March 21, 2018
Statement for the Record
Margaret E. O’Kane, President
National Committee for Quality Assurance
The Implementation of MACRA’s Physician Payment Policies
United State House of Representatives
Ways & Means Health Subcommittee
Chairman Roskam, Ranking Member Levin and distinguished Subcommittee members, thank you for the opportunity to share our thoughts on implementation of the Medicare Access and CHIP Reauthorization Act (MACRA).
The National Committee for Quality Assurance (NCQA) is a nonprofit that for 28 years has improved health care through measurement, transparency and accountability. We strongly support the effort to revise health care payment and delivery systems to reward the value, rather than the volume, of care. MACRA represents a critical milestone in this effort by moving our largest payer – Medicare – toward more value-based payments for physicians and other clinicians.
NCQA believes MACRA implementation to date is yielding meaningful benefits and advancing both value-based and patient-centered care. This includes support for Patient-Centered Medical Homes (PCMH) and Patient-Centered Specialty Practices (PCSPs). Medicare could enhance primary and specialty care, while relieving clinician burden, by providing auto-credit under MACRA’s Advancing Care Information category to PCMH and PCSP clinicians for use of health IT.
As with any effort of this historical magnitude, we will need to refine MACRA to advance quality measurement and the technology to reduce the burden of reporting credible quality metrics going forward.
There are legitimate concerns about the significant time and effort currently required for clinicians to report quality measures and other data for MACRA. NCQA shares these concerns and is aggressively working to reduce reporting burden by promoting alignment of measures across Federal, state and private programs, converting existing measures to digital package formats that allow quicker, more efficient and accurate implementation, and encouraging the use of data intermediaries that extract quality measure data from electronic health systems without requiring clinicians or their teams to do more than is necessary to care for their patients. This will reduce burden, improve accuracy of results, allow for more meaningful measurement – including of outcomes – and support more timely feedback to clinicians.
There also are serious concerns about clinicians in MACRA’s Merit-Based Incentive Payment Program (MIPS) choosing on their own which measures to report that Medicare will then use to adjust their payments. This allows clinicians to “cherry-pick” measures on which they perform best, which suggests that quality is higher than it actually is. It also makes it difficult if not impossible to provide meaningful apples-to-apples comparisons of quality among clinicians. The best way to fix this is to require reporting on core sets of quality measures specific to each clinical specialty.
Finally, we believe Medicare could better support Congressional intent for MACRA by revising its policies on MIPS “virtual group” to include low-volume providers.
We discuss these issues in detail below.
Patient-Centered Practice Auto-credit
NCQA greatly appreciates MACRA’s recognition of and much-needed financial support for PCMHs and PCSPs, which includes auto-credit in the MIPS Improvement Activity Category. NCQA has the largest PCMH program, with approximately 20% of all primary care clinicians in our PCMH program, and the only PCSP program.
We believe Medicare should further strengthen this support for PCMHs and PCSPs by providing auto-credit for their extensive use of health IT in the MIPS Advancing Care Information (ACI) Category. Medicare provides ACI credit to individual Improvement Activity measures that use health IT in ways that meet ACI criteria. Medicare should also provide ACI auto-credit to PCMHs and PCSPs because of the strong focus on Health IT in standards for these programs. ACI auto-credit would reduce unnecessary burden for clinicians who have already completed the rigorous PCMH or PCSP recognition process.
Reducing Reporting Burden
We urgently need to reduce the time and effort clinicians spend to report quality measures so they can instead focus on patient care.
NCQA is working to minimize reporting burden. Measures and their specifications should align across different public and private payer programs for clinicians, networks and health plans. The data used to support these measures should derive from the care provided by clinical teams and documented in their health IT systems. Data from these electronic systems, without further clinician input, can flow to data intermediaries, such as qualified clinical data registries, health information exchanges, data analytics companies and cloud-based electronic health records. Data intermediators calculate measure results based on these data from potentially multiple data source through the application of machine-readable digital measure packages accessed through a cloud-based library of measures. A program such as NCQA’s ONC-approved eMeasure Certification program would certify implementation of the measures and accuracy of results. Once data intermediaries complete certification, they could send results to Medicare and other payers to satisfy reporting needs of clinicians, networks and plans.
This approach can have several advantages over the current reporting system.
- Reduced Clinician Burden: Clinicians only need to enter data into electronic health records and systems that they ordinarily do in routine delivery of care to patients.
- More Accurate Results: Automated systems assess all data pertinent to each measure more comprehensively than most clinicians do when submitting quality measure data on their own. This greatly reduces chances for underreporting performance and better ensures that clinicians get full credit for the true quality of care they provide.
- More Meaningful Measures: Data in electronic systems are much richer than data in claims that are the source for most measurement today. Very importantly, they include the outcomes data that consumers and other stakeholders most want when assessing quality.
- More Rapid Feedback: Also, very importantly, this automated approach allows for much more rapid and meaningful feedback to clinicians on their performance. Today, clinicians deliver care in one year, report on that care the next, and see their performance scores yet another year after that. Data aggregators should be able to provide feedback in nearly real-time so clinicians can much more quickly identify gaps and make needed improvements.
While still a work in progress, we believe this approach is feasible and could begin functioning within the next 2 or 3 years.
Under current regulations, clinicians in MIPS may choose which measures they report on from a vast array of measures of widely different quality. Some specialties have multiple measures to choose from, while others have very few and/or few high-quality measures. Clinicians also may choose to report on only 50% of eligible patients for any given measure. NCQA, MedPAC and others believe this lets clinicians “cherry-pick” measures and patients on which they appear to perform best. Results therefore suggest that quality is higher than it actually is and impede the ability to make meaningful comparisons.
To fix this, Medicare should require clinicians to report on core quality measure sets specific to each clinical specialty for all eligible patients. Developing and refining meaningful core sets requires achieving broad consensus on which measures are most important for each specialty, and filling critical measurement gaps that exist for many specialties. There already are initial core sets for some specialties, and CMS is working to fill measurement gaps through its Quality Measure Development Plan.
Mandatory reporting of core measure sets for all eligible patients would:
- Eliminate cherry picking of measures and patients,
- More accurately identify and target efforts to address performance problems, and
- Provide consumers and other stakeholders with meaningful ability to compare quality across clinicians.
NCQA strongly support Virtual Groups, which allow clinicians to voluntarily join together to have their performance assessed jointly measured as a group. This provision in the law should let practices with small numbers of patients join together to have enough patients for statistically valid measurement. However, current regulations prohibit low-volume practices from joining MIPS and thus virtual groups. This is excluding large numbers of smaller practices from the move to value-based payment and potential rewards for high quality that Congress intended.
We believe Medicare can fix this by amending its low-volume definition to say these practices are ineligible for MIPS “unless they join a virtual group.” Medicare could further promote best use of Virtual Groups by exploring development of a test to determine in advance if a Virtual Group will likely have sufficient numbers for valid measurement. This would help fulfill one of Virtual Groups’ primary purposes of ensuring sufficient numbers for valid measurement.
Medicare could also maximize the potential of Virtual Groups by providing bonus points to clinicians who join them, as it has provided bonus points for other desired clinician behaviors under MIPS.
Thank you again for holding this hearing. Please contact our Director of Federal Affairs, Paul Cotton at firstname.lastname@example.org or (202) 955-5162 If you have any questions.