June 24, Submitted electronically via Regulations.gov

Transcription

1 June 24, 2016 Submitted electronically via Regulations.gov Mr. Andrew Slavitt Acting Administrator Centers for Medicare & Medicaid Services Hubert H. Humphrey Building, Room 445-G 200 Independence Avenue, SW Washington, D.C Re: Commenting on 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 Dear Acting Administrator Slavitt: The American College of Rheumatology (ACR), representing over 9,500 rheumatologists and health professionals, appreciates the opportunity to respond to the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) proposed rule. We welcome the chance to share our concerns on the impact these proposals will have on our ability to provide quality care to the 50 million Americans living with rheumatic diseases. Rheumatologists provide ongoing care for Medicare beneficiaries with complex chronic and acute conditions that require specialized expertise. Rheumatologists provide face-to-face, primarily non-procedure-based care, and serve patients with serious conditions that can be difficult to diagnose and treat, including rheumatoid arthritis, systemic lupus erythematosus, and other debilitating diseases. Early and appropriate treatment by rheumatologists slows disease progression, improves patient outcomes, and reduces the need for costly downstream procedures and care compared to care provided solely by primary care providers. We appreciate the opportunity to provide our input on CMS s proposed rule to significantly alter physician-focused models. We are pleased to provide comments on a number of the complex issues raised within the rule. As a general principle, we encourage CMS to be mindful of our ability to treat and care for patients with chronic and rheumatic diseases. As we strive to meet their needs while practicing in small practices, large practices, or hospital and clinic settings, we are committed to advancing the value of the services we offer to Medicare patients. The demands of practice, combined with changing reimbursement and compliance issues may need to be recognized and considered as changes are implemented. WDC v1

2 Page 2 Key Issues 1) While the ACR supports the MACRA law, the complexity and timing of the requirements are daunting. We are concerned that the proposed timeline will impede rheumatologists ability to prepare and comply with the extensive new requirements. 2) There are few existing Alternative Payment Models (APMs) that are feasible for rheumatologists. Workable alternatives should be developed with attention to facilitating participation of small and solo practices. As currently written, the requirements for qualifying participation in APMs are formidable, and establish too high of an administrative burden. 3) The calculation of resource use (i.e., costs) as currently proposed includes medication costs from Part B, but not Part D, which would result in inaccurate MIPS scoring. The ACR is advocating to minimize this inaccuracy. 4) We appreciate many positive aspects of the proposed rule, including the role of qualified registries, such as the ACR s RISE registry, in successful participation under MACRA; the removal of all-or-nothing scoring mechanisms; the availability in some sections of more measures or points than are needed; and the integration and streamlining of quality reporting programs. The following are general responses to the proposed rule. A. Executive Summary and Background The Merit-Based Incentive Payment System (MIPS) properly recognizes the need to measure physician performance based on multiple performance categories. We are concerned, however, that the timeline set out by CMS seeks to make too many large changes, too fast. We agree that the performance period should be set at one calendar year but the proposal to use 2017 as the first year, which is less than 6 months away, does not provide enough time for providers to implement the required changes. Thus, we urge CMS to delay the timing of the first performance year. One of the largest fundamental changes in Medicare reimbursement must be implemented in a way that allows everyone to evaluate, prepare, and implement these changes to their practice so that reimbursement accurately reflects performance. We recognize that most quality measures are specified for certain reporting periods or minimum sample sizes, and reducing reporting periods may impact performance on the measures in a way that does not accurately reflect true quality. Therefore we request that in implementing this delay in the timing for the first performance year, for any measures where a change in the denominator volume or duration of reporting period could unduly influence performance on the measure, some provision(s) in the reporting or performance requirements be made. These allowances might include allowing smaller minimum sample sizes to reflect the reduced reporting period and allowing flexibility on reporting targets and/or number of required measures during the initial shortened reporting period. We also request that CMS

