MIPS To Prevent 9% Per Year Cuts
ASIPP has successfully submitted comment letter on Merit-Based Incentive Payment System (MIPS) with 4,534 signatures (1,433 physician signatories and 3,101 non-physician provider signatories) and North American Neuromodulation Society (NANS) as a cosignatory. Thanks to overwhelming opposition to MIPS outpouring of support on this issue from membership with grassroots support.
ASIPP also has signed the letter from multiple organizations interested in pain (AAPM, AAPMR, ASA, ASIPP, ASRA, AND NANS).
This is a historic achievement that has never been done for a small specialty.
Considering MACRA consists of 2 separate components with repeal of sustained growth rate formula (SGR) and creation of MIPS and APMs to increase the quality.
These are 2 independent activities. Any changes can be made for MIPS without affecting the other, including repeal, postponement, modification and replacement with an appropriate formula.
Essentially this is a budget balancing measure. It takes approximately $900 million in penalties and gives the same as bonuses. We are suspicious that these numbers can be changing and the composite scores their calculation can be an ever changing process with physician chasing to keep up with the changes. It is a never ending saga.
Please see the letters here:
Letter to CMS:
June 27, 2016
Andy Slavitt
Acting Administrator
Centers for Medicare and Medicaid Services
Department of Health and Human Services
Hubert H. Humphrey Building, Room 445-G
200 Independence Avenue, SW
Washington, DC 20201
Andy.Slavitt@cms.hhs.gov
Re: Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models; Proposed Rule (CMS-5517-P)
Dear Administrator Slavitt:
On behalf of the Board of Directors of the American Society of Interventional Pain Physicians (ASIPP), 50 state societies and the Puerto Rico Society of Interventional Pain Physicians; and North American Neuromodulation Society (NANS), as well as the entire membership of all organizations, we would like to express our concerns and also provide information on a number of proposed provisions affecting the medical community, independent practitioners, and interventional pain management practitioners in particular.
Interventional pain management is defined as the discipline of medicine devoted to the diagnosis and treatment of pain-related disorders principally with the application of interventional techniques in managing subacute, chronic, persistent, and intractable pain, independently or in conjunction with other modalities of treatment (The National Uniform Claims Committee. Specialty Designation for Interventional Pain Management- 09, www.cms.hhs.gov/transmittals/Downloads/r1779b3.pdf).
ASIPP is a not-for-profit professional organization founded in 1998 with over 4,500 interventional pain management physicians and other practitioners who are dedicated to ensuring safe, appropriate, and equal access to essential pain management services for patients across the country suffering with chronic and subacute pain. NANS is a not-for-profit professional organization founded in 1994 dedicated to the promotion of multidisciplinary collaboration to advance neuromodulation, seeking to promote and advance the highest quality patient care. There are approximately 8,500 appropriately trained and qualified physicians practicing interventional pain management in the United States.
ASIPP engaged with Congress, specifically the Energy and Commerce Committee, during the drafting of the Medicare Access and CHIP Reauthorization Act (MACRA) legislation. We supported elimination of the sustained growth rate (SGR) formula and wanted to be participants in the effort to achieve the potential for significant improvement over the previous incentive programs. Our hope and goal was that the effort to improve incentive programs would increase patient care quality and reduce costs and bureaucracy. However, the proposed rule, a 962 page document published on May 9, 2016, took almost 13 months to prepare. It appears to have been prepared by nonmedical or non-practicing individuals. Further, it will be another 4 to 5 months before a final rule on the Merit-based Incentive Payment System (MIPS) is released, which would leave physicians with only 2 months to respond.
As CMS knows very well, there will be no quality improvement. Consequently, the repeal of the SGR part of MACRA must be separated from MIPS. MIPS will destroy independent practices and increase the costs of Medicare, making Medicare insolvent even sooner than expected. In addition, the patient/physician relationship will be damaged and access will be reduced by sending patients to the most expensive and least effective setting. The following comments seek to:
• Exempt or exclude interventional pain management from the proposed MIPS program due to interventional pain management’s independent speciality status without an anchor specialty.
