U.S. GOVERNMENT PUBLISHING OFFICE

36–027 WASHINGTON : 2019

MACRA AND MIPS: AN UPDATE ON THE MERIT– 

BASED INCENTIVE PAYMENT SYSTEM 

HEARING 

BEFORE THE

SUBCOMMITTEE ON HEALTH 

OF THE

COMMITTEE ON ENERGY AND 

COMMERCE 

HOUSE OF REPRESENTATIVES 

ONE HUNDRED FIFTEENTH CONGRESS 

SECOND SESSION 

JULY 26, 2018 

Serial No. 115–160 

( 

Printed for the use of the Committee on Energy and Commerce 

energycommerce.house.gov 

(II) 

COMMITTEE ON ENERGY AND COMMERCE 

GREG WALDEN, Oregon 

Chairman 

JOE BARTON, Texas 

Vice Chairman 

FRED UPTON, Michigan 

JOHN SHIMKUS, Illinois 

MICHAEL C. BURGESS, Texas 

MARSHA BLACKBURN, Tennessee 

STEVE SCALISE, Louisiana 

ROBERT E. LATTA, Ohio 

CATHY MCMORRIS RODGERS, Washington 

GREGG HARPER, Mississippi 

LEONARD LANCE, New Jersey 

BRETT GUTHRIE, Kentucky 

PETE OLSON, Texas 

DAVID B. MCKINLEY, West Virginia 

ADAM KINZINGER, Illinois 

H. MORGAN GRIFFITH, Virginia 

GUS M. BILIRAKIS, Florida 

BILL JOHNSON, Ohio 

BILLY LONG, Missouri 

LARRY BUCSHON, Indiana 

BILL FLORES, Texas 

SUSAN W. BROOKS, Indiana 

MARKWAYNE MULLIN, Oklahoma 

RICHARD HUDSON, North Carolina 

CHRIS COLLINS, New York 

KEVIN CRAMER, North Dakota 

TIM WALBERG, Michigan 

MIMI WALTERS, California 

RYAN A. COSTELLO, Pennsylvania 

EARL L. ‘‘BUDDY’’ CARTER, Georgia 

JEFF DUNCAN, South Carolina 

FRANK PALLONE, JR., New Jersey 

Ranking Member 

BOBBY L. RUSH, Illinois 

ANNA G. ESHOO, California 

ELIOT L. ENGEL, New York 

GENE GREEN, Texas 

DIANA DEGETTE, Colorado 

MICHAEL F. DOYLE, Pennsylvania 

JANICE D. SCHAKOWSKY, Illinois 

G.K. BUTTERFIELD, North Carolina 

DORIS O. MATSUI, California 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

JERRY MCNERNEY, California 

PETER WELCH, Vermont 

BEN RAY LUJA ́ N, New Mexico 

PAUL TONKO, New York 

YVETTE D. CLARKE, New York 

DAVID LOEBSACK, Iowa 

KURT SCHRADER, Oregon 

JOSEPH P. KENNEDY, III, Massachusetts 

TONY CA ́ RDENAS, California 

RAUL RUIZ, California 

SCOTT H. PETERS, California 

DEBBIE DINGELL, Michigan 

(III) 

SUBCOMMITTEE ON HEALTH

MICHAEL C. BURGESS, TEXAS

Chairman 

BRETT GUTHRIE, Kentucky 

Vice Chairman 

JOE BARTON, Texas 

FRED UPTON, Michigan 

JOHN SHIMKUS, Illinois 

MARSHA BLACKBURN, Tennessee 

ROBERT E. LATTA, Ohio 

CATHY MCMORRIS RODGERS, Washington 

LEONARD LANCE, New Jersey 

H. MORGAN GRIFFITH, Virginia 

GUS M. BILIRAKIS, Florida 

BILLY LONG, Missouri 

LARRY BUCSHON, Indiana 

SUSAN W. BROOKS, Indiana 

MARKWAYNE MULLIN, Oklahoma 

RICHARD HUDSON, North Carolina 

CHRIS COLLINS, New York 

EARL L. ‘‘BUDDY’’ CARTER, Georgia 

GREG WALDEN, Oregon (ex officio) 

GENE GREEN, Texas 

Ranking Member 

ELIOT L. ENGEL, New York 

JANICE D. SCHAKOWSKY, Illinois 

G.K. BUTTERFIELD, North Carolina 

DORIS O. MATSUI, California 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

BEN RAY LUJA ́ N, New Mexico 

KURT SCHRADER, Oregon 

JOSEPH P. KENNEDY, III, Massachusetts 

TONY CA ́ RDENAS, California 

ANNA G. ESHOO, California 

DIANA DEGETTE, Colorado 

FRANK PALLONE, JR., New Jersey (ex 

officio) 

(V) 

C O N T E N T S 

Page 

Hon. Michael C. Burgess, a Representative in Congress from the State of 

Texas, opening statement .................................................................................... 1 

Prepared statement .......................................................................................... 3 

Hon. Gene Green, a Representative in Congress from the State of Texas, 

opening statement ................................................................................................ 4 

Prepared statement .......................................................................................... 5 

Hon. Frank Pallone, Jr., a Representative in Congress from the State of 

New Jersey, prepared statement ........................................................................ 87 

WITNESSES

David Barbe, Immediate Past President, American Medical Association .......... 7 

Prepared statement .......................................................................................... 9 

Frank Opelka, Medical Director, Quality and Health Policy, American College 

of Surgeons ........................................................................................................... 15 

Prepared statement .......................................................................................... 17 

Ashok Rai, Chairman of the Board, American Medical Group Association ........ 31 

Prepared statement .......................................................................................... 33 

Parag Parekh, American Society of Cataract and Refractive Surgery ................ 36 

Prepared statement .......................................................................................... 38 

Kurt Ransohoff, Chairman of the Board, America’s Physician Groups .............. 55 

Prepared statement .......................................................................................... 57 

SUBMITTED MATERIAL

Statement of the American Academy of Dermatology Association ...................... 88 

Statement of the American Academy of Family Physicians ................................ 92 

Statement of the American College of Physicians ................................................ 94 

Statement of Connected Health .............................................................................. 103 

Statement of the American Society of Clinical Oncology ..................................... 106 

Statement of the Infectious Disease Society of America ...................................... 108 

Statement of the Medical Group Management Association ................................. 113 

(1) 

MACRA AND MIPS: AN UPDATE ON THE 

MERIT–BASED INCENTIVE PAYMENT SYSTEM 

THURSDAY, JULY 26, 2018 

HOUSE OF REPRESENTATIVES, 

SUBCOMMITTEE ON HEALTH, 

COMMITTEE ON ENERGY AND COMMERCE, 

Washington, DC. 

The subcommittee met, pursuant to call, at 10:00 a.m., in room 

2123 Rayburn House Office Building, Hon. Michael Burgess (chairman of the subcommittee) presiding. 

Members present: Representatives Burgess, Guthrie, Shimkus, 

Latta, Lance, Griffith, Bilirakis, Long, Bucshon, Brooks, Hudson, 

Collins, Carter, Green, Engel, Matsui, Castor, Schrader, Kennedy, 

Eshoo, and Pallone (ex officio). 

Staff present: Mike Bloomquist, Staff Director; Samantha Bopp, 

Staff Assistant; Adam Buckalew, Professional Staff Member, 

Health; Daniel Butler, Legislative Clerk, Health; Jordan Davis, 

Senior Advisor; Adam Fromm, Director of Outreach and Coalitions; 

Caleb Graff, Professional Staff Member, Health; Jay Gulshen, Legislative Associate, Health; Ed Kim, Policy Coordinator, Health; 

Ryan Long, Deputy Staff Director; Drew McDowell, Executive Assistant; James Paluskiewicz, Professional Staff, Health; Brannon 

Rains, Staff Assistant; Jennifer Sherman, Press Secretary; Josh 

Trent, Chief Health Counsel, Health; Hamlin Wade, Special Advisor, External Affairs; Jeff Carroll, Minority Staff Director; Tiffany 

Guarascio, Minority Deputy Staff Director and Chief Health Advisor; Una Lee, Minority Senior Health Counsel; and Samantha 

Satchell, Minority Policy Analyst. 

OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF TEXAS 

Mr. BURGESS [presiding]. The Subcommittee on Health will now 

come to order. And I recognize myself for 5 minutes for an opening 

statement. 

Today’s hearing is one that has been in the works for quite some 

time. As many of you know, this hearing has been rescheduled 

twice. But, given that we have now enacted important technical 

changes, providers having information on their first performance 

year, and this year’s Quality Payment Program rules to discuss, 

this hearing is timely now. I am glad we can complete our due diligence, as members of the Health Subcommittee, and conduct oversight and the implementation of the Medicare Access and CHIP Reauthorization Act of 2015. 

2 

This bill, which came through the 114th Congress, is a product 

of careful, intricate bipartisan negotiations and was passed by both 

chambers of Congress with broad support. Signed into law on April 

16, 2015, this bill repealed the sustainable growth rate formula for 

all time. The sustainable growth rate formula was for calculating 

annual updates to physician payment rates under Medicare. We 

now know that the formula, which was enacted as part of the Balanced Budget Act of 1997, turned out to be unwise. 

As an OB/GYN prior to coming to Congress, I was frustrated 

with the annual exercise of the sustainable growth rate formula, as 

were many other physicians, as were Members of Congress. I would 

like to take a moment to remind members of what the world of 

physician payments looked like before the repeal or before the passage of the Medicare Access and CHIP Reauthorization Act. 

Congress consistently passed legislation to override the SGR. 

That resulted in hundreds of billions of dollars spent that could 

have gone to bolstering Medicare and other health programs. Medicare providers and their patients by extension were under the constant threat of payment cuts under the sustainable growth rate formula. The formula’s unrealistic assumptions of spending and efficiency have plagued the healthcare profession and our Medicare 

beneficiaries for a long time. The Medicare Access and CHIP Reauthorization Act repealed the SGR, provided for statutory updates to 

allow improved beneficiary access, and got medicine to concentrate 

on moving to broad adoption of a quality reporting system. 

One of the most important provisions in the law was a shift from 

a fee schedule system toward a merit-based incentive payment system. The law left behind a pass/fail quality reporting regime whose 

measures were too often set up against a ‘‘one-size-fits-all’’ generic 

standard of care with no financial upside for providers. Since the 

merit-based system was set to go into full effect on January 1st, 

2019, the first payment consequence year, from reporting provided 

in 2017, it is critical that we hold this hearing and hear from our 

witnesses, in a sense, what is working, how the transition is progressing, and where improvements have been made while seeking 

ways to simultaneously encourage stronger participation and reward providers already invested in the MIPS track. 

The Medicare Access and CHIP Reauthorization Act required the 

Secretary of Health and Human Services to establish a methodology to assess merit-eligible practitioners and give each one a performance score which determines payments based on a scale of 1 

to 100. In the first year, the performance benchmark was set at 3. 

This year it was set at 15, and the Centers for Medicare and Medicaid Services recently proposed raising it to 30 for 2019. The 

merit-based incentive payment system incorporated specific performance categories, including quality, resource use, clinical practice improvement activities, and meaningful use of electronic 

health records. The eligible population was also set to change over 

time. And the Centers for Medicare and Medicaid Services recently 

proposed to add a slate of additional providers to the program. 

Overall, stakeholders and physicians have been supportive of the 

transition. In our third hearing, we heard from providers getting 

the benefits of savings by participating in the advanced alternative 

payment model. That said, the Medicare Access and CHIP ReauVerDate Nov 24 2008 14:50 May 21, 2019 Jkt 037690 PO 00000 Frm 00008 Fmt 6633 Sfmt 6633 U:\MY DOCS\HEARINGS 115\HEARINGS\115-160 CHRIS
3 

thorization Act was a long-term project and a viable fee-for-service 

model in the form of the merit-based incentive payment system 

needed to exist. In continuing to follow the Medicare Access and 

CHIP Reauthorization Act implementation, certain decisions were 

made by the Centers for Medicare and Medicaid Services that were 

for the benefit of a smooth transition, but had consequences, consequences that affected the agency’s trajectory of setting the performance threshold. Given this and other developments, I believed 

that the law would benefit from technical updates to improve the 

implementation based on real-time factors. The Bipartisan Budget 

Act of 2018 included three technical fixes. This was done by myself, 

Ranking Member Green, and Representatives Roskam and Levin 

from the Ways and Means Committee. 

The Medicare Access and CHIP Reauthorization Act changed the 

world of Medicare provider payments. It has laid the groundwork 

for increased access to quality care for beneficiaries by eliminating 

the uncertainty of the past, reducing physician burden, and providing incentives where previously there were none. It was never 

a law that was going to be fully implemented with the flip of a 

switch or a signing ceremony. It was designed as a long-term effort 

to move the Medicare program down the value continuum. 

So, once again, I want to thank our witnesses for joining us 

today. I look forward to hearing from each of you about how the 

implementation of this important law is progressing. 

I yield back the balance of my time and recognize the ranking 

member of the subcommittee, Mr. Green, 5 minutes for an opening 

statement. 

[The prepared statement of Mr. Burgess follows:] 

PREPARED STATEMENT OF HON. MICHAEL C. BURGESS

Today’s hearing is one that has been in the works for quite some time. As many 

of you know, this hearing has been rescheduled twice, but given that we now have 

enacted important technical changes; providers having information on their first 

performance year; and this year’s Quality Payment Program Proposed Rule to discuss, I think the hearing will be better for it. So, I am glad we can now complete 

our due diligence as members of the Health Subcommittee and conduct oversight 

of the implementation of the Medicare Access and CHIP Reauthorization Act of 

2015, also known as MACRA. 

MACRA, which I championed through the 114th Congress, is the product of careful, intricate, bipartisan negotiations and passed both chambers of Congress with 

broad support. It was signed into law on April 16, 2015. Most notably, this bill repealed the sustainable growth rate (SGR) formula for calculating annual updates to 

physician payment rates under Medicare. We now know the SGR formula which 

was enacted as part of the Balanced Budget Act of 1997 was a misguided attempt 

to restrain federal spending in Medicare Part B. 

As an OB/GYN prior to coming to Congress, I was overwhelmingly frustrated with 

the annual exercise of the SGR, as were many other physicians and members of 

Congress. I would like to take a moment to remind members what the world of physician payments looked like before MACRA. 

Congress consistently passed legislation to override the SGR, which resulted in 

hundreds of billions in spent funds that could have gone to bolstering Medicare and 

other vital health care programs. Medicare providers, and their patients by extension, were under constant threat of payment cuts under the SGR. The formula’s unrealistic assumptions of spending and efficiency have plagued the healthcare profession and our Medicare beneficiaries for 13 years. MACRA finally repealed the SGR, 

provided for statutory updates to allow improved beneficiary access, and got medicine to concentrate on moving to broad adoption of the unified MACRA quality reporting system. 

4 

One of the most important provisions in the law was the shift from a fee schedule 

system towards the merit-based incentive payment system, or MIPS. The law left 

behind a pass/fail quality reporting regime whose measures were too often set 

against a ‘‘one size fits all’’ generic standard of care with no financial upside for providers. Since MIPS is set to go into full effect on January 1, 2019—the first payment 

consequence year from reporting provided in 2017—it is critical that we hold this 

hearing and assess what is working, how the transition is progressing, and where 

improvements have been made, while seeking ways to simultaneously encourage 

stronger participation and reward providers already invested in the MIPS track. 

MACRA required the Secretary of Health and Human Services to establish a 

methodology to assess MIPS-eligible practitioners and give each one a performance 

score which determines their payments based on a scale of 1 to 100. In the first 

year, the performance benchmark was set at 3. This year, it was set at 15 and the 

Centers for Medicare and Medicaid Services recently proposed raising it to 30 for 

2019. MIPS incorporated specific performance categories, including, quality, resource use, clinical practice improvement activities, and meaningful use of electronic 

health records. The eligible population was also set to change over time, and the 

Centers for Medicare and Medicaid Services recently proposed to add a slate of additional providers to the program. 

Overall, stakeholders and physicians have been supportive of the transition to 

MIPS and to value-based payments. In our third hearing, we heard from providers 

reaping the benefits and savings by participating in an Advanced Alternative Payment Model. That said, MACRA was not a sprint but a marathon and a viable feefor-service model, in the form of MIPS, needed to exist. In continuing to follow 

MACRA implementation, certain decisions were made by the Center for Medicare 

and Medicaid Services that were for the benefit of a smooth transition, but had consequences that would have affected the agency’s trajectory of setting the performance threshold. Given this and other developments, I believed the law would benefit 

from some technical updates to improve the implementation of MIPS based on realtime factors. The Bipartisan Budget Act of 2018 included three MACRA technical 

fixes authored by myself along with Ranking Member Green, Representatives Roskam and Levin. 

MACRA changed the world of Medicare provider payments as we knew it. It has 

laid the groundwork for increased access to quality care for beneficiaries by eliminating the uncertainty of the past, reducing physician burden, and providing incentives where there were none. MACRA was never a law that was going to be fully 

implemented with a flip of a switch, it was designed as a long term effort to move 

the Medicare program down the value continuum. 

I want to thank all of our witnesses for joining us today. I look forward to hearing 

from each of you and learning more about how the implementation of this important 

law is progressing. 

OPENING STATEMENT OF HON. GENE GREEN, A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF TEXAS 

Mr. GREEN. Thank you, Mr. Chairman, for holding today’s hearing on the Medicare Access and CHIP Reauthorization, MACRA, 

and the merit-based incentive payment system, MIPS. 

I also thank our esteemed panelists for joining us this morning. 

The sustainable growth rate, SGR, was a thorn in the side of 

Medicare and doctors who treated Medicare patients for over decade after it was created in 1997. SGR’s formula led to a reduction 

of physician payments, starting in 2002, that had to be patched annually by Congress. 

In 2014 and 2015, our committee, along with other committees 

with jurisdiction, came together and passed bipartisan legislation, 

the Medicare Access and CHIP Reauthorization Act, which permanently repealed the SGR. MACRA did more than just repeal the 

flawed SGR formula. It was designed to overhaul and realign payment incentives for Medicare and transition of our health system 

to one that rewards value instead of just the volume of care. 

MACRA provides civility to Medicare payments for providers for 

5 

the years immediately after the enactment and made it easier for 

providers to report on and deliver high-quality care. 

Critically, MACRA encourages providers to move away from feefor-service and participate in a new delivery model that would reduce costs while increasing quality. Under the law, physicians who 

treat Medicare beneficiaries have a choice between participating in 

MIPS or the advanced alternative to payment plan, APMs, to make 

the shift from fee-for-service and volume-based payment system to 

a value-based payment system. MIPS streamlined three prior quality incentive programs that were sunset in 2016 and have been replaced by a new MIPS category, quality, improvement activities, 

meaningful use, and cost. 

Since starting in 2017, healthcare providers could choose whether to participate in APM or MIPS. Providers are exempt from MIPS 

if they fall below the low-volume threshold. For 2017, the Centers 

for Medicare and Medicaid set the low-volume threshold for providers who see fewer than 100 Medicare Part B patients or have 

less than $30,000 in Part B charges annually. For 2018, CMS increased the low-volume threshold to $90,000 in Part B charges or 

fewer than 200 Medicare patients per year. And for the next year, 

CMS has proposed maintaining the low-volume threshold for MIPS 

while adding a third exemption route for clinicians providing less 

than 200 covered services. CMS has proposed allowing clinicians 

who meet the exemption criteria to opt into MIPS. 

Under MACRA, the Department of Health and Human Services 

is required to set the performance threshold by 2019 at the mean 

or median of final scores for all MIPS-eligible clinicians. In February, Congress passed legislation changing the timeline to ease 

the burden of the MIPS transition. The Bipartisan Budget Act of 

2018 granted HHS an additional 3 years to ensure gradual, incremental transition to the mean or median of performance. 

I look forward to hearing from our panelists regarding their experience with MIPS and recent changes made by Congress, whether additional action is necessary to ensure physicians participating 

in MIPS is generating savings to Medicare and improving patient 

outcomes. 

Thank you, Mr. Chairman. I yield back my time. There is nobody 

on our side. So, I don’t think they want any time. 

[The prepared statement of Mr. Green follows:] 

PREPARED STATEMENT OF HON. GENE GREEN

Mr. Chairman, thank you for holding today’s hearing on the Medicare Access and 

CHIP Reauthorization Act (MACRA) and the Merit-Based Incentive Payment System (MIPS). 

I also thank our esteemed panelists for joining us this morning. 

The Sustainable Growth Rate (SGR) was a thorn in the side of Medicare and doctors who treated Medicare patients for over a decade after its creation in 1997. 

SGR’s formula led to a reduction of physician payments starting in 2002 and had 

to be patched annually by Congress. 

In 2014 and 2015, our committee, along with other committees of jurisdiction, 

came together and passed bipartisan legislation, the Medicare Access and CHIP Reauthorization Act, which permanently repealed the SGR. 

MACRA did more than just repeal the flawed SGR formula. It was designed to 

overhaul and realign payment incentives for Medicare and transition our health system to one that rewards value instead of just volume of care. 

6 

MACRA provides stability in Medicare payments for providers for the years immediately after its enactment and made it easier for providers to report on and deliver 

high quality care. 

Critically, MACRA encourages providers to move away from fee-for-service and 

participate in a new delivery model that will reduce costs while increasing quality. 

Under the law, physicians who treat Medicare beneficiaries have a choice between 

participating in MIPS or the Advanced Alternative Payment Models (APMs) to 

make the shift from fee-for-service and volume-based payment system to a valuebased payment system. 

MIPS streamlined three prior quality incentive programs that were sunset in 

2016 and have been replaced by new MIPS categories: Quality, Improvement Activities, Meaningful Use, and Cost. 

Starting in 2017, health care providers could choose whether to participate in an 

APM or MIPS. Providers are exempt from MIPS if they fall below the ‘‘low volume’’ 

threshold. For 2017, the Centers for Medicare and Medicaid Services (CMS) set the 

low volume threshold for providers who see fewer than 100 Medicare Part B patients or have less than $30,000 in Part B charges annually. 

For 2018, CMS increased the low volume threshold to $90,000 in Part B charges, 

or fewer than 200 Medicare patients per year. And for next year, CMS has proposed 

maintaining the low volume threshold for MIPS, while adding a third exemption 

route for clinicians providing less than 200 covered services. 

CMS has also proposed allowing clinicians that meet the exemption criteria to opt 

into MIPS. 

Under MACRA, the Department of Health and Human Services is required to set 

the performance threshold by 2019 at the mean or median of final scores for all 

MIPS eligible clinicians. 

In February, Congress passed legislation changing the timeline to ease the burden 

of the MIPS transition period. 

The Bipartisan Budget Act of 2018 granted HHS an additional three years to ensure a gradual and incremental transition to the mean or median of performance. 

I look forward to hearing from our panelists regarding their experience with 

MIPS, the recent changes made by Congress, and whether additional action is necessary to ensure physicians participating in MIPS are generating savings to Medicare and improving patient outcomes. 

Thank you, Mr. Chairman. I yield the remainder of my time. 

Mr. BURGESS. I thank the gentleman for yielding back. The gentleman does yield back. 

There is 3 minutes left on the vote on the floor. We are going to 

recess until immediately after the vote on the floor. 

[Recess.] 

Mr. BURGESS. I call the committee back to order. 

We are still waiting on the return of the ranking member and 

the chairman of the full committee, but anticipating that they will 

arrive, let’s thank our witnesses for being here today and taking 

time to testify before the subcommittee. 

