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RPA Response to CMS Request for Information on Medicare Incentive Payment Systems and Alternate Paym

Creation/Revision Date: November 17, 2015

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November 17, 2015 

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-3321-NC: Request for Information Regarding Implementation of the Merit-Based Incentive Payment System, Promotion of Alternative Payment Models, and Incentive Payments for Participation in Eligible Alternative Payment Models 

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 respond to the recent Request for Information (RFI) on implementation of the Merit-Based Incentive Payment System (MIPS) and promotion of Alternative Payment Models (APMs) as mandated by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). RPA’s comments focus on the following issues:

•     Minimal Administrative Burdens for Participation in MIPS 
•     Virtual Groups 
•     Quality Measure Development and Refinement Issues 
•     Use of CAHPS Reporting Mechanism in MIPS 
•     Resource Use 
•     Clinical Performance Activities 
•     EHRs and Meaningful Use 
•     Attribution in APMs 

Minimization of Administrative Burdens for Physician Participation in MIPS

In the RFI, CMS seeks comments on a series of issues relating to what specific identifier(s) should be used to appropriately identify MIPS eligible providers (EPs) for purposes of determining eligibility, participation, and performance under the MIPS performance categories. RPA concurs with groups such as the American College of Physicians (ACP) that the Agency must make every effort to minimize the administrative burden created by the methodology used to implement a provider identifier. Requiring all EPs to register with CMS to create a new, distinct MIPS identifier would create a potentially insurmountable administrative burden for both EPs and for the Agency. We are concerned with the ability of CMS’ existing infrastructure to handle the creation of a new distinct MIPS identifier, especially ahead of the start of the MIPS reporting period and with enough lead time to allow all EPs to register. It is also not clear that CMS would be able to administer payments or penalties sufficiently through a new identifier separate from a TIN, and whether it would require an addition to the 1500 claims form. Toward this end, we believe that the use of an existing structure such as the Provider Enrollment, Chain, and Ownership System (PECOS) system makes sense, as opposed to the creation of a separate, parallel process, so that EPs participating in the MIPS program would not have to register multiple times for CMS programs. 

Virtual Groups

RPA echoes the following points from the AMA with regard to virtual groups:  

There should be maximum flexibility for physicians, small practices, and other EPs to form virtual groups. 
There should be no initial, annual, or other limits placed on the maximum number of virtual groups that could be approved each year. Setting limits on the establishment of virtual groups, including the maximum number of groups, minimum or maximum size, geographic proximity, or particular specialty, would have a chilling effect and discourage the EPs from pursuing this option. Such limitations could particularly harm the practices with limited resources and administrative support, which would most benefit from being in a virtual group.
There is unlikely to be a flood of virtual groups signing up in the beginning, as smaller practices will likely take some time to learn about this option and take the actions necessary to form a virtual group. So this should not cause an undue administrative burden for CMS. 
It would not be appropriate to set arbitrary geographic limitations, including a 50-mile radius. This is unnecessary in a world where telemedicine and electronic communications are widely available. It also could hinder small groups of physician sub-specialties from joining together in a virtual group. We would therefore urge CMS to use the broadest geographic area possible and no less than the two adjacent Core Based Statistical Areas (CBSAs) used as part of the ESRD Seamless Care Organization (ESCO) project which is in effect an alternate payment model in kidney disease care (and we urge CMS to specifically clarify that ESCOs do qualify as APMs).
EPs or small practices that practice in a certain specialty or sub-specialty may want to create a virtual group and report on the same quality measures and Clinical Practice Improvement activities. However, there should be no requirement that all EPs within a virtual group are within the same specialty.
CMS may want to consider developing a separate identifier for each virtual group (especially virtual groups that do not already operate under a single TIN). This could be an “internal” identifier, solely for use by CMS, or an “external” identifier that the virtual group would also be required to use.
EPs and small practices should be allowed to break away from larger TINs to form virtual groups. The remaining EPs within the TIN should be allowed to elect how they participate in MIPS or in APMs.
Quality Measure Development and Refinement Issues 

