March 21, 2017
Seema Verma
Administrator
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Hubert H. Humphrey Building, Room 445-G
200 Independence Avenue, SW
Washington, DC 20201
Dear Administrator Verma:
The undersigned physician organizations welcome the Trump Administration’s emphasis on reducing regulatory burdens. Congress recognized when it passed the Medicare Access and CHIP Reauthorization Act (MACRA) in an overwhelming bipartisan vote that the existing Medicare value-based purchasing programs affecting physicians—Meaningful Use (MU), Physician Quality Reporting System (PQRS), and Value-based payment modifier (VM–needed to be streamlined and aligned. As the Centers for Medicare & Medicaid Services (CMS) implemented MACRA through the Quality Payment Program (QPP), we were grateful the agency recognized there were a number of challenges with the requirements of MU, PQRS, and VM. Consequently, we urge the Administration to take a series of steps to address these same challenges in MU, PQRS, and VM prior to their replacement by MACRA and minimize the penalties assessed for physicians who tried to participate in these programs. Clearly this would send a strong message to the physician community about the extensive regulations with which physicians have been dealing and the Administration’s commitment to reduce the burden.
As directed by the 21st Century Cures Act, CMS must establish a strategy to relieve the electronic health record (EHR) documentation burden. To fulfill this legislative directive, we urge CMS to establish a new “Administrative Burden” category of hardship exemption for the 2016 MU performance year. Eligible providers should not be penalized for focusing on providing quality patient care rather than the arbitrary “check the box” requirements of MU. Creating an administrative burden hardship exemption would provide immediate relief for those impacted by the programs that predate MACRA.
We also urge CMS to create a hardship exemption for physicians who attempted to report PQRS in 2016 but were unsuccessful due to the complexity of the reporting requirements and the significant number of measures that were required. The AMA has heard from many physicians who tried to successfully report PQRS 2016, but were unable to find nine measures that were applicable and meaningful for their specialty. Physicians also reported difficulties with the requirements that one measure had to be a cross-cutting measure, and the nine measures had to cover three National Quality Strategy Domains. Therefore, we recommend that CMS create a hardship exemption that would allow physicians who successfully reported on any number of PQRS measures in 2016 to avoid the two percent penalty in 2018.
CMS recognized the difficulty of the reporting requirements and lack of applicable measures by reducing the requirements in the QPP to six measures and eliminating the domain and crosscutting
measure requirements.
In addition, CMS should take a number of steps to protect physicians from additional penalties of up to four percent under the VM. As a starting point, any physician who avoided the PQRS penalty in 2018 should be exempt from any VM penalties as well. These physicians would then all be eligible to participate in a voluntary quality-tiering program where positive, negative, or neutral payment adjustments would be distributed based on a comparison of performance on the applicable VM cost and quality measures for all tiering-eligible physicians, including those who chose not to enter the tiering process. In other words, physicians who met the nine-measure PQRS submission requirements or were eligible for a PQRS hardship exemption would not be penalized under the VM unless they voluntarily chose to compete and then scored poorly in the tiering process. Payment adjustments would be budget neutral, with bonuses for high performers financed by penalties for those who did not attempt to participate in PQRS or performed poorly in the tiering process. Practices of all sizes would receive a performance feedback report so that they could gain a better understanding of Medicare cost and quality measures and identify areas where their performance could be improved.
As indicated in the MACRA law and final regulations, policymakers in Congress and the Administration clearly understand that fair and accurate measurement of physicians’ performance will not be possible until better tools become available. We are extremely appreciative of the efforts CMS has made to recognize and compensate for methodological shortcomings in MU, PQRS, and VM. We believe that the policies outlined above are consistent with the direction CMS is taking as we go forward with MACRA. We also believe the steps we have outlined are in keeping with President Trump’s efforts to reduce regulatory burden.
We recognize that there might be other ways to achieve the same goal. We are open to discussing other options.
Sincerely,
American Medical Association
Advocacy Council of the ACAAI
American Academy of Allergy, Asthma & Immunology
American Academy of Family Physicians
American Academy of Hospice and Palliative Medicine
American Academy of Neurology
American Academy of Otolaryngology-Head and Neck Surgery
American Academy of Physical Medicine and Rehabilitation
American Association of Hip and Knee Surgeons
American Association of Neurological Surgeons
American Association of Neuromuscular & Electrodiagnostic Medicine
American College of Allergy, Asthma and Immunology
American College of Emergency Physicians
American College of Gastroenterology
American College of Mohs Surgery
American College of Physicians
American College of Rheumatology
American College of Surgeons
American Congress of Obstetricians and Gynecologists
American Gastroenterological Association
American Osteopathic Association
American Psychiatric Association
American Society for Radiation Oncology
American Society for Surgery of the Hand
American Society of Anesthesiologists
American Society of Cataract and Refractive Surgery
American Society of Clinical Oncology
American Society of Dermatopathology
American Society of Neuroradiology
American Society of Plastic Surgeons
American Society of Retina Specialists
American Society of Transplant Surgeons
American Urological Association
Congress of Neurological Surgeons
Endocrine Society
Medical Group Management Association
North American Spine Society
Obesity Medicine Association
Renal Physicians Association
Society for Cardiovascular Angiography and Interventions
Society of Critical Care Medicine
Society of Hospital Medicine
The Society of Thoracic Surgeons
Medical Association of the State of Alabama
Alaska State Medical Association
Arizona Medical Association
Arkansas Medical Society
California Medical Association
Colorado Medical Society
Connecticut State Medical Society
Medical Society of Delaware
Medical Society of the District of Columbia
Florida Medical Association Inc
Medical Association of Georgia
Hawaii Medical Association
Idaho Medical Association
Illinois State Medical Society
Iowa Medical Society
Kentucky Medical Association
Louisiana State Medical Society
Maine Medical Association
MedChi, The Maryland State Medical Society
Massachusetts Medical Society
Michigan State Medical Society
Minnesota Medical Association
Mississippi State Medical Association
Missouri State Medical Association
Montana Medical Association
Nebraska Medical Association
Nevada State Medical Association
New Hampshire Medical Society
New Mexico Medical Society
Medical Society of the State of New York
North Carolina Medical Society
North Dakota Medical Association
Ohio State Medical Association
Oklahoma State Medical Association
Oregon Medical Association
Pennsylvania Medical Society
Rhode Island Medical Society
South Dakota State Medical Association
Tennessee Medical Association
Texas Medical Association
Vermont Medical Society
Medical Society of Virginia
Wisconsin Medical Society
Wyoming Medical Society
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