Each witness is going to have the opportunity to give an opening 

statement, followed by questions from members. Today we will 

hear from Dr. David Barbe, the Immediate Past President of the 

American Medical Association; Dr. Frank Opelka, Medical Director, 

Quality and Health Policy, American College of Surgeons; Dr. 

Ashok Rai, Chairman of the Board, American Medical Group Association; Dr. Parag Parekh, American Society of Cataract and Refractive Surgery, and Kurt Ransohoff, Chairman of the Board, 

America’s Physician Groups. 

We appreciate you being here today, Doctors. 

And, Dr. Barbe, you are now recognized for 5 minutes to give an 

opening statement, please. 

7 

STATEMENTS OF DR. DAVID BARBE, IMMEDIATE PAST PRESIDENT, AMERICAN MEDICAL ASSOCIATION; DR. FRANK 

OPELKA, MEDICAL DIRECTOR, QUALITY AND HEALTH POLICY, AMERICAN COLLEGE OF SURGEONS; DR. ASHOK RAI, 

CHAIRMAN OF THE BOARD, AMERICAN MEDICAL GROUP ASSOCIATION; DR. PARAG PAREKH, AMERICAN SOCIETY OF 

CATARACT AND REFRACTIVE SURGERY, AND DR. KURT 

RANSOHOFF, CHAIRMAN OF THE BOARD, AMERICA’S PHYSICIAN GROUPS 

STATEMENT OF DR. DAVID BARBE 

Dr. BARBE. Chairman Burgess, Ranking Member Green, and 

committee members, thank you very much for the opportunity to 

come here today and to update you on the continuing implementation of MACRA. 

I am a practicing family physician from rural southern Missouri, 

actually in Congressman Long’s neck of the woods, and as you say, 

Past President of the AMA. 

Physicians are familiar with value-based payment mechanisms. 

We have been subject to those for over 10 years, starting with 

PQRI, which was the original quality-based program. That was in 

2007. Meaningful use came in in 2009. Value-based payments 

began in 2013. But each of these programs came in at separate 

times under separate bills, were never harmonized, never even contemplated working together. And all of them started as incentive 

programs, but most of them have transitioned into penalty programs which are additive. 

As of now, a physician who is not able to perform, for whatever 

reason, in those programs could be subject to up to 11-percent negative adjustment in their Medicare reimbursement. That was simply not sustainable, and we thank you and the others that worked 

so hard on MACRA in 2015. That is a significant step forward. Not 

only did it repeal the SGR, as has been noted, but it began to harmonize these programs, bringing them under one administration, if 

you will, and it also reset, very importantly, the incentive and penalty corridor, such that for performance in the first year of 2017, 

it was a plus or minus 4 percent, certainly a better opportunity for 

physicians to succeed under that particular framework. So, we appreciate the work that went into that. 

We share a common goal with you in seeing that these new quality payment programs are implemented appropriately, that the 

transition is smooth. Because we believe that the success of these 

programs has a real opportunity to improve quality for patients, to 

bend the cost curve. But, for them to be successful, physicians have 

to be able to succeed under these programs as well. Again, MACRA 

took us a significant step toward physician success and improving 

these programs. 

In your opening remarks, you mentioned BBA 2018 and the significant improvements and technical fixes that were made. We 

really appreciated those as well. We will continue to work closely 

with you because, as you also suggested, this wasn’t a one-anddone. This is an evolving process. And hearings like this today, allowing us to update you, are critical in continuing to improve that 

process for patients, physicians, and for the Medicare program. 

8 

As a part of the BBA 2018, we strongly support the Part B drug 

cost exclusion. We support flexibility for CMS to re-weight the cost 

performance measures. We appreciate the performance threshold 

flexibility that you gave CMS. We need now for CMS to use the 

flexibility that you gave them to make this transition appropriate. 

So, we will continue to work with them. We have made multiple 

suggestions already, and we will continue to try to make this transition appropriate. 

One of the other pretty important parts of what you enabled was 

for PTAC to consult with physician groups as we develop physicianfocused payment models. The PTAC has been doing what you have 

wanted it to do. They have received dozens of proposals, and they 

have even recommended about 10 of those onto CMS. Unfortunately, CMS has not seen fit to adopt any of those yet, and I think 

it is thwarting the creativity and innovation that physicians are 

willing to bring to the table. So, we will continue to work with CMS 

to try to get them to consider and adopt some of those alternative 

payments models that are physician-focused that PTAC has recommended. 

And I think, lastly, you may hear some discussion today about 

the limitation of the upside opportunity to something in the 2-percent range, rather than the 4 percent that was originally contemplated. Again, the goal is to help physicians succeed. All of the 

organizations represented here represent a wide range of physician 

practices, physician styles. The AMA certainly does. We represent 

physicians from all specialties, all practice types. 

It is critically important that all those physicians have an opportunity to succeed under this program. Whether you are a large 

megagroup like the one I am in or whether you are a single, independent physician practicing someplace else in Missouri, you need 

an opportunity. And so, CMS needs flexibility. We need a smooth 

transition, and we really appreciate the continued opportunity we 

have to dialog with you on this. 

[The prepared statement of Dr. Barbe follows:] 

9 


36027.001

Statement 

of the 

American Medical Association 

to the 

U.S. House of Representatives Committee on Energy and Commerce 

Subcommittee on Health 

Re: MACRA and MIPS: An Update on the Merit-based Incentive 

Payment System 

July 26, 2018 

Division of Legislative Counsel 

(202) 789-7426 
10 


36027.002

STATEMENT 

of the 

American Medical Association 

to the 

U.S. House of Representatives Committee on Energy and Commerce Subcommittee on Health 

Rc: MACRA and MIPS: An Update on the Merit-based Incentive Payment System 

July 26, 2018 

The American Medical Association (AMA) appreciates the opportunity to present our views to 

the U.S. House of Representatives Committee on Energy and Commerce Subcommittee on 

Health. As the largest professional association for physicians and the umbrella organization for 

state and national specialty medical societies, the AMA is heavily invested in the successful 

implementation of the Medicare Access and CHIP Reauthorization Act of2015 (MACRA). 

Since the enactment ofMACRA, we have worked closely with policymakers and the Centers for 

Medicare and Medicaid Services (CMS) to ensure that implementation of the law reflects the 

intent of Congress to focus on improving quality and value, and that physician practices are able 

to successfully participate. We remain committed to working with both Congress and CMS to 

promote a smooth implementation of the Quality Payment Program (QPP) that will allow 

physicians to be successfuL 

We continue to believe that MACRA, and more specifically the Merit-Based Incentive Payment 

System (MIPS), represents an improvement over the flawed sustainable growth rate (SGR) 

payment methodology and the three legacy reporting programs it replaced: the Physician Quality 

Reporting System (PQRS), Meaningful Use (MU), and the Value-Based Payment Modifier 

(VM). We recognize that the MIPS program is still in its initial stages and must continue to be 

improved and simplified. We commend Congress for the 2018 statutory improvements to the 

MACRA law which extends CMS' flexibility to set the perfommnce threshold and reweight the 

cost performance category for an additional three years. We also appreciate Congress' 

clarifications that Medicare Part B drugs are not included in the incentive and penalty payments 

for the MIPS program. While we believe these changes strengthened the MIPS program, we are 

committed to continuing to work with the CMS and Congress to further improve the program. 

Improvement Over Legacv Programs 

The AMA was supportive when Congress replaced the flawed, target-based SGR fonnula with a 

new payment system under MACRA in 2015. Due partially to the fundamentally flawed concept 

of the SGR- namely that the threat payment cuts for all physicians would serve as an individual 

incentive to limit volume growth and partially to the failure of Congress to do more than 

temporarily block cuts, scheduled payment cuts prior to the implementation of MACRA 
11 


36027.003

exceeded 20-percent. Those cuts would have had a devastating impact on physician practices 

and beneficiary access to care. Under MACH.A, the SGR formula was replaced with specified 

payment updates for 201 5 and beyond. MACRA also created an opportunity to address problems 

found in existing physician reporting programs (i.e., PQRS, MU, and VM). In addition, the law 

sought to promote innovation by encouraging new ways of providing care through APMs. 

MACRA was designed to offer physicians a choice between two payment pathways: a modified 

fee-for-service model, MIPS, or new alternative payment models that support high value 

services, including those not typically covered under the Medicare physician fee schedule, or 

APMs. While MIPS is complex, it represents an improvement over the prior reporting programs. 

For example, under prior law, possible combined penalties for the PQRS, MU, and VBM 

programs could be up to negative II percent in 2019 based on 2017 reporting, and PQRS did not 

offer an opportunity to cam an incentive. Under MIPS, the maximum penalty physicians can 

receive in 2019 is negative four percent based on 201 7 reporting. The maximum penalty 

increases to negative nine percent in future years, which is at least two percentage points less 

than the possible penalties under legacy reporting programs. Also, there is a potential for bonus 

points for high performers under MIPS. 

Furthermore, the AMA supports the accommodations for small practices that arc included in the 

MIPS program. Specifically, the low volume threshold exemption excludes numerous small 

practices or physicians who see very few Medicare patients. In 2018, physicians with annual 

Medicare allowed charges of $90,000 or less or 200 or fewer Medicare patients, arc exempt from 

the QPP altogether. In 2019, CMS proposes to also exclude physicians who provide 200 or fewer 

covered professional services to Medicare Pmt B beneficiaries. The AMA has also supported 

reduced reporting requirements for small practices, hardship exemptions from the Promoting 

Jnteroperability MIPS performance category for qualifying small practices, bonus points for 

small practices, and technical assistance grants to help small practices succeed in the program. 

Among small practices that are not exempted by the low volume threshold, CMS estimates that 

91 percent of eligible professionals in practices of one to 15 physicians will experience a positive 

or neutral payment adjustment in 2020 based on 2018 reporting. The AMA believes this is a 

notable improvement over the barriers small practices faced in previous rcpolting programs. 

Each performance category under MIPS also contains improvements over the legacy reporting 

programs. For example, in the Quality performance category, physicians are required to report 

six measures as opposed to the nine they were required to report under PQRS, and they can now 

receive partial credit for reporting fewer than six measures. CMS' recent proposals for the 

Promoting lntcroperability pcrfom1ance category in 2019 eliminate the base and performance 

categories and reduce the number of required measures, many of which were problematic for 

physicians as they led to physicians being scored based on the actions of others. In the Cost 

category, CMS has been working to develop a new suite of episode-based measures, the first 

eight of which they propose for usc during the 2019 pcrfmmance period. 

Physicians participating in APMs also benefit under MACRA. While there are currently a 

limited number of Advanced APMs, physicians participating in these models will receive a five 

percent bonus payment for the first six years of the program. MACRA also allows favorable 

treatment for qualified medical homes as Advanced APMs and in the MIPS Improvement 
12 


36027.004

Activities category. In addition, certain APMs, such as Track 1 accountable care organizations in 

the Medicare Shared Savings Program, are defined as MIPS APMs and allow their physician 

participants to meet their entire MIPS reporting requirements through their APM participation. 

The AMA strongly supports the development of additional APMs to offer more patients and 

physicians the opportunity to participate in models that help reduce costs and improve the quality 

of health care. 

Support for Technical Corrections 

The AMA strongly supports the changes to MACRA in the Bipartisan Budget Act of2018 

(BBAl8). We believe these technical changes to the statute will help simplify and improve the 

MIPS program. Since the enactment ofBBA18, CMS released the Medicare Program: Revisions 

to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for 2019; 

Medicare Shared Savings Program proposed rule. We are in the process of thoroughly 

evaluating the proposed rule and will be submitting our comments to CMS by the September 10 

deadline. 

We commend Congress for excluding Medicare Part B drug costs from MIPS payment 

adjustments. Including these additional items and services created significant inequities in the 

administration of the MIPS program. Although in the past CMS included Medicare Part B drugs 

in the calculation and comparison of physician costs under the VM, none of the legacy programs 

applied adjustments to reimbursement for the drugs. Excluding Medicare Part B drug costs from 

MIPS payment adjustments eliminates a significant departure from previous policy that could 

have penalized some physicians whose patients require high-cost Part B drugs and created a 

potential windfall for others whose patients can be treated with less costly drugs. This policy also 

would have underpaid physicians for the cost of acquiring drugs if they received a low MIPS 

score, and overpaid them if they received a high MIPS score. We also commend CMS for 

proposing to implement the revised Part B dmgs policy beginning in2019. 

We also appreciate the flexibility given to CMS to reweigh! the Cost performance category to 

not less than ten percent for the third, fourth, and fifth years of MIPS. We agree that, while 

development of resource use measures is an ongoing effort, more time is needed to test them and 

make any necessary changes. Unlike the program's quality measures there was no physician 

input in the development and review of resource use measures prior to the enactment of 

MACRA. The AMA strongly supported additional flexibility for CMS to reweight the Cost 

performance category and believed that allowing three additional years for the cost score to be 

weighted at less than 30 percent would allow additional time for CMS to build on its ongoing 

initiative to utilize panels of physicians to develop, test and refine resource usc measures. We are 

concerned, however, that CMS is proposing to increase the Cost category score to 15 percent in 

the 2019 perfom1ance period, given that 2019 is the first year it is testing eight newly developed 

episode-based cost measures. We question whether proposal does not align with Congress' intent 

to keep the weight of the Cost performance category low until episode-based cost measures are 

adequately tested and available for a variety of physician specialties, and will be providing 

comments to CMS to this effect. 

In addition, we strongly support the ability for CMS to exercise flexibility in setting the 
13 


36027.005

perfonnance threshold for three additional years. Physicians are still becoming familiar with the 

MIPS program, and allowing CMS three additional years of flexibility in setting the perfonnance 

threshold will help smooth the transition to a perfonnance threshold at the mean or median. As 

Congress intended, we believe the goal of the program should be to help doctors succeed, not to 

cause doctors to fail. In the proposed rule, CMS is proposing to double the perfonnance 

threshold from 15 points in 2018 to 30 points in 2019. While the 30 point performance threshold 

is likely lower than the mean or median for 2019, we continue to urge CMS to use the flexibility 

provided by Congress to increase the perfonnancc threshold very gradually during the first five 

years of the program. 

Finally, we strongly support the ability for the Physician-Focused Payment Model Technical 

Advisory Committee (PT AC) to provide initial feedback on proposed APM models regarding the 

extent to which they meet criteria and an explanation of the basis for the feedback. With the 

creation of the PTAC, Congress sent a strong signal to !IllS and CMS that implementing 

physician-developed APMs is a critical element of the transition to value-based payment models 

for Medicare patients. Therefore, we are extremely concerned that none of the APM models 

recommended by PTAC to the Secretary of the U.S. Department of Health and l!uman Services 

(l-IHS) have been tested or implemented to date. We are pat1icularly conccmed given that the 

MACRA statute only provided six years of bonus payments to facilitate physicians' migration to 

Advanced APMs, yet we are approaching the three-year mark for the initial implementation and 

there is still not a robust APM pathway for physicians. Sec our recent letter to HHS for more 

details on our concerns. 

Further Improvements arc Needed 

CMS has also proposed numerous policies that the AMA strongly supports. For example, we 

support the addition of a third criterion of providing fewer than 200 covered professional 

services to Part B patients for physicians to meet the low-volume threshold, and the ability of 

physicians to opt-into the MIPS program if they meet fewer than three of the low-volume 

threshold detetminations. We also support the retention of bonus points for small practices and 

physicians who treat complex patients. We believe CMS' proposal to consolidate the lowvolume threshold detcnnination periods with the dctennination periods for identifying a small 

practice, non-patient facing physicians, and hospital-based physicians will reduce confusion and 

program complexity. We also commend CMS for eliminating the pcrfonnance and base scores, 

reducing the number of measures physicians must report on, and providing physicians more 

f1exibility in the Promoting Interopcrability performance category. Furthermore, we support the 

option for facility-based physicians to use facility-based scoring in the Quality and Cost 

perfonnancc categories beginning in 2019. Finally, we were very pleased to see CMS propose 

the Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) demonstration and 

strongly support allowing physicians participating in risk arrangements in MA similar 

advantages to those enjoyed by physicians participating in traditional Medicare APMs. 

While we commend CMS for these proposals, we also believe there are numerous additional 

improvements that can further simplify MIPS and help physicians succeed in reducing health 

care costs while improving health care quality. Our overarching goals in shaping MACRA 

regulations continue to be choice, flexibility, simplicity and feasibility. 
14 


36027.006

For example, there arc several steps CMS can take now to simplify the overly complex scoring 

system including harmonizing the scoring across the four separate components of MIPS so that 

physicians can more easily calculate their progress toward achieving success and increasing 

opportunities for physician reporting to be counted across multiple categories in a more coherent 

payment system. 

CMS should also change Promoting lntcropcrability reporting requirements to attestation alone 

and develop new measures that utilize not only certified electronic health records (EliRs), but 

also technology that builds on certified EHRs. 

Furthermore, the AMA has strongly urged CMS to move away from the siloed, check-the-box 

legacy programs to a single program that is more holistic and clinically relevant. Specifically, the 

AMA has worked with state and specialty medical societies to develop a proposal that would 

allow physicians to focus on activities that fit within their workflow and address their patient 

population needs, while receiving credit for those activities across multiple MIPS performance 

categories. 

In addition, there are further changes to the program that would reduce physicians' 

administrative burden, including reducing the number of quality measures a physician is required 

to report within the Quality performance category and allowing physicians the option to report 

for a minimum of90-days in all performance categories to better align reporting periods. CMS 

should also expand the facility-based definition to provide physicians in settings such as postacute care facilities and long-term care facilities a meaningful way to participate in MIPS. Our 

recommended changes would reduce physicians' administrative burden, allowing them to spend 

more time with their patients. 

The AMA remains committed to ensuring that the MACRA program is successful. We 

appreciate the opportunity to provide our comments on the current MACRA program, and we 

look forward to continuing to work with the Committee and CMS to make further improvements. 
15 

Mr. BURGESS. Thank you, Dr. Barbe. 

Dr. Opelka, you are recognized for 5 minutes, please. 

STATEMENT OF DR. FRANK OPELKA 

Dr. OPELKA. Chairman Burgess, Ranking Member Green, members of the committee, on behalf of the 80,000 members of the 

American College of Surgeons, we appreciate the invitation to 

share our thoughts with you today. 

The American College of Surgeons again expresses our thanks to 

Congress for the aspects of MACRA which have eliminated the sustainable growth rate and led to efforts designed to link payment 

more closely to quality and value. Congress’ efforts have not only 

reduced maximum penalties, your efforts seek to phase in new incentives and provide potential for positive updates. Particularly 

noteworthy are the congressional efforts to combine and simplify 

value-based goals for measuring quality improvement. After all, we 

measure, so that we can improve, not just get paid. We also appreciate the congressional directives for moving from fee-for-service to 

alternative payment models. We would wish CMS would improve 

their efforts to work with the American College of Surgeons’, ACS, 

physician-focused payment model. We are mindful of Congress’ interest in oversight of CMS’s implementation of MACRA. 

In order for clinicians to assume risk in value-based payment 

programs, physicians must have reliable and valid measures of 

both quality and the cost of care. The American College of Surgeons seeks to support the congressional intent of MACRA through 

our work product for building meaningful quality measures for surgical patients and surgeons, as well as proffering the CMS our 

APMs which are based on true total cost of care. 

The American College of Surgeons began over 100 years ago, 

when America had more hospitals than we have today. They were 

small and care was not standardized. To standardize quality, we 

formed the College of Surgeons, and we created the first hospital 

accreditation. In later years, this became The Joint Commission. 

Today, we continue those verification programs in order to promote 

standards for quality of care in trauma centers, such as Level I, 

Level II, and Level III trauma centers. 

Neither the Federal Government nor commercial payers do much 

to recognize the over 200 quality standards we create to maintain 

a national trauma system for this country. Our verification programs are a model which measure what matters to patients. We 

measure the team and the totality of care. We worry less about 

measuring the individual surgeon and focus more about measuring 

the outcome to patients. We, then, credit the entire team with its 

successes and we use the knowledge gained from our programs to 

create learning networks which teach others and spread improvement widely, none of this recognized in payment programs. 

In much the same way, we have created cancer verification, 

breast care verification, bariatric care, pediatric surgical care, and 

now more. Yet, CMS offers meaningless measures which do little 

to help the surgical patient. CMS feels constrained from measuring 

team-based measures, instead seeking simply constructed measures such as surgeons having to track patients’ immunizations, 

rather than measuring the surgical team. The end result is measVerDate Nov 24 2008 14:50 May 21, 2019 Jkt 037690 PO 00000 Frm 00021 Fmt 6633 Sfmt 6633 U:\MY DOCS\HEARINGS 115\HEARINGS\115-160 CHRIS
16 

ures become meaningless, burdensome, and distractions. Hospital 

CEOs end up defunding valued surgical quality programs to chase 

the wrong measures, simply because that is how they get paid. 

It is time we, as the American College of Surgeons, seek congressional directives for CMS to build a strong surgical quality program 

for each major surgical domain, just as the College has done in our 

team-based models for hospitals for trauma, for cancer, and more. 

It is time that we measure what matters. It is time for payment 

models to align with clinical care and not force clinical care to conform to payment. 

Lastly, the American College of Surgeons serves as a leader in 

digital information and health IT. We are focused on patient-centered digital records, not just EHRs, since patients’ lives exist in 

more than one EHR. This calls for an expansion of our thinking beyond EHRs into a world of interoperability, connecting patients 

across EHRs, across smart devices, across clinical registries, for activities such as clinical decision support, machine learning, and artificial intelligence. There is so much more we can do for quality 

and for lowering cost by leveraging digital information. We have to 

stop thinking of EHRs and think beyond them. We could use your 

support in promoting this level of interoperability to make an interoperable digital patient medical record. We look forward to working 

with the Congress to help surgeons care for patients. 

Thank you very much. 

[The prepared statement of Dr. Opelka follows:] 

17 


36027.007

Statement of the 

American College of Surgeons 

Presented by 

Frank Opelka, MD, FACS 

before the 

Subcommittee on Health of the 

Committee on Energy and Commerce 

United States House of Representatives 

MACRA and MIPS: 

An Update on the Merit-based Incentive Payment System 

July 26, 2018 
18 


36027.008

Chairman Burgess, Ranking Member Green, and Members of the Subcommittee, on behalf of 

the more than 80,000 members of the American College of Surgeons (ACS), I wish to thank 

you for inviting our participation in this hearing. ACS has a long-standing commitment to 

improving the quality of care for the surgical patient. This commitment extends to ensuring 

that the ongoing implementation of the lvfedicare Access and CHIP Reauthorization Act 

(MA CRA) is accomplished in a way that improves the delivery of medicine for patients and 

removes administrative burdens on physicians. This is a critical time in the process of 

implementing the law and CMS would benefit not only from additional guidance from the 

physician community, but also from the committees in Congress who conceived the Meritbased Incentive Payment System (MIPS) and Alternative Payment Model (APM) pathways to 

restate the vision of that bill and refocus on Congress' original intent. We welcome this 

opportunity to share our experience, our impressions of the MIPS program thus far, and 

suggestions on how to make the program more meaningful for patients and physicians through 

implementation. 

ACS · understanding at the time of passage of MA CRA was that surgeons and other physician 

specialties would be evaluated based on measures related to the care they provide and would 

have access to APM options suitable to their practice. lfthese were unavailable at the time of 

passage, opportunities were built in by Congress to allow specialties to develop them. 

