AHA asks MedPAC to slow its roll on MACRA proposals

The American Hospital Association (AHA) believes that changes to the implementation of the Medicare Access and CHIP Reauthorization Act (MACRA) (P.L. 114-10) should wait until more data is available from providers. In a letter to the Medicare Payment Advisory Commission (MedPAC), the AHA expressed concerns about several proposals, including assigning clinicians to groups, aggregating results at the local market level, and replacing most clinician-reported measures. The AHA also addressed rising drug costs, encouraging MedPAC to focus on the issue.

MedPAC meeting

The letter serves as AHA’s response to MedPAC’s January meeting, during which the commission discussed items to include in a report to Congress in June. MACRA created two payment systems, the Merit-based Incentive Payment System (MIPS) and the Advanced Alternative Payment Model (APM), which are in the early stages of implementation by clinicians and hospitals. The January meeting involved discussion of several policy changes, including a MIPS redesign, which the AHA believes should be delayed until data and experience from these clinicians is available for consideration. The AHA noted that the first performance period for both programs began January 1, 2017, and that CMS views this as a “transition year” for MIPS.

Policy proposals

MedPAC proposed assigning clinicians to groups or regions and assigning an aggregate MIPS quality and cost performance score based on the performance of others in the community. The AHA believes that clinicians should be permitted to voluntarily collaborate, and that applying an aggregate score would be arbitrary. Additionally, the AHA proposes providing an option for hospital-based physicians to use the hospital’s CMS quality and resource use measure performance for MIPS. However, the association opposes the proposal to replace clinician-reported outcomes measures with CMS measures based on Medicare claims data. The AHA pointed out that claims data does not reflect a patient’s particular history, course of care, and risk factors, which would result in basing clinician performance on unreliable data.

The APM has an incentive payment designed to encourage participation in the model, rather than reward or penalize performance. MedPAC proposed only allowing participating clinicians to receive this incentive upon successfully achieving the APM’s goals. The AHA views such a change as a double reward or double penalty for participants, rather than compensation for the learning curve and resource investment required upon entering new payment models. The AHA also expressed concerns about the proposals intended to “balance” incentives offered for MIPS and APMs, believing that these proposals make MIPS less attractive than APMs, even though AHA members believe that MIPS is already a less attractive option.

Drug pricing

The AHA believes that changes to Medicare Parts B and D could alleviate some of the drug cost burdens borne by the federal government and beneficiaries. The AHA expressed several concerns about Part B drug payment policy solutions, fearing that these changes could penalize hospitals for price increases and shift the burden for high list prices onto physicians. However, the AHA supports MedPAC’s Part D proposals while offering proposals of its own: disallowing co-pay assistance cards, developing value-based payment arrangements, requiring rebates, varying patient cost-sharing, and issuing annual reports.