3 Page 3 appropriately reconstruct the percentage value for those components of the overall MIPS score that are affected. The ACR believes Advanced Alternative Payment Models (APMs) offer an innovative opportunity to uniquely reward quality care and reduce costs to Medicare. Fundamental to APMs being successful is that the models are flexible and have easy to understand criteria. As proposed, the rule provides that Physician Focused Payment Models (PFPMs) may not necessarily meet the criteria to be considered an Advanced APM. It is important to note that providers are unlikely to pursue a PFPM if it does not qualify as an Advanced APM. We seek clarification from CMS regarding whether or not a PFPM qualifies as an Advanced APM. Additionally, quality measures need to be uniform in format and easily integrated with provider workflow in order to ensure that they are reliably and easily used. Medical Home APMs should also permit specialty physicians to participate, including small groups and multispecialty groups, in keeping with the need for APMs to be flexible with their criteria and the role of specialty physicians in providing chronic care. We recognize the significant value that performance data will have to patients, providers, and CMS, as it will provide vital information that will allow patients to compare providers, encourage providers to improve, and allow CMS to ensure patients receive quality care. In order to provide patients with the clearest picture of the information gathered, it is vital that the Physician Compare website for MIPS include key contextual information so that the public can make meaningful comparisons. For example, context could be provided related to the goals of specific measures. Likewise, some description of the practice setting indicating rural or medically underserved areas, and case mix index could allow more meaningful data interpretation. In order to provide patients with meaningful information, we believe that data which are potentially misleading or do not help patients make decisions about their healthcare be withheld. One example of data which we believe would not benefit patients is global resource use data. Presenting these data is likely to cause confusion and create misleading interpretations of physicians performance. To appropriately interpret data on resource use, data must also be provided that contextually describes factors such as relative complexity of the patient population and achievement of quality measures, which in part drive that cost. II. Provisions of the Proposed Regulations A. Meaningful Use Prevention of Information Blocking and Surveillance Demonstrations for MIPS Eligible Clinicians, EPs, Eligible Hospitals, and CAHs The ACR supports interoperability of EHRs, which is critical to ensuring the benefits of EHR are achieved. We support prevention of data blocking and prohibiting physicians from contributing to data blocking. Additionally, while EHRs offer significant benefits to patients and providers, they are expensive and inaccessible to some providers, particularly small practices. We seek

4 Page 4 clarification on how EPs, particularly small practices, will be expected to demonstrate their compliance to CMS. B. MIPS Program Details The ACR agrees with CMS that clinicians should be incentivized to engage in valid and reliable improvement measures relevant to their patient populations. It is imperative that small groups be given special consideration due to their low-volume, frequent care for patients in rural areas of poor coverage. Clinicians in areas that are rural and federally qualified health centers should be exempt from MIPS. For those non-patient-facing MIPS eligible clinicians, we seek clarification from CMS regarding whether EPs who are not in these specialties but who see fewer than 25 patients will receive exemptions from MIPS. C. MIPS Eligible Clinician Identifier The ACR appreciates CMS s recognition that clinicians may practice in multiple settings, therefore we support CMS s proposal to use multiple identifiers that allow MIPS eligible clinicians to be measured as individuals or through a group s performance. In some cases, a single identifier will be insufficient to properly assess a provider, and allowing the use of a combination of the TIN/NPI will help make sure performance data are accurate. D. Exclusions The ACR agrees with CMS s proposal that new Medicare-enrolled Eligible Clinicians should not be treated as MIPS eligible clinicians immediately when they begin practice. CMS has proposed that these ECs will not be considered MIPS eligible clinicians until the subsequent performance year of their first performance year. However, we do not believe CMS has fully considered that a calendar year period for new doctors may be problematic. Most training programs end in July. This means that if a calendar year is used for this exemption, under CMS s proposal the grace year would actually only be 6 months. The ACR urges CMS to ensure that these new ECs have one full 12 month period before participating in MIPS. We also request clarification regarding whether those in this exclusion category would receive the base rate without positive or negative rate adjustment. E. MIPS Category Measures i. QCDR Data Should be Included as a Reporting Mechanism The ACR is home to the Rheumatology Informatics System for Effectiveness (RISE) Registry a robust quality improvement infrastructure tool, offered free to all members. RISE allows users to report, self-assess, and analyze data on demographics, medications, lab data, disease activity, functional status and other metrics directly from their practice s electronic health records system to benchmark performances on key rheumatology clinical quality measures and align with best practice standards. This iterative process leads to improved patient outcomes,

