June 27, Dear Mr. Slavitt:

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1 Mr. Andrew M. Slavitt Acting Administrator Centers for Medicare & Medicaid Services Department of Health and Human Services Attention: CMS-5517-P Submitted electronically to: Re: CMS-5517-P, 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 Proposed Rule. Dear Mr. Slavitt: On behalf of the Premier healthcare alliance serving approximately 3,600 leading hospitals and health systems and 120,000 other providers, including some of the nation s largest physician practices, we appreciate the opportunity to comment on the Centers for Medicare & Medicaid Services (CMS) proposed rule on the 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. Premier healthcare alliance, a 2006 Malcolm Baldrige National Quality Award recipient, maintains the nation's most comprehensive repository of hospital clinical, financial and operational information and operates one of the leading healthcare purchasing networks. Our comments primarily reflect the concerns of our owner hospitals and health systems that not only employ physicians, but also operate accountable care organizations. Premier runs one the largest population health collaboratives in the country, the Population Health Management Collaborative, in addition to an extensive Bundled Payment Collaborative. The intent of MACRA and an overarching Health and Human Services goal is to increase the percentage of payments that are covered by alternative payment models. While many aspects of the proposed rule encourage movement towards APMs, we are concerned that some of the policies are too difficult to achieve and will deter clinicians from participating in APMs. Moreover, clinicians who are currently participating in Advanced APM models will have to prepare to participate in both MIPS and the APM model in the event that they are unable to meet the established thresholds. Finally, we are concerned that few options exist for clinicians to participate in APMs, particularly options for small and rural providers. In the absence of new models being quickly available, clinicians who are not currently participating in APMs will have little opportunity to move into an APM during the years a bonus is offered for participation in an Advanced APM. We request that CMS aggressively work to implement new Advanced APM models so that all clinicians have an opportunity to seek the Advanced APM bonus payment.

2 Page 2 of 56 PREVENTION OF INFORMATION BLOCKING AND SURVEILLANCE DEMONSTRATIONS COOPERATION WITH SURVEILLANCE AND DIRECT REVIEW OF CEHRT CMS proposes that eligible clinicians, EPs, eligible hospitals, and CAHs would be required to attest that they have cooperated in good faith with the surveillance and ONC direct review of their health IT certified under the ONC Health IT Certification Program, to the extent that such technology meets (or can be used to meet) the definition of Certified Electronic Health Record Technology (CEHRT). Cooperation under the attestation would include responding in a timely manner and in good faith to requests for information about the performance of the certified EHR technology capabilities in use by the provider in the field, accommodating requests for access to the provider s CEHRT for the purpose of carrying out authorized surveillance or direct review, and demonstrating capabilities and other aspects of the technology, to the extent that doing so would not compromise patient care or be unduly burdensome for the eligible clinician, EP, eligible hospital, or CAH. The Premier healthcare alliance applauds ONC for increasing its oversight of CEHRT and supports ONC in its efforts to review CEHRT. In conducting its surveillance we ask that CMS and ONC seek to understand challenges providers face when upgrading to new versions of CEHRT or utilizing enhanced functions in CEHRT. SUPPORT FOR HEALTH INFORMATION EXCHANGE AND THE PREVENTION OF INFORMATION BLOCKING MACRA requires that to be a meaningful EHR user, an EP must demonstrate that they have not knowingly and willingly taken action (such as to disable functionality) to limit or restrict the compatibility of certified technology; MACRA makes similar requirements for eligible hospitals and CAHs. CMS is proposing to require that an EP, eligible hospital, or CAH under the Medicare and Medicaid EHR Incentive Programs must attest to a three-part attestation that includes: Attesting that the provider did not knowingly and willfully take action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified EHR technology. Attesting that the provider implemented technologies, standards, policies, practices, and agreements to ensure that the certified EHR technology was connected, compliant with all standards applicable to the exchange of information and implemented in a manner that allowed for timely access by patients and timely exchange of information. Attesting that the provider responded in good faith and in a timely manner to requests to retrieve or exchange electronic health information, including from patients, health care providers, and other persons, regardless of the requestor s affiliation or technology vendor. We appreciate the efforts by CMS and ONC to support an interoperable HIT infrastructure; however we are concerned that oversight activities are too focused on providers. In our experience data is locked in proprietary software systems, preventing

3 Page 3 of 56 providers from being able to connect and exchange information. We ask that CMS oversight include monitoring EHR systems and understanding barriers (financial or other) clinician face in implementing EHR functions that support interoperability. MERIT-BASED INCENTIVE PAYMENT SYSTEM MIPS ELIGIBLE CLINICIANS, IDENTIFIERS, AND EXCLUSIONS Eligible Clinicians In accordance with MACRA, CMS proposes to define MIPS eligible clinicians as physicians, nurse practitioners, physician assistants, certified registered nurse anesthetists and clinical nurse specialists. CMS proposes to allow eligible clinicians who are not MIPS eligible professionals the option to voluntarily report measures and activities for MIPS so that they have the opportunity to gain experience in the program. CMS proposes to define a non-patient facing MIPS eligible clinician as an eligible clinician or group that bills 25 or fewer patient-facing encounters during a performance period. CMS considers a patient-facing encounter to include general office visits, outpatient visits, surgical procedure codes, and telehealth services. We support the proposed definitions of eligible clinicians and non-patient facing eligible clinicians. MIPS Identifiers CMS proposes to use a variety of identifiers for MIPS: A combination of National Provider Identification (NPI) and Tax Identification Number (TIN) for individual MIPS eligible clinicians A groups billing TIN for group reporting; CMS also proposes to define a group as a single TIN with two or more MIPS eligible clinicians who have reassigned their billing rights to the TIN An APM ID (identifies an APM model), APM Entity ID (assigned to each APM Entity participating in any APM model), TIN, and NPI will identify eligible clinicians who participate in an APM Entity. We believe these identifiers will be sufficient for individual, group, and APM reporting in MIPS; however, we request that CMS establish an identifier for virtual groups. Exclusions CMS proposes three exclusions for eligible clinicians who are exempt from MIPS: professional who first becomes a Medicare-enrolled eligible clinician within the PECOS during the performance period; qualifying and partial qualifying Advanced APM participants; and clinicians who do not exceed the low-volume threshold. The proposed low-volume threshold is MIPS eligible clinician or group who, during the performance period, has Medicare billing

