Coping With COVID-19: ACP Calls for Additional Changes to Proposed 2021 QPP Payment Rules

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ACP urges CMS to issue a broad MIPS performance exception and hold Advanced APM participants harmless from financial losses through 2021

Oct. 23, 2020 (ACP) – The American College of Physicians is calling on the Centers for Medicare & Medicaid Services (CMS) to make needed changes to the proposed 2021 Quality Payment Program (QPP) updates so that physicians can continue to weather the COVID-19 pandemic.

The Medicare Access and CHIP Reauthorization Act was designed to shift physician payment so that it rewards value and quality over volume via the creation of the QPP. The QPP offers two pathways for Medicare reimbursement, including the default Merit-Based Incentive Payments System (MIPS), which adjusts physician payments on a percentage basis based on performance metrics. Alternatively, physicians can elect to participate in one of several available Advanced Alternative Payment Models (APMs). Every year, CMS proposes changes through its annual Medicare Physician Fee Schedule and QPP proposed rule. CMS recently requested public input on its proposed 2021 changes, which are slated to be implemented on Jan. 1.

Specifically, CMS is considering raising the MIPS performance threshold for 2021. ACP is urging CMS to extend the broad MIPS exception for 2021 as they did for 2019 and 2020 due to the COVID-19 pandemic. “The pandemic lasted longer than we wanted it to. This is not the time to hit clinicians with an additional penalty,” said Suzanne Joy, ACP senior associate of regulatory affairs. ACP suggests that at minimum, CMS should revert the performance threshold to 30 points, the 2019 threshold, since clinicians were eligible for broad hardship exceptions for the 2019 and 2020 performance years due to the pandemic. If a physician does not meet a minimum threshold of MIPS points, they are hit with financial penalties. Higher points are needed to earn bonuses.

CMS also proposes to delay initial implementation of its new MIPS Value Pathway (MVP) to 2022 at the earliest due to the pandemic. This new pathway aims to reduce reporting burden by aligning criteria and creating subsets of measures and activities centered on a particular specialty, condition or patient population that can be used to satisfy MIPS reporting requirements. ACP previously submitted its own draft MVP proposals for preventive care and chronic disease management for CMS to consider. ACP understands the need to delay but hopes to further the dialogue on these and other MVPs.

ACP also suggests that Advanced APM participants be held harmless from financial losses for performance years 2019 through 2021. Performance data for these years should not be used against them, Joy said. APMs reward clinicians and physicians for reaching quality and spending benchmarks that achieve better outcomes and/or a more efficient allocation of resources. “These are people who are taking on financial risk as CMS has asked, and they are not getting the same protection as clinician in MIPS,” Joy said. “This could fundamentally jeopardize physician confidence in future APMs, which is the last thing we want.”

CMS is suggesting that the thresholds to qualify as a Qualified Participant (QP) in an Advanced APM increase significantly. “This is terrible timing,” Joy said. “We are urging the Secretary of Health and Human Services to exercise its authority to maintain the current patient count threshold through at least 2022.”

ACP is also opposing the CMS proposal to change the way APM bonus payments are made to focus more on where clinicians are during the payment year, instead of performance year. “Under the proposal, if I worked for practice A and met all of this stringent criteria and earned a bonus based on my time there and the infrastructure they set up, then I move to practice B, practice B would get that bonus I earned even though they really had nothing to do with it,” Joy said. “ACP supports the group practice model and knows the decisions and infrastructure investments to join an APM are typically made at the Tax Identification Number (TIN) or APM Entity level. Moving accountability further from actions taken during the performance year is the opposite of what we want. ACP is instead urging CMS to make the Advanced APM incentive payments sooner to shorten the window for clinicians to potentially leave that practice.”

CMS is striving to promote consistency and reduce reporting burden with its proposed new “APM Performance Pathway” within MIPS, which among other changes, would require all APM participants to report the same six quality measures for the purposes of MIPS. But, Joy cautioned, this is too restrictive and may actually increase reporting burden. “You can't expect a primary care physician participating in Comprehensive Primary Care Plus in Colorado to report the same quality measures as an orthopedist in the Bundled Payments for Care Improvement Advanced Model in Alaska,” she said. “Practices need flexibility. We all want fewer boxes to check, but we need multiple measures to choose from so we can be sure they are clinically relevant to our given specialty and patient population.” ACP urged CMS to delay the proposal to allow more time for stakeholder engagement and to remediate potential unintended consequences.

In the proposed rule, CMS also suggests removing the Web Interface (WI) as a data submission mechanism, which up to now was required for Accountable Care Organizations (ACOs). “This is not the year to completely change the way ACOs have been reporting since the program's inception,” Joy said. With this change, ACOs and other practices reporting through WI would need to find a new vendor, align internal systems and workflow processes, train staff and, ideally, test. “Expecting a smooth implementation by Jan. 1, 2021 is asking for the impossible,” Joy said, “especially with the delayed release of the rule this year.”

The proposed rule, usually released in early July, was delayed until Aug. 3 due to the pandemic. CMS says it does not expect to meet its Nov. 1 deadline for the final rule, though implementation will remain on Jan. 1, 2021. “Practices will be working with an even shorter runway this year, so ACP will be working overtime to provide educational resources to help practices wrap their head around and comply with finalized changes,” Joy said.

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