As CMS identifies, develops, and refines quality measures for use in either the MIPS or APM processes, we would urge that the following issues be addressed prospectively so that the quality measures implemented as part of MIPS or APMs are equitable and do not result in physicians being inappropriately penalized in these areas: 
Measures developed by groups such as the National Quality Forum (NQF) or other endorsing bodies should be used; 
Inherent in using measures from endorsing groups such as the NQF is that the underlying endorsed specifications should be used in an unaltered manner, and thus include the same specifications and exclusions in those measures; 
Any measures not tested in a specific disease population such as those with ESRD and in the appropriate setting specifically (such as an ESRD facility) should be so tested before being adopted as MIPS/APM measures; 
Patients with different goals of care, such as those seeking palliative and not curative care, should have quality measures appropriate for their care goals; 
Patients such as those with ESRD who can be predicted to have a poor prognosis (6 month survival of less than 50%) based on an evidence-based, validated prognostic tool should be excluded from the MIPS/APM measures. A different set of measures should be developed and tested in ESRD patients with a poor prognosis. 
If a technical expert panel (TEP) process is used to identify and refine quality measures, the TEP nomination process should be open and transparent; and 
If used, the TEP public reporting process should be thorough; for example, the voting numbers and the individual comments of the TEP members should be part of the public record for these measures.
Further, while we were pleased that the MACRA legislation included funding for quality measure development, we are concerned that the specialty societies that are the engines of quality measure development will not have access to that funding. The expense of underwriting the development, testing, and maintenance activities required to support quality measurement is prohibitive, especially for smaller physician specialties such as nephrology. The cost of development alone of a single physician quality measure has been estimated at approximately $50,000, and this figure does not account for subsequent review and maintenance. We therefore urge CMS to provide an ongoing and stable funding stream for the development, review, implementation, and maintenance of evidence-based physician quality measures to physician specialties developing quality measures that will be used in the MIPS/APM programs. 

Use of CAHPS Reporting Mechanism in MIPS 

In the area of reporting mechanisms available for the quality performance category, CMS inquires about the use of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys, including whether this information should be part of the quality performance category or the clinical improvement category, and what other considerations should be accounted for in implementation. RPA does believe that there is a place for the use of CAHPS survey information in the MIPS program, and it seems appropriate to RPA that it should be accounted for as part of the clinical improvement category rather in its current use in determining quality performance since the CAHPS surveys include factors outside the control of the physician. 

However, our experience in the kidney care delivery milieu is that there is inconsistency and a lack of uniformity both within the CAHPS survey process, and in the external reporting and dissemination of the CAHPS information, and that this variability compromises the aggregate integrity of the CAHPS information. In dialysis some vendors and dialysis providers administer the CAHPS surveys differently, and to the extent that these differences continue over time the comparisons among dialysis units locally and states and regions more broadly will suffer. As such we believe that this variance must be addressed before the CAHPS information is widely used as a comparator among EPs, and since this could adversely affect an EP’s PQRS payment in an inequitable way. 

Lastly, we would urge CMS to be mindful of patient survey fatigue as it plans to use CAHPS surveys and similar processes among the factors to determine clinical improvement. In dialysis the patient may be completing these surveys in the dialysis unit, the nephrologist’s office, and the primary care physician’s office; this multiplicity of surveying will likely apply in other specialties and disease states as well. To the extent that patients are over-surveyed, the end result may be adversely affected. 