4 Page 4 of 56 charges less than or equal to $10,000 and provides care for 100 or fewer Part B-enrolled Medicare beneficiaries. We support the MIPS exclusions and request that CMS continually monitor the low-volume threshold to ensure it appropriately excludes MIPS eligible clinicians who are unlikely to have sufficient data to report in MIPS. GROUP REPORTING CMS proposes that a group must meet the proposed definition of a group at all times during the performance period. In addition, CMS proposes in order to have their performance assessed as a group: individual MIPS eligible clinicians within a group must aggregate their performance data across the TIN; and the group would be assessed as a group across all four MIPS performance categories. Additionally, CMS proposes only to require groups to register to have their performance assessed as a group when the group is submitting data on performance measures via the CMS Web Interface or the group elects to report the Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS survey for the quality performance category. We agree with CMS proposals for group reporting and appreciate that CMS has eliminated the registration process, allowing clinicians more flexibility in choosing whether to report as individuals or groups. Virtual Groups MACRA allows providers to form virtual groups for the purpose of MIPS reporting; however CMS is not proposing to implement virtual groups for the 2017 performance year and will make virtual groups available for the 2018 performance year. CMS proposes to establish an election process for virtual groups that would end on June 30 of the year preceding the performance year. During the election process, CMS proposes that individual MIPS eligible clinicians and groups electing to be a virtual group would be required to register in order to submit reportable data. We do not support this approach and believe it s feasible for CMS to support virtual group reporting for the 2017 performance period. We believe that this option will be the best approach for many small and rural providers so it should be available in the first performance period. In the absence of a virtual group reporting option CMS should not provide negative payment adjustments to small and rural providers. Additionally, similar to group reporting we believe a registration process for groups will introduce unnecessary burden; registration by virtual groups should only be required if the group is choosing to submit via the Web interface. CMS notes that third-party data submission mechanisms are able to obtain information and designate that the information submitted represents groups or individual clinicians; third-party data submission mechanisms are able to take the same approach for virtual groups. CMS also requests feedback on factors it should consider for virtual groups. CMS should maintain flexibility in this option by not limiting this option by practice size, specialty or region; additionally, CMS should not limit the number of virtual groups. To ensure that virtual groups have shared accountability for performance improvement, CMS should limit the reporting mechanisms for virtual groups to mechanisms that require providers in the virtual group

5 Page 5 of 56 to collaborate on ongoing quality analysis and improvement, such as qualified clinical data registries and traditional registries. MIPS PERFORMANCE PERIOD CMS proposes that for 2019 and subsequent payment adjustment years, the performance period under MIPs would be the calendar year (January 1 through December 31) that is two years prior to the year in which the MIPS adjustment is applied. The performance period for the 2019 MIPS adjustment would be January 1, 2017 through December 31, We support this approach; however, we recognize many providers, particularly small and rural providers, have little experience in the Physician Quality Reporting System (PQRS) and the Value-Based Payment Modifier (value-modifier) and may have difficulty being prepared by January 1, We encourage CMS to increase its outreach to clinicians who have not successfully reported in PQRS in the past. CMS also seeks comments on accounting for partial-year data. For individual MIPS eligible clinicians and group practices with less than 12 months of performance data to report, CMS proposes that the individual MIPS eligible clinician or group would be required to report all performance data available from the performance period. If a MIPS eligible clinician is reporting with a group, then the group would report all performance data from the performance period, including partial year performance data available for the individual MIPS eligible clinician. CMS notes that the low-volume threshold and insufficient sample size for specific measures will help mitigate the impact of partial-year data. We support this approach but note that many MIPS measures were designed to assess a full calendar year of reporting. It s feasible that a provider with partial-year data will not have any performance measures that meet the minimal sample size. Additionally, CMS will need to provide guidance on how clinicians attest to the Advancing Care Information performance category for a partial year when the attestation is intended to cover one full calendar year. MIPS PERFORMANCE CATEGORY SUBMISSION MECHANISMS CMS proposes that individuals and groups would be required to submit data on measures and activities for the quality, CPIA and advancing care information performance categories (as indicated in Table 1 below); however, data submission requirements are not proposed for the resource use performance category as the measures are calculated using administrative claims. Table 1. Proposed Data Submission Mechanisms Performance Category Individual Reporting Group Reporting Quality Claims QCDR Qualified registry EHR Administrative claims (no submission required) QCDR Qualified registry EHR CMS Web Interface (groups 25) CMS-approved survey vendor for CAHPS for MIPS (must be reported in

6 Page 6 of 56 Performance Category Individual Reporting Group Reporting conjunction with another data submission mechanism) Administrative claims (no submission required) Resource Use CPIA ACI Administrative claims (no submission required) Attestation QCDR Qualified registry EHR Administrative claims (no submission required) Attestation QCDR Qualified registry EHR Administrative claims (no submission required) Attestation QCDR Qualified registry EHR CMS Web Interface (groups 25) Administrative claims (no submission required) Attestation QCDR Qualified registry EHR CMS Web Interface (groups 25) MIPS eligible clinicians and groups may choose to submit MIPS information using multiple mechanisms but they must use the same mechanism for each performance category; CMS encourages using the same mechanisms for all three performance categories. The proposed data submission deadline for the qualified registry, QCDR, EHR, and attestation submission mechanisms is March 31 following the close of the performance period. For the CMS Web Interface submission mechanism, the submission deadline will occur during an eight-week period following the close of the performance period that will begin no earlier than January 1 and end no later than March 31. We appreciate that CMS has allowed third-party vendor submission across the three performance categories that require data submission. The Premier healthcare alliance supports the proposed data submission mechanism and submissions deadlines. We encourage CMS to explore methods for allowing test submissions (whether throughout the performance period or during the submission window) to uncover any possible submission errors. This would provide an opportunity for CMS to provide feedback to clinicians and third-party vendors in advance of the submission deadline. QUALITY PERFORMANCE CATEGORY Quality Performance accounts for 50 percent of the MIPS composite performance score in the initial payment year of MIPS.