• Replace MIPS with a better system or delay the implementation of MIPS for 2 years so that pilot programs can be started in order to evaluate the value and validity of the various measures and regulations introduced, as well as its value and validity in improving quality and reducing costs.
• Clarify multiple misleading proposals in the MIPS program to ensure that it facilitates meaningful opportunities for performance improvement and decreases administrative and compliance burdens.
• Accommodate the needs of interventional pain management physicians in solo and small practices in order to enhance their opportunities for success and avoid unintended consequences.
• Provide a guarantee to the physician community that the Centers for Medicare and Medicaid Services (CMS) will depart from its path of destruction of independent practices and instead assist them to progress into the future. Further, assurance is needed that the program is only for improving quality initiatives, rather than balancing the budget and improving the pockets of a few by changing regulations as they fit the needs of CMS and also misinterpreting or misconstruing the intent of the law.
Exemption of Interventional Pain Management
As shown above, interventional pain management is a small specialty with a specialty designation provided in 2002. Since then, this specialty has grown significantly, with a significant proportion of expenditures, with its own special practice expense and membership on Carrier Advisory Committees (CAC). Interventional pain management includes physicians from multiple specialties as approved by the American Board of Medical Specialties (ABMS), including anesthesiology, physical medicine and rehabilitation, neurology, psychiatry, interventional radiology, emergency and sports medicine, and finally general practice/family medicine. The specialty is expanding, also attracting physicians from multiple other specialties.
The primary societies for the specialties from which interventional pain management physicians come have been highly involved in the Current Procedural Terminology (CPT) coding and the Relative Value Update Committee (RUC), in collaboration with the American Medical Association (AMA). But, regarding Meaningful Use, the Physician Quality Reporting System (PQRS), the value based modifier and now MIPS, these societies are focusing on their primary specialities.
Consequently, interventional pain management is left without an anchor specialty. Unfortunately, CMS, also in its proposed rule, has not provided any specialty specific measures for interventional pain management. However, interventional pain management physicians can adopt multiple measures from various other specialties including physical medicine and rehabilitation, internal medicine, radiology, orthopedic surgery, mental/behavioral health, neurology, and preventive medicine. In fact, the 7 specialty-specific measures provided for physical medicine are all related to interventional pain management or pain management rather than physical medicine.
In addition, previous experience with meaningful use and PQRS has taught us numerous lessons, even though interventional pain management physicians have scrambled to identify measures to fit into interventional pain management from various specialties.
Additionally, cost comparison data have been extremely bizarre with inclusion of any patient who presents even for a single visit to interventional pain management for an initial evaluation and subsequent follow-ups or treatments. The interventional pain management physician can be held responsible for extensive expenditures based on hospitalizations and other expenses that he or she has no control over, factors such as the costs associated with heart disease, diabetes, hypertension, and stroke.
The major issue appears to be CMS’s method of calculation. The physician community has contended that CMS changes its calculation of the composite score without any rhyme or reason. Calculations of clinicians never seem to correlate with CMS composite scores. We are hoping MIPS will change that.
Finally, CMS has never allowed interventional pain management physicians from ASIPP, the largest society representing interventional pain management physicians, to participate in the preparation of any type of measures or sought our opinion.
Consequently, it is justifiable to exempt interventional pain management as a whole or exempt us from penalties and provide bonuses for those enthusiastic individuals who meet the criteria.
Repeal or Delay the Merit-based Incentive Payment System (MIPS)
We propose that CMS should delay implementation of MIPS for at least 2 years so that CMS can conduct a pilot program to test its efficacy concerning quality measures, improvement in quality of care, and reduction in costs. This will provide a scientific basis for utilization of such measures. The proposed rule at many places states that either there is no evidence or there is very little evidence on many aspects of this proposed rule.