Resource Use 

In the RFI CMS makes numerous inquiries regarding resource use as a performance category in the context of the underlying MACRA legislation, but in our reading of this section the Agency only seems to peripherally allude to the issue of risk adjustment and/or patient severity. Issues of this nature are of particular concern in specialties treating chronic illness patient populations such as nephrology. Patients with chronic kidney disease (CKD) and especially end-stage renal disease (ESRD) who are typically treated by nephrologists are among the sickest and most vulnerable in the Medicare program, and if the magnitude of potential resources use chronically ill and high risk patients is not appropriately accounted for, it will be exceptionally difficult for nephrologists to perform well in the resource use category. CMS should also make the effort to reward both high achievement and strong improvement in resource use (and other quality and clinical improvement categories) as MIPS rulemaking evolves. Both achievement and improvement are considered in other CMS incentive programs (such as the ESRD Quality Incentive Program—QIP—for dialysis facilities), thus providers who may be disadvantaged relative to resource use can be measured by their own improvement rather than solely by unrealistic goals of achievement. Lastly, CMS should give the EP the ability to review their resource use data and if they believe it is erroneous, either appeal the data or seek some other corrective action. RPA therefore urges CMS to proceed with all due deliberation in developing resource use measures applicable to specialties treating chronic illness patient populations, and to account for patient severity, high achievement and substantive improvement, and offer a path to appeal the data as necessary. 

Clinical Performance Activities

RPA believes that the vast majority of nephrologists and other physicians do not necessarily object to being evaluated on their clinical performance, but rather are extremely frustrated by the difficulty involved in reporting on these activities in a compliant manner. Accordingly, RPA believes that CMS must take every step possible to minimize the burden on physicians in attesting to clinical performance activities. As such, we concur with the AMA’s recommendation for CMS to reconsider the current PQRS requirement of 9 measures across 3 domains, which is an arbitrarily high yardstick that is not always relevant to patient care and often results in reporting for the sake of reporting and generates data that is of little value. 

Further, we are concerned that for many measures there is not strong evidence that satisfying the measure actually improves patient care, and could encourage a ‘treat to the test’ dynamic that does not benefit patient care. For these reasons, we urge CMS to: (1) highly prioritize the use of evidence-based clinical performance measures (as opposed to measures that are not strongly evidence-based); (2) continually improve and enhance the evidence basis of the measures that are being used; and (3) utilize measures that are both straightforward and relevant so that nephrologists and other physicians can minimize the amount of time and energy that is focused on satisfying measure criteria and maximize their efforts to provide the most effective and patient-centric care possible. 

In response to the question regarding an appropriate attestation timeframe, we believe that annual attestation is a reasonable interval for doing so, and we concur with the AMA that the attestation process would be best facilitated through a web portal that is simple to access and use. Further, transmission of clinical performance improvement should be encouraged through qualified clinical data registries (QCDRs). 

Lastly, RPA believes that the clinical performance activities being reported on should be as specialty-specific as possible. Use of a ‘one size fits all’ model will not account for the heterogeneity of physician specialties and practice types. Requiring nephrologists to report on activities that are not germane to the delivery of kidney disease care would defeat the intent of MACRA to streamline participation in and the measures of Medicare’s various quality incentive programs (and this obviously applies to other specialties and disease states). CMS should therefore work with the specialties to identify clinical performance activities relevant to the care they provide, and appropriate measures and thresholds for use in evaluating that care. 

EHRs and Meaningful Use 

In the RFI CMS asks whether the performance score for within the Meaningful Use of CEHRT Performance Category should be based solely on full achievement of meaningful use. RPA’s response is definitively no, and that an EP should receive partial scoring credit proportionate to the extent that they satisfy meaningful use (MU) criteria. Utilization of an all or nothing scoring approach would mean that if participant is unsuccessful with MU, they would (in theory) be losing the entire percentage of the MIPS score assigned to MU. Given all of the uncertainty surrounding the various stages of the meaningful use program, RPA strongly urges CMS to provide partial credit for the elements of meaningful use criteria that an EP does successfully fulfill. 

Attribution in APMs

While it may be self-evident to note that appropriate attribution is critically important to the success of the APM model, RPA believes that this importance cannot be overstated. Nephrologists generally are willing to accept responsibility (and therefore have outcomes attributed) for patients to whom they provide a substantive amount of care. However, attribution of a patient to a nephrologist who he/she may have only seen once and has only been incidentally involved in his/her overall care would be inappropriate. We therefore urge CMS to consider and address attribution issues of this nature carefully and prospectively in the rulemaking process. 

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 endeavors. 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 signature
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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