related proposed rules, including the QPP implementation policy for the 2017 performance period, voicing these concerns.
Among the policies finalized in the 2017 QPP rule, one of particular concern for the AACU related to the adoption of Certified EHR Technology (CEHRT). The final 2017 QPP rule gave physicians the option to use either the 2014 or 2015 Edition of CEHRT, or a combination of both. But starting in 2018, physicians would no longer have this option and instead would be required to use only the 2015 Edition CEHRT.
However, as the AACU and other urology organizations have pointed out, very few vendor products meet the 2015 certification criteria required for approval by the government-mandated Health IT Certification Program. As such, many urologists worry that requiring the 2015 Edition CEHRT starting in 2018 would unfairly subject them to financial penalties or force them to file for hardship exceptions due to unavailable vendor products.
In response to this negative feedback from the provider community, CMS proposed to continue allowing MIPS-eligible physicians to use either the 2014 or 2015 Edition CEHRT in 2018, granting a bonus to physicians using only the 2015 Edition CEHRT in 2018 as opposed to penalizing those who do not.
CMS also addressed physician criticism regarding the low-volume exemption, which excludes otherwise-eligible physicians and groups from participating in MIPS if they meet the low-volume threshold. The threshold amount, as established in the 2017 QPP rule, is no more than $30,000 in Medicare Part B allowed charges annually, or 100 Medicare patients treated.
Like many other groups, the AACU emphasized that the current threshold amount is insufficient and urged CMS to either raise the threshold amounts or associate the threshold with actual practice size so exemptions are appropriately applied and small practices are not burdened to the point of closure. CMS responded by proposing to raise the threshold amount in 2018 to no more than $90,000 in Part B charges annually, or 200 Medicare patients treated.
While this is undoubtedly an improvement, there is still significant concern that even the increased low-volume threshold is still too low for most urologists in solo or small practices. Since urologists see, on average, a greater number of Medicare patients than other types of physicians, the AACU recently urged CMS to consider increasing the low-volume threshold even more than is currently proposed, or at the least to gather urology-specific data on this exemption and analyze its effect on urologists and other specialty physicians.
Better, but still a long way to go
All in all, there were significant improvements in the 2018 proposed rule, and it is impossible to deny that CMS made an effort to truly consider feedback from physicians and the health care community by incorporating suggestions for improvement in year two of the QPP. But there are still substantial problems with QPP implementation that will continue to burden urologists treating Medicare patients.
Moreover, the underlying fundamental issue with QPP and its implementation still remains: numerous and fragmented compliance requirements and complex scoring mechanisms are not only difficult for providers to understand, but have also proven to be near impossible for providers to practically integrate and fully implement. And despite CMS’s best efforts, a 1,058-page proposal does very little to help that.
But urologists should not give up hope. CMS has proven that it is willing to work with providers by listening and working with them to address their complaints and reduce administrative burdens. The proposal for 2018 is an improvement on 2017 QPP policies, and as long as physicians continue to voice their concerns and engage with CMS, understanding and complying with MACRA may start to get easier.