However, these new models and measures have not materialized, and not for lack of effort on 

the part of the physician community. ACS has, for years, sought to be a partner in developing 

solutions to the most complex challenges facing Medicare. This includes efforts to develop 

2 
19 


36027.009

innovative payment strategies as part of a replacement for the sustainable growth rate (SGR) 

as well as more recent work to create APM options for surgeons and other providers and new 

tools for participants to improve care for Medicare patients. 

I would like to thank Congress for eliminating the Sustainable Growth Rate (SGR) and 

designing a program intended to tie payment more closely to quality and value. It is easy to 

forget the challenges faced prior to MACRA in the face of ongoing implementation efforts. 

There are a number of positive concepts to be noted in MACRA beyond the elimination of the 

much-maligned SGR cost control formula that were aimed at addressing these challenges. 

These include: 

• Overall reduction of maximum penalties associated with PQRS, VM and EHRMU from I 0+ percent in 2016 to five percent this year and growing to a 

maximum of nine percent over time. 

• Incorporation of a meaningful potential for positive updates. Prior to MACRA, 

penalties fi-om PQRS and EHR-MU were lost from the physician 

reimbursement pool. Under MACRA these funds stay in the pool and are used 

to provide positive payment adjustments for high achievers. While we strongly 

believe there is a need for realistic updates to the physician fee schedule, we 

welcome the much greater upside potential. Surgeons, like all humans, arc risk 

averse and reward focused. As such, we believe an asymmetrical risk profile 

with greater upside potential is more likely to incentivize behavioral change. 

• Goal of combining and simplifying existing programs into a single streamlined 

program. We also recognize the focus on quality as witnessed by the weight 

3 
20 


36027.010

ascribed to both Quality and Improvement Activities. Continued physician 

input is essential to merge quality measurement and improvement activities 

scamlcssly into the clinical care model. 

• Goal of moving from fee-for-service to APMs as well as a pathway to develop 

new models. While we greatly appreciate this provision and have taken 

advantage of the Physician-focused Payment Model Technical Advisory 

Committee or (PTA C) pathway to propose a new model, we feel that more 

could be done to expedite testing of models once they have been recommended. 

To date, none of the models recommended by the PT AC have been 

implemented or even tested by the Center for Medicare and Medicaid 

Innovation (CMMI). 

Inclusion of additional incentivizcs for the highest perfonners in MIPS as well 

as early APM adopters. 

Congress showed foresight in providing a period of stability in the original MACRA legislation, 

and we commend Congress for extending this flexibility in the Bipartisan Budget Act of 2018 

(H.R. 1892) in recognition of the difficult task faced by CMS in implementing this program, 

and by physicians in educating themselves and changing their practices as necessary to meet 

the new requirements. To be clear, ACS plans to make good usc of this opportunity to advise 

CMS on how best to measure quality for surgeons. If we are putting providers at risk based on 

these metrics, we must ensure that the appropriate physicians are being rewarded or penalized. 

W c see this new discretion being used by CMS in the recently proposed mle to implement the 

QPP for 2019 in several areas including the cost portion of MIPS and the setting of the 

4 
21 


36027.011

threshold for the Final Score payment adjustment determinations. 

Congress has now made the transition from its legislative role to one of oversight to ensure 

that the MACRA law is being implemented in the best interest of Medicare patients, as you all 

intended. This is important because unfortunately, we have reason to be concerned that actions 

taken by CMS since the passage of J',;JACRA may not be sufficient to take us to our shared end 

goals. While some of these actions may have been well intentioned and taken in the name of 

reducing reporting requirements or reducing overall burdens of participation, others seem 

counter to the very spirit of the law, such as the failure to move forward on any of the APMs 

reviewed by the PTA C. We need Congress' help to ensure the law is implemented correctly so 

that physicians who are providing high quality, high value care to their patients are able to 

succeed. We believe CMS needs additional guidance from Congress at this point to ensure the 

intent of moving the physician payment system toward quality and value is upheld. 

Implementation of the MIPS program needs to be refocused to better achieve some of these 

intended goals. ACS would like to lend our century of experience in setting standards for 

surgical quality to that end. This history includes founding what is now refetTed to as the Joint 

Commission and creation of accreditation programs such as that used to verify trauma centers 

and quality improvement efforts such as the National Surgical Quality Improvement Program 

(NSQ!P). We believe this experience may assist CMS with creating novel ways to improve the 

accuracy and validity of quality measurement while continuing to tackle unnecessary burdens 

on physicians. 

Achieving the Goals of MIPS 

5 
22 


36027.012

To reiterate, the underlying concept of MIPS was to simplify the existing CMS quality 

programs, combine them into a single program that compares the value of care provided by 

participants (as judged based upon quality and cost metrics, use of electronic health records 

and improvement activities) and adjusts payments up or down based on that comparison. 

As originally envisioned, the idea was to provide physicians with a period of stability after 

repeal of the SGR and its threatened reimbursement cuts, during which time CMS would 

develop the regulations to implement the new payment system and physicians could adapt their 

practice to meet the new requirements. The new program would then be gradually phased in 

over several years with certain additional incentives (such as an additional pool of money for 

bonus payments to early APM adopters) available in the early years of the program. The 

amount of money at risk for providers would gradually grow to nine percent, which was 

comparable to (but slightly less than) the maximum combined penalties associated with the 

Physician Quality Reporting System (PQRS), Value Based Modifier (VM), and Electronic 

Health Record Incentive Program (EHR-MU) programs. Unlike the prior programs however, 

MIPS has the potential for equivalent positive payment adjustments. Since payment 

adjustments are largely budget neutral and few physicians were penalized during the first 

transition year, we have not seen the positive updates of four percent for 2019 equivalent to 

the maximum four percent penalty for that year. This is due to low volume exclusions and 

favorable "pick-your-pace" policies which made it relatively straightforward to avoid penalties 

during the transition period. 

Given the complexity of the underlying PQRS, VM, and EHR-MU, and the extremely diverse 

and broad range of physicians to be evaluated and compared, simplification has proven to be 

6 
23 


36027.013

a daunting task. Providing physicians with credit for their efforts to improve their clinical 

practice, while worthwhile, further adds to this challenge. 

While Congress' goals surrounding the aforementioned policies were laudable, and while we 

acknowledge that CMS' resources arc limited, the implementation of this new payment system 

is taking longer than anticipated in some areas, especially in the crucial development of new 

quality and cost measures. The first funding opportunity for measure development was 

delayed until this year and funds allocated in MACRA for the development of new quality 

measures have still not been awarded for this purpose. Similarly, the development of accurate, 

episodic cost measures is proving both difficult and time consuming. Currently cost 

measurement is based solely on legacy total cost of care measures. 

Surgeons support being held accountable for the quality of care received by their patients. It 

is. however, essential that efforts to do so arc accurately measuring quality in a way that can 

lead to improvement and which does not overburden providers, inadvertently taking their focus 

away from the patient. To accomplish this, CMS needs measures that accurately and 

meaningfully target the episode of care being assessed, providing useful information to 

physicians and patients. This is not currently the case. For example, surgeons are frequently 

being evaluated based on a patient's immunizations. This is not relevant to the care surgeons 

provide, and therefore is seen as unnecessary and burdensome. This in turn reflects poorly on 

MIPS and its intention, causing a lack of buy-in on the part of many surgeons. This buy-in on 

the part of all physicians will be necessary if MIPS is to be successful in its goal of improving 

quality and value in health care; otherwise it will simply be seen as a new set of burdensome 

boxes to check as part of a payment program. Unfortunately, this focus on check-the-box 

7 
24 


36027.014

measures to maximize reimbursement will have the unintended consequence of crowding out 

quality programs that truly improve care to the patient. This is most certainly not aligned with 

the Congress' intent when MACRA was passed and the ACS is committed to working with 

Congress to ensure CMS prioritizes meaningful measure development for all specialties 

moving forward. 

Measuring Quality in Surgery 

Surgeons and surgical patients arc best positioned to understand what elements of care are 

important to measure in order to evaluate the quality of care and provide the information 

needed for improvement. As noted above, surgical quality measurement in MIPS is seen by 

many as poorly representing surgical care. Measures reported by large groups are typically 

related to primary care or are population-based measures that arc not at all related to the care 

surgeons provide. These measures can be complex, burdensome, and frustrating as it takes time 

and resources away from other efforts that could have a greater impact for patients. 

Unfortunately, that means that what affects payment is not directly related to what affects 

quality, as Congress intended. 

ACS has taken advantage of the additional flexibility granted recently by Congress to further 

develop our thoughts on how best to measure surgical quality in a way that is accurate. The 

right measures for quality and improvement, no matter how complex, are never burdensome. 

It is meaningless measures, such as many of those currently reported to CMS, which are 

burdening care teams. 

8 
25 


36027.015

We have proposed to CMS that surgical quality measurement should include a combination of 

three elements: standards-based facility-level verification programs, patient reported 

experience and outcomes measures, and traditional quality measures such as those currently in 

MIPS, including registry and claims-based measures. Combining these three elements will 

provide a much clearer picture of the quality of care provided to the patient, including not just 

the surgeon, but the entire care team involved. The verification programs used have a long 

history of success, including the Joint Commission and ACS' Trauma, Bariatric, and Cancer 

accreditation programs. 

We wish to draw attention to ACS' Verification, Review, and Consultation (VRC) program 

for trauma verification as a model program. We have developed and offer trauma verification 

and review consultations to assist trauma centers in the evaluation and improvement of trauma 

care. Using the Optimal Care of the Injured Patient as a guide, the VRC validates resources at 

trauma centers with the goal of assisting a trauma center to attain a designated level of service 

-Level I, II, or III. To achieve the highest recognition, Level I, means the trauma facility must 

meet or exceed more than 200 clinical standards for optimal care. Who, if seriously injured, 

does not want to seek care at a Level I trauma unit? Thousands of lives have benefited from 

these trauma verification standards, with only limited recognition from CMS, the federal 

govemmcnt, or commercial insurers. 

These verification programs are proven to measure quality and to drive improvement. We are 

currently developing pediatric trauma care and geriatric trauma care verification programs as 

well. It is time the US Congress and the ACS come together to set expectations from CMS 

9 
26 


36027.016

and our commercial insurers which leverages standards in verification programs for all aspects 

of surgical care such as cancer, bariatrics, cardiac care, orthopedics, and so forth. 

The importance of setting standards at the facility level to achieve quality outcomes cannot be 

overstated. Our experience tells us, if you put a surgeon with the highest technical skill level 

into an undcrperforming environment where the resources needed are not available and 

systems are not in place to protect the patient, that surgeon will struggle to provide the highest 

quality care. Conversely, if you put an average surgeon in a great system, their outcomes are 

likely to improve and patients will receive better, more coordinated care. ACS' recently 

published manual, entitled Optimal Resourcesfor Surgical Quality and Safety, describes key 

concepts for developing standards in quality, safety, and reliability, and explores the essential 

elements that all hospitals should have in place to ensure patient-centered care. Publication of 

the Optimal Resources for Surgical Quality and Safetv further reinforces ACS' commitment 

to high-quality and coordinated care. 

To compliment the verification program, patient reported outcomes or PROs are important to 

validate, from the patient directly, that their personal goals for their surgical care were met. 

PROs represent the views and perceptions of patients and can be extremely useful in improving 

patient care. These measures are the mainstay in the promotion of patient-centered care. 

Finally, our quality model includes traditional claims-based measures to be aggregated with 

limited burden, primarily as an additional check to verify that quality care is being delivered. 

If the correct measures are selected, they can be seen as infonnative and meaningful to 

physicians, not burdensome. It is important to ensure that collection of these data enhances 

10 
27 


36027.017

patient care rather than taking the focus away from what is important. Many existing measures, 

including outcome measures, arc not sufficient on their own for measuring the quality of care 

provided. 

Due to decades of continuous quality improvement efforts, there is little variation in outcomes 

for many surgical procedures as judged by existing outcome measures. In fact, there is so little 

variation that use of these measures is statistically not valid in many cases due to the large 

sample size that would be needed. Instead, attaining high quality care through a combination 

of ensuring that standards are being achieved and validating outcomes through measuring the 

patient's perspective on whether goals of care and other milestones are being achieved may be 

more reliable. 

Promoting Interoperability 

For many providers, Promoting lnteropcrability (PI) remains the most frustrating aspect of the 

MIPS program. The category is focused too narrowly on the EHR and less on the advancement 

of broadly applied patient digital health information from all data sources as the original name 

of"Advancing Care Infonnation" implies. In implementing MIPS, CMS should have a laser 

focus on making sure that a complete view of a patient's digital health infonnation is available 

to physicians, in a useful, standardized form, when it matters most. A patient's longitudinal 

care profile rarely exists in a single EHR. Physicians need a digital health infmmation 

environment which represents the patient with enabling information from EHRs, smartphones, 

iPads, tablets and other available sources. The passage of MACRA, along with the recent 

removal of the counterproductive requirement that EIIR meaningful use standards grow ever 

!I 
28 


36027.018

more stringent over time (a provision of the aforementioned Bipartisan Budget Act) have 

created an opportunity to reimagine what constitutes meaningful use. 

When the HJTECH Act was originally enacted, meaningful use was intended to be a means to 

validate that Congress' investment on EHRs was spent wisely. The resulting program 

therefore focused on the meaningful use of specific, Certified EHR technology or CEHRT 

required by the program. The federal govemment is no longer subsidizing adoption of this 

technology however, and ACS believes that we should take this opportunity refocus to the 

original goals of using technology, and more specifically digital health information at the 

patient level, to improve care and lessen the focus on EHRs alone. PI should focus on who is 

using digital health information to build a more complete patient record that is available to 

patients and physicians at the point of care, and how they arc using this information to improve 

the quality and efficiency of care. The ACS looks forward to working with Congress, CMS, 

and the Office of the National Coordinator (ONC) to help create a digital health infotmation 

environment that achieves these goals. 

Development of Alternative Payment Models 

One aspect of the law where ACS has seen both great promise and significant frustration is in 

the area of APMs and specifically the potential for new physician-focused models. The 

incentives included in MACRA made it clear to the ACS that an underlying goal of the 

legislation was to incentivize the creation of and move to APMs and Advanced APMs (AAPMs). These incentives include the five percent lump sum bonus for qualified /\-APM 

participants for the first six years of the QPP, the reduced reporting requirements potentially 

associated with these models and higher updates to the conversion factor for APM participants 

12 
29 


36027.019

than those in MIPS in later years. MACRA also included a new pathway for APM development 

in the PT AC. ACS saw the value of creating such a model and was the first organization to 

submit a proposal to the PT AC. Our experience with the process was smooth and helped 

greatly in refining our model (known as the ACS-Brandeis Advanced Alternative Payment 

Model) and our thinking on APMs, as well as informing our positions on quality and cost 

measurement in team-based health care. However, there appears to be a disconnect with the 

PTAC recommendation process compared to the testing of new models by CMS. 

To date, the PTAC has received more than 20 proposals and reviewed and made 

recommendations on 15 models. Of these, 10 were recommended to the Secretary of Health 

and Human Services for either limited scale testing or implementation. Yet despite all of this 

work on the part of the PTAC and the organizations who have developed these proposals, none 

of the recommended models have been tested or implemented by CMS. In fact, Secretary 

Azar recently declined to move forward on testing of eight of these PT AC-recommended 

models in a single letter. While we feel there is great merit in the move toward APMs, and 

plan to continue work on developing core concepts of the ACS-Brandcis A-APM, it is 

unfortunate that the input from the broader health care community is being largely ignored. 

Given the challenges noted previously from the perspective of our specialty, as well as those 

noted by others, it may be invaluable to commission a study on these challenges, including 

CMS' ability to measure the true quality of care provided by physicians of all specialties, the 

availability of cost measures that arc meaningful and actionable in concert with these quality 

measures, physicians' ability to access patient health infmmation when they need it and in a 

standardized predictable format, and the availability of APMs that grant physicians of all 

13 
30 


36027.020

specialties the opportunity to be creative in using their expertise to increase quality and value 

of care to the patient. 

I, and the ACS, appreciate the opportunity offered by the Chainnan, Ranking Member, and the 

committee to testify at this hearing. MACRA and MIPS should be seen as an opportunity for 

ongoing and iterative improvement in how physicians are paid under Medicare, and more 

importantly, on how quality in medical care can be incentivized. This hearing represents an 

impOiiant example of congressional leadership and oversight to ensure that the promise of the 

new law and the new payment system arc achieved. We look forward to continued partnership 

in improving the quality of care enjoyed by Medicare patients. 

14 
31 

Mr. BURGESS. Thank you, Doctor. 

And, Dr. Rai, you are recognized for 5 minutes, please. 

STATEMENT OF DR. ASHOK RAI 

Dr. RAI. Chairman Burgess, Ranking Member Green, and distinguished members of the Energy and Commerce Committee on 

Health, thank you for the opportunity to testify today. 

I am Dr. Ashok Rai, and I am here today as Chair of AMGA, 

which represents multi-specialty medical groups and integrated delivery systems. Our membership provides care for one in three 

Americans. 

I am a board-certified internist with 17 years of experience, providing care to patients in Green Bay, Wisconsin. Since 2009, I have 

served as the President and CEO of Prevea Health, a multi-specialty medical group which employs more than 350 providers, including 60 medical specialties. In total, we employ more than 2,000 

people, and I am proud of the impact we have on the people of Wisconsin. 

I wanted to express my appreciation to Congress for repealing 

the SGR formula for Medicare Part B payments. The annual SGR 

cliffs were obstacles to sound planning and hindered our ability to 

make strategic decisions that would help us care for patients. 

I applaud the committee’s leadership role in passing the muchneeded MACRA law which puts providers on a path towards valuebased care. We agree with Congress that the current fee-for-service 

payment system is not sustainable, nor is it good for our patients. 

We need to move to a system where the payment aligns with the 

way medical groups focus on the health of a population, rather 

than only the sickness of patients. 

Under MACRA, CMS combined existing programs such as the 

physician quality reporting system, the value-based modifier, and 

meaningful use programs to create the merit-based incentive payment system, better known as MIPS. Under the MACRA statute, 

MIPS providers would have the opportunity to have positive or 

negative payment adjustments based on their performance, starting at plus or minus 4 percent in 2019 and eventually plus or 

minus 9 percent in 2023. 

By putting provider reimbursement at risk, I believe Congress 

intended to move Medicare to a value-based payment model where 

high performance was rewarded and poor performers were incented 

to improve with lower payment rates. In fact, high-performing 

groups like Prevea Health have been preparing for this value transition for years by participating in MIPS’s legacy programs such as 

PQRS, VM, and MU. As a result, our efforts to perform in these 

legacy programs have improved the value of care provided through 

increased quality and decreased cost. 

But the problem we face now as healthcare providers is that 

CMS is excluding a majority of providers from the MIPS program. 

CMS has bypassed the intent of MACRA by excluding 58 percent 

of providers from MIPS requirements for performance year 2019 

and the recently-proposed quality payment program, or MACRA 

rule. This will result in the 2021 payment year adjustment being 

around 2 percent for high-performers, instead of closer to 7 percent, 

which the statute dictates. Last year, CMS excluded 60 percent of 

32 

eligible clinicians, which collapsed the potential reward for highperformers from 5 percent to 1.5 percent. 

To give you a real-life example of how this works, in the four Tax 

Identification Numbers that Prevea Health bills under in partnership with our hospital partners, Hospital Sisters Health System, 

Prevea Health scored three perfect scores of 100 and one of 97. 

However, because of the MIPS exclusions, our payment adjustment 

was only 2 percent. Why is this important? To get to value, to create change is incredibly difficult. It requires changes in how we deliver care, how we set up our administrative and financial processes. It means investing millions of dollars in information technology and people. Importantly, it requires buy-in from every member of the team, especially the providers. 

The changed management challenges presented by creating a 

new value-based delivery system are enormous. And Prevea Health 

undertook this challenge because we viewed MACRA as the incentive program that would reward us for making these changes and 

doing well by our patients. Now, though, I have to go back to the 

physicians and providers at my group and say the investments we 

made, they weren’t rewarded. The better care we delivered was not 

recognized. That is a difficult message to deliver, and I don’t think 

that is the message that this committee or Congress wanted us to 

make, but it is the one we have to tell providers at Prevea because 

of the way MACRA is being implemented. 

I appreciate the concerns so ably expressed today by my colleagues for physicians practicing in solo or smaller practices. The 

reporting burden on them is real. However, I have to point out that 

the MIPS program is a continuation of quality programs that have 

been in existence for years, and no one is excluded from these programs, certainly not 58 percent of them. I firmly believe Congress 

passed MACRA to push the transition to value in Medicare Part 

B. Ironically, by excluding the majority of clinicians from MIPS, if 

anything, we have taken a step back from this transition. These exclusions need to end. Only then can MACRA meet your goal of 

moving Medicare meaningfully towards value. AMGA stands ready 

to work with Congress and CMS to ensure MIPS, and MACRA, 

serves as the transition tool to value, as it was intended to be. 

Thank you. 

[The prepared statement of Dr. Rai follows:] 

33 


36027.021

Statement of 

Ashok Rai, M.D. 

President and Chief Executive Officer, Prevea Health 

On 

MACRA and MIPS: An Update on the Merit-based Incentive Payment System 

Before the Subcommittee on Health 

Of the 

Committee on Energy and Commerce of the U.S. House of Representatives 

July 26, 2018 

Chairman Burgess, Ranking Member Green, and distinguished members of the Energy and Commerce 

Subcommittee on Health, thank you for the opportunity to testify on behalf of AMGA. Founded in 1950, 

AMGA represents more than 450 multispecialty medical groups and integrated delivery systems that 

employ more than 175,000 physicians who care for one-in-three Americans. I serve as chair of AMGA's 

board of directors and throughout my experience with this organization, I have witnessed these medical 

groups work diligently to provide innovative, high-quality, patient-centered medical care in the most 

efficient manner possible. 

Since 2009, I have served as President and Chief Executive Officer of Prevea Health, a multispecialty 

group in Green Bay, Wisconsin, that offers over 60 medical specialties, and employs about 350 providers 

and more than 2,000 employees. I am a board-certified internist and have practiced medicine for over 

17 years. In that time, I have witnessed and helped lead major transformations in care delivery 

throughout Prevea Health. 

First of all, I wanted to thank Congress for eliminating the Sustainable Growth Rate (SGR) formula in its 

attempt to bring more stability to the Medicare Part B program. As you know, the SGR formula 

necessitated continuous fixes every year, forcing policymakers to think in the short term, and we 

appreciate that we now have the opportunity and ability to plan for the future. Congress' subsequent 

passage of the landmark Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 by adjusting 

payments based on quality and other key factors, represents an opportunity for providers to begin to 

move away from the current fee-for-service reimbursement model and transition towards value-based 

care. 

MACRA is designed to reward providers by adjusting their Part B payments, which are based largely on 

the quality of care they provide. In guidance and public comments before it promulgated rules on 

MACRA, the Centers for Medicare & Medicaid Services (CMS) purported that the law would help achieve 

three goals for the healthcare system-better care, smarter spending, and healthier people. The law 

and regulations would achieve this by rewarding physicians who performed well in three key areas: 

payment incentives, care delivery, and information sharing. Per the MACRA statute, CMS implemented 

the program by streamlining existing initiatives under the new Merit-based Incentive Payment System 
34 


36027.022

(MIPS) program. Specifically, the program includes the Physician Quality Reporting System (PQRS). the 

Value-Based Payment Modifier (VM). and the Meaningful Use (MU) program. And, for those providers 

further on the pathway to value-based care, it provides bonus payments for participation in eligible 

Alternative Payment Models (APMs). 