5 Page 5 patient population management, and quality reporting such that CMS has designated RISE as a qualified clinical data registry (QCDR) allowing rheumatologists who wish to use RISE for MIPS reporting to do so seamlessly. As proposed, MIPS will grade performance based on a ECs quality, resource use, clinical practice improvement, and advancing care information. The ACR firmly believes that in keeping with the goal of improving patient outcomes and providing maximum flexibility to ECs, QCDR must be included as a reporting mechanism that MIPS ECs and Groups can use to submit data on quality measures and activities. Further, some groups, particularly those that are small or rural, will need sufficient time to gather and report their data and, it is therefore, important that the reporting deadline for the submissions to the qualified registry QCDR, EHR, and attestation submission mechanism be the maximum practical time permissible. ii. The Performance Category Should Not Penalize Providers Who Depend on Part B Drugs for Patient Care The ACR strongly supports CMS s goal of simplifying the reporting criteria and administrative burden for the quality performance category. We are encouraged by the rule s proposal to reduce the number of measures and align them with other payments and national payers, as well as the use of all-payer data wherever possible. Particularly in the early years of MIPS, the heavy-weighting of the performance category will be helpful as CMS resolves issues surrounding drug cost issues under Parts B and D. Such weighting will protect those specialties that perform high quality care, but also require using expensive drugs to adhere to published evidence-based guidelines. For certain specialties including rheumatology, maintaining this weighting rather than reducing it over the years makes it less critical to solve the challenging issues surrounding Parts B and D drug cost issues. We seek clarification from CMS regarding the number of quality measures that must be reported. Specifically, in the case of reporting a specialty measure set, would a provider need to report all the measures within, or would they only be required to report six measures? For the performance criteria for quality measures for groups electing to report consumer assessment of healthcare providers and systems (CAHPS) for MIPS Survey, options are needed for the measures and standardized and meaningful measures are imperative for specific disease states. If all measures in a set must be reported, we request creation of a separate measure set for rheumatology that does not include allergy and immunology. We request the following measures be included in such a measure set: Rheumatoid Arthritis (RA): Tuberculosis Screening; Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity; Rheumatoid Arthritis (RA): Functional Status Assessment; Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis; Rheumatoid Arthritis (RA): Glucocorticoid Management; and Rheumatoid Arthritis (RA): Disease Modifying Anti-Rheumatic Drug (DMARD) Therapy. These measures have been developed by the American College of Rheumatology and represent factors which we believe are most important to quality care.

6 Page 6 iii. Data Submission of Quality Measures Should Be Easy for Providers to Understand and Comply With The accurate and complete submission of measures to CMS is dependent on ECs having clear and realistic standards up front. CMS s proposal to require data completeness of percent concerns us because such a goal, while laudable, may be practically unobtainable in many cases. The ACR believes that some data submission criteria may be unobtainable for some physicians and a more feasible percentage, such as percent, is more advisable. Such a benchmark will produce strong data for analysis, while reducing the burden on providers. We seek clarification as to what subspecialty providers who have a low percentage of patients for whom the available measures apply are supposed to report and how they will be scored. For example, a rheumatologist who primarily treats lupus patients will be unable to use the rheumatoid arthritis, osteoarthritis, osteoporosis, and other measures, because the large majority of their patients, those with lupus, will not have these measurements. As we witnessed with the problematic launch of Healthcare.gov, it is vital that new complex technology systems are well-tested prior to real-time use in order to ensure a smooth launch for the user and the technology provider. Therefore, we urge that the quality data submission criteria include a test submission system that will allow vendors and providers to familiarize themselves with the system and work out any deficiencies prior to its real-time use. Such a test will also allow vendors to determine whether they have the capacity to meet submission requirements. For the application of the quality measures to non-patient-facing MIPS Eligible Clinicians, we seek clarification from CMS on the strategies it has listed on page 113 of the proposed rule. Specifically, we seek clarification on allowing non-patient-facing MIPS eligible clinicians to report on a specialty-specific measurement set, allowing non-patient-facing MIPS eligible clinicians to report through a QCDR that can report non-mips measures, and non-patient-facing MIPS eligible clinicians being exempt from the cross-cutting measure. Further, we propose the application of additional system measures for a facility-based EC that elects to use their institution s performance rates as a proxy for the quality score should be through an election. F. Selection of Quality Measures for Individual MIPS Eligible Clinicians and Groups The ACR has been engaged in quality measure development for years. Our most recent measures are clinically meaningful and have been endorsed by the NQF, and we recommend their adoption. These measures are process-based quality measures, though outcome measures are currently being developed. The proposed rule suggests that CMS will only accept new outcome-based quality measures and by inference no longer accept new process measures. We are working on developing outcome based measures, but these measures will not be ready until 2017 at the earliest. The ACR firmly believes that in keeping with CMS s goal of accurately assessing patient case, the best measures should be used, which may not always