7 Page 7 of 56 Data Submission Criteria for MIPS Data Submission Criteria for Claims, Qualified Registries, QCDRs and EHR Submission Methods CMS proposes that eligible clinicians and groups must report at least six measures, including one cross-cutting measure and one outcomes measures. If an outcome measure is not available another high priority (i.e. appropriate use, patient safety, efficiency, patient experience, or care coordination) measure should be reported, if fewer than six measures apply then each applicable measure should be reported. CMS proposes an increase in data completeness; 80 percent of the clinician s or groups Medicare Part B patients that meet the measure denominator criteria for claims submission and 90 percent of the clinician s or groups patients, regardless of payer, that meet the measure denominator criteria for QCDR submission. Recognizing that many clinicians have struggled to successfully report in PQRS, we appreciate that CMS has lowered the number of required measures from nine to six; outcome and cross-cutting measures requirement. We recommend eliminating this requirement and simply awarding bonus points for reporting these types of measures. Additionally, we believe increasing the data completeness requirements will make it challenging for many clinicians to report. Currently in PQRS, data completeness is 50 percent for most reporting mechanisms and the measure groups option only requires reporting on 20 patients. We recognize CMS desire to have information reported that is reflective of the entire patient population but recommend that data completeness remain at 50 percent for the first performance period of MIPS and is increased over time. Prior to increasing the data completeness requirement, we ask CMS to analyze and provide information on clinicians abilities to meet or exceed existing data completeness requirements. Data Submission Criteria for the Web Interface Groups of 25 or more can choose to report through the Web Interface. CMS proposes that the group would be required to report on all measures included in the CMS Web Interface completely, accurately, and timely by populating data fields for the first 248 consecutively ranked and assigned Medicare beneficiaries in the order in which they appear in the group's sample for each module/measure. We support the continued use of the web interface; however, we have concerns if it is appropriate to apply all measures in the Web Interface to the quality score. Groups reporting through other mechanisms are only required to report six measures while the web interface requires 18 measures. If a group performs highly on some web interface measures but not others, their overall quality score will be lowered. To ensure comparability across reporting mechanisms, CMS should allow groups reporting through the web interface to select which six quality measures in the web interface will be used to calculate the quality performance score. We also request that CMS allow third-party data submission for the web interface reporting mechanism; the web interface requires manual submission and remains one of the few reporting mechanisms that do not allow vendors to report on behalf of the reporting entity. Our members routinely recount difficulties in submitting measures via the GPRO Web interface. Allowing

8 Page 8 of 56 vendor submission will not only relieve some burden for providers, but will also increase the accuracy of reporting as vendors can do automated accuracy checks of the data and return it for correction before submission. Data Submission Criteria for CAHPS CMS proposes to allow groups to voluntary elect to participate in the CAHPS for MIPS survey but seeks comments on requiring CAHPS for groups of 100 or more in later years. CAHPS should remain optional for all providers, regardless of group size. CAHPS is geared towards ambulatory providers and may not be appropriate for all providers participating in MIPS; providers should have the option to use other patient satisfaction surveys (e.g., surgical CAHPS). Additionally, providers participating in APMs may participate in patient satisfaction survey at the APM Entity level, negating the need to survey at the individual or group level. Global and Population-Based Measures CMS proposes to use the acute and chronic composite measures of the Agency for Healthcare Research and Quality (AHRQ) Prevention Quality Indicators (PQIs) for all clinicians with a case size of 20. We do not support the inclusion of the AHRQ PQIs; these measures were developed to assess the health of communities. When applied to individual clinicians and groups performance is highly variable, as one case can significantly change the performance rate. We recommend that CMS include the PQIs on the MIPS measures list and allow clinicians to choose to report the measures; as with other high priority measures CMS could award bonus points for clinicians choosing to report the PQIs. CMS also proposes to include the all-cause hospital readmission measure from the VM and to limit this measure to groups with 10 or more clinicians and require 200 cases (similar to the current VM requirements). While we appreciate that CMS has adopted this measure across settings, we are concerned with how this measure is implemented for clinicians. The comparable measure used for hospitals is found to be reliable and valid only when using a three-year rolling average. We re concerned that clinician performance will vary widely from year to year, based on a few cases. Accordingly, we request that CMS explore assessing the measure over a longer time period. RESOURCE USE PERFORMANCE CATEGORY Resource Use accounts for 10 percent of the MIPS composite performance score in the initial performance period of MIPS; CMS proposes to use the total per capita cost measure, the Medicare Spending Per Beneficiary Measure and up to forty-one episode-based payment measures for the initial performance period. As we have stated in previous comment letters, we have ongoing concerns with the resource use measures. First, measures of federal spending are not real indicators of value for beneficiaries as they neither capture the quality of care, nor are paired with measures that do so. Moreover, the measures do not give beneficiaries a sense of their financial obligation. Accordingly, these measures are not useful for public reporting and beneficiary engagement purposes. Next, the measures have not been shown to be actionable for

