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RPA Comments on Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Ince
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December 19, 2016 

Andrew Slavitt 
Acting Administrator 
Centers for Medicare and Medicaid Services 
Room 445–G 
Hubert H. Humphrey Building, 
200 Independence Avenue, SW 
Washington, DC 20201 

RE: CMS-5517-FC: Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models; Final Rule With Comment Period 

Dear Acting Administrator Slavitt: 

The Renal Physicians Association (RPA) is the professional organization of nephrologists whose goals are to ensure optimal care under the highest standards of medical practice for patients with kidney disease and related disorders. RPA acts as the national representative for physicians engaged in the study and management of patients with kidney disease. We are writing to provide comments on selected portions of the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Final Rule. 

RPA’s comments focus on the following issues: 

• Impact of ‘Pick Your Pace’ on MIPS Implementation 
• Attribution and Nephrology 
• Proposed Elimination of the Specialty-Specific Risk Adjuster 
• Reduction of Administrative Burden for Advancing Care Information 
• Development of Quality Measures as Part of QCDRs 

Impact of ‘Pick Your Pace’ on MIPS Implementation 

CMS’ decision to incorporate the ‘Pick Your Pace’ program as part of MIPS implementation substantially mitigates the burden that many physician practices, particularly those that are small or mid-sized, would have faced in striving to participate in MIPS in a compliant manner in 2017, and we heartily commend the Agency for its foresight and flexibility in developing the Pick Your Pace options. 

RPA recommends that CMS consider extending the Pick Your Pace framework for reporting in 2018, for the 2020 payment year, for either all practices, or at least practices with 15 providers or fewer. We believe that to the extent that eligible professionals (EPs) have challenges in reporting MIPS measures during 2017, some of the issues will be beyond their control, perhaps related to interactions with external EHR vendors, and as such may not be resolved by the end of 2017. Therefore, RPA recommends that CMS extend the use of the Pick Your Pace program for the 2018 reporting year, for at least physician practices with 15 providers or fewer, if not all practices. 

Attribution and Nephrology 

In RPA’s comments on the proposed rule, we recommended that CMS exclude ESRD patients from the MIPS calculation, as we believe their inclusion could have dire consequences for our specialty. The reasons motivating this recommendation included but were not limited to: (1) the exceptional disease burden and high number of co-morbid illnesses experienced by the typical ESRD patient; (2) the involvement of multiple other subspecialties in treating these co-morbid illnesses (in addition to and distinct from the nephrologist’s ESRD care); (3) the high costs and the logistical complexities inherent to the provision of comprehensive care needed by ESRD patients; (4) legacy difficulties experienced by nephrologists pertaining to the meaningful use program, in that a heavy majority of the encounters between nephrologists and ESRD patients occur in settings that are not CEHRT-certified or in which CERHT is not available for documentation of care. 

In short, RPA’s recommendation was based on the recognition that ESRD patients and the nephrologists directing their care face demanding medical circumstances and challenges that are unique to the specialty. As the Quality Payment Program (QPP) broadly and MIPS specifically evolve, RPA urges attention to the accounting of these issues so that the subspecialty treating this most vulnerable Medicare patient subpopulation remains viable. RPA therefore urges CMS to consider the unique characteristics of the Medicare beneficiary sub-population with kidney disease and the nephrology specialty when making determinations affecting kidney disease care. 

Elimination of the Specialty-Specific Risk Adjuster 

In the final rule, CMS maintains its proposal to remove the specialty adjustment from the Medicare Spending Per Beneficiary (MSPB) measure’s calculation. The Agency’s rationale for this decision in the rule is that:  

As currently reported on the Quality and Resource Use Reports (QRURs), the MSPB measure is risk adjusted to ensure that these comparisons account for case-mix differences between practitioners’ patient populations and the national average. It is unclear that the current additional adjustment for physician specialty improves the accounting for case-mix differences for acute care patients, and thus, may not be needed.

RPA continues to be deeply concerned that removal of this adjuster will in general negatively affect nephrology practices. The exceptionally vulnerable health of ESRD patients (and even those patients with chronic kidney disease—CKD and acute kidney injury—AKI) and the difficulties of physician attribution for patients with multiple chronic illnesses speak to the need for specialty adjustment in order to account for the case mix differences that are inherent in the acute care of ESRD patients. As noted above, ESRD patients typically suffer from a plethora of co-morbid illnesses in addition to and integrally affecting their care both in the dialysis facility and out, by the nephrologist and by other subspecialty providers. Removing the specialty adjustment because it is unclear if it works and may not be needed is in our opinion an insufficiently evidence-based rationale for which to make this decision. RPA strongly maintains our recommendation that CMS not implement this proposal, or at least keep these specialty-specific adjustors in place for a minimum of 2 years (performance years 2017 and 2018). 

Reduction of Administrative Burden for Advancing Care Information

With regard to the Advancing Care Information (ACI), RPA commends CMS for its approach in transitioning to the ACI component of MIPS, as the Agency has done a reasonable job balancing thresholds of performance and customizable reporting, and reduced the ‘all-or-nothing’ aspect of the Meaningful Use program. 