7 Page 7 be outcome-based measures. We seek clarification regarding whether new process-based measures will continue to be accepted. The ACR agrees that quality measures must be properly reviewed and analyzed before they are put into use but we are concerned that the proposed methodology for accomplishing this may be difficult or not possible to accomplish. MACRA requires CMS to submit new measures for publication in applicable, specialty-appropriate, peer-reviewed journals before including such measures in the final annual list of QMs. Further, the submission must include information about the QM s development and selection, including clinical and other data supporting the measures. In many cases, measure developers will have previously submitted their data to a peer-reviewed journal, prior to their submission to CMS. CMS should recognize that many journals will be very reluctant to publish measures that are already in the public domain. The measure deadline of July 1 of each year provides for a very narrow window for publication. If a measure is submitted to CMS as well as to a journal for publication, the journal may be reluctant to publish the measure because it has already been disseminated in the public record. We recommend that the measure developers submission of their data to a peer-reviewed journal should satisfy the criteria. Therefore in order to support the development of new quality measures, we propose that CMS consider an alternative option whereby CMS could require that a measure developer provide proof that its QMs have already been selected for publication. There may be difficulties with this scenario as well since developers cannot share the details of their drafted publication with outside parties. We seek clarification from CMS regarding how it proposes to handle this situation. The ACR fully supports the exception for QCDR measures. We are encouraged that it will allow for the whole measurement area to be more fluid and respond more quickly to measures that are successfully conceived of and implemented in registries, without requiring the years-long process of formal QM development and testing. Additionally, while we generally agree with the encouragement of the use of use of NQF-endorsed measures, these measures may not always be the best measures. For example, some NQF-endorsed measures are rudimentary and outdated, particularly those used for gout and rheumatoid arthritis. We encourage CMS to use updated standards that accurately reflect the conditions they are measuring. G. Resource Use Performance Category i. Part B and D Drug Costs Must Be Treated Fairly The ACR believes that rheumatologists, like other physicians, are motivated by serving the best interests of their patients, not by the financial incentives in the reimbursement system. Like other physicians, we cannot control the cost of drugs, the cost of the coinsurance of drugs and services, and the costs of acquiring drugs and infusing them for our patients especially when there are limited treatment options.