Like many AMGA members, Prevea Health has made significant investments in people and technology in 

response to MACRA. Prevea Health has been using an electronic health record system for 16 years, so 

we have thorough access to data on our patient population. But, having data and utilizing it are two 

different things. We have made investments in platforms that identify gaps in our patients' care and 

enable us to address them. We also streamlined how our patients interface with us. For example, we 

offer online appointment scheduling, which has simplified the process for our patients and providers. 

We continue to make multiple investments in data analytics to improve our patient population's health. 

Additionally, we are investing in diversifying our provider population. For example, we successfully 

improved patient and provider satisfaction by hiring multiple registered nurse (RN) care managers. We 

found that those patients who were managed with a care manager cost a third of what those managed 

solely by a physician cost. We also have quantifiable evidence that patients with chronic disease who are 

managed in our patient-centered medical home model have better outcomes and cost the healthcare 

system less. 

These investments were made based on the understanding that MACRA would be implemented with 

the intent to reward value and innovation. Now, in the third year of rulemaking, it is clear that CMS is 

not implementing MIPS as intended by this Committee and Congress. If changes are not made, MIPS will 

not drive change at the clinician level or transition Medicare Part B to value-based reimbursement. 

Under the MIPS program, providers have the opportunity to earn an annual adjustment to their 

Medicare Part B payments based on their performance. These adjustments increase over time. For 

example, based on performance in 2017, payments would potentially adjust up to 4% in 2019. 

Performance in 2018 will adjust payments in 2020 up to 5% for top performers. For performance in 

2019, top performers could potentially be rewarded a 7% payment adjustment in 2021. Also, in 2019 

performance year, a 9% payment adjustment could be rewarded to top performers for 2023. 

Conversely, as included in the law, poor performance will result in negative payment adjustments of4%,-5%,-7%,-9% in 2019,2020, 2021, and 2023 respectively. However, these payment adjustments 

assume meaningful participation in the program, since Congress designed MIPS to be a budget-neutral 

program. 

We believe that CMS has bypassed the intent of MACRA by excluding 58% of providers from MIPS 

requirements for performance year 2019 in the recently proposed Quality Payment Program (QPP) or 

MACRA rule (CMS-1693-P). This exclusion will result in negligible payment adjustments for highperformers that have made meaningful investments to improve quality of care for the communities they 

serve. This action effectively collapses the MIPS payment adjustment distribution curve. As a result, the 

payment adjustment for 2021 of up to 7% instead is projected to be 2% for high performers. In fact, 

CMS has included some form of exclusions to MIPS in all past QPP rules. In 2019, MIPS high performers 

are expected to receive 1.1%, based on their 2017 performance, even though the law authorized an 

adjustment up to 4%. In 2020, high performers are expected to receive a 1. 5% adjustment, but they 

were working under the understating that they could potentially earn up to a 5% payment increase. 
35 


36027.023

As you know, MIPS is a not a brand-new program, rather a continuation of existing value-based 

programs, namely PQRS, VM, and MU. CMS did not exclude providers from these programs, as it has 

from MIPS. Prevea Health utilized its time reporting to these legacy programs to streamline the 

eventual transition to value. As a result, our efforts to perform in these legacy programs have improved 

the quality and value of our care. In the four tax identification numbers that Prevea Health bills under 

partnership with our hospital partners, Hospital Sisters Health System, we scored three perfect scores of 

100 and one of 97. However, because of the MIPS exclusions, our payment adjustment does not reward 

us for this performance. 

If Medicare providers are going to successfully transition to value-based arrangements, more of them 

should be subject to MIPS. I realize that some providers may lack the resources to participate in these 

programs, but as mentioned above, this transition has been a work in progress for years. In addition, 

CMS provides technical support and favorable scoring for some providers. Our patient population 

deserves a provider workforce that is willing and capable of providing the best level of care possible. 

These MIPS exclusions do not prepare practices of any size to transition to a post fee-for-service 

payment environment and unfairly penalize those who have worked in good faith to make that 

transition. 

CMS has implemented policies that exclude otherwise eligible clinicians and set a low composite 

performance score threshold, which determines the physician payment adjustments under MIPS. The 

resulting payment adjustments for high performers in the program will neither incentivize the required 

investments in health information technology and process changes, nor will they cover the costs and 

burdens associated with reporting the required data. Finally, they will not incentivize healthcare 

provider organizations to engage with CMS in moving toward value-based care. 

We commend this Committee on its commitment to MACRA implementation oversight and stand ready 

to assist you in this process. Thank you for the opportunity to testify. 
36 

Mr. BURGESS. Thank you, Doctor. 

Dr. Parekh, you are recognized for 5 minutes, please. 

STATEMENT OF DR. PARAG PAREKH 

Dr. PAREKH. Chairman Burgess, Ranking Member Green, and 

members of the Health Subcommittee, thank you for the opportunity to provide feedback on MACRA implementation. 

I am here today on behalf of the Alliance of Specialty Medicine, 

a coalition of 15 medical specialty societies, representing more than 

100,000 physicians and surgeons. My name is Dr. Parag Parekh. 

I am a private-practicing eye surgeon in rural western Pennsylvania and the only board-certified, fellowship-trained ophthalmologist specializing in cataract and refractive surgery as well as cornea and glaucoma surgery in that entire geographic area. I chair 

the Government Relations Committee of the American Society of 

Cataract and Refractive Surgery, one of the alliance member organizations. 

The alliance greatly appreciates your leadership to repeal the 

SGR, create MACRA, and revamp the legacy quality reporting programs. Listening to physicians’ concerns, Congress created MIPS, 

which streamlined the existing programs and allows physicians to 

focus on the measures and activities that most closely align with 

our practices. Successful implementation and long-term viability is 

important, since MIPS is the only pay-for-performance option for 

many specialists. We also appreciate the technical corrections advanced earlier this year, which strengthen the law, continue 

progress made to date, and will improve the ability of specialty 

physicians to engage in quality improvement activities. 

MACRA provides two value-based reimbursement tracks for physicians under Medicare. Under one, physicians can opt to remain 

in fee-for-service and participate in MIPS. In the other, physicians 

can participate in advanced alternative payment models. For many 

specialists, including ophthalmologists like me, MIPS is the only 

meaningful and viable pathway. Many specialists have no opportunities to participate in advanced APMs, given that they are designed with a primary care focus. 

While there is always more work to be done, many specialists 

have made significant strides to deliver high-quality and efficient 

care. In the last 50 years, ophthalmologists have made tremendous 

strides in cataract surgery by reducing complications and the variations in cost. Ophthalmology has developed meaningful outcomes 

measures, including for cataract surgery, which are being reported 

through the MIPS program. And CMS proposed to include cataract 

episode cost measures as well. Therefore, it is critically important 

that Congress maintain a viable fee-for-service option in Medicare 

Part B, along with the MIPS program, to ensure that specialists 

can continue to meaningful engage in the quality improvement initiatives and deliver high-quality care. 

The MIPS technical corrections gives CMS additional flexibility 

to determine the appropriate weight of the MIPS cost category, 

allow CMS to gradually increase the performance threshold before 

reaching the mean or median standard, and exclude Medicare Part 

B drugs from MIPS payment adjustments and eligibility determination. 

37 

However, additional modifications are needed to support more 

meaningful measures and lessen the complexity of reporting and 

scoring. Currently, clinicians must comply with four performance 

categories, each with distinct requirements and scoring methodologies. Allowing clinicians to get credit across multiple MIPS categories by engaging in a single set of actions would make the program much less confusing. 

For example, tracking outcomes through a clinical data registry 

and using such data to improve patient care should count for multiple categories of MIPS. Alliance specialty societies continue to invest heavily in the development of quality measures, including outcome measures and those reported by patients, and have established robust clinical data registries that have been qualified for 

use in the MIPS program. In my own specialty, the American 

Academy of Ophthalmology has the IRIS registry, which serves as 

a key tool in reporting MIPS data and tracking outcomes. 

Measure implementation is another ongoing challenge. Our member societies continue to develop new specialty-focused measures, 

but CMS threatens to eliminate them when they do not immediately produce enough data to set reliable performance benchmarks. In addition, for more established measures previously developed by specialties, CMS has determined some of them to be 

topped-out and, then, remove them from the program, even though 

these measures continue to improve care and continue to be meaningful to specialty physicians. Removing them from the program 

limits our ability to participate in MIPS. 

Finally, the alliance opposes MedPAC’s recommendation to eliminate the MIPS program and replace it with the voluntary value 

program, which relies on population-based measures geared towards primary care and eliminates the one program, MIPS, that 

specialists can actually use to demonstrate and improve their quality and overall value. The VBP would discourage specialists from 

developing relevant quality and outcomes measures, disincentivize 

the use of high-value clinical data registries to track patterns of 

care, and thwart efforts to collect and report performance data. 

Again, thank you for your work to ensure successful and timely 

implementation of MIPS. 

[The prepared statement of Dr. Parekh follows:] 

38 


36027.024

Summary of Testimony from the Alliance of Specialty Medicine by Parag D. Parekh, MD, MPA 

American Society of Cataract & Refractive Surgery (ASCRS) 

Before the House Energy and Commerce Health Subcommittee 

"MACRA and MIPS: An Update on the Merit-based Incentive Payment System"" 

Thursday, July 26, 2018 

Moving to Value-Based Payment in Medicare: For many specialists, the Merit-based Incentive Payment 

System (MIPS) is the only meaningful and viable pathway for participating in programs established under 

MACRA. In fact, many specialists have no opportunities to participate in Advanced Alternative Payment 

Models (APMs) since the vast majority were designed with a focus on primary and preventive care. Only 

a handful of Advanced APMs have been designed for a narrow subset of specialty physicians and complex 

health conditions they are best equipped to diagnose, treat and lead teams in managing patient care. 

Specialty physicians have faced significant challenges as they have attempted engagement in Medicare 

ACOs. The Alliance has recommended a number of changes in Medicare's Shared Savings Program 

regulations that would address these and other challenges with ACO participation by specialists. For 

specialty physicians, however, engagement in the MIPS track, which relies on a fee-for-service 

reimbursement structure, remains the most appropriate mechanism. 

Importance of Technical Corrections Approved by the Congress: We appreciate the provisions in the 

Bipartisan Budget Act of 2018 to ease the ramp up of the MIPS Program and to allow those committed to 

value-based care improvement to remain in this QPP track, especially the provision giving CMS three 

additional years offlexibility to determine the appropriate weight of the MIPS cost category based on the 

availability of relevant measures. A significant amount of work remains to ensure that new episode-based 

cost measures are developed and integrated to accurately reflect the complexities of cost measurement, 

without inadvertently discouraging clinicians from caring for high-risk and medically complex patients. 

The Alliance also appreciates provisions that allow CMS to more gradually increase the MIPS performance 

threshold year-over-year before reaching the "mean or median" standard and the technical correction 

that ensures Medicare Part B drugs and other items and services outside the physician fee schedule are 

not included in the application of MIPS payment adjustments and determination of MIPS eligibility. 

Additional Refinements to MIPS Still Needed: The Alliance supports practical solutions that would lessen 

the complexity of MIPS scoring, including additional opportunities for clinicians to get credit across 

multiple MIPS categories for engaging in a single set of actions. Measures and reporting mechanisms that 

recognize patient and clinician diversity must be supported. Despite the advantages physicians gain 

through their use, qualified clinical data registries (QCDRs) face ongoing challenges connecting to certified 

electronic health record technology (CEHRT), which is prevented by vendors blocking the bi-directional 

exchange of this important health information. This is a huge impediment to our success and we strongly 

encourage you to address this obstacle. Measure implementation is another ongoing challenge and more 

flexibility is needed, especially for smaller specialties, to support participation in MIPS and to incentivize 

the data collection needed for benchmarks over time. 

MedPAC Recommendation: The Alliance opposes the Medicare Payment Advisory Commission's 

(MedPAC) recommendation to eliminate the MIPS program and replace it with a new Voluntary Value 

Program (VVP). The Alliance has shared its concerns with the Commission and has called to their attention 

the lack of Advanced APMs in which specialists can meaningfully engage, the limitations of populationbased measures in determining quality and cost of specialty medical care, and MACRA's intent to promote 

the development of clinically relevant, specialty-based quality measures. We urge the committee to 

disregard MedPAC's recommendation and instead work toward ongoing improvements to the MIPS 

program as it continues to mature. 
39 


36027.025

Testimony from the Alliance of Specialty Medicine by Parag D. Parekh, MD, MPA 

American Society of Cataract & Refractive Surgery (ASCRS) 

Before the House Energy and Commerce Committee 

Subcommittee on Health 

"MACRA and MIPS: An Update on the Merit-based Incentive Payment System" 

Thursday, July 26, 2018 

Chairman Burgess, Ranking Member Green, and members of the Health Subcommittee, thank you 

for the opportunity to provide feedback on implementation of the Medicare Access and CHIP 

Reauthorization Act of 2015 (MACRA). My name is Dr. Parag Parekh. I am a private practicing 

ophthalmologist in rural Western Pennsylvania, and the only board-certified, fellowship-trained 

ophthalmologist specializing in cataract and refractive surgery, as well as cornea and glaucoma surgery, 

in that geographic area and the entire S'h district. I am an active member in multiple professional medical 

societies. Notably, I am the Chair of the American Society of Cataract & Refractive Surgery (ASCRS) 

Government Relations Committee where I have served as a member for the past 10 years. I also serve on 

relevant technical expert panels (TEP) formed by the Centers for Medicare and Medicaid Services (CMS) 

to address the programs established by the Medicare Access and CHIP Reauthorization Act of 2015 

(MACRA) and implemented under CMS' Quality Payment Program (QPP). 

I am here today on behalf of the Alliance of Specialty Medicine ("Alliance"). The Alliance is a 

coalition of medical specialty societies representing more than 100,000 physicians and surgeons from 

specialty and subspecialty societies dedicated to the development of sound federal health care policy that 
40 


36027.026

fosters patient access to the highest quality specialty care. As patient and physician advocates, the Alliance 

welcomes the opportunity to provide input in the formulation of health and Medicare policy. 

Today's hearing is an important step to ensuring the Congressional intent of MACRA in providing 

flexible options for clinicians to meaningfully engage in the program. The Alliance has worked closely with 

policymakers and CMS to ensure that implementation of the law is consistent with Congress' intent. For 

this reason, we greatly appreciate that Congress included "technical corrections," as part of the February 

9, 2018 Continuing Resolution (CR). Not only will these adjustments strengthen the law and continue 

progress made to date, it will significantly improve the ability of physicians, particularly specialists, to 

engage in quality improvement activities, and specifically in the Merit-based Incentive Payment System 

(MIPS) track of MACRA. 

Specialists are an essential and needed component of the healthcare system. Specialists use their 

deep knowledge and expertise to reach a precise medical diagnosis, present the full array of available 

interventions, collaborate closely with their patients to determine which option is most appropriate based 

on their preferences and values, and coordinate and manage their specialty and related care until 

treatment is complete. No other clinician, provider or health care professional can replace the value 

offered by specialty physicians. To that end, MIPS must be implemented successfully and set up for longterm viability since it will be the only option for many of these specialists to engage in pay-forperformance given they will have no other option than to remain in fee-for-service. 

Moving to Value-Based Payment in Medicare 

Member organizations of the Alliance have continuously sought out and developed robust 

mechanisms (including clinical decision support, clinical data registries, and other tools) aimed at 

2 
41 


36027.027

improving the quality and efficiency of care specialty physicians provide. In addition, Alliance member 

organizations have analyzed, and heavily scrutinized data related to the services they provide, looking for 

ways to improve how they diagnose, treat, and manage some of the most complex health care conditions 

in their respective specialty areas. For example, the American Association of Neurological Surgeons 

(AANS) and Congress of Neurological Surgeons (CNS) support multiple registries that promote national 

quality research efforts, including comparative effectiveness research, practice data collection 

requirements for board certification, and robust data for structured quality improvement studies in the 

areas of spine surgery, cerebrovascular, stereotactic radiosurgery and brain tumors. In addition, 

AANS/CNS is working on other clinical decision support tools, including predictive risk calculators to 

counsel patients and assess their risks and potential outcomes from spine surgery. Another example is 

the American Gastroenterological Association's (AGA) "My IBD Manager" patient app and the "Ask AGA: 

IBD" clinical platform. These tools work together to improve the physician/patient relationship and to 

simplify access to clinkal evidence and clinical guidelines, while providing patients a one-stop-shop to 

learn about their disease, monitor symptoms and share information with their health care team. 

Members of this committee will recall Congress' 17 interventions over 11 years, which were 

necessary to prevent steep reductions in Medicare physician payment under the Sustainable Growth Rate 

(SGR) formula in some cases up to 24%. Without your help, physician practices would have been 

financially devastated and access to care would have been severely restricted for America's frailest, and 

most vulnerable population. Congress also established quality improvement programs on top of the 

flawed SGR reimbursement mechanism, including the Physician Quality Reporting System (PQRS), 

Physician Value-Based Payment Modifier (VM) and the Medicare and Medicaid Electronic Health Record 

Incentive Program, or "Meaningful Use." While the goals of these programs were laudable, they had 

disparate reporting requirements that included overlapping measures. Physicians and practices were at 

3 
42 


36027.028

a loss to keep up with the various deadlines and would face stiff penalties if they made even minor clerical 

errors due to the "ali-or-nothing" nature of the programs. Congress listened to the concerns about these 

legacy quality reporting programs raised by physicians and created the MIPS program, which streamlined 

the existing programs and allowed physicians to focus on the measures and activities that most closely 

align with their practices. As a key example of that, the addition of the clinical practice improvement 

activities gives physicians MIPS credit for activities designed to improve care-many of which physicians 

were already doing. 

Now, with the looming threat of yearly cuts in Medicare reimbursement due to the flawed SGR 

removed, thanks to Congress, and members of this committee in particular, Alliance member 

organizations can further efforts to improve specialty care with incentives and technical assistance 

provided under MACRA. 

Importantly, the Alliance appreciates the approach Congress took, and in particular, this 

committee, when drafting MACRA, which established two value-based reimbursement tracks for 

physicians under Medicare. Under one track, physicians can opt to remain in fee-for-service and 

participate in MIPS. Through the MIPS program, physicians report and are measured on their performance 

on: (1) relevant, self-selected quality measures, typically developed by and for their specialty; (2) 

meaningfully use certified electronic health technology (CEHRT), reporting their performance on 

objectives and measures that generally align with how their practice uses EHRs and other health 

information technologies; (3) demonstrating clinical practice improvement through various activities, 

such as using data from a qualified clinical data registry to tailor care management plans for discrete 

patient populations within their practice or collect and follow-up on patient experience and satisfaction 

data related to beneficiary engagement; and finally, (4) cost of care provided to certain beneficiaries in 

4 
43 


36027.029

key clinical areas, although considerable work remains before physicians, and specialists in particular, 

should be held accountable for efficient resource use. Specifically, CMS should continue efforts to develop 

episode-based cost measures and remove flawed population health measures that potentially hold 

physicians accountable for the cost of care they did not provide. In the second track, physicians can 

significantly participate in Advanced Alternative Payment Models (APMs) and potentially earn incentives 

and increased reimbursement under Medicare. Both tracks are built on Medicare's current fee-for-service 

payment system, and both entail financial risk and reward. Both tracks also measure quality of care, and 

to a certain extent, hold participants accountable for financial efficiencies. 

For many specialists, including ophthalmologists like me, MIPS is the only meaningful and viable 

pathway for participating in programs established under MACRA. In fact, many specialists have no 

opportunities to participate in Advanced APMs, at all. A review of CMS' MIPS exclusion tables from the 

2017 Quality Payment Program Final Rule shows that family medicine, internal medicine, 

obstetrics/gynecology, and nurse practitioners, are the primary specialties that will make up the vast 

majority of Advanced APM qualifying participants (QPs), based on 2017 estimates. By comparison, CMS 

projected that specialists, such as ophthalmologists, neurosurgeons and rheumatologists, would be less 

likely to engage in APMs, with only 153 (0.7 percent), 46 (0.8 percent) and 79 (1.4 percent) of these 

specialty physicians, respectively, expected to reach QP status based on 2017 performance. 

As this committee is aware, only a handful of Advanced APMs have been designed for a narrow 

subset of specialty physicians and complex health conditions they are best equipped to diagnose, treat 

and lead teams in managing patient care. The vast majority of Advanced APMs, including the various 

Medicare Accountable Care Organizations (ACOs) and the Medical Home Model, were designed with a 

focus on delivering primary and preventive care and to address broad population health goals, led by 

5 
44 


36027.030

teams of primary care providers. Specialty physicians have attempted engagement in Medicare ACOs but 

have faced significant challenges. For example, small, primary-care led ACOs maintain closed or "narrow 

networks," excluding some or all specialty physicians. While specialists have had more success 

participating in large, hospital- or health system-centered ACOs, their engagement has been passive. In 

fact, specialists that participate in large ACOs tell us they have no meaningful role in improving the quality 

or cost of care for the ACO's assigned population because there are no metrics focused on the conditions 

they cover or the care they deliver. The Alliance has recommended a number of changes in Medicare's 

Shared Savings Program regulations that would address these and other challenges with ACO participation 

by specialists, and we will continue those efforts. 

Even before passage of MACRA, several Alliance organizations were working diligently to foster 

alternative payment and delivery models for their specialty through existing agency channels. Despite a 

multitude of meetings with CMS' Innovation Center, these models were dismissed even those that 

addressed services representing a high proportion of Medicare expenditures and had been successfully 

tested in the private insurance market. Candidly, Innovation Center officials told some of our 

organizations that models centered on primary care were the agency's priority. Now, as evidenced by the 

multiple letters of intent and proposed models submitted for review and deliberation by the Physician 

Focused Payment Model Technical Advisory Committee (PTAC), it should be clear that specialists are eager 

to contribute to responsible stewardship of federal health programs. It is frustrating to be viewed as a 

costly part of the Medicare program, while simultaneously being turned away when we present proactive, 

innovative solutions and proposals. 

While there is more work to be done to encourage value-driven health care, and several disease 

states and procedures are prime for quality and resource use improvements, many specialists have made 

6 
45 


36027.031

significant strides to engage in activities that deliver high-quality, efficient care. In fact, some have already 

refined key conditions and procedures through medical advancement and technological innovation. For 

example, some specialists have moved services and procedures from expensive inpatient settings to 

lower-cost outpatient settings; some perform all aspects of a surgical service in the physician officesetting, ensuring high-quality and reducing inefficiencies, while lowering government and beneficiary 

costs; and, others have eliminated variations in cost, quality and access to their procedures through longterm performance improvement, which is documented in the literature. 

A key example is my own specialty of cataract surgery, Cataract surgery is performed in either an 

Ambulatory Surgery Center (ASC) or Hospital Outpatient Department (HOPD). When complications, but 

also variations in outcome occur, it is often due to patient co-morbidities, such as diabetes, glaucoma, 

macular degeneration or retinal disorders, or other significant pre-existing health issues. There have not 

been demonstrated gaps in the quality, cost, or access to care based on the site of service. In the last 50 

years, since the advent of phacoemulsification, ophthalmologists have made tremendous strides in 

improving cataract surgery so that complications are relatively rare. While still an intensive procedure 

requiring the special skill of ophthalmologists, the medical innovation of the last half-century means that 

patients will have a reliable assurance that the outcome of their surgery will contribute positively to their 

overall quality of life. There are very few opportunities for further improvements to quality or efficiency 

in cataract surgery, which makes developing or participating in an Advanced APM difficult. 