As noted above and in recent RPA correspondence sent to the Office of the National Coordinator for Health Information Technology in response to their Request for Information (RFI) Regarding Assessing Interoperability within MACRA, there is one issue still existing in the Meaningful Use program that we urge CMS to address as MACRA is implemented. Many nephrologists have a large volume of interactions with their kidney patients in a dialysis facility, where patient level data is captured in the dialysis information system (DIS). The DIS is almost universally different and not connected to the hospital or the physician’s office-based electronic health record (EHR). Typically, nephrologists direct care for patients with ESRD within multiple dialysis facilities often owned and operated by different dialysis companies, each utilizing a vendor-chosen DIS. Most patients receive dialysis treatments three times per week and are seen by the nephrologist weekly. Therefore, a large amount of patient data is generated in the dialysis facility DIS, and remains there, distinct and separate from the office or hospital medical record for any given patient. As is the case for nursing homes and ambulatory surgery centers, dialysis providers were excluded from the Meaningful Use program and thus, many DIS are not certified EHRs. This exclusion of relevant dialysis patient data precludes meaningful assessment of providers’ use of electronic data exchange and has historically caused difficulties for nephrologists when trying to attest for the Meaningful Use program. 

Thus, RPA believes that for measures assessing a provider's electronic exchange of information to be comprehensive and accurate dialysis units should be considered a valid recipient or sender of information to a nephrologist utilizing certified EHR software in their office setting. Thus, nephrologists utilizing EHR software in their office that differs from the software selected and provided by the operators of the dialysis units will be encouraged and rewarded to exchange information, across all venues of care (dialysis unit to office to hospital) and between providers of care (such as when patients travel or change physicians). Use of structured data templates will be critically important to ensuring that accurate, usable and appropriate information regarding the patient's typical dialysis care is being exchanged. To that end, RPA believes that for this electronic exchange to count toward one of the measures in MIPS, the data sent or received should utilize a consolidated clinical document architecture (CCDA) file or other standardized templates. 

In short, RPA advocates for the inclusion of dialysis facilities as valid recipients or senders of electronic health information and strongly suggests that interoperability measures inclusive of dialysis facilities (and possibly a non-CEHRT dialysis information system on one end of a data exchange transaction) include the use of structured data templates for electronic exchange. We would be open to other reasonable and minimally burdensome requirements to ensure that the interoperability measure is counting as a meaningful exchange of data. 

Development of Quality Measures as Part of QCDRs

RPA is very encouraged by the emphasis on the use of Qualified Clinical Data Registries (QCDRs) in the proposed rule. We believe the ability of QCDRs to collect data for the purpose of patient and disease tracking will foster improvement in the quality of care provided to patients and prove to be invaluable in advancing CMS’ efforts to ensure that outpatient care is being provided with appropriate incentives for providers to achieve the triple aim of controlled cost, broad access, and high-quality care. Indeed, the flexibility of a QCDR to offer specialty specific reporting measures in addition to PQRS measures, a comprehensive and inclusive picture of overall quality of care as informed by data from all payers and the nimbleness and cost efficiency of being led by a specialty society with experience in measure development and maintenance are integral factors to achieving these aims. As such, RPA is pleased that CMS did not implement a requirement that QCDR measures be endorsed by the National Quality Forum (NQF) before being approved for use in QCDRs, as we believe that such a move would be counter to the underlying principle for creating the QCDR and obviate the need for its development. 

However, RPA is concerned about the scoring methodology being proposed for quality measures that are new and/or specialty-developed, such as for a nephrology-focused QCDR. Under the framework of the final rule, measures with low volumes of reporting (less than 20 participants reporting on less than 20 cases), are automatically given a score of 3 points. However, in the development and deployment of new measures for a specialty QCDR there is no way to guarantee participation. We are concerned that QCDR users will ignore specialty-developed measures that are new and/or do not have robust benchmarking data. This raises concern regarding the issue of how to incent QCDR participants to spend additional resources and time collecting data for quality measures for which they may not earn the highest performance-based scoring (even if the measures reflect the best care a specialist can offer). And without utilization of society-developed, specialty-specific measures, we are concerned that specialty society owned QCDRs will have little reason to be sustained. 

RPA strongly encourages the agency to consider: 

Giving QCDRs time to develop and deploy new measures before demanding harmonization or removal of a measure (minimum of 3 years);


Designate an “in testing” status for QCDR-reported, specialty-developed quality measures in their first 3 years of deployment (3-year time limit or until adequate benchmarks established);


Offer bonus points for MIPS Eligible Providers (MEPs) in Quality category for submitting data on “in testing” quality measures in addition to 6 chosen measures;


Offer Improvement Activities (CPIA) for clinicians and practices reporting on new quality measures, such as offering 20 points for reporting on 2-3 measures or 10 points for 1 measure without clear benchmarks that are designated as “in testing.”


RPA strongly commends CMS for its responsiveness to the physician community in refining the proposals for MACRA implementation outlined in April, and for continuing to accept input on these issues by establishing a comment period for the final rule. As noted in our comments on the proposed rule, we believe that the numerous and varying unique characteristics of the kidney disease patient population and kidney care delivery (including but not limited to numerous comorbidities and polypharmacy issues, partially capitated payment structure for care predominantly provided in a bundled care environment, and with attribution barriers to Meaningful Use engagement) call for the design of an advanced care delivery model that will achieve optimal quality outcomes and Medicare program cost-savings. Additionally, the primacy of society-developed, specialty-specific measures in the quest to achieve these goals cannot be underemphasized. RPA believes that our requests outlined in this comment letter address these issues and are consistent with CMS’s goal of shifting toward non fee-for-service value-based payment models in the form of APMs, and, specific to kidney disease care, ESCOs. 

As always, RPA welcomes the opportunity to work collaboratively with CMS in its efforts to improve the quality of care provided to the nation’s kidney patients, and we stand ready as a resource to CMS in its future work on MACRA implementation. Any questions or comments regarding this correspondence should be directed to RPA’s Director of Public Policy, Rob Blaser, at 301-468-3515, or by email at


Rebecca Schmidt, DO 


Renal Physicians Association

1700 Rockville Pike
Suite 220
Rockville, MD 20852

Phone: 301-468-3515
Fax: 301-468-3511

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