8 Page 8 We appreciate that CMS is working on including Part D drug costs in the resource use performance category in the future and we eagerly want to work with CMS on the best way to do this. Until Part D drug costs are included in the category, we are concerned that the resource use category does not include these costs in relationship to the value modifier. Without including Part D costs in the resource use category, this measurement will unfairly penalize providers such as rheumatologists whose patients depend on Part B services. Rheumatology, unlike many other specialties, has few treatment options to choose from and the drugs and biologics we and our patients depend on are often times more expensive than those used by other specialties. True and complete evidence-based patient care requires us to use these medications and we should not be penalized for doing so. The ACR strongly urges CMS to exclude penalties related to resource use or the entire resource use component of MIPS until Part D drugs can be accurately accounted for. Alternatively, Part B drug costs should be excluded from resource use until part D drugs can be accurately accounted for. As an alternative, if CMS decides to include drug costs from Part B and not Part D, then, the weight of the composite performance score should not increase as proposed until a solution is found that accounts for the vital use of Part D drugs. We enthusiastically welcome the opportunity to work with CMS to find solutions so that providers are accurately and fairly compared and held responsible only for costs that are within their control. ii. Defining Episodes Should Reflect Accurate Measurement of Rheumatic Diseases Rheumatoid arthritis is a chronic condition in nature. As proposed, the episode-based measure for rheumatoid arthritis provides that it will be triggered by two E&Ms with a principal or secondary diagnosis of any RA trigger code occurring within 30 days. Such a measurement standard does not align with the nature of a chronic condition as requiring patients to have two episodes in a 30-day period in order to qualify would mean very few patients would satisfy the criterion. Most of our patients who would qualify under this criterion would principally be those who have carriers that will not pay for services on the same day as an infusion and office visit, or those who are very ill. Those two patient groups should not be considered equivalent in an episode as they will require different resource allocation. We seek clarification regarding the episode-based measure for rheumatoid arthritis and the attribution methods, specifically how an episode of rheumatoid arthritis will be defined--as 30 calendar days or an entire year? The ACR also seeks clarification on whether all medical costs will be counted for the episode or whether just those costs related to rheumatoid arthritis will qualify. In addition, we seek clarification on how these costs will be attributed to the correct specialist, particularly for those providers who have multiple specialties. It is critically important that CMS consider how to best incorporate Part D costs into the resource use category as a failure to include Part D will skew quality data and create unintended incentives for providers to alter care away from effective therapy. Finally, we seek clarification on how existing condition and episode-based measures with total per capita costs will be adjusted for risk and specialty. We request information on what method will be used for identifying these measures (i.e. ICD-10).

9 Page 9 F. Clinical Practice Improvement Activity Category (CPIA) Category The ACR thanks CMS for including qualified clinical data registry (QCDR) participation in the CPIA category options. We support providing the utmost support for small and rural practices which provide vital care in underserved areas. We seek clarification on how CMS proposes to define rural areas and urge CMS to adopt a consistent definition for the term small practices. For CPIA, CMS has proposed defining small as those practices with 15 or fewer providers, but other CMS programs use a different standard. We propose that a small practice should be defined as a practice with 25 or fewer providers. In considering activities that would be appropriate for these practices in future years, CMS should require minimal outlay from practices, i.e. there should be low-cost interventions. We request that CMS recognize continuing medical education (CME) activities provided by nationally recognized accreditors and providing free care to those in need as clinical practice improvement activities (CPIA). ACR is committed to improving the care of patients with rheumatic diseases and advancing the rheumatology subspecialty. Our CME mission is to provide audiences with comprehensive, evidenced-based educational activities to maintain, develop, and increase their knowledge, skills and performance within this expansive field, and to enhance practice performance and improve the quality of care for those with or at risk for arthritis, and other rheumatic and musculoskeletal diseases. As demonstration of our commitment to physician lifelong learning and achieving our CME mission through innovation and measureable impact, ACR was awarded accreditation with commendation by the Accreditation Council for Continuing Medical Education (ACCME) in the provision of CME for physicians. The ACR also concurs with the Council of Medical Specialty Societies that the following CME activities are appropriate for consideration as CPIAs: Accredited CME activities that involve assessment and improvement of patient outcomes or care quality, as demonstrated by clinical data or patient experience of care data, such as Performance Assessment and/or Improvement CME, Quality Improvement CME Accredited CME that teaches the principles of and hopefully aids in the application of quality improvement and the basic tenets of MACRA implementation, including application of the "three aims," the National Quality Standards and the CMS Quality Strategy The ACR believes accredited CME activities that further physician awareness and compliance with best practices, thus meeting MACRA objectives, should be included as CPIAs. Just as QCDRs report to CMS, the ACCME s PARS system could be enhanced and integrated into the CMS MIPS reporting system to ensure consistent reporting. Further, because these systems are already in use, it would not complicate the process for users and remains an efficient process and reliable data source for CMS. Additionally, the proposal currently requires approved CME