For me and certain other specialists, engagement in the MIPS track, which relies on a fee-forservice reimbursement structure, remains the most appropriate mechanism. More specifically, the MIPS 

track allows specialists- those without suitable Advanced APMs options- a fair opportunity to remain in 

fee-for-service while continuing to measure, report, and improve performance on key areas of clinical 

7 
46 


36027.032

quality that matter to their practice and their patients. It is critically important that Congress maintain a 

viable fee-for-service option in Medicare Part B, along with the MIPS program, to ensure specialists can 

continue to meaningfully engage in federal quality improvement initiatives, and more importantly, 

continue to deliver high-quality care to America's senior and disabled population. 

Importance of Technical Corrections Approved by the Congress 

We greatly appreciate that Congress included provisions in the Bipartisan Budget Act of 2018 

(Public law No. 115-123), to ease the ramp up of the MIPS Program and to allow those committed to 

value-based care improvement to remain in this track of the QPP. We are particularly supportive of the 

provision that would give CMS three additional years of flexibility to determine the appropriate weight of 

the MIPS cost category based on the availability of relevant measures. Given the state of readiness of cost 

measures, this flexibility is essential. A significant amount of work remains to be done to ensure that new 

episode-based cost measures are developed and integrated in a way that accurately reflects the 

complexities of cost measurement and does not inadvertently discourage clinicians from caring for highrisk and medically complex patients. 

I have been participating in efforts to develop episode-based cost measures. I served on two eMSappointed technical expert panels related to these measures, including the ophthalmic clinical committee 

that developed the cataract surgery measure. Throughout this process, my fellow committee members 

and I have worked to ensure that physicians are not penalized for the cost of care outside their control, 

unlike the current flawed measures held over from the Value-based Payment Modifier-Medicare 

Spending per Beneficiary and Total per Capita Cost of Care that are meaningless to specialists. We have 

looked at every aspect of care related to cataract surgery, including pre-, intra-, and post-operative costs. 

We accounted for difference in cost related to the differing facility payments for procedures performed 

8 
47 


36027.033

in ASCs versus HOPDs, and risk -adjusted for costs related to significant ocular co-morbidities. My 

colleagues serving on other subcommittees also grappled with cost drivers relevant to their own 

conditions and procedures. It is a painstaking process that requires analysis tailored to each unique 

procedure or condition. 

While CMS is proposing to include the cataract surgery episode measure and seven other 

procedure and condition-based episodes in MIPS for 2019, it will be several years before a significant 

number of measures can be developed. The additional time provided by the technical corrections will 

allow further refinement and development of these measures. 

In addition, we appreciate provisions that allow CMS to more gradually increase the MIPS 

performance threshold year-over-year before reaching the "mean or median" standard. For 2019, CMS 

has proposed to increase the performance threshold to 30 points, up from the 2018 performance 

threshold, which was set at 15 points, and the 2017 performance threshold, which was set at 3 points. 

Gradually increasing the performance threshold gives physicians the opportunity to implement necessary 

practice changes as they gain experience. It also ensures that the performance threshold is not set too 

high, which could discourage participation or negatively impact practices with fewer resources. Data on 

physician participation and performance collected by CMS will best determine clinician readiness and 

should guide the agency as it works with the physician community on increasing program requirements. 

CMS reports that 91% of eligible physicians participated in the first year of MIPS, which should provide 

ample data for the agency to evaluate and determine how to proceed in coming years. 

We also appreciate the technical correction that ensures Medicare Part B drugs and other items 

and services outside the physician fee schedule are not included in the application of MIPS payment 

9 
48 


36027.034

adjustments and determination of MIPS eligibility. Without the correction, CMS would have been 

authorized to penalize and reward clinicians based on the volume of medicines they administer in their 

offices. Not only would these adjustments potentially hinder access to care for beneficiaries whose 

physicians are penalized, but positive adjustments to practices that administer Part B drugs would unfairly 

reduce the incentive pool for all other clinicians. 

Alliance member organizations, such as my own, ASCRS, have developed extensive training 

materials to help physicians understand and thrive in the program. Efforts include the development of 

guides tailored to each specialty, in-person training programs for physicians and their practice 

administrators, webinars and other online education, infographics and visual aids, among other resources. 

These extensive education efforts have already started to pay off as many specialists are participating in 

MIPS and are active members of the quality improvement community. Additional time and flexibility will 

ensure that all specialists are prepared and can be successful as the performance thresholds increase each 

year. 

Additional Refinements to MIPS Still Needed 

While the Alliance greatly appreciates the added flexibilities included in the Bipartisan Budget Act 

of 2018, we believe that additional modifications are needed to make MIPS less administratively 

burdensome and costly for physicians; more meaningful, relevant and actionable to both physicians and 

patients; and more transparent. A more simplistic and applicable approach will ensure not just greater 

clinician engagement, but more purposeful engagement, which is the only way to effect real change. The 

Alliance supports practical solutions that would lessen the complexity of MIPS scoring, including additional 

opportunities for clinicians to get credit across multiple MIPS categories for engaging in a single set of 

10 
49 


36027.035

actions. Members of the Alliance have been working with its colleagues to flesh out these proposals and 

would be happy to have a more detailed follow-up discussion with members of the subcommittee. 

To that end, we greatly appreciate proposals put forward by CMS in its recent Year 3 Quality 

Payment Program proposed rule that would address key challenges physicians have faced with the MIPS 

program, and particularly the Promoting lnteroperability performance category, formerly known as the 

Advancing Care Information performance category. CMS is proposing to reduce the number of objectives 

and measures that physicians would report to be meaningful users of certified electronic health record 

technology, eliminate the convoluted scoring construct, and to focus exclusively on a clinician's 

performance on a more limited set of measures. If finalized, these modifications will make a meaningful 

difference in the ability of many specialists to engage in the MIPS promoting interoperability performance 

category. We look forward to working with CMS, Congress, and members of this committee on additional 

refinements that will further interoperability across electronic health records and other health 

information technologies, including qualified clinical data registries (QCDRs). I'll discuss more about this 

in a moment. 

There is also an ongoing need to support measures and reporting mechanisms that recognize 

patient and clinician diversity. Most specialties still lack a robust set of meaningful measures due to the 

complexity of their care, nuanced variations in their patient population, and ongoing barriers to data 

collection. Nevertheless, members of the Alliance continue to invest in efforts to better track the 

performance of their care. Specialty societies in the Alliance continue to invest heavily in the development 

of quality measures, including outcomes and those reported by patients, and have established robust 

clinical data registries, that have been qualified for use in the MIPS program. These QCDRs are especially 

important for specialty physicians looking to deepen their understanding of quality and performance for 

11 
50 


36027.036

relevant episodes of care. Not only do the data collected and resultant information fuel important 

improvements in practice-level outcomes, it also helps specialty societies engage in education at the 

national level, benefiting their respective professions at the broadest level. In my own specialty of 

ophthalmology, the IRIS registry serves as a key tool in not only reporting MIPS data, but tracking 

outcomes for ophthalmic surgery and the care of patients with chronic eye disease. Despite the 

advantages physicians gain through their use, QCDRs face ongoing challenges connecting to certified 

electronic health record technology (CEHRT), which is prevented by vendors blocking the bidirectional 

exchange of this important health information. The Alliance hopes to work with this Committee to ensure 

this challenge is addressed by the Secretary as required under the 21'' Century Cures Act. This is a huge 

impediment to our success and we strongly encourage you to address this obstacle. 

Measure implementation is another ongoing challenge. Specialty societies often find themselves 

in a catch-22 in that newly implemented measures need to be reported by a sufficient number of 

physicians to produce reliable benchmarks that can be used for performance scoring. Our member 

societies continue to confront situations where they invest heavily in the development of new, specialtyfocused measures, but when they do not immediately produce enough data to set reliable performance 

benchmarks, CMS threatens to remove them from the program. The Alliance asks for more flexibility, 

especially for smaller specialties, to support physician participation in MIPS and to incentivize the 

collection of data needed for benchmarks over time. We appreciate that CMS has proposed an "opt-in 

policy" that would allow previously exempted physicians to participate in the program. This policy, if 

finalized, will significantly assist with data collection and the establishment of benchmarks that are 

desperately needed for new specialty-focused quality measures. Additional incentives, such as assigning 

"high priority" status to new quality measures, would also help support the reporting of new measures. 

12 
51 


36027.037

MedPAC Recommendation 

The Alliance would also like to express our concerns with the Medicare Payment Advisory 

Commission's (MedPAC) recommendation to eliminate the MIPS program and replace it with a new 

Voluntary Value Program (VVP). MedPAC's recommendation, coupled with forthcoming 

recommendations to "rebalance" the Medicare physician fee schedule (MPFS) toward primary care, 

undercuts and devalues the role of specialists in providing thorough examinations, rendering accurate 

diagnoses, offering a complete range of treatment options, to include performing surgery, and delivering 

comprehensive and effective management of complex health conditions. 

MedPAC has specifically called for the Congress to eliminate the current Merit-based Incentive 

Payment System and establish a new voluntary value program in fee-for-service Medicare in which 

clinicians can elect to be measured as port of a voluntary group and qualify foro value payment based on 

their group's performance on a set of population-based measures. According to MedPAC staff, spending 

implications include distributing the $500 million MIPS exceptional performance bonus pool to improve 

payment for primary care or encourage engagement in Advanced APMs. 

We again reiterate that the MIPS program provides the only mechanism for many specialists and 

subspecialists to engage in federally-sponsored quality improvement activities and demonstrate their 

commitment to delivering high-value care. Specialty care is often targeted as being high cost and of 

variable quality. These claims cannot be validated nor addressed by adding yet another program that 

relies on a set of population-based measures more geared toward primary care and eliminating the one 

program that specialists can actually use to demonstrate and improve their quality and overall value. 

Eliminating MIPS in favor of MedPAC's proposed new quality program would discourage specialty 

physicians from developing robust quality and outcomes measures that are most relevant to their patient 

13 
52 


36027.038

populations, disincentivize the use of high-value clinical data registries to track patterns of care, and 

thwart efforts to collect and report performance data, overall. 

It would also exacerbate the whiplash and confusion that physicians are already experiencing as 

they transition from multiple pay-for-reporting and pay-for performance programs that have evolved 

since the Physician Voluntary Reporting Program (PVRP) commenced in 2006. The types of changes we 

are all hoping for take time-time for policymakers and regulators to work with stakeholders to develop 

and establish the policies, and time for physicians to implement the programs and adapt their practices 

to the changes. It took 15 years to solve the SGR conundrum and develop MACRA; scrapping the MIPS 

program as a failure when it has barely launched is grossly inappropriate and unfair, particularly given the 

support the medical community demonstrated in helping the Congress and this committee establish the 

program under MACRA. 

We disagree with MedPAC that the reporting requirements under MIPS are ineffective at 

improving care because physicians can choose the quality measures to be graded on. In contrast, this is 

one of the most important aspects of the MIPS program, which was recognized by the drafters of the 

MACRA law, Had Congress intended for the Medicare agency to select quality measures for physicians to 

report, it wouldn't have emphasized the development of quality measures by medical specialty societies 

and provided requisite funding. Physicians know which measures are most applicable to their practice 

based on their clinical specialty or subspecialty area, the services and treatment options they provide, and 

the patient population they serve. Holding physicians, and particularly specialists, accountable for 

measures that are not applicable to their practice or patients would pose an undue regulatory burden and 

result in meaningless data of little value to both specialists trying to improve the quality of care and 

patients trying to make well-informed medical decisions about the quality of care provided by specialists. 

14 
53 


36027.039

While we understand CMS' interest in pursuing a more parsimonious set of measures through initiatives 

such as "Meaningful Measures" and "Patients Over Paperwork," it is critical that CMS maintain a diverse 

enough set of measures to appropriately capture the quality of care provided across specialties and 

practice settings. 

We also disagree with MedPAC that quality measures do not focus on clinical outcomes. Out of 

the 271 MIPS quality measures, more than 168 are 'high priority' measures, which include more than 70 

outcomes measures. This does not include outcomes measures that are exclusive to the multiple 

specialty-focused QCDRs. In ophthalmology, including cataract surgery, the vast majority of clinical quality 

measures are outcomes-based. Specialty societies continue to develop outcomes-based clinical quality 

measures where appropriate and feasible. 

The Alliance has shared its concerns with MedPAC about the adverse impact the Commission's 

recommendation would have on specialty physicians and the beneficiaries they serve. Specifically, we 

called to their attention the lack of Advanced APMs in which specialists can meaningfully engage, the 

limitations of population-based measures in determining quality and cost of specialty medical care, and 

MACRA's intent to promote the development of clinically relevant, specialty-based quality measures. 

Moreover, we explained that fee-for-service remains the only viable reimbursement structure for many 

specialists and subspecialists. 

Similar to the discussion above regarding the VM cost measures, population-based quality 

measures, such as those used in Medicare's ACO program or reported by Medicare Advantage 

Organizations (MAOs) under the "Star Ratings" program, are not reflective of specialty medical care. As 

such, these measures cannot help specialists improve or change behavior, and will not help CMS 

differentiate between high and low-value specialists, nor yield meaningful information that drives 

15 
54 


36027.040

beneficiaries toward high-value specialty providers. In fact, one of the concerns specialty physicians have 

raised with CMS is that the quality measures in the Medicare ACO program and Medicare Advantage 

hinder specialty participation because their value cannot be demonstrated. Both Medicare ACOs and 

Medicare Advantage plans have "narrow networks" that exclude specialist participation because few of 

the quality measures they are held to account for specialty medical care. Rather, these models are focused 

on broad population-health measures that are generally under the purview of primary care providers. This 

is one reason why small, physician-led ACOs, are dominated by primary care physicians, and why larger, 

hospital- or health system-led ACOs only passively engage specialists. 

We urge the Congress, and members of this committee, to disregard MedPAC's recommendation 

and instead work toward ongoing improvements to the MIPS program as it continues to mature. 

The Alliance of Specialty Medicine is committed to the successful and timely implementation of 

the law while still providing practitioners time and opportunities to succeed. We look forward to working 

with the subcommittee to ensure the implementation of MACRA continues to be successful, and we would 

be happy to discuss any other questions you may have going forward. 

16 
55 

Mr. BURGESS. Thank you, Doctor. 

And, Dr. Ransohoff, you are recognized for 5 minutes, please. 

STATEMENT OF DR. KURT RANSOHOFF 

Dr. RANSOHOFF. Thank you, Chairman Burgess, Ranking Member Green, and esteemed members of the committee, for inviting 

me to present today. 

For the last few years, my group, Sansum Clinic in Santa Barbara, California, has been on a journey going from the SGR payment system to become a devoted MIPS provider, only to evolve 

into a Track 1+ ACO. Our journey will provide some insight into 

what is good and what is less good about the recent shifting of the 

tectonic plates on which the Medicare physician payment system 

stands. 

Before going further, let me tell you about me and my group. I 

am a general internist. I have practiced in the same exam rooms 

for the last 26 years. I have been doing this long enough to recall 

handwriting my patient progress notes and to have cared for multiple generations of families. I have been able to say to a 70-yearold man, ‘‘Your murmur sounds exactly like your dad’s did at your 

age.’’ I have been honored to have practiced for that long in the 

same setting. 

Sansum Clinic is a nearly 100-year-old not-for-profit medical 

foundation with 200 doctors. It is an oddity in that it is not affiliated with a hospital. We have participated in the whole alphabet 

soup of modern health insurance from HMOs to PPOs to ACOs. 

For the last 2 years, I have been the Board Chair of America’s 

Physician Groups. APG is a professional association representing 

more than 300 of the nation’s most advanced medical groups in the 

country, many of whom take full financial risk in caring for their 

patients. 

With that background, let me return to our story of our journey 

from the SGR days to being a Track 1+ ACO. Whatever criticisms 

there are about MIPS and MACRA, almost all doctors will say 

thank you, as all of us have, to Congress for doing away with that 

flawed process. In the SGR days, our budgeting process was basically chaos. The cut that was generated by the formula would mean 

that we would be entirely unable to balance our books. So, we just 

ignored it and prayed that the implementation would be put off, as 

it was every year, usually at the 11th hour. We also had a great 

sigh of relief when the SGR was repealed. 

Then, there was this new process, MACRA, on the scene. Over 

the last few years, our clinic became a very successful MIPS participant. We got 100 and we made lot of investments in care processes 

to enhance the health of our populations and patients. And yet, we 

have left MIPS and we have gone on to become a Track 1+ ACO. 

The details in the journey are included in my remarks, but I will 

try to summarize the take-home messages of our journey. 

What have we learned? SGR was really problematic, and though 

there remains some issues within the MIPS program that need to 

be addressed, it is far and away a better system than the dreaded 

‘‘doc fix’’ gamble that we all had to rely on for years. The way MIPS 

has been implemented is not the way it was planned. It is an 

asymmetric process. The intended larger reward for high scorers is 

56 

gone, but the intended large loss for those who score poorly is still 

there. Most of that is because so many doctors are excluded from 

MIPS, more than half a million, according to The Federal Register. 

We fully recognize that exemptions are necessary in some cases, 

but this level of exemptions undermines the spirit of the law and 

impedes the goal of moving our nation’s healthcare system to value. 

There are real benefits to the patients and to the healthcare system that come from the clinical processes that are put in place to 

try to do this work well. At the same time, the metrics on which 

doctors are graded need to be relevant for their specialty and their 

practice. 

Here are a few suggestions that we think can encourage the 

movement from volume to value: 

Lower the threshold for excluding groups entirely from MIPS 

and, thereby, increase the number of physicians participating in 

the program. At the same time, in recognition of the fact that 

smaller groups have fewer resources, MIPS for smaller groups may 

need to look different than MIPS for larger groups. In other words, 

give smaller groups a different test more suitable for their resources, instead of excluding them entirely. 

Even if there are flaws in MIPS, there is value for individual patients and populations and, importantly, the payer of all of this, the 

American taxpayer, in encouraging data collection and encouraging 

the use of, and the reporting of, high-quality and high-value care. 

The processes that are created to do that will help move Medicare 

from volume to value. We should find ways of making it feasible 

for more providers to participate in that process, instead of excluding them. MIPS can and should be fixed. It should not be discarded. 

Thank you for allowing me to speak, and I will be happy to answer any questions. 

[The prepared statement of Dr. Ransohoff follows:] 

57 


36027.041

Statement of 

Kurt N. Ransohoff, MD, FACP 

Chief Executive Officer 

Sansum Clinic, Santa Barbara, CA 

Before the House Energy and Commerce Committee, 

Subcommittee on Health 

July 26, 2018 

Thank you, Chairman Burgess, Ranking Member Green, and esteemed members of the 

Committee for inviting me to present today. 

My group, Sansum Clinic, has been on a journey, going from the previous sustainable 

growth rate (SGR) payment system, to becoming a devoted MIPS provider under the Medicare 

Access and CHIP Reauthorization Act of 2015 (MACRA), to becoming a Track One Plus 

Accountable Care Organization (ACO), all over a period of several years. Our journey will 

provide some insight into what is good and what is less good about the recent shifting of the 

tectonic plates on which the Medicare physician payment system stands. 

Before going further, let me tell you about me and my group. I am a general internist. I 

went to UCLA Medical School and then did my internship, residency, and chief residency at 

UCLA. I was on the faculty there for a few years after finishing my training, before moving to 

Sansum Clinic in Santa Barbara as a general internist 26 years ago. I've continued to practice in 

the same exam rooms for the last 26 years. I've been doing this long enough to recall handwriting my patient progress notes and to have cared for multiple generations of family 

members. I have been able to say to a 70-year-old man- "Your heart murmur sounds just like 

your dad's at your age." I've been honored to practice for that long of a time in the same 

setting. 
58 


36027.042

Sansum Clinic is a nearly 100-year-old not-for-profit Medical Foundation. It is an oddity 

in that it is not affiliated with a hospital. We have about 200 doctors and care for about 125,000 

patients each year. We have almost all of the different specialties. Over the last 40 years, we 

have been involved in capitated HMOs, Fee For Service {FFS) models, POS plans, PPOs, ACOs, 

and the whole alphabet soup of modern health insurance. That is important because we have 

been comfortable with the many different models and can appreciate the advantages and 

disadvantages of each. 

For the last two years, I have been the Board Chair of America's Physician Groups (APG). 

APG is a professional association representing more than 300 of the most advanced medical 

groups in the country. All are involved in integrated and coordinated care, with most taking risk 

to various degrees. Our tag line "Taking Responsibility for America's Health" is truly what our 

groups do. We all take clinical responsibility for America's health. Many take complete financial 

responsibility too. 

With that background, I will return to the story of our journey from the SGR days to 

being a Track One Plus ACO. 

Whatever criticisms there are about MIPS and MACRA, almost all doctors will say 

"Thank You!" to Congress for doing away with the flawed SGR process. In the SGR days, our 

budgeting process would begin with trying to manage the double-digit decrease called for by 

the SGR formula. It would make it impossible to balance our budget. The implementation of the 

cut would mean insolvency, so we would explain to our Board that we were going to ignore the 

projection and assume a flat payment from Medicare or a one percent increase. Board 

members would understandably think it was crazy to do this the first time they heard about this 
59 


36027.043

process. Then they would get used to the annual chaos of ignoring what was published. We all 

sighed a great sigh of relief when the SGR was repealed. 

There was then this new process, MACRA, on the scene. It was a bit of a mystery at first. 

There was a wonderful slide APG had created that showed a doctor standing at a fork in the 

road, with one fork indicating the MIPS road and the other Advanced Alternative Payment 

Model (AAPM) road. That was how we all saw it. Everyone had to choose, either you go down 

the MIPS road or the AAPM road. There was no rest area in the slide. There was no parking lot 

in which someone could just wait until a different road was built, or just settle in the parking lot 

and never move on. 

That is important. At the outset, the idea was that almost everyone would be in MIPS or 

an AAPM. The idea was to move everyone from volume to value. As a provider you had to 

choose one of the roads. So, we chose to be a MIPS provider. I was a zealous supporter of MIPS. 

I participated in panels explaining why MIPS was a good choice for many groups, including ours. 

And yet, as I said, we ultimately wound up being a Track One Plus ACO. What happened? 

We believed MIPS would be as presented. Most would participate. Those who moved 

strongly in the value direction would be rewarded as outlined, with at least a four percent 

bonus for high-scoring groups in the initial 2017 performance year. The bonus would increase in 

later years. There would be a large pool of money that would fund high-scoring groups, with 

the funding provided by groups that did not move in the value direction. 

Due to multiple factors in the implementation process, that is not how it played out. 

Many were exempted. The initial year became a transition year, with the ability to meet a 

neutral adjustment with minimal effort. Then there were lots of exclusions. There were rural 
60 


36027.044

exclusions, small group exclusions, exclusions related to hurricanes and weather events 

(whether or not the physician was indeed affected by said event). The most powerful exclusion 

was based on the low volume threshold, under which one was exempt from MIPS. It went from 

$30,000 and 100 patients, which, according to the Federal Register, would have exempted 

380,000 providers to $90,000 or 200 patients, exempting more than 540,000 providers. We 

fully recognize exemptions are necessary in some cases, but this level of exemptions 

undermines the spirit of the law. 