9 Page 9 of 56 providers. For example, CMS data has previously shown that variation in total Medicare payments for episodes are primarily due to readmission rates and post-acute care. Post-acute care use varies due to wide ranging differences in local market availability of these services and patterns of care, which are not within the provider s control. Finally, CMS should risk adjust the measures for socio-demographic (SDS) factors. In addition to our overarching concerns with the measures, it is not meaningful to simultaneously assess providers on measures that capture all costs (i.e. Total Per Capita Costs and MSPB) and measures that are condition-specific drill-downs of costs (i.e. the episode-based payment measures). If a clinician performs poorly on episode-based payment measures they will also perform poorly on MSPB and total per capita costs; creating duplicative penalties in this category. We recommend that CMS assess clinicians on a measure that captures all costs or the episode-based payment measures; total per capita costs and MSPB may be most appropriate for clinicians or groups who are responsible for the ongoing care of a patients while the episode-based measures may be more appropriate for clinicians who are responsible for particular episodes or procedures. The patient relationship codes that will be required in 2018 can help determine whether overall cost measures or episode-based measures should apply to a particular clinician or group. Prior to that, CMS should allow clinicians to choose if they will be assessed on an overall cost measures or the episode-based payment measures. For those choosing to be assessed on an overall cost measure, MSPB should be applied for those who have sufficient episodes as it supports alignment across settings with Total Per Capita Costs applied for others. Total Per Capita Cost Measure CMS proposes including the total per capita cost measure. CMS is not proposing to include the VM total per capita cost measures for the four condition-specific groups (COPD, CHF, CAD, and DM). We support CMS proposal and appreciate that CMS has eliminated the duplicative condition-specific cost measures. Medicare Spending Per Beneficiary CMS is proposing two modifications to the methodology used in the VM. First, CMS proposes to remove the specialty-adjustment from the MSPB measure s calculation. For the VM, the MSPB measure is risk adjusted to ensure that comparisons account for case-mix differences between practitioners patient populations and the national average. CMS states that it is not obvious that this additional adjustment improves the accounting for case-mix differences for acute patients and thus may not be needed. The second proposed change modifies the cost ratio used within the MSPB equation; specifically, CMS proposes that instead of summing all of the observed costs and dividing by the sum of all the expected costs, it would calculate the observed to expected cost ratio for each MSPB episode assigned to the MIPS eligible clinician or group and then take the average of the assigned ratios. CMS notes the two proposed changes in the MSPB measure would improve both the ability to calculate costs and the accuracy to make clinician-level performance comparisons.

10 Page 10 of 56 With these changes, the MSPB measure meets the desired 0.4 reliability threshold used in the VM for over 88 percent of all TINs with a 20 case minimum, instead of the current policy of a 125 case minimum for the VM. Accordingly, CMS proposes to use a minimum of 20 cases for the MSPB measure. While we understand that CMS has made changes to ensure that the measure can be applied to more clinicians the case-mix change is a significant change that should be reviewed for NQF-endorsement. Additionally, the changes do not meet desired reliability for over 10 percent of clinicians; CMS should increase the case minimum so that 0.4 reliability is achieved for all clinicians. Episode-Based Payment Measures CMS proposes 41 clinical condition and treatment episode-based measures for a variety of conditions and procedures that it identifies as high cost, having high variability in resource use, or are for high impact conditions. The episode-based measures include Medicare Part A and Part B payments for services determined to be related to the triggering condition or procedure. CMS proposes to use the minimum of 20 cases for all episode-based measures and not to include any measures that do not have average moderate reliability (at least 0.4) at 20 episodes; because these measures have never been used for payment purposes CMS states they may choose to only include a subset of these measures in the final rule. We have concerns with implementing the episode-based payment measures for the first performance year of MIPS. First, the measures are still being refined and have not been reviewed for NQF endorsement or considered for inclusion by the Measure Applications Partnership (MAP). The finalized measures should be reviewed for NQF endorsement and considered by MAP prior to implementation in the program; this step is imperative to ensuring that clinicians are being assessed with valid and reliable measures that fit the purpose of the program. Moreover, when patient relationship codes are introduced in 2018 the attribution methods for these measures will change. Implementing the measures in 2017 and then having significant changes in 2018 will create confusion clinicians. Accordingly, CMS should delay use of the episode based payment measures until the 2019 or 2020 payment year. Individual and Group Attribution For MIPS eligible clinicians whose performance is being assessed individually, CMS proposes to attribute the resource use measures using the TIN/NPI rather than just the TIN that is currently used in the VM and supplemental quality and resource use reports. For eligible clinicians that choose to have their performance assessed as a group, CMS proposes to attribute resource use measures at the TIN level (the group TIN under which they report). CMS discusses an alternative proposal and seeks comments on whether MIPS eligible clinicians who choose performance as a group, should first be attributed at the individual TIN/NPI level and then have all cases assigned to the individual TIN/NPIs attributed to the group under which they bill. In the absence of data on how performance and reliability may shift with these two methods, we are unable to comment. We ask that CMS provide more detailed information on both approaches and seek comment through the measure development process. Additionally, the attribution method should be considered as part of review for NQF endorsement.