10 Page 10 activities to last at least 90 days. We request that inclusion of surveys, interviews, or testing at or beyond 90 days following an activity should meet compliance requirements. G. Advancing Care Information Performance Category We applaud that the proposed rule encourages flexibility and movement away from a single threshold in the advancing care information performance category. The ACR believes that using a full year reporting window for this category will stifle innovation. We proposed that ECs should be allowed to exercise an innovation exemption whereby during that year, a 90-day window would be required for installing a new EHR. An EC could exercise this exemption only once every 5 years. Most importantly, interoperability and transmission of CCD discrete data must be included as criteria for EHR certification. We ask that CMS require that EHRs connect with registries in a way that is not burdensome from a cost perspective for the provider. H. Reporting Requirements and Scoring Methodology The ACR supports the base measure that excludes CPOE and CDSS. We are encouraged that there are 80 possible performance points to achieve the remaining 50 percent necessary. I. MIPS Composite Performance Score Methodology The ACR supports a scoring methodology which minimizes burdens, enhances flexibility, and is easy to understand. In implementing a unified scoring system, we support the use of bonus and cross-cutting points for use of certain high-value measures. In incorporating improvement scoring for all performance categories, the scoring should be individualized per measure because some measures will be easier to affect than others. By way of example, a provider does not have the ability to control the cost Part B and D drugs. In fact, if trends continue those costs will only increase. In establishing quality measure benchmarks, we support allowing new quality measures being submitted by specialty societies, with supporting data from QCDRs. We also recommend low thresholds be used in the first one to two years of reporting until widespread data can be collected. We request that CMS more specifically define how benchmarking will work. For assigning points based on achievement, CMS should seek to ensure that measures are topped out as this will reflect that the measure is high value. Those topped out measures that have new measures to replace them should be replaced year after year with stakeholder engagement about new measures. High value topped out measures should be retained and full credit should be given for attaining the threshold. For example, if e-prescribing is a high value measure and 90 percent of people e-prescribe less than 80 percent of the scripts, then the measure should be retained and full credit should be given to anyone achieving 80 percent of scripts e-prescribed.

11 Page 11 We recommend that CMS require attestation from physicians who claim they are unable to report on quality performance requirements. It is important that CMS is very clear about the requirements in order to prevent confusion and wrongdoing. The ACR supports MACRA s consideration of rewarding those providers who show improvement. In evaluating improvement and including it in the scoring methodology, the scoring should account for the fact that improvement gets harder to achieve the more successful you are. In other words, it is much easier to raise a patient s health outcomes from 20 to 50 percent than it is to raise the patient s compliance from 95 to 98 percent. If physical therapists and other health practitioners are eventually considered EPs, CMS should reduce the administrative burden for those providers for scoring the Advancing Care Information Performance Category. Groups that contain physicians and physical therapists together should be able to report as individuals or as a group or both, in order to choose different quality measures. It is important that when calculating the composite performance score (CPS), CMS should ensure that this accurately accounts for risk factors. The nature of our practices is that we do not see healthy patients, we primarily only have patients referred to us when they are very ill. The calculation of the CPS score should reflect that the patients we treat will take more effort and resources to effectively treat. In accounting for risk factors, the risk adjustment must eventually go beyond specialty and measure specific to a patient level designation, such as CMI or a new risk score. We seek clarification from CMS regarding CMS s plans on identifying MIPS eligible clinicians without sufficient measures and activities and the reweighting of those performance categories. Specifically, will the reweighting still allow a provider to max out their CPS? J. MIPS Payment Adjustments ACR seeks clarification from CMS regarding whether the MIPS payment adjustment will be made in lump sum at the end of the year or whether the payment adjustment will be reflected in each claim paid. K. Review and Correction of MIPS Composite Performance Score Our providers want to work with CMS in order to make sure that they achieve the best possible performance. In order to accomplish this, we urge CMS to work closely with stakeholders to provide ECs with timely, frequent, clear, and helpful feedback. Thus, in order to maximize clinicians ability to improve their performance, all performance data should be provided to MIPS eligible clinicians on a quarterly basis after year one. We request that CMS consider rolling back the first performance feedback to create a shorter inaugural measurement period, in order to allow practices more time to learn how they are performing and make appropriate adjustments. We expect that providers will experience some surprises in their initial