We had assumed it was going to be a standardized test, like the SAT, which most 

everyone would take and would be graded on the curve. Instead, it became an SAT test, still 

graded on the curve, but with only Advanced Placement students taking it. Many were simply 

told "You don't need to worry about that test; it is not for you." 

We studied hard and tried to do well at MIPS. Much of it entailed starting new systems 

to be sure we captured missing gaps in care and made sure that all rowed in the direction of 

value. We made significant financial investments in that. We scored 100 on MIPS. We recently 

found out our adjustment would be 2.02 percent not the four percent or more that was 

advertised. This is still meaningful, but the costs of doing well are considerable, and the 

reduction of incremental payment reduced our margin significantly. 

Given these factors, we decided that we needed to get off the MIPS road and get onto 

the AAPM road. We looked and felt that the Track One Plus ACO was the best choice for us. It 

gives us an exemption from the unpredictability in MIPS and gives us the chance to earn a five 

percent increase in our Medicare reimbursement. We are now working with our local hospital 

in managing our Fee-For-Service Medicare population. That is allowing us to do things that will 
61 


36027.045

improve the health of that population in ways that we would not otherwise have been able to 

do. But it is important to note, despite its flaws, many of the skills we learned during our MIPS 

phase are still valuable and still important. 

What have we learned? 

• The way MIPS has been implemented has not been the way it was planned. A large 

fraction of doctors is exempt. The few left in MIPS will, on the whole, do very well in 

their scores, but achieve very little in return, even if they have done everything well that 

the legislation encouraged them to do. It is now an asymmetric process; the intended 

large reward for high-scorers is gone, but the intended large loss for those who score 

poorly is still there. 

• The clinical benefits are real in terms of care itself and the care processes that are 

created to achieve the goals of the program. Those processes can be infrastructure 

intensive and to participate fully in MIPS is complex and not practical for a small group. 

• There are a number of AAPM models, allowing groups to leave MIPS and move more in 

the direction of population management. That is good, though ironically it worsens the 

MIPS problem. 

• There has been a recent acknowledgment that CMS should look outside of the FFS 

Medicare world for models that can be used to encourage the movement from volume 

to value. The recently proposed Medicare Advantage Qualifying Payment Arrangement 

Incentive {MAQI) demonstration is an example of that. 

Here are some suggestions that can encourage the movement from volume to value. 
62 


36027.046

Lower the threshold for excluding groups entirely from MIPS, and thereby increase the 

number of physicians participating in MIPS. At the same time, in recognition of the fact 

that smaller groups have fewer resources, MIPS for smaller groups may need to look 

different from MIPS for larger groups. In other words, give smaller groups a different 

test, more suitable for their resources, instead of excluding them entirely. Doing so will 

help move more doctors from volume to value and allow more to participate, while 

acknowledging that smaller groups have more limited resources to comply with an 

overly burdensome test. 

• Look at other models that will allow groups of doctors that are willing to embrace risktaking and high value care to do that. APG has a model, known as the "Third Option" 

that does just that. 

• Continue to look at care models outside of traditional FFS Medicare, most notably 

capitation, in which groups assume financial risk and responsibility. The care given in 

that model, when the activities of doctors are measured, should count towards the 

value-based care Congress is trying to promote. 

• Even if there are flaws in MIPS, there is value for individual patients and populations of 

patients and, importantly, the payer for all of this- the American taxpayer- in 

encouraging data collection and reporting and promoting high-quality and high-value 

care. The processes that are created to do that will help move Medicare from volume to 

value. We should find ways of making it feasible for more providers to participate in that 

process instead of excluding them. Encouraging participation in a manner that is 

sensitive to a group's resources will create more providers with the competencies and 
63 


36027.047

ability to know the needs of their patient populations, to better address those needs, to 

more wisely deploy financial resources, to produce better outcomes, and to better 

coordinate the care of seniors that sorely need that coordination. 

Thank you for allowing me to speak with you this morning. I will be happy to answer questions. 

Kurt Ransohoff, MD, FACP 

CEO Sansum Clinic, Santa Barbara, CA 
64 

Mr. BURGESS. Thank you, Dr. Ransohoff. 

I don’t see our chairman or the ranking member of the full committee back yet. So, we will proceed with the question-and-answer 

portion of the hearing. If either the chairman or the ranking member do show up, we will, obviously, yield to them for their statements as well. 

And I, again, want to thank each of you for being here. 

Many of you have mentioned different milestones along the journey that took us from where we were in the early 2000s to where 

we are now. I will just say, when I first got here, the goal of repealing the SGR became one my primary focus, and early on it was to 

repeal the sustainable growth rate formula. I thought if I replaced 

that with the Medicare Economic Index plus an inflation factor 

every year, so MEI plus 1 sounded reasonable to me, pretty simple 

and straightforward. So, that was my original proposal. The Congressional Budget Office threw about $300 billion of cold water on 

that idea, and I attracted no supporters, and I literally was pursuing that by myself, I think through two Congresses. 

So, that is part of what led to the journey of where we are now. 

Obviously, things have happened along the way. The PQRS, many 

of you mentioned having to come to a conclusion at the end of every 

year and provide a ‘‘doc fix’’. And how many remember PQRS in 

2006 was sort of Bill Thomas’ parting gift to medicine, if I can use 

that term? But PQRS was to pay for the ‘‘doc fix,’’ right? That is 

how we got PQRS, and PQRS is one of those legacy programs that 

now finds itself in MIPS. 

One of the largest contacts I get on social media is about a new 

payment rule for labs in Medicare, and I appreciate that it is causing some stress. That is based upon a provision in what was really 

literally the last ‘‘doc fix’’ in 2014, a bill called PAMA that, again, 

provided the dollars to bring us to ‘‘doc fix’’. 

So, underscoring everything else, the SGR is gone and we are not 

having to deal with the ‘‘doc fix’’ at the end of the year, as I think, 

Dr. Barbe, you mentioned having to go to your banker every year 

and explain, ‘‘Well, it isn’t really going to happen.’’ Right? ‘‘They 

say it, but it isn’t really going to happen.’’ So, that burden also has 

been lifted. And now that it is no longer there, we kind of forget 

that it was something that literally it was the end of every Congress every December of every year that I was here for quite some 

time. 

So, having provided that background, obviously, I am going to 

ask the easy question first, and I do want everyone to answer. In 

the tradition of Chairman Dingell, I am going to make this a yesor-no question. Better off today under the system that we have or 

were we better off under the SGR legacy? 

Dr. Barbe, I will start with you. Better off today? 

Dr. BARBE. Much better. 

Mr. BURGESS. Dr. Opelka? 

Dr. OPELKA. Absolutely. 

Mr. BURGESS. And Dr. Rai? 

Dr. RAI. We are better today. 

Mr. BURGESS. That is an affirmative. 

Dr. Parekh? 

Dr. PAREKH. Much, much better. 

65 

Mr. BURGESS. Affirmative also. 

And Dr. Ransohoff? 

Dr. RANSOHOFF. A rare opportunity for five doctors to agree. 

[Laughter.] 

Mr. BURGESS. OK. I wasn’t going to do this, but you reminded 

me. One of my greatest wishes is to someday come into this committee hearing, having five doctors at the table who are going to 

discuss how economists should be paid. 

[Laughter.] 

We will save that for another day. This group gets it. 

The economists don’t think that is funny, and I have tried that 

on them from time to time. 

So, no program is absolutely perfect, and I appreciate, I guess, 

Dr. Ransohoff, your journey that took you, first, to the direction of 

the small practice and, then, to the alternative payment method. 

And I will also add, as we were going through the discussions 

that led to this bill finally getting firmed up, I believed it would 

take 10 years in this process. Once again, I had a simple formula; 

let’s do 10 years with a 1-percent update every year. That seemed 

like a good fit. Again, the CBO threw a bunch of cold water on that 

idea, and it was condensed down to 5 years at a 0.5-percent update, 

which actually got a little further lowered after that. But I always 

thought it would take longer. 

This is a big change, and more than just having the change and 

having the bill signed, it is important to get it right. And I hope, 

if nothing else, this hearing today—this is the fourth hearing we 

have had on the implementation of this law. And if anyone at the 

agency is listening, I want them to understand this as well. It is 

important that we get it right. It is not important that we passed 

the bill and that we had a signing ceremony down at the White 

House. It is important that we get it right, because, obviously, patients are counting on it. Obviously, doctors are counting on it, and 

the taxpayer is also one of the variables in this equation that we 

have to consider as well. 

So, I think I have heard the answer to this question during your 

testimony, but I will ask you for the record. Would it be better for 

Congress to continue to work with the agency, with the Centers for 

Medicare and Medicaid Services, to implement the merit-based system as laid out in statute or just scrap it entirely and go back to 

the drawing board? 

Dr. Barbe, we will start with you. 

Dr. BARBE. We are eager to continue to work on this. We think 

it has potential. 

Mr. BURGESS. Thank you. 

Dr. Opelka? 

Dr. OPELKA. Mr. Chairman, quality is a never-ending cycle. We 

have to continuously work on this. 

Mr. BURGESS. That is great. Thank you. I am going to steal that 

quote. 

Dr. Rai? 

Dr. RAI. I would agree that we need to continue to work with you 

on MIPS. 

Mr. BURGESS. Dr. Parekh? 

66 

Dr. PAREKH. I also agree. In business school, they teach us about 

continuous quality improvement, and I think that principle applies 

here, too. 

Mr. BURGESS. Yes, sir. 

Dr. Ransohoff? 

Dr. RANSOHOFF. There is a lot of good to this program, and it 

should be continued to be worked on. 

Mr. BURGESS. I have some other questions, but I will submit 

them for the record. 

Just one last story about the journey that got us here. There was 

one morning when the then-Majority Leader came up to me, and 

I was whining about this problem not having been solved. And he 

said, ‘‘Well, Doc, would it be easier if we put everybody into an 

ACO?’’ Well, the short answer to his question is, yes, it would be 

easier, but it wasn’t the right thing. 

I appreciate the journey that you have been on, Dr. Ransohoff, 

and I think that kind of told me what, in fact, I was telling the 

Majority Leader that morning. We are not quite sure about what 

the journey that different practices will have to take, and it is important for the entire panoply of practices to be able to prosper in 

the environment. 

And I will yield back and recognize Mr. Green for 5 minutes, 

please. 

Mr. GREEN. Thank you, Mr. Chairman. 

And thank each of you for joining us today. 

MACRA was an important step forward for our healthcare system, building on the successes of the Affordable Care Act. One of 

the key goals was to further reforms that would promote value over 

volume and incentivize providers to find new ways to offer more coordinated and efficient care. In order to further that goal, MACRA 

created the Physician-Focused Payment Model Technical Advisory 

Committee, PTAC, and to make recommendations to the Secretary 

for proposals for physician-focused payment models that would help 

control healthcare spending and improve quality. 

Dr. Opelka, can you describe why MACRA and the creation of 

PTAC was so critical to our efforts toward delivery system reform? 

Dr. OPELKA. I think the key here is—and we really appreciate 

the congressional action to create the physician input into business 

models—the care models have changed, and they change every 

year. They have changed over the last 50 years. The payment 

model has been stuck from 50 years ago. So, we need to take the 

care model and put a business model on top of it that works, which 

means that the payer community, particularly in our case the 

agency, needs to listen to us and figure out how are we going to 

incentivize quality; how are we going to reach the congressional 

goal of value by actually putting a payment model that maps to the 

care model? And having that relationship, the Congress open that 

door, and what we need now is for an agency that is willing to, and 

has the resources to, accept that. 

Mr. GREEN. Does anyone else on the panel want to comment on 

how it was working with the PTAC? 

Yes, sir, Doctor? 

Dr. BARBE. Thanks for asking that. As I mentioned earlier, physicians want to be engaged and involved in this process. PTAC was 

67 

created for that very reason. They have received dozens of proposals that come from the ground level, physicians that are practicing that know what will work in their practices, and perhaps in 

their specialty. And yet, none of these have been adopted by CMS 

or, really, we think given serious consideration. And these span everything from very focused proposals in GI medicine to reduce rehospitalization in Crohn’s patients, all the way up to the end-stage 

renal disease that could have a very broad effect on improving care 

and reducing costs for dialysis patients. So, we think there is great 

opportunity there if CMS will listen to us. 

Mr. GREEN. Any other comments? 

[No response.] 

Which gets me to my point, I want to turn to the CMS decision 

not to test many of the models that the PTAC has submitted for 

testing. 

And, Dr. Barbe, you get the first one. Can you expand on your 

remarks in your testimony about the Secretary of HHS decision not 

to implement or test most of the physician-focused models that 

PTAC has submitted for testing? Why is it so problematic for 

MACRA implementation? 

Dr. BARBE. So, the original ideas, these very innovative ideas 

were brought forth from the ground level. PTAC was designed to 

evaluate these, look at the merit, look at the rigor, and make recommendations. And they have not recommended positively on all 

of these proposals, but they have recommended positively on 10. 

Again, up to this point, CMS has not seen fit to continue to work 

on those, to dialog and say, ‘‘Well, this is what we don’t like’’ or 

‘‘what we do like about this proposal. If you could change it, maybe 

we could adopt it.’’ They seem to be interested in coming up with 

ideas on their own, and I think that is not only reinventing the 

wheel potentially, but it is not taking advantage of some very creative and innovative proposals that have come forward. 

Mr. GREEN. Anyone else? 

Yes, sir, Dr. Opelka? 

Dr. OPELKA. So, Congressman Green, we did propose to the 

PTAC. We were early on accepted. We were, then, accepted in a 

letter by the Secretary for consideration by the Innovation Center. 

The Innovation Center had a few conference calls with us and one 

2-hour in-person meeting on a product that we developed that took 

almost 5 years in the making. There is no resources and no capability in the Innovation Center to complete a design and, then, to 

create an implementation and have a sandbox or a pilot area in 

which to test. 

And so, the PTAC has done a fantastic job. The Secretary vetted 

us. And I think we are the only one that went from the Secretary 

and was recommended to the Innovation Center, and it died in 

there because it is just not wired to really innovate. And we really 

need to turn that on. 

Mr. GREEN. Dr. Barbe, or anyone else, has the AMA or any other 

specialty societies received further feedback from HHS or CMS on 

why HHS is not testing these models that the PTAC has recommended? Have you gotten any feedback other than—well, I want 

to hear from Dr. Barbe. 

68 

Dr. BARBE. We have submitted just a month ago a four-page letter outlining what we believe are some merits of a few of the very 

specific proposals that PTAC recommended on up to CMS. And 

while they acknowledge receipt of those, they acknowledge the 

work that the PTAC has done, they really have not offered any explanation. As I said, we would be happy to work through PTAC 

with them to modify, if there was a deficiency they saw in the 

model and they said the idea is good, but it won’t go for this reason. I think we are all eager to work with them. We are 3 years 

into a 6-year program on this particular issue and still don’t have 

a model that physicians can embrace and use that has been approved. 

Mr. GREEN. Mr. Chairman, my time is out, but somewhere along 

the way HHS should clarify and have coordination between not just 

AMA, but also the specialty societies, because, as you know, specialties sometimes are different than a doctor down the road. And 

we need to see whether our subcommittee can maybe encourage 

HHS and CMS to give feedback and coordinate with you on where 

we are going with this. 

Thank you. 

Mr. BURGESS. I don’t disagree. A future hearing that would include both the agency and stakeholders on PTAC issue seems like 

a good idea. 

The Chair recognizes Mr. Guthrie, 5 minutes for questions, 

please. 

Mr. GUTHRIE. Thank you very much, Mr. Chairman. 

Thank you, everybody, for being here. 

And I know you have touched on some of this in your opening 

statements, but I know that the 5 minutes is kind of limited. So, 

I want to just go back and give you each a chance to ask—I will 

do these two questions together. 

So, my question is, for each of you, what specifically has each of 

you done, or are doing, in your own practices to daily set yourselves 

up for success under MIPS, and if you went through MIPS and out 

of MIPS specifically? And what can physicians do right now to position themselves to succeed in MIPS? 

So, I will just start with Dr. Barbe. Or, no, let me go right to left, 

since we went the other way. Dr. Ransohoff, I will start with you, 

then, and go left. 

Dr. RANSOHOFF. Thanks. That is an excellent question, Congressman. 

I will give an example. We became a patient-centered medical 

home. We had a long history of capitated care. So, we are a very 

integrated medical group. But, going into MIPS, even we, who are 

pretty far along, decided that we needed to have a culture change 

within our organization. And so, we adopted this PCMH model, 

which really has changed the way we do things. Our medical assistant, our nurse will, as the patient is coming into the room, will 

find out have you had a mammogram that we don’t know about; 

have you had a vaccination that we don’t know about. So, we can 

update it in our system. It is a small thing, but it turns out that 

is actually an important culture change because it has engaged us 

in a much more team-focused approach to care. So, that is one exVerDate Nov 24 2008 14:50 May 21, 2019 Jkt 037690 PO 00000 Frm 00074 Fmt 6633 Sfmt 6633 U:\MY DOCS\HEARINGS 115\HEARINGS\115-160 CHRIS
69 

ample of how MIPS has sort of propelled us along in what we think 

is the right direction. 

Mr. GUTHRIE. OK. Thank you. 

Dr. Parekh? 

Dr. PAREKH. Thank you for the question. 

I would say that there is a two-pronged approach to answering 

your question. One is on a personal level, and then, the other one 

is our professional society. So, within the eye doctor, eye surgeon 

community, we have, of course, my organization, the American Society of Cataract and Refractive Surgery, and we have the American Academy of Ophthalmology. We work very closely together to 

develop measures that are relevant to my day-to-day practice and 

that align very much with what patients want, I think with what 

you all want, and with what we want in terms of what is best for 

our patients. 

So, part of it is developing outcome measures, which we have, developing cost measures. It is not an easy task. I personally serve 

on some of these committees. We spend hours and hours and hours 

on this, but it is hugely important on a global level to have that, 

your professional society helping to create those measures. 

And then, it’s like a one-two punch almost. On a personal level, 

I will tell you, participating in MIPS and getting good scores has 

not been very difficult. My EMR makes it very simple. I have a 

coach through my EMR system. We talk regularly. We email regularly. I can keep track of my score of how I am doing this year. And 

so, having the good measures is very important, and then, having 

a good EMR system, and then, just putting forth the personal effort 

to pay attention to those measures. And then, improve my deficiencies, become a better surgeon, become a better doctor, and also 

keep track of those measures. So, it has been a two-pronged approach. 

Mr. GUTHRIE. Thank you. 

Dr. Rai? 

Dr. RAI. So, to answer your first question, what have we done to 

prepare for MIPS and MACRA, really, it is redesigning how we 

practice. The physician is no longer the center of the healthcare 

system. The patient should be. And we have redesigned all of our 

practices, both primary care and specialty care, to put the patient 

in the middle and establish team-based care, making sure that 

nurse care managers are interacting with patients, making sure 

that if you have a chronic disease, your visit never ends. It is just 

how often we connect with you. 

And we have also made significant investments in data infrastructure. An EMR without the ability to draw the data in is just 

a really expensive word processor. And we have had to make significant investments in drawing the data out, but, then, also make 

significant digital investments that are patient-facing and forward 

to identify gaps in their care, to establish online scheduling, all of 

which we have done in this last year. 

Your other question, what should other physicians do to prepare, 

really, it is no longer focusing on the sickness of our patients, but 

the health of our population. We need to make more investments 

on keeping people out of the hospital, even out of our clinics, which 

isn’t always financially viable, but we, through MACRA, through 

70 

MIPS investments, are rewarded for that. And we have to use 

those value rewards to redesign how we practice medicine. 

Mr. GUTHRIE. OK. Thanks. 

Dr. Opelka, we are about out of time. So, go ahead, if you have 

got a couple—— 

Dr. OPELKA. Very quickly, for the most part, MIPS does not 

measure surgical care. So, we do the best we can to help our surgeons get the credit they need for payment purposes, but, then, we 

try to refocus them on the quality metrics programs that we have 

separate from MIPS. 

Mr. GUTHRIE. OK. Dr. Barbe, do you have just one quick 

thought? 

Dr. BARBE. Our group has been very successful, but we have invested heavily over a decade in order to be successful. I am concerned that some of these programs now simply don’t give physicians enough upside opportunity to invest like that in order to be 

successful. 

Mr. GUTHRIE. OK. Thank you. 

And I yield back. 

Mr. BURGESS. The Chair thanks the gentleman. The gentleman 

yields back. 

The Chair recognizes the gentleman from Oregon, Dr. Schrader, 

5 minutes for your questions, please. 

Mr. SCHRADER. Well, thank you, Mr. Chairman. 

Dr. Rai, why are 58 percent of the practices excluded from MIPS? 

What is your opinion? 

Dr. RAI. I think CMS created those exclusions because physicians 

felt they weren’t ready to participate. But, for MIPS to be successful, for MACRA to be successful, there has to be a plus and a negative. It is a budget-neutral program. So, there has to be a carrot 

and a stick. 

The 58 percent really came from CMS—— 

Mr. SCHRADER. But why are they excluded? Why are they not 

ready? 

Dr. RAI. Why are they not ready? I think some consider themselves not ready because they have not made the investments or 

are willing to make the investments or take the risks that are involved in now making that transition from fee-for-service to value. 

Mr. SCHRADER. Investments in terms of expensive computers, or 

whatever, or what are you talking about? 

Dr. RAI. I think the investments are multi-fold. I think probably 

the most significant investment that we have made is in people, in 

making sure that we redesign how we practice healthcare. It is in 

staff. It is not only in staff, but in—— 

Mr. SCHRADER. So, it is basically a decision by those offices not 

to engage, frankly, in the new era of modern medicine? 

Dr. RAI. It is. It is. It is people that would really like to hang 

on to fee-for-service for as long as they can. 

Mr. SCHRADER. All right. All right. 

So, I guess, Dr. Parekh, why is MIPS the only option for a specialist? I would understand that you are not a primary home model 

type of thing, but why is that the only APM? Or why doesn’t some 

other form of APM work for you? 

71 

Dr. PAREKH. Again, I will give you my answer, multiple key reasons. First and foremost, most practically speaking, there are no 

APMs in my area that I could join, even if I wanted to. 

Mr. SCHRADER. Sure. 

Dr. PAREKH. So, there is just a geographic barrier to that. You 

will know better than I about the spread of those APMs through 

the country, but, certainly, in my area it is just not a choice. 

The ACOs are very primary care-focused. When I think of how 

an ACO works and what the potential is to save money and to improve quality of care, it makes the most sense for primary care to 

be doing that because they are the quarterbacks of the team. They 

help coordinate the entire ship. My wife is an internist. I mean, we 

have this discussion at the dinner table all the time. 

When we in ophthalmology are trying to improve our patients’ 

care, I mean, think of it from our perspective. I am trying to do 

a good job on cataract surgery. I am trying to lower my patient’s 

eye pressure from glaucoma, so that they don’t go blind. But, if we 

were in a big model, those measures are likely not going to be used. 

So, they wouldn’t actually do anything for my patients. They 

wouldn’t actually give me a solid, meaningful measure that I could 

do, I could measure myself; I could say, oh, I am deficient; I want 

to improve. That is not going to exist because the system is so big. 