11 Page 11 of 56 CLINICAL PRACTICE IMPROVEMENT (CPIA) CATEGORY Clinician Practice Improvement Activities accounts for 15 percent of the MIPS composite performance score. PCMH and APM Participation MACRA requires that that a MIPS eligible clinician or group that is certified as a patientcentered medical home (PCMH) or comparable specialty practice with respect to a performance period must be given the highest potential score. We agree with CMS proposal to recognize patient-centered medical homes that are nationally recognized programs (e.g., NCQA specialty recognition, NCQA PCMH recognition, Joint Commission designation, etc.). CMS seeks comments on how to provide credit for patient-centered medical home designations in the calculation of the CPIA performance category score for groups when the designation only applies to a portion of the TIN. In such instances we recommend that CMS develop a weighted-average for the TIN; the EPs who do not have PCMH designation would have to provide information on CPIA activities. CMS could establish a threshold for which the entire TIN receives full credit on CPIA; for example, if 75 percent of clinicians in the TIN have PCMH designation or 75% percent of the TIN s charges are billed by PCMH designated clinicians, the TIN would receive full credit. MACRA also requires that MIPS eligible clinicians or groups who are participating in an APM for a performance period must receive at least one half of the highest potential score for the CPIA. While CMS notes this applies to all MIPS eligible clinicians, they only make proposals in the context of the APM Scoring Standard. We ask CMS to clarify how clinicians and groups participating in APMs that are not considered MIPS APMs will receive credit for APM participation in this performance category. Will clinicians simply have to attest to APM participation or will CMS rely on information on APM Participant Lists as proposed for the MIPS APM Scoring Standard? As the intent of MACRA is to encourage APM participation, we suggest that CMS increase the amount of points awarded for APM participation. When clinicians participate in APMs there must closely monitor cost and quality against benchmarks. When doing so, APM entities and clinicians participate in a variety of activities similar to the high-weighted clinical practice improvement activities proposed. In recognition of this we recommend awarding full credit to clinicians participating in a MIPS-APMs or Advanced and a majority of points (50 points or eighty-three percent in the proposed scoring methodology) to clinicians participating in all other APMs. Data Submission Criteria CMS proposes a differentially weighted model for the CPIA category with two categories: medium and high. CMS proposes to award high-weighted activities 20 points and mediumweighted activities 10 points; accordingly clinicians and groups would have to attest to 3-6 activities to receive full credit. Further, CMS proposes that clinicians or groups must perform the

12 Page 12 of 56 CPIAs for at least 90 days. Generally, we agree with CMS proposals; however, we believe 3-6 activities is too many activities to meet the total points; clinicians who are unable to report any high-weighted activities will have to participate in multiple activities that will overlap during the year. Additionally, the distinction between medium and high-weighted activities is not clear; some CPIAs are highly detailed while others are more broad also many of the CPIAs overlap; this makes it difficult for clinicians to know how to properly attest to completing the activates. Recognizing that this is a new category and CPIAs will be refined over time, we request greater flexibility in scoring. We suggest that CMS reweight the CPIAs so that a clinicians or groups would have to report 2-4 activities, or one medium-weighted activity per quarter. CMS could then increase the number of required activities and developed a more detailed scoring methodology in later years of the program. CMS proposes that clinicians or groups that are small groups ( 15 clinicians), located in rural areas or geographic HPSAs, or non-patient-facing MIPS eligible clinicians, are required to submit two CPIAs (either medium or high) to obtain a score of 100 percent. We appreciate that CMS recognizes these providers have fewer resources and will have more difficulty in achieving full points in this category; however, we suggest that CMS only require one CPIA to obtain a full score in the initial years of MIPS. This will allow providers more time to gain experience with the category and provide CMS an opportunity to carefully study how CPIA can best be assessed for these providers. CPIA Inventory and Call for Measures CMS notes that high-weighted activities are those that align with CMS national priorities and programs such as the Quality Innovation Network-Quality Improvement Organization (QIN/QIO) or the Comprehensive Primary Care Initiatives. CMS discusses plans to develop a call for CPIAs and its guidelines for CPIA inclusion; however, we ask that CMS provide general criteria for determining whether an activity is high or medium-weighted. We believe this will provide greater transparency with regard to CMS expectations for this category. CPIA and QCDRs CMS notes that there are several CPIAs in the inventory that incorporate QCDR participation. CMS proposes that each activity must be selected and achieved separately; an eligible clinician or group cannot receive credit for multiple activities just by selecting one activity that includes participation in a QCDR. We agree that clinicians or groups should identify how they are using QCDRs to engage in population health; however, we believe that the scoring methodology does not align with the weighted-scoring model. Typically QCDR participation is all year (the proposed MIPS performance period) and cannot be limited to any 90-day period. As proposed, a clinician or group cannot attest to the same CPIA for multiple 90-day periods; therefore a clinician using a QCDR only receives 20 points (high-weighted CPIA: QCDR generates feedback reports to summarize patters/outcomes, includes vulnerable populations) unless they are also using more advanced QCDR functions (medium-weighted activities related to QCDRs). In recognition that QCDR participation spans the entire performance period and facilitates

13 Page 13 of 56 population health management, we suggest CMS award 40 points for QCDR participation and assigns 10 additional points for each advanced QCDR function. CMS also discusses how the inclusion of additional measures and activities captured by QCDRs could enhance the ability of MIPS eligible clinicians or groups to capture and report on more meaningful activities. CMS also notes that in future years it will consider allowing QCDRs to define specific CPIAs for specialty and non-patient-facing MIPS eligible clinicians or groups through the already-established QCDR approval process for measures and activities. The Premier health alliance applauds CMS for recognizing that QCDRs provide a venue for clinicians to report valuable measures and activities that are not part of the MIPS; we would welcome partnering with CMS to identify additional CPIAs and encourage CMS to allow QCDRs to develop custom CPIAs beginning with the second performance period. ADVANCING CARE INFORMATION PERFORMANCE CATEGORY The advancing care information (ACI) category assesses the measures and objectives previously assessed under the EHR incentive program and accounts for 25 percent of the composite performance score. To align with the rest of the MIPS performance categories, the proposed performance period is one full calendar year. As few clinicians have achieved meaningful use based on a 90-day performance period, one full calendar year may be too high of a bar in the initial performance period. We suggest that CMS allow clinicians to report on any one quarter of data for the 2017 performance period. For 2017, MIPS eligible clinicians would be able to use EHR technology certified to either the 2014 or 2015 Edition certification criteria; for 2014 CEHRT clinicians would use the modified Stage 2 objectives and measures and for 2015 CEHRT clinicians would be able to choose to report modified Stage 2 or Stage 3 objectives. We appreciate CMS has maintained flexibility that will allow clinicians to transition from 2014 CEHRT to 2015 CEHRT. CMS is also proposing to allow group reporting for the ACI category; the data submission criteria for the advancing care information performance category would be the same when submitted at the individual and group level, but the data submitted would be aggregated for all MIPS eligible clinicians within the group practice. We appreciate that CMS has proposed group reporting of ACI because it reduces burden for groups using one EHR system across the entire practice. Reporting Requirements and Scoring Methodology CMS is proposing that that the score would be comprised of a score for participation and reporting, referred to as the base score, and a score for performance at varying levels above the base score requirements, referred to as the performance score. With few providers achieving MU, we applaud CMS for proposing an approach that bases performance on levels of achievement with full points awarded to providers who are advanced users of CEHRT. This gives recognition to providers who have can achieve MU benchmarks while encouraging those who have not to continue working toward MU.