12 Page 12 performance scores as they adjust and it is vital that they are provided with timely feedback and sufficient time to institute the required changes. CMS should not include first year measures in the performance feedback. It would be helpful to have all of the variables used in the calculation of resource use as well as the benchmarking data for determining deciles and where the provider falls short. Data should show both scoring and decile placement for individual providers across the areas scored. We request that the performance feedback data is provided without charge. In cases of targeted reviews, we request that CMS guarantee firm turnaround times and offer teleconferences to work with providers in reviewing the patient data. The data validation and auditing process requires a system of checks and balances. We support CMS adding an independent audit with an appeals process to assure due process is upheld. Finally, the ACR welcomes CMS s proposal to compile and post a list of entities that qualify to submit data to it as a QCDR for purposes of MIPS. L. Public Reporting on Physician Compare The data that CMS gathers should be presented in a manner that is easily discernable to the general public. We recommend that CMS should present the information in a manner other than tables in order to accomplish this. Further, we believe that a preview period of 60 days would be more appropriate than the 30 day review period proposed in order to allow for more comprehensive review. We seek clarification from CMS on the review process that will be available to providers who believe that the data posted on them is erroneous. For the Clinical Practice Improvement Activity (CPIA) category, clinicians should be able to submit their continuing education and completion of other state/local licensing requirements as credit for CPIA. Thresholds over and above state requirements should translate into higher performance scores or bonus points. We also believe that utilization data in the Physician Compare downloadable database needs to include complexity of cases and cannot be based on single simple diagnosis in order to ensure accurate reporting. For APMs, the criteria for making a PFPM an Advanced APM should be less stringent than for other APMs. If CMS wants small groups of specialist to pursue PFPMs these must be considered Advanced APMS. Small groups do not have the same resources as large groups nor do they have the expertise to navigate confusing regulations. In addition, there should be a lower threshold financial risk for small groups pursuing PFPMs as Advanced APMs. In determining Advanced APMs, a simplified pathway is needed to promote PFPMs to small groups as the current rule is prohibitively confusing for physician led small groups. M. Financial Risk for Monetary Losses

13 Page 13 We believe that CMS s proposal to set the marginal risk to at least 30 percent of losses in excess of expenditures would be excessive compared to the margins that rheumatologists work under with medications. A more appropriate level of risk would be near 4 percent. N. Qualifying APM Participant (QP) and Partial QP Determination For group determinations, we seek clarification from CMS regarding its proposal that the Participation List for each Advanced APM Entity be compiled from CMS-maintained lists that will be used to identify each eligible clinician by a unique TIN/NPI combination attached to the identifier of the Advanced APM Entity. In small-medium markets, this will lead to aggregation of high performers, leaving low performers to fend for themselves, which may create genuine medical care quality problems as access to the better performing groups becomes selective because of market phenomena. Our providers are aware of doctors who refuse to see Medicaid patients without a supplementary policy. Doctors in larger markets who see their ratings fall because of dilution will not tolerate lower reimbursement as punishment for group inefficiencies. Rather, they will stop accepting insurance or create alternative models. This will eventually harm Medicaid access as more and more beneficiaries seek care from fewer and fewer providers, thereby further diluting quality measures. We seek clarification from CMS regarding the proposed exception to allow making QP determinations at the group level. If a provider participates in multiple APMs, how can they be weighted or averaged to reflect a true contribution of the provider without a carve-out? Such negates the advantage of APM participation and would effectively make the provider a MIPSprovider. O. Qualifying APM Participant Determination: Medicare Option We seek clarification from CMS on the attributed beneficiary list that has been proposed. Please provide us with information on how often will this list be updated and what data will be included in the list. We also seek clarification on the attributed beneficiaries on Advanced APM attribution lists that CMS has proposed using in making QP determinations. The American College of Rheumatology appreciates the work that CMS does and the opportunity to respond to this proposal. We look forward to being a resource to you and to working with the agency. Please contact Adam Cooper, Senior Director of Government Affairs, at acooper@rheumatology.org or (404) if you have questions or if we can be of assistance. Sincerely, Joan M. Von Feldt, MD, MSEd President, American College of Rheumatology