ASCRS Submits Comments on Quality Payment Program Proposed Rule; Urges CMS to Move Back the Start Date; Opposes Elimination of Measures Groups and Increased Quality Reporting Thresholds

This week, ASCRS submitted comments on CMS’ Quality Payment Proposed Rule, which implements the Medicare Access and CHIP Reauthorization Act (MACRA) and includes the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). As we have reported previously, ASCRS and the medical community have identified several provisions we oppose in the proposed rule and are recommending that CMS make major changes in the final rule. Below is a summary of ASCRS’ comments. Read the comment letter for full details.

ASCRS also has joined with the Alliance of Specialty Medicine to submit comments and signed a letter from the medical community recommending key changes in the final rule.

Performance Period Timing

ASCRS has a major concern that the implementation timeline is too short, and physicians will not be ready to participate in the new program on January 1, 2017. Physicians and their practice administrators must have time to be educated on and understand the new program. Our primary recommendation is to urge CMS to move back the first performance period to begin no sooner than July 1, 2017, so that physicians and practices have ample time to transition from the existing reporting programs (PQRS, Value-Based Payment Modifier, and EHR/Meaningful Use) and be successful in the new payment program, which also incorporates a new component—Clinical Practice Improvement Activities.

During the first transition year, we recommend CMS provide physicians with flexibility to choose a performance period that best fits their practice. Physicians should have the option to report for a full year, or choose a shorter performance and reporting period. In addition, physicians should have an optional look-back to January 1, 2017, which would allow them to report on quality measures specified around a 12-month reporting period or surgical measures needing time to determine outcomes. Finally, we recommend CMS hold any providers harmless from penalties in the first transition year of the program if they are negatively impacted by the timing of the performance period.

MIPS Program Structure

  • ASCRS supports CMS’ proposal to allow physicians to report performance either as a group or individual. We also support the proposal to allow physicians to report through a variety of submission methods in the first year, but oppose the proposal to require providers to report via a single submission method in future years. ASCRS recommends CMS provide prospective and more timely and actionable feedback reports to physicians, since physicians and practices will need more information as they implement the new program.
  • ASCRS reiterated previous serious concerns that CMS cannot adequately adjust for risk in any of the elements of the program. ASCRS warned that current models do not account for comorbidities and patient compliance. They do not adequately reflect management of such chronic diseases as glaucoma and macular degeneration, from which the patient will never improve, and treatment involves preventing the disease from progressing and is generally only successful with good patient compliance.

MIPS Component Categories

Quality Performance Category (previously PQRS)

  • ASCRS opposes CMS eliminating the Measures Group reporting options and urges that they be reinstated. We argue that not only do the Measures Groups provide a less burdensome option for small practices, they are centered around specific conditions and episodes of care—in accordance with CMS’ own previously stated goals.
  • In addition, ASCRS urges reducing the reporting thresholds from the proposed 90% of all patients if reporting via registry and 80% of Medicare Part B patients if reporting via claims, to the current PQRS threshold of 50% of Part B patients.
  • ASCRS also opposes the proposed “global and population” measures CMS will calculate and attribute to physicians using the same flawed attribution method as currently employed by the Value-Based Payment Modifier (VBPM).
  • ASCRS requests that when developing scoring standards for the measures and calculating improvement in subsequent years, CMS takes into consideration that procedures such as cataract surgery are already overwhelmingly successful, and does not set arbitrary benchmarks that might penalize surgeons providing excellent care. ASCRS also reiterated our previous concerns about risk adjustment models.

Resource Use (previously VBPM)

  • ASCRS opposes CMS’ proposals for measuring resource use, or cost, under MIPS. The program retains the current VBPM cost measures, which are primary care-focused and do not apply to our specialty, as well as the flawed attribution methodology that potentially holds physicians responsible for care they did not provide.
  • ASCRS recommends the resource use category be reweighted to 0% in the first year and the attribution methodology be adjusted to one similar to ACO methodology that excludes certain specialties that bill E/M codes, such as ophthalmology.
  • ASCRS also opposes the proposal to use episode groupers to measure resource use.

Advancing Care Information (previously Meaningful Use)

  • ASCRS appreciates that providers will have the ability to customize the program to better suit their needs, but contends that the proposal does not actually remove “all-or-nothing” scoring, since providers must satisfy all of the objectives and measures under the base score in order to receive any points for the category at all.
  • ASCRS opposes the measures included in the category that hold providers responsible for information over which they have no control, such as the patient engagement and health information exchange measures, and recommends they be removed.
  • ASCRS supports the proposal to allow providers to continue with Modified Stage 2 of Meaningful Use, particularly when using 2014-certified technology for the first year, as many of our members do not yet have 2015 technology.
  • We urge CMS to set the performance score benchmarks at levels that can reasonably be achieved by all providers, particularly in the first performance period. The measures included in the performance score are analogous to Stage 3—which ASCRS and the medical community opposed—and we urge CMS not to set the thresholds at the unattainable levels it previously set in Stage 3.

Clinical Practice Improvement Activities (new category)

  • ASCRS recommends that additional activities, such as participating in continuing medical education or fellowships, be included in the list of available Clinical Practice Improvement Activities (CPIAs). We applaud CMS’ plan to develop a process for future years of MIPS where stakeholders can recommend activities for potential inclusion in the CPIA inventory. We urge CMS to be flexible and allow as many proposed CPIAs onto the final list as possible.
  • We recommend CMS provide more detail in the final rule regarding descriptions for individual CPIAs. We find many of the descriptions for individual CPIAs to be lacking in clear detail as to what constitutes successfully completing a CPIA.
  • ASCRS appreciates and supports CMS’ proposal to reweight individual activities to 30 points and require practices with fewer than 15 providers to report on only two CPIAs for full credit, as required by MACRA.
  • ASCRS opposes CMS’ proposal to measure performance on CPIAs to determine the provider’s category score in the future.

Advanced Alternative Payment Models (APMs)

  • ASCRS reminded CMS that we have very few members who will be able to meet the thresholds required to participate in an Advanced APM as qualifying participants. CMS has itself stated that very few specialists will qualify for APMs in the first few years. We encourage CMS to develop and approve more APM options so that specialists have the opportunity to participate in these models if they so desire. Currently, the majority of APMs are focused on primary care.
  • We encourage CMS to provide clear, prospective information to providers about their eligibility for credit under MIPS or full participation in an advanced APM. As proposed, providers will not know until after the reporting period is over if they qualified for the APM based on number of patients or payments.

Resources for ASCRS•ASOA Members

ASCRS and our allies in the medical community will continue to advocate for changes to be included in the final rule. The final rule is expected to be released sometime this fall. When it is finalized, we will be providing ASCRS•ASOA members with additional training and resources to help them implement the new system. In the meantime, members are urged to review our recently released guides on each of the MIPS components.

These guides and other resources are available on the ASCRS MACRA Implementation Center. As new resources are available, they also will be posted there.

If you need additional assistance, please contact Allison Madson, manager of regulatory affairs, at or 703-591-2220.