14 Page 14 of 56 Base Score CMS proposes that the base score would account for 50 of 100 total possible points. To achieve the base score clinicians or groups must report the modified Stage 2 or Stage 3 objectives and measures. The Protect Patient Health Information objective is a must pass element and failure to report would result in an ACI score of zero. We support this approach. For the Public Health and Clinical Data Registry Reporting objective, CMS proposes that an eligible clinician would only need to complete submission on the Immunization registry reporting measure; completing any additional measures (e.g., public health registry reporting or clinical data registry reporting) under this objective would earn one additional bonus point in the performance category score. The current EHR Incentive Program requires that eligible clinicians participate in up to three registries we ask that CMS to encourage continued participation in registries. Accordingly, we recommend CMS award five bonus points for each additional measure under the Public Health and Clinical Data Registry Reporting objective. We also seek clarification with regard to the definitions for specialized registry (in modified Stage 2 objectives), clinical data registry (in Stage 3 objectives) and QCDR (a MIPS reporting mechanisms). We believe the intent of the Public Health Reporting objective was to assess if information was submitted to registries that can be used to improve health outcomes. Accordingly, we proposed that CMS align definitions by changing the measure to use the term qualified clinical data registry. Performance Score CMS proposes that a MIPS eligible clinician would earn additional points above the base score for performance on eight associated measures: Patient Access o Stage 3: timely access o Stage 2: same Patient-Specific Education o Stage 3: CEHRT to identify patient-specific education o Stage 2: same View, Download, or Transmit o Stage 3: % who v,d,t o Stage 2: same Secure Messaging o Stage 3: % receiving secure message o Stage 2: same Patient-Generated Health Data o Stage 3: % patients where patient-generated health data in CEHRT Patient Care Record Exchange o Stage 3: electronic exchange of summary of care o Stage 2: Health Information Exchange Request/Accept Patient Care Record o Stage 3: elecctonic summary of care received

15 Page 15 of 56 Clinical Information Reconciliation o Med list, medication allergy list, current problem list reconciled o Stage 2: Medication Reconciliation Each of the measures would be worth 10 points, the entire performance score accounts for 80 of 100 total possible points. CMS notes the total available points exceed the maximum 100 points, which allows clinicians flexibility in which measures to focus on for their performance score. While we generally support the proposed approach to the performance score, we have several concerns. First, as we have commented in the past we have concerns with measures that are outside of the clinician s control. For example, the View, Download or Transmit measure assesses the percentage of patients that actively engage with the EHR, providers have minimal control over patients accessing information electronically. Similarly, the Request/Accept Patient Care Record measure assess if the provider incorporates into the patient's EHR an electronic summary of care document; providers are not able to control the behavior of other providers and cannot guarantee that a summary of care document will be received or received electronically. Next, we re concerned that the performance score is empirically assessed, that is, the performance rate is directly translated into points (e.g., 85 percent is awarded 8.5 points). This method assumes that it is feasible to achieve 100 percent on any of the measures in the performance score. Given our concerns about clinicians ability to control performance on these measures and the historical low performance on these measures, we suggest that CMS calculate benchmarks and award points using decile breaks, similar to the proposals for scoring quality measures. Alternatively, the total possible points could be lowered so that there is greater flexibility for clinicians to identify measures of focus for the performance score. For example, setting the total possible points to 80 points would allow clinicians to focus on achieving a high score for just three of the measures in the performance score. Finally, the performance score is structured that it disadvantages clinicians who report using the modified Stage 2 objectives. Of the 8 measures contributing to the performance score only 4 are also available in Stage 2 (Patient-Specific Education; View, Download, or Transmit; Secure Messaging) while another 2 are slightly different (Patient Care Record Exchange is Health Information Exchange in modified stage 2; Clinical Information Exchange is Medication Reconciliation in modified stage 2). CMS should clarify how the performance score applies to clinicians reporting modified Stage 2objectives and measures. As proposed, clinicians who must (i.e. use 2014 CEHRT) or choose to report using the modified Stage 2 objectives and measures are unable to achieve the full performance score. CMS should revise the performance score so that clinicians reporting the modified Stage 2 objectives have the same possible points as clinicians reporting the Stage 3 objectives. CMS can address this by awarding more points for the modified Stage 2 objectives (e.g. each measure worth points so that total possible performance score remains at 80 points) or limit the performance score to the measures that are included in both modified Stage 3 and Stage 3 objectives. Scoring Considerations MACRA states that any year in which the proportion of EPs who are meaningful users is 75 percent or greater, the Secretary may reduce the weight of the ACI category contribution to the total composite score. CMS proposes to define a meaningful user as clinicians who earn 75 percent on the ACI category, or alternatively 50 percent. As a score of 50 percent reflects only the base score