So, I think we lose something when you have such a massive system. The primary care gets the weight of that in these bigger systems and I think the specialists are lost. 

MIPS, on the other hand, gives me a measure that directly affects what I do. If I am—— 

Mr. SCHRADER. Do you interface with primary care systems at 

all? Is there any primary care system in your geography? 

Dr. PAREKH. No. 

Mr. SCHRADER. OK. All right. In rural Oregon, we have been able 

to make that happen. I am not talking to your situation, but just 

for the sake of the panel and others, there are ways to make APM 

systems work, ACOs work in rural settings. It is a culture, and 

after a while you figure out how to do it, like you all are doing as 

you adopt new practices and stuff. 

So, Dr. Ransohoff, you suggested maybe lowering the exclusion 

threshold in the MIPS program. Could you elaborate on that a little bit? To my investments, I mean, I would assume that the outcomes, whether you are a large practice or a small practice, the 

outcomes shouldn’t really change. If it is patient-centered, you 

want the patient to be healthy, less readmissions, less time between surgeries, whatever the option is. Could you talk a little bit 

about that? 

Dr. RANSOHOFF. Yes. I think that the main issue is just trying 

to get more doctors involved in the process. The way it is set up 

now, in a way what you have is you have a bunch of people who 

are believers, if you will, and are kind of going down that path, and 

then, you have a bunch of people who are just saying, ‘‘Thank goodness this doesn’t affect me,’’ and are not making any efforts to 

change. 

Mr. SCHRADER. Right. 

Dr. RANSOHOFF. I think that, in the absence of change, I don’t 

understand how any of this gets to be affordable. And so, I do think 

72 

there is going to have to be some change. By lowering the threshold 

from $90,000 to some number less than that, you would start a 

gradual transition. People would know it was coming. 

I do think that, as my colleague here in solo practice points out, 

I think that this is doable. It is just that people don’t want to do 

it. 

Mr. SCHRADER. So, maybe some sort of phase-in with the thresholds, so that people can see a path or eventually develop a path 

going forward? 

Dr. RANSOHOFF. Correct. 

Mr. SCHRADER. So, the last question real quick, Dr. Barbe, everyone has pretty much referenced electronic medical records and 

EHR. I am very, very concerned that, while individual practices 

and groups are making huge investments—originally, there was 

some money from the Federal Government to help out; gone now. 

Maybe that is something we should continue or think of strictly for 

small practices. But I am concerned about the systems—and you 

guys have alluded to this—not talking to one another. And there 

is a vested interest, with all due respect to our EHR developers, to 

keep that system pretty proprietary and pretty unique, so that you 

have got to buy their stuff. Could you talk a little bit about trying 

to broaden that out? Is there a role for the Federal Government to 

require some of these developers to make it easier for doctors to 

share their information across specialties, primary care, frankly, 

nutritionists, the whole gamut? 

Dr. BARBE. So, yes, we believe the Office of the National Coordinator can facilitate better interoperability. Many groups are trying 

workarounds now, all the way from health information exchanges 

to other cloud-based. Dr. Opelka earlier referenced activities of the 

American College of Surgeons. The AMA has significant activities 

around an IHMI, or Integrated Health Model Initiative, that we believe has some great potential. But all of those are workarounds because the industry has not made data interoperable and, in fact, 

has blocked data in many cases. 

Mr. SCHRADER. Thank you. And my time is up, but I think that 

is a critical issue for this committee to address, if we are going to 

be successful going forward. 

Thank you very much, Mr. Chairman. 

Mr. BURGESS. Thank you, Dr. Schrader. 

I would just point out that the third title in the Cures bill that 

we were planning on having oversight of the implementation was 

the electronic health records. We did have the mental health title 

evaluation earlier this week, I think, or was it last week? But, in 

any case, that has been held up because a rule has been stuck at 

the Office of Management and Budget, and we had initially 

planned to have that hearing in June and it was postponed because 

of that reason. Then, we are eventually just likely going to have 

to have the hearing without the rule having been finalized or released by OMB. 

I would now like to recognize the gentleman from Illinois, the 

chairman of the Subcommittee on Energy and Environment, Chairman Shimkus, 5 minutes. 

Mr. SHIMKUS. Thank you, Mr. Chairman. This is a great hearing. 

Tough names out there. So, if I butcher them, I apologize for that. 

73 

For Dr. Schrader, I think we do need to look at this as an exemption issue. If this is a movement forward, and there are cost challenges, we ought to get everybody onboard on the quality bandwagon. 

I can’t remember who mentioned it in their opening statement, 

but someone, one of you mentioned that high-performers are not 

getting rewarded. Can you just address that a minute? Because, 

obviously, you mentioned, I think—correct me if I am wrong—poorperformers are being identified, but high-performers are not being 

rewarded. 

Dr. RAI. Yes, I think both Kurt and I mentioned that. At the end 

of the day, for the budget neutrality to work, there has to be just 

as many people involved in this. And that is what the exclusions 

created, was the incentive was cut in half for high-performers. Because there weren’t as many people in there, the threshold was 

changed. So, from expecting a 4-percent to a 2-percent increase, yet 

making all the investments to value, is where we felt that high-performers were literally being penalized for making the right investments. 

Mr. SHIMKUS. Any more? Dr. Ransohoff, I am going to go with 

you to the next question, too. So, why don’t you answer that also? 

Dr. RANSOHOFF. Yes, we have the same issues. We spent probably half—we will get a 2.02-percent reward for getting 100—we 

probably spent half of that trying to get it. Now we had done that 

because we thought that the reward would be significantly more, 

and it is the right thing to do, but there is an economic issue with 

it. 

Mr. SHIMKUS. Yes, and I am going to talk economics a little bit, 

too. But I want to go back. What intrigued me about your comment 

to another question was, electronic health records or whatever, 

EMR, or whatever you want to call them, asking patients about indices that they may not be there for. We have been dealing with 

that with the opioid issue and trying to change law, so that there 

is a little more conversation. As you all know, there are catastrophic stories of the firewall between information, which has 

turned out deadly, and this whole committee has been trying to do 

things that we can do to address that. So, I applaud that, and 

hopefully, the legislation that we are moving forward, hopefully, 

with the Senate concurrence and a presidential signature, will 

start making that a little more available. 

The concern is always going to be data privacy, personal privacy, 

and the like. So, you are the folks in the field and you are the ones 

who have to really help us see and help direct us on protection 

versus sharing of information throughout the practice. Especially if 

we are doing a patient center, as you guys were mentioning, holistic, with different people around, that information has to be shared 

throughout the practice. So, excellent point. 

I wanted to ask, I wanted to kind of go off, not totally off-script, 

and I am not trying to get this partisan or political, but in this current world today how much is, what are you paying—how do you 

want to answer this question. I have always been worried about 

uncompensated care. Even with a government-run healthcare policy, high deductibles, can you talk to me about—and that is all the 

time I am going to have. So, whoever wants to talk to me about, 

74 

even in a system where we are doing Medicare and Medicaid, that 

doesn’t pay costs, even if we are moving to high performance. So, 

if we are not paying the cost of care, and then, you have folks, and 

then, you are eating uncompensated care, that is where I think our 

system just breaks down. Anyone want to talk about uncompensated care or charity writeoffs, or however you want to define it? 

Dr. BARBE. So, what the AMA would like to see is no uncompensated care not from our side, but because that means patients have 

coverage that will help them get access to care. That is the bottom 

line here. So, it is not a matter of how we handle uncompensated 

care. It is how do we get more people covered, so that they can 

have access? 

Mr. SHIMKUS. Quickly, anybody else want to jump in? Everybody 

else is compensated fully and there are no writeoffs? That is what 

you are saying? Or you just don’t want to go into this debate right 

now? 

Dr. OPELKA. Well, you have opened up a very complex subject 

matter. 

Mr. SHIMKUS. Yes, right. 

Dr. OPELKA. The bottom line is that the uncompensated care patients, when they come in to seek surgical care, it is already too 

late. They are way behind the power curve. And that is the most 

unfortunate thing. We all see them. We all treat them. We take 

care of them. 

Mr. SHIMKUS. We should take care of them in the internist level 

or early intervention and provide that care—— 

Dr. OPELKA. Their cancers are diagnosed late. So, they have a 

poor outcome. Let’s get in front of the disease, and the uncompensated care patients come in a day late and a dollar short. 

Mr. SHIMKUS. My time has expired. Thank you, Mr. Chairman. 

Mr. BURGESS. The Chair thanks the gentleman. The gentleman 

yields back. 

The Chair will recognize the gentlelady from California, Ms. Matsui, 5 minutes for questions, please. 

Ms. MATSUI. Thank you, Mr. Chairman. 

And I thank the witnesses for being here today. 

We were talking about telehealth, and a group of us on the Energy and Commerce worked together to advance telehealth legislation, legislative and with the administration. As we have worked 

on legislative efforts, we have found CMS and CBO to be resistant 

to expanding access to telehealth due to cost concerns. Expansion 

has often been judged as adding a new service that could be overbilled, rather than taking into account that reducing hospital and 

ER visits would result in better care that could result from getting 

patients access to care sooner and more conveniently. 

I am encouraged that CMS has taken steps in this recently-proposed rule to expand access to telehealth in Medicare, as this is 

what we have been working toward. There will be no way to prove 

success in the Medicare population without covering services. And 

I am curious to hear from our witnesses about the types of telehealth services that they currently implement. 

Starting with you, Dr. Barbe. 

Dr. RAI. I would be happy to start. 

75 

Currently, in our organization we provide telestroke coverages to 

rural hospitals. 

Ms. MATSUI. OK. 

Dr. RAI. We also are opening up very small cities in Wisconsin, 

northern Wisconsin, so just Ladysmith at the new site, and we 

would love to provide more services to there. Some of our specialists live 5 to 6 hours from there—— 

Ms. MATSUI. Right. 

Dr. RAI [continuing]. But easily could provide followup services 

or counseling services. There is not a lot of times in medical specialties especially, such as endocrinology, that we generally necessarily need to examine the patient. We need to be able to have 

that conversation and counsel that patient, or other services that 

are not even physician-based. But, unfortunately, we run into the 

wall with CMS and other payers without an ability to pay for that 

infrastructure, which does not come cheap. But we have done it 

with telestroke. We have done it. We have done it very well. We 

hope to do more. 

Ms. MATSUI. OK. That is great. 

Anyone else want to comment on that? 

Dr. BARBE. So, there are many types of services and sites of services—— 

Ms. MATSUI. Right. 

Dr. BARBE [continuing]. That are actually prohibited from participating in telehealth or digital medicine. We can start by getting 

rid of some of those restrictions. We can start by unbundling some 

of these payment codes, so that we can charge differently for 

consults versus remote patient monitoring. 

Ms. MATSUI. Right. 

Dr. BARBE. My particular group is very robust in what we call 

virtual care, which is digital medicine, and we put monitoring devices in patients’ homes. We will even run the internet to their 

home, because in rural southern Missouri many don’t have that. 

So, there are a lot of things, but we can’s do this because there is 

no direct payment. The only reason we can do it now is we are in 

some risk-sharing arrangements. 

Ms. MATSUI. All right. Anyone else here? 

Dr. OPELKA. Just very quickly, where there are capitated environments, all these barriers to payment go away, and telehealth actually becomes very creative and innovative. In a capitated environment, in my former practice we dealt with rural, like was mentioned, but we also dealt with prisoners, and putting telehealth in 

the prison became a very effective way of getting better care to the 

prisoner, rather than having to transport somebody with all kinds 

of guards and other security. Telehealth was a savior. 

Ms. MATSUI. OK. Let me just go on. One of my legislative efforts 

with Representative Bill Johnson on Energy and Commerce is H.R. 

3482, which would remove originating site and geographic restrictions on telehealth in Medicare. And the steps CMS has taken to 

pay for virtual check-ins is very much in line with this idea. We 

passed a limited version of that bill for opioid service in the House 

opioids packages, and I hope the Senate will move to take this important legislation. And I really do look forward to having it expand further, and I think it would be helpful for all of you. 

76 

I have been working to advance interoperability between electronic health records, and the proposed rule has implemented a 

performance measurement in order to promote interoperability. I 

guess, Dr. Opelka, you have talked about this. What success have 

providers had in working toward a goal of interoperability? Do you 

feel that the implementation of MACRA has been helpful? 

Dr. OPELKA. I don’t know that MACRA itself has actually drawn 

attention to this. When we moved away from dealing with the 

EHRs and we created a patient cloud, and we began moving data 

into the cloud environment, in which we could represent information either to a patient or to a clinician from wherever that patient 

was seen, those models are now emerging separate from the EHR 

vendors. It is making a huge difference in care in those environments. That is the direction we need to go in, and that is where 

we need to actually educate the government to help us push incentives that drive us more to a patient cloud environment, rather 

than to say, this hospital, this EHR, it is this patient and all the 

hospitals they get care in. 

Ms. MATSUI. Right. OK. 

I think I have run out of time. I yield back. Thank you. 

Mr. BURGESS. The Chair thanks the gentlelady. The gentlelady 

yields back. 

The Chair recognizes the gentleman from Ohio, Mr. Latta, 5 minutes for questions, please. 

Mr. LATTA. Thank you. Thank you, Mr. Chairman. I want to 

thank you for the hearing today. 

And I want to thank all of you for being with us today. Because 

I am sitting here looking at you thinking to myself of all the patients you would be seeing right now in the time that you are taking to testify before us on this important matter. 

One of the great things that we get to do, we travel around in 

our districts. We talk to our docs back home. And we also have the 

ability to see a lot of the third-year, four-year medical students 

from our states come through. They are working on a lot of their 

specialties and everything else, but, at the same time, they kind of 

bring up with you all the sundry things that they are going to have 

to be doing to practice medicine. 

And I wonder if you all would mind answering a question for me, 

just going down the line, if you wouldn’t mind. How much time do 

you take out, if you took a percentage, that you are practicing medicine or you are doing the administrative side of your job? 

Dr. BARBE. I can answer that very precisely. The AMA has done 

two studies. It shows that physicians spend about two hours in 

front of their computer screen or doing other paperwork for every 

hour they have in direct clinical contact. We did a second study 

that shows, for primary care physicians, they spent 60 percent of 

their day in non-direct-patient-care activities. 

Dr. OPELKA. And it is roughly about 20 percent of their time 

doing administrative burden. 

Dr. RAI. It is ballpark around that same number. We at our own 

organization started to look at EMR utilization after 5:00 or 6:00 

p.m., when they log in from home after dinner, and how long they 

are on it. A significant amount of our primary care physicians are 

77 

logging in late at night to complete their day, which is definitely 

leading to a nationwide situation with burnout. 

Dr. PAREKH. I will echo the comments. I mentioned earlier my 

wife is an internist, and the kids go to bed around 9:00 p.m. and 

we get on our computers. 

Dr. RANSOHOFF. We have done the same kind of study. We see 

that internists, it varies somewhat by specialty, but in primary 

care it is not uncommon for doctors to spend 20 hours a week after 

hours doing documentation on the computer. 

Mr. LATTA. And I know they are calling votes on us right here. 

I am going to ask just one question then. The clinical data registries and the certified EHRs that are envisioned by MACRA as 

serving as critical reporting mechanisms for providers to interact 

with the Medicare, would these represent a decrease in that administrative burden then? And just go down the line. 

Dr. BARBE. They haven’t yet. The EHRs still just don’t work for 

physicians. There is too much point, click, move from one field to 

the next. Even in the certified technologies, which we have, we are 

still burdened significantly by that. 

Dr. OPELKA. So, the clinical data registries, we run about seven 

international registries. They actually pull data in and generate 

knowledge, and that knowledge is delivered at the moment of care 

that allows for clinical decision support, that allows for better care, 

higher quality, et cetera. So, while they may take on time, they actually reduce burden and improve patient outcome. So, they are 

very welcome. 

Dr. RAI. I would echo that. The registries are welcome. They help 

us identify gaps in care that patients may need on an active basis, 

on a more timely basis, and the ability to access a patient to make 

sure that we get in front of them before they get in front of us in 

an acute situation. 

Dr. PAREKH. As I mentioned in my testimony, the Academy of 

Ophthalmology created the IRIS, I-R-I-S, registry, and it has been 

a huge help. I will give you an example. Let’s say, 2 days ago, I 

was doing surgery. My EMR records the date of the surgery on the 

right eye, for example. And then, when we see the patient back, of 

course, we record how the vision is doing. And one of our measures 

is, is the patient 24/40 or better within 90 days? So, it is an outcome measure, like I said, very important to our specialty, very important to our patients. And so, as soon as that vision reaches that 

threshold, the EMR automatically captures that data. The point is, 

we are getting outcomes data and it is very little additional work 

because the registry is able to grab that info without me typing it 

in again for the registry. So, it has been great. 

Dr. RANSOHOFF. There is nothing faster than ineligible handwriting that is not shared with anyone. 

[Laughter.] 

And I practiced in those days. The computer systems that are out 

there now are more time-consuming. I do think they are much better. 

I prescribed recently—the patient was on two unusual medications, and they computer said there is going to be a drug interaction. And so, there are real benefits to it, but it is definitely more 

time-consuming. 

78 

Mr. LATTA. OK. Well, Mr. Chairman, my time has expired, and 

I yield back. 

And I thank our witnesses again for spending time with us 

today. Thank you. 

Mr. BURGESS. The gentleman yields back. The Chair thanks the 

gentleman. 

The Chair does acknowledge there is nothing faster than bad 

handwriting, particularly if you are lefthanded. 

The Chair now recognizes the gentlelady from California, Ms. 

Eshoo, 5 minutes for questions, please. 

Ms. ESHOO. Thank you, Mr. Chairman. 

And thank you to the witnesses. You represent so many that 

practice medicine across our country in the different disciplines, 

and have headed up, and do head up, organizations that are representing them. 

I would like to go to Dr. Rai and Dr. Ransohoff with this question. Earlier this month, CMS released a proposed rule that estimated that 42 percent of physicians participating in Medicare will 

need to comply with MACRA. So, my question to both of you is, 

with so many physicians that are exempt from both APMs and 

MIPS, has CMS undermined the original intent of MACRA? Would 

that be your take? And with so many physicians exempt, will 

MACRA meet the original payment reform goals it set out to 

achieve? 

Dr. RAI. I do believe CMS has gone against the intent of MACRA 

with the exemptions. For this to work, for us to truly move to 

value, the intent of MIPS, as one of my colleagues has been quoted 

to say, MIPS was the on-ramp to value and CMS has created an 

exit ramp. 

Ms. ESHOO. Why do you think they are doing this? 

Dr. RAI. Change is never easy. The change of going from fee-forservice to value, to taking risks—— 

Ms. ESHOO. Oh, we have been doing that for a long time. This 

isn’t exactly something that happened in the last 90 days. We have 

been in transition since I first came into the Congress on this 

thing, and I have been here for a while. 

Dr. RAI. I don’t disagree with you at all. The legacy programs did 

not have the exemptions. And now, all of a sudden, we are exempting people, and it is truly preventing—it is another kick-the-candown-the-road. It is becoming SGR 2.0 if they continue that behavior. 

Ms. ESHOO. Well, how do you think CMS can improve the MIPS 

implementation? 

Dr. RAI. Implement it as it was written. Really implement what 

you passed. 

Ms. ESHOO. Great. Good answer. Good. All right. Well, that is 

confidence in the work that we have done, Mr. Chairman. 

To Dr. Opelka and Dr. Parekh—is it ‘‘Parak’’ or ‘‘Paresh’’? 

Dr. PAREKH. Parekh. 

Ms. ESHOO. Parekh. 

I have heard from physicians in my congressional district—it is 

the Silicon Valley district in California—that those in small practice and who practice specialty care face barriers in participating 

79 

in MIPS. Do you face barriers, as some of my physicians have reported? And if so, what are they? 

Dr. PAREKH. Thank you for the question. 

As an ophthalmologist, again, I feel very lucky. We have amazing 

professional societies. We have been working for a long time, as 

you said, coming up with measures. We have been preparing for 

this moment for a while, coming up with outcomes measures, coming up with process measures, creating cost measures, having a 

registry. So, I am very fortunate—knock on wood, I thank our professional societies—it hasn’t been that hard for us in ophthalmology. 

Ms. ESHOO. Well, that is good. Do you know Dr. Chang? 

Dr. PAREKH. Dr. David Chang. 

Ms. ESHOO. Dr. David Chang, yes. 

Dr. PAREKH. Yes, he is one of my very good friends. In fact, he 

knew that I was coming today and sent me a very kind email. 

In ophthalmology, I think our numbers to some extent back up 

what I am saying. I think people who participated in our registry, 

I think 85 percent got a score of 100, getting the 2 percent that was 

mentioned earlier, and I think 99 percent got some type of bonus. 

So, again, we have been working very hard at this, and I think it 

is blossoming. 

Ms. ESHOO. Would you recommend anything to us that would 

lessen the burden on physicians, so that you can more actively participate in MIPS or do you think it is just working swimmingly? 

Dr. PAREKH. I think there is always room for improvement. 

Ms. ESHOO. Always, yes. 

Dr. PAREKH. Like I said, it is a continuous quality improvement 

mindset that we have to have. 

Ms. ESHOO. But do you have something, anything specific? Anyone have anything specific? 

Dr. OPELKA. Sure. So, this whole matter of participating or exclusions, if you don’t measure what matters, putting money and investments into something that is senseless, nobody wants to participate. 

Ms. ESHOO. And that is what we are doing? 

Dr. OPELKA. So, all the surgical specialties, all of them, including 

ophthalmology, the majority of their measures have nothing to do 

with surgical care. 

Ms. ESHOO. Wow. 

Dr. OPELKA. They are measuring primary care. So, it doesn’t surprise me that primary care says everyone should be in, but it also 

doesn’t surprise me when surgery care says, ‘‘It doesn’t matter to 

the patients I am treating. So, why am I spending money in my 

practice to send CMS tobacco cessation and immunization rates?’’ 

Nobody comes to me as a surgeon with breast cancer to talk about 

those things. We are not measuring what matters. And so, as long 

as we are going to measure silly things, everyone is going to say, 

‘‘I want to be excluded.’’ If you want to measure what matters, put 

me in. Put me in, coach. I want to play. But that is not what we 

are getting. 

Ms. ESHOO. Well, I think that that is highly instructive to us, 

Mr. Chairman. 

Mr. BURGESS. That is the reason we are having the hearing. 

80 

Ms. ESHOO. Yes. Well, that is what happens in hearings. 

Mr. BURGESS. And I appreciate your—— 

Ms. ESHOO. But what I am suggesting is that we work with CMS 

to get rid of what was just described as the—did you use the word 

‘‘silliness’’? 

Dr. OPELKA. Yes. 

Ms. ESHOO. OK. Thank you to all of you. You are the healers of 

the Nation. So, thank you for what you have devoted yourselves to, 

and taking on the extra responsibility of heading up organizations. 

Mr. BURGESS. If the gentlelady will conclude her soliloquy—— 

Ms. ESHOO. Thank you. 

Mr. BURGESS [continuing]. We have about a minute left on a vote 

on the floor. 

Ms. ESHOO. I yield back. 

Mr. BURGESS. I am going to recess after I acknowledge the presence of Dr. Boustany, former Member of Congress and member of 

the Ways and Means Committee. We appreciate your attendance 

here today. 

And we will stand in recess until after this vote. 

[Recess.] 

Mr. GUTHRIE [presiding]. The committee will come back to order. 

