MACRA comments urge CMS to push back start date

Pushing back the 2017 start date for reporting under new payment models set up after passage of the Medicare Access and CHIP Reauthorization Act (MACRA) was one of several common suggestions included in comments on CMS’s proposed rule.  

The deadline to submit comments passed on June 27, with CMS Acting Administrator Andy Slavitt saying 3,772 were submitted—and in those comments, the worries ranged from smaller, specific suggestions such as extending reporting periods to broader concerns like overburdening small practices and limiting access to alternative payment models.

Several large groups called on CMS to push back the timetable for implementing MACRA’s new payment models. Instead of begin reporting on Jan. 1, 2017, the American Medical Association (AMA) said the agency should create a “transitional” reporting period beginning in July 2017, arguing clinicians, vendors and registries won’t have enough time to understand the new system in such a short time frame.

“As a practical matter, starting the program on July 1, 2017 rather than January 1, 2017 provides additional time between the issuance of the MACRA final rule and the start of the performance period,” the AMA wrote. “Physicians need to be educated about the new requirements and change their practices to accommodate the MIPS and APM programs. CMS, however, is unlikely to publish the final rule before the fall of this year, leaving participants with only a few months before the proposed start date. Without adequate notice of final program requirements, a final list of qualified APMs, specified program thresholds and other details, CMS is setting up the program for potential failure.”

The American Academy of Family Physicians (AAFP) also suggested a July start date, along with arguing the two-year gap between reporting and payment periods goes against one of the main goals of the legislation.

“As the program matures, the sophistication of physician practices will demand more timely data reporting, so we would encourage you to establish a more reasonable timeframe from the beginning,” the AAFP wrote.

The Medical Group Management Association (MGMA) went further with its criticism of the start date, asking it to be pushed back to 2018, while keeping 2019 as the first payment year.

“If the final rule were released tomorrow and vendors and practices had six months to update their products to conform to the new standards, perform the necessary staff training and get the proper work flows in place, a January start date would still be a Herculean task,” the MGMA wrote.

Other suggested tweaks to reporting requirements dealt with individual measurement categories under the Merit-based Incentive Payment System (MIPS), which will include most Medicare physicians. The American Hospital Association (AHA) suggested reducing the reporting period under the Advancing Care Information (ACI) category.

“The proposed rule includes a full calendar year of reporting for the ACI category,” the AHA wrote. “The AHA recommends that CMS finalize a shorter, 90-day reporting period for the ACI category and for any provisions in the final rule where an eligible clinician would use a certified (electronic health record) to meet a program requirement.”

Beyond the implementation date, many groups had concerns about the rule’s other payment tracks, called Advanced Alternative Payment Models (APMs), arguing the proposed rule would close off this payment model for most clinicians.

“The AAFP completely objects to the implementation of the entire section of this proposed rule related to ‘MIPS APMs,’" the AAFP wrote. “This section of the proposed regulation is incredibly confusing and we have concerns that, as written, CMS is incentivizing physicians to remain in the fee-for-service program rather than to continue their progress towards APMs. In concept, we believe physicians and practices should proceed towards Advanced APMs versus slipping back into the fee-for-service program.”

Specialty associations, like the American College of Rheumatology, echoed those complaints.

"There are few existing Alternative Payment Models (APMs) that are feasible for rheumatologists," ACR’s letter said. "Workable alternatives should be developed with attention to facilitating participation of small and solo practices. As currently written, the requirements for qualifying participation in APMs are formidable, and establish too high of an administrative burden."

Not all the feedback was negative. Most letters applauded the proposed CMS for reducing the number of performance categories and providing flexibility in the new payment models. At least one group went against other associations and asked CMS to stick to the proposed implementation timeline.

“MACRA presents an exciting opportunity to transform care delivery in Medicare,” said Don Crane, president and CEO of the California Association of Physician Groups. “We call on CMS to stay the course and finalize the timeframes as proposed.”

CMS would normally read through the thousands of comments before issuing a final rule, but the AMA suggested a different course for such a massive change. Its letter asked the agency to release an “interim final rule” first, and then allow another period of comment from medical societies and professional groups.