16 Page 16 of 56 (reporting information) we believe 75 percent better reflects the percentage of clinicians who are demonstrating the meaningful use of CEHRT. Reweighting ACI for Certain Clinicians CMS proposes to assign a weight of zero to the advancing care information performance category for purposes of calculating a CPS for hospital-based eligible clinicians, MIPS eligible clinicians facing a significant hardship, and Nurse Practitioners, Physician Assistants, Clinical Nurse Specialists, and Certified Registered Nurse Anesthetists. With an exception for non-patient-facing MIPS eligible clinicians, CMS proposes that an application must be submitted for reweighting the advance care information performance category. Additionally, CMS proposes to define a hospital-based MIPS eligible clinician as a MIPS eligible clinician who furnishes 90 percent or more of their care in an inpatient hospital or emergency room setting. We support exempting hospital-based clinicians, non-physician clinicians and clinicians with a significant hardship. APM SCORING STANDARD FOR MIPS ELIGIBLE CLINICIANS PARTICIPATING IN MIPS APMS CMS proposes to establish a scoring standard for MIPS eligible clinicians participating in certain APMs in order to reduce reporting burden by eliminating the need to report under MIPS and the APM. Accordingly, CMS proposes to assess the performance of a group of MIPS eligible clinicians in an APM Entity based on their collective performance as an APM Entity group. We appreciate that CMS has considered how to simplify reporting for MIPS eligible clinicians participating in APMs; however, as discussed in further detail below, we have concerns with the definition of MIPS APMs and the reweighting of the MIPS performance categories. Criteria for MIPS APMs CMS proposes to define a MIPS APM as one that (1) participates in the APM under an agreement with CMS; (2) includes one or more MIPS eligible clinicians on a Participation List; and (3) bases payment incentives on performance (either at the APM Entity or eligible clinician level) on cost/utilization and quality measures. We believe this definition is too limiting and prevents clinicians participating in APMs that are not considered MIPS APMs from reporting as an APM Entity. MIPS APMs should not be limited to those that include MIPS eligible clinicians on a Participant List; CMS should recognize the multiple avenues available for clinicians to participate in an APM. Under the APM Incentive, CMS proposes to use affiliated practitioners, eligible clinicians who are in a contractual relationship with an Advanced APM Entity based at least in part on supporting the Advanced APM Entity's quality or cost goals under the APM, to determine the eligible clinicians used for the Qualified Participant (QP). We believe this approach can also be applied to MIPS APMs and suggest CMS use a consistent approach for who is considered a participant under Advanced APMs and MIPS APMs. CMS also indicates that the APM scoring standard would not apply to MIPS eligible clinicians involved in APMs that include only facilities as participants (such as the Comprehensive Care for Joint Replacement Model). We

17 Page 17 of 56 disagree with this approach as the existing hospital-led APMs have been some of the most successful models to date. Moreover, hospital-led APMs have facilitated clinicians transitioning to APMs by providing additional resources to clinicians, such as care managers and EHR technology. Preventing facility-led APMs from being MIPS APMs will prevent clinicians employed by hospitals from utilizing the APM scoring standard and deter clinicians from participating in facility-led APM models; this would cause facility-led APMs in mandatory models to fail as clinicians would be reluctant to engage in contracts based on the APMs quality and cost goals. We request that CMS allow facility-led APM entities to qualify as APMs and revise the requirement that the APM entity includes one or more MIPS eligible clinicians on a Participation List or an Affiliated Providers List. While we agree with CMS that MIPS APMs should base payment incentives on cost/utilization and quality measures, this requirement will exclude some of the existing APM models that base payment incentives on cost/utilization only. Accordingly, clinicians participating in APMs that are not considered MIPS APMs will have to participate in quality measurement activities for the APM and for MIPS. We believe this will discourage some clinicians in those APMs from remaining in the models. We ask that CMS delay implementing the requirement that MIPS APMs base payment incentives on quality performance until existing APM models are modified to meet the requirement. In the initial performance period, the requirement should be simply that the APM entity reports measures of quality and bases incentives on cost/utilization. Regardless of the payment incentives, all clinicians in APM Entities have a goal of collective success under the terms of the APM entity and are ultimately working in coordination to achieve quality and cost benchmarks, similar to group reporting. We believe this will encourage clinicians to remain in existing APM models. Additionally, the purpose of the MIPS is to adjust clinician payment based on quality measures, so APMs that do not base incentives on quality performance will still be held accountable for quality performance through MIPS. APM Entity Group Scoring for the MIPS Performance Categories CMS proposes to calculate one Composite Performance Score (CPS) for each MIPS APM entity; the APM entity group score would then be applied to each eligible clinician in the APM entity. To determine an APM entity CPS, CMS proposes to: Use quality measure data submitted through the Web Interface to evaluate the quality performance category; for entities that do not submit data through the Web Interface the APM entity would not submit data for the MIPS quality performance category until the second performance period (2018). Not assess the resource use category since APMs usually assess resource use as total cost of care, rather than narrower claims-based measures in MIPS. Aggregate the clinical practice improvement activity (CPIA) scores of TINs or individual eligible clinicians that participate in the APM Entity to determine an overall APM CPIA score; each TIN or individual clinician will automatically receive half the total points in this category. Aggregate the advancing care information (ACI) scores of TINs or individual eligible clinicians that participate in the APM Entity to determine an overall APM ACI score.