As of now, there is no evidence for the efficacy or necessity to use any of the measures.
Multiple reasons for repeal or delay are:
• Quality measures have nothing to do with quality. The Medicare Payment Advisory Commission (MedPAC) agrees.
• MIPS penalizes small practices and solo physicians. While it is supposed to be based on quality initiatives, CMS has already announced how many will get bonuses and how many will get negative adjustments, which essentially shows that it is a pre-possession. The major issue here appears to be balancing the budget—not improving health care.
• Quality metrics only look at data points. They utilize numerous measures which are irrelevant to the particular specialty, to patient care, and finally to measures which are not controlled by that particular physician.
• At minimum, provide a one-year delay, followed by implementation of MIPS for only one of 4 quarters to qualify. This will provide opportunities to prepare appropriately over a period of one year, both for CMS and physicians; as well as if in fact this improves quality, it can be observed in a 3-month follow-up. In addition, if a person participating during the first or second 3 months fails to achieve the scores, that person may participate again in the third or fourth quarters.
While organized medicine, including the undersigned organization, was involved in MACRA legislation. Finally, CMS has never allowed interventional pain management physicians from ASIPP, the largest society representing interventional pain management physicians, to participate in the preparation of any type of measures, or sought our opinion. The formulation of the proposed rule by CMS was conceivably created by non-practicing physicians and others who are non-physicians who seemingly did not ask for any input from physicians or relevant organizations.
Meaningful Use has been renamed Advanced Care Information, even though you have stated Meaningful Use was ending. Even though it is presented that Advancing Care Information is more flexible than Meaningful Use, that statement appears to be questionable.
In fact, at the annual Healthcare Information and Management Systems Society (HIMSS) conference in March 2016, you stated the obvious: physicians are extremely frustrated with current electronic health record (EHR) systems. You shared findings from 8 focus groups CMS conducted with front line physicians on EHRs. The main theme was that EHRs were not intuitive and usable for a physician’s work flow. One doctor interviewed by CMS complained that it took 8 clicks to order aspirin in the EHR, and it took 16 clicks to order full-strength aspirin. For interventional pain management physicians it takes a minimum of one minute to order one controlled substance with multiple clicks when a system is functioning appropriately. The dislike for EHR systems, especially in terms of usability, has been boiling for several years and continues to decline with its approvals. According to a survey conducted by the AMA and American EHR Partners, a research company which rates vendors in the space, satisfaction with EHR systems among physicians plummeted almost 30 percentage points from 62% in 2010 to 34% in 2014 – thanks to the advances and complicated regulations from CMS. Now EMR use is also declining.
Essentially, current EHRs take too long to enter data, require a number of things that need to be entered that do not seem to be valuable for patient care, are designed to fulfill federal programs rather than the needs of the physicians and the patients using them, and they do not display information in a way that is usable and helpful to doctors as it should be as per Steven J. Stack, an emergency physician and President of AMA. This effect is much more exacerbated for practicing physicians, specifically in a chronic management setting such as interventional pain management.
In addition, EMRs do not talk to each other, the main reason EHRs were widely deployed to share information across different sites of care and clinicians, and they simply don’t do that at any level at present and they increase the time required to acquire the data. A majority of the times, Meaningful Use requirements and PQRS requirements necessitate documentation of data that are neither applicable to the specialty nor to the treatment the patient is receiving.
Dr. Robert Wachter, a physician and professor and interim chairman of the Department of Medicine at the University of California, San Francisco, as well as the author of The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age, succinctly stated that the core problem with EHRs is that they are not built with usability in mind or an appreciation for a physician’s work flow. Moreover, Dr. Wachter does not think that it is a coincidence that higher rates of physician burnout have correlated with widespread EHR adoption.