18 Page 18 of 56 We suggest that the APM Scoring Standard assess MIPS APMs on quality and clinical practice improvement only. As currently proposed, clinicians participating in Advanced APMs that are also MIPS APMs would have to proactively submit data for CPIA and ACI prior to knowing if they will meet thresholds to be considered partial qualified participants or qualified participants. In later years it s possible that an APM entity is considered a qualified participant one year and is not the following year; TINs or clinicians in these entities would not report CPIA and ACI information assuming they will be exempt MIPS. To avoid confusion on what information is needed for the MIPS and the APM model, CMS should structure the APM Scoring Standard so that there is no additional reporting burden on eligible clinicians in MIPS APMs. While we agree that CMS should use quality measure data currently submitted for MIPS APMs, we do not think this should be limited to APMs reporting through the Web Interface in the first year. CMS should work to eliminate any obstacles with APM quality reporting prior to the 2017 performance period. We agree with CMS that resource use should not be assessed because cost reduction it is an underlying goal of all APMs. As discussed in our comments on the clinical practice improvement category, MIPS eligible clinicians participating in APMs should receive the total points possible for CPIA. In order to achieve the savings required in APM models, APM entities must engage in multiple types of clinical practice improvement activities; for example, activities targeted to specific facilities or clinicians in the APM, activities performed at the APM entity level and activities focused on coordination across the care continuum. In recognition of the current level of effort APMs devote to performance and practice improvement and CMS overall intent to drive payment into APMs, APM participation should be awarded full points. At a minimum, CMS should allow reporting of clinical improvement activities to occur at the APM entity level, rather than the aggregate of TINs or individual clinicians, to reduce reporting burden. Finally, ACI should not be scored as part of the APM scoring standard but rather use of certified EHR technology should be incorporated into the APM models. Alternatively, CMS should assess ACI at an APM Entity level. For example, an APM entity could meet ACI if they attest to using data produced from CEHRT for population heath or information exchange, such as health risk assessment, forecasting, other analytic modeling, feeding registries and exchange with participant network through HIE or other mechanisms. Additionally, CMS could use a measure of the percentage of TINs and clinicians in the APM Entity using certified EHR technology. At a minimum, CMS should award bonus points based on using CEHRT for population health or information exchange. APM Participant Identifier and Participant Database CMS plans to establish and maintain an APM participant database that will include all of the MIPS eligible clinicians who are part of the APM Entity. CMS proposes that only those MIPS eligible clinicians who are listed as participants in the APM Entity in a MIPS APM on December 31 (the last day of the proposed performance period) would be considered part of the APM Entity group for purposes of the APM scoring standard in recognition that they may be instances

19 Page 19 of 56 where MIPS eligible clinicians change TINs or change their APM participation status during a performance period. Each model has different submission dates for the participant list (as early as June for some models); we ask CMS to clarify if APMs will submit new participation lists for the purpose of MIPS or use participation lists submitted for the APM model. There are also instances where an APM closes during the performance period. While these clinicians would not be able to use the APM scoring standard it may be difficult for them to report any MIPS information as the APM would maintain all data and information needed to report. We ask that CMS develop guidance for eligible clinician reporting when an APM closes during the performance period. MIPS COMPOSITE PERFORMANCE SCORE METHODOLOGY Quality CMS proposes the following approach for scoring the quality performance category: Assign one to ten points for each measure, based on a clinician s performance compared to benchmarks Zero points are awarded if the clinician fails to submit data on a required measure If data submission is completed, the clinician would either receive a score or the measure would not be counted because the case minimum is not met or if a benchmark is unable to be calculated Currently PQRS has successful submission requirements where a clinician will completely fail the program if they do not report the required number of measures. We appreciate that CMS has eliminated the successful submission requirements and is using an approach that will allow clinicians to receive credit for each measure they report. Benchmarks CMS proposes that separate benchmarks be created for submission mechanisms that do not have comparable measure specifications: EHR, claims, QCDR, and qualified registry. Measurespecific benchmarks would be computed based on performance during the baseline period (two years prior to the performance period, 2015 for the first performance period). Baseline performance data would be divided into deciles to assign points to measures, the top decile would receive ten points for the measure. Benchmarks would be calculated from the performance period (2017) if the measure is new, if the measure has had significant changes since the baseline performance period or if there are not a sufficient number (at least 20) of clinicians reporting the measure. We applaud CMS for setting benchmarks in advance and creating separate benchmarks for each reporting mechanism. We agree with CMS rationale for when benchmarks would be calculated using the performance period; however, this prevents clinicians from knowing benchmarks in advance. When data is not available from the baseline period CMS should use the year prior to the performance period; this will provide clinicians the opportunity to understand how they will perform in MIPS. We understand that there will still be instances when benchmarks will be calculated from the performance period.

20 Page 20 of 56 We recommend that CMS also stratify the benchmarks by group size. For example, small group practices of two to nine physicians and large group practices of 100 or more physicians will be compared to one another if they report the same measure. This places small group practices at a disadvantage as they have less experience reporting performance measures (as large groups were required to participate in PQRS and VM before small groups) and tend to have fewer resources to devote to quality improvement. Moreover, while they may meet the measure minimums, they may still experience higher variability in their performance results as a result of lower volume. CMS impact analysis demonstrates that small group practices are the most likely to receive a negative adjustment; adjusting benchmarks on group size can mitigate this impact. For the web interface reporting mechanism, CMS proposes to use benchmarks from the Shared Savings Program. We support this approach because clinicians using the APM Scoring Standard will have consistent benchmarks for the ACO and MIPS. Creating separate benchmarks for MIPS and the ACO models will create confusion and could potentially lead to being scored favorably in one program while being scored unfavorably in the other program. Topped Out Measures CMS proposes an alternative scoring approach for topped out measures, CMS proposes to limit the maximum number of points given for the measure based on how clustered the scores are. CMS does not believe that high performance on a topped out measure conveys the same meaning as high performance on other measures, so the same score should not be awarded. The proposed definition of topped out is similar but not identical to that used in the HVBP Program; a MIPS measure would be considered topped out if the truncated coefficient of variation is less than 0.10 and the 75th and 90th percentiles are within two standard errors (a test of whether the range of scores in the upper quartile is statistically meaningful) or if it is a process measure and the median value is 95 percent or greater. In its modeling of the proposed benchmark methodology using 2014 PQRS measures, CMS found that about half the measures proposed under the quality performance category are topped out. We understand CMS desire to discourage reporting of topped out measures; however, having a sufficient number of measures to report remains a challenge for some clinicians. We recommend that CMS delay limiting the maximum number of points awarded for topped out measures until later years of MIPS. Generally, we believe that topped out measures should be removed from the program; however, we understand the need to keep measures in the program as options for certain clinician types. When the policy is implemented we recommend that clinicians must know in advance of the reporting period if a measure is considered topped out. Specifically, if a measure is not topped out during the baseline period but becomes topped out during the performance period, the maximum number of points should not be limited. Incentives to Report High Priority Measures CMS proposes to award clinicians for submitting certain high priority measures; two bonus points would be provided for each outcome (in addition to the one already required) and patient