The increasing requirement for documentation, which does not seem to help patient care or to improve quality, is creating great stress upon physicians. A recent assessment of burnout among pain management physicians showed that 61% of interventional pain management physicians suffer with emotional exhaustion, 43% suffer with a lack of personal satisfaction and accomplishments, and 36% reported depersonalization. Another recent survey on physician burnout showed EMRs increased their stress level substantially; physicians reported stress levels of 80% to 90% and a significant proportion of them will be dropping out of practice sooner or later, while the majority of them choose to pay a penalty.
However, patient safety is the core of the issue. According to Dr. Wachter, EHR-related workflow issues can lead to bigger problems apart from burnout. He stated that, “the most disturbing thing (that can happen) are major medical mistakes . . . they happen all the time.” Obviously these mistakes have been underreported.
The CMS data itself show that solo and small practices will get hit hardest under the new incentive payment system with 87% of solo practitioners likely to be penalized with inclusion of 103 eligible clinicians; whereas groups with 2 to 9 physicians comprising 124,000 eligible clinicians will be likely to be penalized at a 70% rate. The penalties start reducing at 60% for 10 to 24 physician groups, which incorporates only 81,000 physicians and 45% for 25 to 99 physician groups. The MIPS program seems to be specifically designed to force small and solo practices out of Medicare. The majority of physicians have already flocked to hospitals and they constitute 100 or more physicians in a group with a total of 306,000 with only 18% likely to be penalized. Consequently, MIPS will send many physicians into hospital employment. Ironically, hospital settings are the most costly with the least cost effectiveness and present with low quality with entangled bureaucracy.
This push to hospital-based care is in total conflict with the philosophy of Congress to provide high quality care with reduced costs.
CMS estimates that approximately $900 million will be provided in bonuses, which will be recouped from penalties. Essentially, this states to any person with business experience or economists that if CMS is not able to achieve this goal with the present regulation, it will change it so that more and more will be penalized with the composite score being changed or the measures will be instituted so that they cannot be appropriately implemented. Consequently, CMS should delay MIPS for at least 2 years for all the reasons cited above, and Congress should repeal it on a bipartisan basis. This meaningless, valueless provision in the law, which will affect patients and physicians across the United States, will increase costs and reduce quality.
Clarify Multiple Issues
Even with postponement of implementation, CMS must clarify the following 3 questions. These questions have been raised by the Ways and Means Committee to CMS. Even then, the Ways and Means Committee has not received a reply to clarify these questions.
1. Are the measures separate for each individual category such as quality, Meaningful Use, etc., or can one measure apply to more than one category?
• It is extremely crucial that CMS provide an appropriate response and clarify these questions even with potential delay in implementation and repeal. As described in the proposed rule, there are multiple measures which can cut across all 3 categories, namely Advancing Care Information, quality reporting, and clinical practice improvement activities.
Overall, it appears to be prudent for CMS to incorporate multiple measures cutting through multiple parameters and be credited in each category towards calculation of the composite score.
CMS has proposed that as an example, the category of quality will incorporate 50% of the composite score in 2019, which is reduced to 45% in 2020 and 30% in 2021. However, the resource use changes from 10% to 30% within 2 years. The proposed rule shows that clinical practice improvement activity stays at 15% and Advancing Care Information also stays at 25%; however, this appears to be contradicting their own proposed rule. The proposed rule essentially states that with widespread penetration of EHRs, the proportion of Advancing Care Information will be reduced or even eliminated.
2. While CMS has clearly provided in the past the included CPT codes for consideration for PQRS, it has not provided the type of CPT codes to be used for MIPS assessment.
• The question is that are these limited to evaluation and management services only, or all services? If so, how do they receive implementation for what measures?
• Are they different based on the type of service provided or the visit such as a procedure, surgery, or only a follow-up visit?
3. CMS also has not answered the question in reference to if the procedures are performed in a surgery center or hospital, is the physician still obligated to provide these measures or not?
It is essential to understand this aspect. As many as 60% of interventional pain management procedures are performed in either an ambulatory surgery setting or hospital outpatient departments, which are exempt from MIPS. Consequently, is a physician still responsible for collecting the data and submitting for these services as there will be a physician service bill on these patients apart from the facility bill?
Certain clinical improvement activities provide inclusion if a physician is participating in service conducted by JCAHO. However, it does not offer the same for other agencies approved by CMS such as AAAHC.
Thus, CMS must immediately respond to the above questions with clarifications so that participants can prepare, provided there is time to prepare and accommodate. Accommodation seems to be the essential ingredient lacking in this proposed rule. Accommodation can come in multiple ways. It is essential that CMS accommodate the needs of the most vulnerable physicians in solo and small practices and do not lead to the end of independent medical practices. It has been stated that the changes in MIPS have the potential to upend the way medicine is practiced today, accelerating the move towards hospital employment and making the small group practice a thing of the past. This is achieved at a high cost for physicians and to the public.
Accommodate the Needs of Independent Physicians
1. Repeal MIPS leaving intact other provisions of MACRA with SGR. As it is, SGR repeal has been problematic in future years. Physicians are already struggling with the future prospect of major cuts. In addition, physicians have been burned with onerous regulations from CMS over the years, most recently, ICD-10-CM, and, now, MIPS. Thus, repeal and do nothing after that is the number one option.
2. The number 2 option is repeal the present proposed MIPS and replace it with real quality improvements with appropriate delay.
3. The third option is delay for 2 years with multiple pilot programs demonstrating efficacy and the value of this MIPS.
4. Change requirement to per quarter than yearly.
5. Only implement rewards, but not penalties. This essentially means CMS and Congress would need $900 million per year. This savings can easily be achieved.
• Approximately $4 to $6 billion can be obtained by removing the site of service differentials with hospitals being paid at the same rate as ambulatory surgery centers for surgical services performed in the operating room and being paid at the same rate as 10% higher than the office expense rate.
This has been proposed by MedPAC as well as the Department of Health and Human Services/Office of Inspector General with no action from CMS. Congressional action would be good on this aspect; however, CMS with all its powers and with its fee schedule can implement the site of service equalization. This will be the most accountable activity ever performed by CMS.
Finally, we appreciate CMS for consideration of our comments. Our common goal is the provision of quality, cost-effective care to Medicare recipients. Our concern is that the MIPS program as developed by CMS will not achieve that goal.
A copy of this is being sent to appropriate committee chairs and ranking members in both houses and all the members of Congress. If you have any questions, please feel free to contact us.
Letter to Congress:
June 28, 2016
Honorable Senator Mitch McConnell, Senate Majority Leader
Honorable Senator Harry Reid, Senate Minority Leader
Honorable Representative Paul Ryan, Speaker of the House
Honorable Representative Kevin McCarthy, House Majority Leader
Honorable Representative Nancy Pelosi, House Minority Leader
Senate Committee on Finance
Honorable Senator Orrin Hatch, Chairman, Senate Committee on Finance
Honorable Senator Ron Wyden, Ranking Member, Senate Committee on Finance
Health, Education, Labor and Pensions
Honorable Senator Lamar Alexander, Chairman, Health, Education, Labor and Pensions
Honorable Senator Patty Murray, Ranking Member, Health, Education, Labor and Pensions
Energy and Commerce Committee
Honorable Representative Fred Upton, Chairman, Energy and Commerce Committee
Honorable Representative Frank Pallone, Ranking Member, Energy and Commerce Committee
Ways and Means Committee
Honorable Representative Kevin Brady, Chairman, Ways and Means Committee
Honorable Representative Sander Levin, Ranking Member, Ways and Means Committee
Oversight and Government Reform Committee
Honorable Representative Jason Chaffetz, Chairman, Oversight and Government Reform Committee
Honorable Representative Elijah Cummings, Ranking Member, Oversight and Government Reform Committee
Re: Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models; Proposed Rule (CMS-5517-P)
Dear Honorable Leadership and Members of Senate and House:
On behalf of the Board of Directors of the American Society of Interventional Pain Physicians (ASIPP), 50 state societies and the Puerto Rico Society of Interventional Pain Physicians; and North American Neuromodulation Society (NANS), as well as the entire membership of all organizations, we would like to express our concerns and also provide information on a number of proposed provisions affecting the medical community, independent practitioners, and interventional pain management practitioners in particular.
The proposed rule, a 962 page document published on May 9, 2016, took almost 13 months to prepare. It appears to have been prepared by nonmedical or non-practicing individuals. Further, it will be another 4 to 5 months before a final rule on the Merit-based Incentive Payment System (MIPS) is released, which would leave physicians with only 2 months to respond. We have submitted a letter to CMS (CLICK LINK FOR LETTER: http://www.asipp.org/COMMENT-CMS-MIPS-APM.pdf) with 1,433 physician signatures and 3,101 non-physician provider signatures, with a total of 4,534. This letter also contains all the signatures.
Medicare Access and CHIP Reauthorization Act (MACRA) consists of 2 separate components.
• Repeal of the sustained growth rate (SGR) formula
• Institution of the Merit-Based Incentive Payment System (MIPS) and alternative payment models.
Contrary to common belief, these are 2 independent activities. If repeal of the SGR formula causes damage, it is still coming in the future with marked reductions in physician payments. However, MIPS will start causing damage right away.
Independent practices already have been reduced from two-thirds of practicing physicians in 2008 to one-third now, and will become one-fifth by 2019 when penalties start taking effect. MIPS is a hypothetical quality and cost cutting measure administered by bureaucrats (even MedPAC says it will not improve quality or costs).
It takes approximately $900 million in the form of penalties and awards them as bonuses. Elimination or repeal of the formula has no effect on anything except that they will not be getting bonuses and CMS will reduce its workforce with net savings. At the same time, there won’t be any cuts. If true quality measures to improve quality and reduce costs can be found, then it will be worthwhile. Otherwise, independent practices will be reduced and all of them will flee to hospitals. Medicare will become insolvent much sooner due to an increased strain on Medicare with the most expensive and least efficient setting becoming the model of practice. It will completely destroy the patient-physician relationship as it has eroded substantially. It is also important to note that adoption of electronic medical records (EMRs) is decreasing rather than increasing.
Consequently, ASIPP is seeking the following to maintain the survival of independent practices and patient access at an affordable price.
• Exempt or exclude interventional pain management from the proposed MIPS program due to its independent speciality status without an anchor specialty.
• Replace MIPS with a better system or delay the implementation of MIPS for 2 years so that pilot programs can be started in order to evaluate the value and validity of the various measures and regulations introduced, as well as its value and validity in improving quality and reducing costs.
• Clarify multiple misleading proposals in the MIPS program to ensure that it facilitates meaningful opportunities for performance improvement and decreases administrative and compliance burdens.
• Accommodate the needs of interventional pain management physicians in solo and small practices in order to enhance their opportunities for success and avoid unintended consequences.
• Provide a guarantee to the physician community that the Centers for Medicare and Medicaid Services (CMS) will depart from its path of destruction of independent practices and instead assist them to progress into the future. Further, assurance is needed that the program is only for improving quality initiatives, rather than balancing the budget and lining the pockets of a few by changing regulations as they fit the needs of CMS and also misinterpreting or misconstruing the intent of the law.
We appreciate the Senate and House leadership and membership for considering our comments. Our common goal is the provision of quality, cost-effective care to Medicare recipients; however, the MIPS program as developed by CMS will not achieve that goal and will have the opposite effect by reducing quality and increasing costs and ending independent practices with hospitals dominating the entire scene.
We are also providing a detailed explanation (CLICK LINK FOR EXPLANATION: http://www.asipp.org/EXPLANATION-MBIPS-REQUEST.pdf) of these issues.
Thank you again. If you have any questions, please feel free to contact us.