Thank you. 

There will be other members that are voting and will be back 

shortly to ask questions, but we are going to continue the question 

period. 

All right. The Chair recognizes Dr. Bucshon for 5 minutes to ask 

questions. 

Mr. BUCSHON. Thank you, Mr. Chairman. I appreciate that. 

And thank you to all the witnesses for being here. I was a 

cardiothoracic surgeon before coming to Congress, and this is critically important for our patients at the end of the day, right? And 

that is what I try to focus on. 

As you know, the participation in MIPS is low. Everyone outlined 

roughly 60 percent of physicians are excluded from the program, 

leaving only $118 million of the $70 billion baseline for incentive 

payments for practices. Participation in the alternative payment 

models in MACRA is even smaller, with only 5 percent of physicians enrolled in an APM. CMMI has not approved a single APM 

submitted from PTAC, and PTAC cancelled its June meeting due 

to lack of APMs to review. 

I am interested in ways to increase participation in and the number of APMs, which is why I introduced the Medicare Care Coordination Improvement Act, H.R. 4206, which three of you on the panel’s organizations have signed a letter in support of—and I will get 

to that in a minute—which would encourage development, testing 

of participation in APMs by exempting practices from the volume 

and value prohibitions in the Stark law. After all, how can practices deliver on value-based care if they cannot remunerate their 

physicians based on value? 

Mr. Chairman, I ask unanimous consent to submit the letter to 

the record. 

Mr. GUTHRIE. Without objection, so ordered. 

81 

Mr. BUCSHON. The American College of Surgeons, the American 

Medical Association, and AMGA, among many others, have signed 

onto the letter. 

Basically, it says they are in strong support of the act that we 

introduced and ‘‘The legislation would substantially improve care, 

coordination for patients, improve health outcomes, and restrain 

costs by allowing physicians to participate and succeed in alternative payment models.’’ The bill would modernize the Stark selfreferral law enacted nearly 30 years ago. 

The things that it would do is provide HHS with the same authority to waive the prohibitions of the Stark law and associated 

fraud and abuse laws for physicians seeking to develop and operate 

APMs, as was provided for ACOs in the Affordable Care Act; remove the volume or value prohibition in the Stark law, so that physician practices can incentivize physicians to abide by best practices and succeed in the new value-based alternative payment models. This protection would apply to physician practices that are developing or operating an alternative payment model, including the 

advanced APMs, APMs approved by the physician-focused payment 

model, the Technical Advisory Committee, MIPS APMs and other 

APMs specified by the Secretary; and finally, ensure that CMS’s 

use of current administrative authority promotes care coordination, 

quality improvement, and resource conservation. 

I guess I will ask the question of everyone. How do you think 

changes to the Stark law would help physicians coordinate and improve care and help MACRA succeed? And how important do you 

think that would be in the overall success of what we are trying 

to do with the MACRA legislation and, also, as you have noted, 

transition to an outcome-based, patient-centered-based way to reimburse providers? 

I will just start that. If any of you aren’t aware of what we have 

done, that is OK. But we can start with the surgeons. 

Dr. OPELKA. Thank you very much. 

First of all, yes, we are in strong support of this effort. Specifically, the way that Stark is written, you can be held accountable 

without intent, and that is a problem. So, when we have alternative payment models with shared savings opportunities between 

all the parties, legal counsel, when they review these contracts, become extremely worried about how clean are these waivers or exemptions from Stark. They have got to be bulletproof because Stark 

is so broad and overreaching, it is easy for a court to interpret 

things different than your own counsel interpreted them. 

For that reason, when we go to these alternative payment models 

where there are parties that will be involved in shared savings, or 

whatever different payment models are applied, we need to be sure 

that there is clean, crisp lines that exempt or waivers that are provided for Stark, so the parties can come together. That is really 

what we see. When we put our own APM forward to PTAC, we included the need for Stark waivers and the exemptions. But we 

agree with you and fully support what you are doing. 

Dr. RANSOHOFF. In order to have an ACO, particularly an ACO 

like this that requires risk-taking and risk-sharing, you need to get 

a group of physicians together who are willing to work together 

and share the risk and, also, generally, a hospital. So, you need all 

82 

of those parties to do that. Then, these laws become a serious impediment to doing that. Just the legal expenses of trying to make 

sure it is even OK to have a meeting become daunting. So, I think 

if you are going to encourage doctors and hospitals to try to take 

risks together in a fee-for-service world, you do need to look at the 

regulatory barriers that exist. 

Mr. BUCSHON. All right. Thank you. 

Beg your indulgence, Mr. Chairman. 

Anyone else have any comments quickly? Anyone else? Yes? 

Dr. RAI. Stark made sense in a fee-for-service environment, but 

if we are truly going to move to value, we need regulatory relief, 

as explained by my colleagues. 

Mr. BUCSHON. OK. Thank you. I appreciate that. 

Thanks, Mr. Chairman. I yield back. 

Mr. GUTHRIE. Thank you. The gentleman yields back. 

The Chair now recognizes Mr. Griffith of Virginia, 5 minutes for 

questions. 

Mr. GRIFFITH. Thank you very much, Mr. Chairman. I appreciate 

it. 

I appreciate you all being here. With two votes series disrupting 

the committee, it is tough as witnesses, and I do appreciate your 

patience. 

Let me echo what my colleague just said about the Stark Act. I 

think it is outdated probably in more ways than most people do. 

And I find it inhibits some collaboration in rural areas where we 

are underserved already. And why would we put barriers up? 

Does anybody disagree with that statement? I am looking at the 

entire panel. Just for the record, none of them disagrees with that 

statement. 

All right. Let’s see. Given that, now I have got a question that 

we want to get on the record. On June 29th, CMS allowed MIPS 

participants to see their performance score based on 2017 reporting. Would each of you please share what your scores were? 

Dr. RAI. I would be happy to start since I brought mine with me. 

Mr. GRIFFITH. All right. That would be fine. 

Dr. RAI. We bill under four Tax ID Numbers because of how we 

are regionally divided. Three, we scored 100, and on the fourth one 

we had a 97. 

Mr. GRIFFITH. OK. Anybody else weigh in who knows? Yes, sir? 

Dr. PAREKH. I like your question because it also relates to the 

previous issue of physician participation. I was in a big group practice and I decided to start my own practice. And so, it was the end 

of 2015 and into 2016 that I was doing that. The 2017 measurement, what you are asking about, is based on your surgical volume 

or your volume at the end of 2016, but that is when I was starting 

my practice. 

I knew, of course, about our Academy’s IRIS registry. I knew myself. I knew that I could do a good job on those measures, but there 

was no opportunity for me to participate. I couldn’t opt in. I 

couldn’t believe that I couldn’t opt in. So, I asked multiple people. 

I am like, ‘‘Are you sure I can’t opt-in? I would love to do this. This 

is great. That is a good measure.’’ Multiple people assured me I 

could not. 

Mr. GRIFFITH. OK. 

83 

Dr. PAREKH. So, unfortunately, I was not eligible, even though I 

wanted to be. 

Mr. GRIFFITH. All right. 

Dr. RANSOHOFF. As I have said before, we bill under a single Tax 

ID Number, and we did get 100. 

Mr. GRIFFITH. OK. And last, but not least. 

Dr. OPELKA. I am retired from practice. 

Mr. GRIFFITH. Yes? So, no data? All right. I appreciate that. 

Thank you so much. 

My concern, of course, is rural areas, as I mentioned before, 

when I was talking about the Stark Act. So, when we are looking 

at rural areas, can you describe or can any of you illuminate us on 

the challenges of physicians practicing in the rural areas and the 

pressures they face to remain in practice? And how do the legacy 

programs add to those burdens? I know a lot of the burdens they 

have already. But how do the legacy programs add to those burdens, and has MIPS eased those burdens? And even if it has eased 

them a little bit, what else can we be doing to help our rural 

friends? 

Dr. Barbe? 

Dr. BARBE. Maybe I will weigh in on that first. So, I was amazed 

when MACRA passed and we were looking at MIPS, and we had 

a lot of physicians come out of the woodwork and say, ‘‘Oh, my 

gosh, how are we going to comply with MIPS?’’ And I thought in 

my mind, well, have they not been doing the legacy programs already? And the answer is, no, they hadn’t. Hundreds of thousands 

of physicians didn’t participate in all three or didn’t participate 

successfully. So, there are a lot of physicians that are now working 

to make this transition. 

Specifically, with regard to rural, Dr. Opelka said it very well. 

We need meaningful measures that relate to that individual physician’s practice. We need to make them easy to capture, and we 

need to make them, if you will, activities that are applicable across 

more than one of those dimensions of MIPS. If you have got a diabetic patient and you are changing your processes and you are improving care, and you are using an electric record, why don’t you 

get credit across all three domains? 

Mr. GRIFFITH. All right. Yes, sir? 

Dr. OPELKA. Very quickly, the trauma program is a classic example where we have Level I, II, and III levels of service. Typically, 

in the rural environment we are dealing with a Level III. The number of standards they need to meet are significantly less than the 

200-plus standards for a Level I. So, you need to tailor measurement down to the point of care and the care model that that environment has. The MIPS program does not do that. It is a one-sizefits-all program. So, the rural element is no different than, in surgery, it is no different than in the city. They are not meaningful 

and fit for purpose. And therefore, the surgeons pay attention to it 

for purposes of payment, but not for the purposes of quality of care. 

Mr. GRIFFITH. OK. Anybody else? Yes? 

Dr. RAI. We operate many rural clinics, but because they are 

part of a larger multi-specialty group, we are able to spread our infrastructure more efficiently to them. 

84 

And to your other question about was it easier under MACRA to 

submit versus the legacy programs, I have talked to our quality department. It was slightly easier this year to submit to CMS. The 

mechanism of submitting all three at once was easier than the previous legacy format. 

Mr. GRIFFITH. So, it was a little bit better? 

Dr. RAI. A little bit better, yes, sir. 

Dr. PAREKH. I would echo all these comments. Understand that 

rural medicine is very different than urban/suburban. And I know 

in Washington oftentimes people talk about a bubble in Washington, but coming from central Pennsylvania, it is a very different 

environment here. Let me tell you, there are hospitals where I 

can’t get internet service. Just think about that statement. And my 

EMR, of course, is a cloud-based EMR. This is a true issue. But, 

again, I think MACRA has certainly helped, to answer the second 

part of your question. 

Mr. GRIFFITH. Other parts of our committee are trying to work 

on those internet issues. 

Dr. Ransohoff? 

Dr. RANSOHOFF. Technically, right now for someone who had just 

done nothing, MIPS is actually better, just by the algebra of it initially, because the cut would have been less. 

But I agree with my colleagues, and I have said previously I 

think for small practices in rural areas they just need a different— 

they need relevant standards that resonate with their practice, but 

they probably need to have a different test, so that they can participate. Fewer measures I think would be a very reasonable approach. 

Mr. GRIFFITH. All right. Thank you very much. I appreciate it. 

And my time is up and I yield back. 

Mr. GUTHRIE. Thank you. The gentleman yields back. 

The Chair now recognizes Mr. Carter from Georgia for 5 minutes 

for questions. 

Mr. CARTER. Thank you, Mr. Chairman. 

And thank all of you for being here. 

Before I begin my questions, I have to say this. Earlier in the 

hearing there was a conversation about doctors’ handwriting. And 

I just want to say, I want to represent my profession as a practicing pharmacist for over 30 years. So, you get it? You understand 

what I am saying. 

[Laughter.] 

Anyway, I couldn’t resist that and I apologize. Too many times 

have I struggled to understand what a doctor was writing. 

I wanted to talk to Dr. Rai. OK, I am sorry. I know I butchered 

that. 

But, nevertheless, as a pharmacist, I am a member of the Doctors Caucus. We had sent a letter to CMS earlier this month about 

MACRA and MIPS implementation and the $500 million that had 

been authorized to ensure positive payment adjustments. But one 

of the things that we have run into is that we just don’t have 

enough physicians who are participating. And I just wanted to ask 

you. CMS estimates that it is over 60 percent that aren’t participating. What are the obstacles? What are some of the obstacles 

that are preventing or prohibiting providers from switching to this? 

85 

Dr. RAI. I think some of the obstacles are inherent to how they 

have been practicing medicine and how their own structures have 

been developed over time. Some may say they have not followed 

the legacy programs, as was mentioned earlier. So, they have not 

actually implemented the EMR or using it in a meaningful way. 

They have not developed patient-centered medical homes or have 

the ability to tap into registries. There are a variety of reasons why 

people are not participating. 

But for us to truly move to value, we need everybody to participate. MACRA was written to be a carrot-and-a-stick program. So, 

for it to work, everybody has to be in. 

Mr. CARTER. I suspect that I would be correct to say that it is 

worse in rural areas than it is in urban areas. Is that correct? 

Dr. RAI. I haven’t seen CMS’s distribution of who is not participating, but I think it is across the board. I think you will see it 

in small single specialty in a very urban area. But, yes, you will 

probably see it a lot in urban areas that don’t have a system infrastructure supporting them. 

Mr. CARTER. OK. Can you describe very briefly about some of the 

investments that your organization has made in order to participate in this? 

Dr. RAI. I can break the investments into three categories, the 

first being people. The most important category in healthcare is 

continuously investing in people. Team-based care is not inexpensive—nurse care managers, extra medical assistance, making sure 

the physician or the provider is surrounded by the best people to 

take care of their population, not just the patient that is in front 

of them that day. 

The next area is, like I mentioned, an EMR is only as good as 

you can draw the data out of. So, our largest area of investment 

in the EMR is not really the EMR anymore. It is digital platforms 

to draw the data out, to analyze it, to hopefully someday get access 

to claims data, which we need, to be able to look at a risk population and predict what is going to happen to a patient before it 

happens to them. 

And the third area of investment is that digital platform that is 

patient-facing. Our patients want access to their record. It is not 

our medical record; it is their medical record. It is creating environments for them to interact with us in virtual care, like we launched 

this year, where they don’t have to come into the office. 

Those have been the three categories of investments that we personally made to make sure we are successful not only with 

MACRA, but with value down the line. 

Mr. CARTER. Right. Thank you. 

Dr. Parekh, I wanted to ask you, in your testimony you had mentioned that MedPAC had made the recommendation that MIPS 

should be replaced with a voluntary value program that might be 

phased in over time. And I just wanted to ask you—and in full disclosure, I agree with you; I don’t agree with MedPAC. I think that 

would be the wrong route for us to go. I think we are headed in 

the right direction with this. We ought to figure out a way, I think, 

if not to incentivize, then to require physicians to do this. And I 

don’t like that. I don’t like the heavy-handed government, particuVerDate Nov 24 2008 14:50 May 21, 2019 Jkt 037690 PO 00000 Frm 00091 Fmt 6633 Sfmt 6633 U:\MY DOCS\HEARINGS 115\HEARINGS\115-160 CHRIS
86 

larly in healthcare. But, at the same time, I am convinced we are 

moving in the right direction. 

I just wanted to ask you, what are some of the challenges to developing outcome measures in the practice of medicine? 

Dr. PAREKH. It is just hard. It is hard to do. You have to have 

a clean measurement. You don’t want all these other comorbidities 

that are ‘‘messing up your outcomes’’. So, let’s take cataract surgery, for example. If I have a patient who has got severe blinding 

macular degeneration at baseline, and then, they have developed a 

cataract on top of that, as bad as it originally was, now it is worse. 

So, I take their cataract out and I get them maybe to 2400, which 

is the big ‘‘E’’, legal blindness still. They are ecstatic, but my measure might look bad because, ‘‘Oh, Dr. Parekh, this patient, you operated on them and they are legally blind.’’ So, things like that, 

those subtleties, the devil is in the details. 

Mr. CARTER. Right. 

Dr. PAREKH. Those subtleties make all the difference. So, coming 

up with those kind of clean outcomes is very hard to do. 

Mr. CARTER. Right. 

Dr. PAREKH. And so, there are certain surgeries that lend themselves to that, but others that don’t. 

Mr. CARTER. I am out of time. But I want to thank all of you for 

your efforts in moving this forward, because I do believe it is we 

are headed in the right direction with this. 

And I yield back. 

Mr. GUTHRIE. Thank you. The gentleman yields back. 

Seeing there are no further members wishing to ask questions, 

I would like to thank you all for being here today. As somebody 

mentioned earlier, you are missing a lot of patients today to be 

here to inform us, but it is important that you do. 

And I would like to submit the following documents for the 

record: American Academy of Dermatology Association, letters from 

the American Academy of Family Physicians, the American College 

of Physicians, Connected Health, American Society of Clinical Oncology, Infectious Disease Society of America, and Medical Group 

Management Association. 

Mr. GREEN. No objection, Mr. Chairman. 

Mr. GUTHRIE. Without objection, so ordered. 

[The information appears at the conclusion of the hearing.] 

Mr. GUTHRIE. Pursuant to committee rules, I remind members 

that they have 10 business days to submit additional questions for 

the record, and I ask that witnesses submit their response within 

10 business days of receipt of the questions. 

Mr. GREEN. Without objection. Mr. Chairman, I would just like 

to recognize a family from my district, the Garcia family. We spend 

a whole lot of time in these committee meetings. But I thank them 

for coming here. 

Mr. GUTHRIE. Welcome. Welcome to Washington. Thanks for 

being here. 

So, without objection, the subcommittee is adjourned. 

[Whereupon, at 12:13 p.m., the subcommittee was adjourned.] 

[Material submitted for inclusion in the record follows:] 

87 

PREPARED STATEMENT OF HON. FRANK PALLONE, JR. 

We’re meeting today to discuss one of the great bipartisan success stories of this 

Committee, the Medicare Access and CHIP Reauthorization Act of 2015, or MACRA. 

MACRA built upon the successes of the Affordable Care Act to improve the quality 

and efficiency of the Medicare program, and of our health care system more broadly. 

The ACA took major steps towards improving the quality of our health care system by creating new models of health care delivery within the Medicare program. 

These new payment and delivery models focused on transforming clinical care and 

shifting from a volume- to a valuebased care model, such as Accountable Care Organizations (ACOs) and Patient Centered Medical Homes (PCMHs). 

With MACRA, we are entering the next phase of delivery system reform. MACRA 

builds on reform efforts by offering opportunities and financial incentives for physicians to transition to new payment models known as Advanced Alternative Payment 

Models, or AAPMs. AAPMs must meet a number of criteria, and requires clinicians 

to accept some financial risk for the quality and cost outcomes of their patients. 

Physicians can join existing and successful models that qualify as AAPMs, such as 

ACOs and the Comprehensive Primary Care Plus (CPC+) model, which we will hear 

about today. They can also develop their own models, known as Physician-Focused 

Payment Models. 

MACRA also created the Merit-Based Incentive Payment System, or MIPS. This 

is an alternative path for clinicians to make the shift away from a volume-based 

system to a valuebased system. It focuses on quality, value, and accountability. 

Our witnesses practice in a variety of settings across the country and represent 

diverse expertise and training. They each have a unique perspective to share with 

us regarding the implementation of MACRA. I know that some of our witnesses 

have concerns about how MIPS has been implemented by CMS, in particular the 

decision by the agency to exclude 58 percent of providers from MIPS requirements 

through the low-volume adjustment. I share these concerns and want to learn more 

about how CMS’s decisions may impact successful MACRA implementation going 

forward. 

I want to thank you all for your commitment to delivery system reform-it is only 

through the sustained commitment of the leading physician organizations and clinicians such as yourselves that we can hope to bend the cost curve and create a system that truly rewards high value care. I hope that after hearing from our panelists 

today, we will all have a better understanding of the opportunities and challenges 

faced by physicians in the MIPS program. 

Thank you, I yield back the remainder of my time. 

88 


36027.048

U.S. House of Representatives 

Committee on Energy and Commerce 

Subcommittee on Health 

Hearing on "MACRA & MIPS: An Update on the Merit-Based Incentive Payment System" 

Thursday, July 26, 2018 

American Academy of Dermatology Association 

Statement for the Record 

Chairman Burgess and Ranking Member Green, on behalf of the American Academy of 

Dermatology Association (Academy), which represents more than 13,800 dermatologists 

nationwide, thank you for your leadership in convening the hearing on "MACRA & MIPS: An 

Update on the Merit-Based Incentive Payment System." The Academy is pleased to submit the 

following statement for your consideration. 

The Academy is committed to excellence in the medical and surgical treatment of skin disease; 

advocating high standards in clinical practice, education, and research in dermatology; and 

supporting and enhancing patient care to reduce the burden of disease. We applaud you for 

continuing to monitor the implementation of Medicare Access & CHIP Reauthorization Act 

(MACRA) and ensuring that the needs of physicians and other healthcare providers, as well as 

those of our patients, are taken into account as the requirements of the Quality Payment Program 

(QPP), and the Merit-Based Incentive Payment System (MIPS) specifically, are developed. 

We greatly appreciate the substantive progress that was made in 2017 to implement the Quality 

Payment Program (QPP) under MACRA in a manner that provides regulatory relief to physicians. 

The Centers for Medicare and Medicaid Services (CMS) increased the threshold for individual 

Merit-Based Incentive Payment System (MIPS) eligible clinicians or groups to be considered 

exempt, excluding from the new system those with up to $90,000 in Medicare Part B allowed 

charges or up to 200 Part B beneficiaries. CMS added a new hardship exception for clinicians in 

small practices (15 or fewer clinicians) under the Advancing Care Information (ACI) performance 

category, and CMS also provided relief to physicians who faced disasters such as the California 

wildfires and the devastating hurricanes of 2017. Finally, as MACRA requires 25 percent of the 

MIPS final score be based on performance in the ACI performance category, CMS made an 

important modification to the performance score changes to give 10 points for participating in a 

specialized registry such as the Academy's Qualified Clinical Data Registry (QCDR), DataDerm. 

Rewarding physicians for participating in a QCDR not only allows physicians to report on 

performance measures that are approved by CMS, but it also promotes QCDRs' development of 

quality measures that are relevant and meaningful to practicing physicians. 

As the Subcommittee convenes this hearing today, there are four issues that the Academy would 

bring to the Subcommittee's attention. 

Suzann\! Olbricht, MD, FAAD Tht!i<:>do•·v Ro,.en, MD, FAAD 

Jane M. Grant-K~!s, MD, FAAD 

Barbara M. Math.,s, MD, FAAO Elaine Weiss 

E•~'·'''""D,,cotr,• ,;ndCEO 
89 


36027.049

July 26, 2018 

Page 2 of 4 

Cost Performance 

First, the Academy is concerned that it is premature for physician payment to be based on cost 

performance given the flaws in the current patient attribution methods. For 2018, CMS finalized a 

10 percent weight for the cost performance category in the final MIPS score. This is intended to 

ease the transition to a 30 percent weight for the cost performance category in the 2021 MIPS 

payment year. For the 2018 MIPS performance period, CMS is adopting the total per capita costs 

for all attributed beneficiaries measure and the Medicare Spending per Beneficiary (MSPB) 

measure, both of which were adopted for the 2017 MIPS performance period. 

However, many physicians have reported problems with the current attribution methods. For 

instance, a dermatologist provided the most Evaluation and Management services to a patient 

during the reporting period. That patient suffered from recurring mental health problems that 

resulted in admission to an inpatient facility. The costs for hospitalization and other care 

associated with the mental illness were attributed to the dermatologist. This indicates that the 

attribution method is clearly flawed, and we understand that the appeals process does not seem 

to be functional. Until CMS corrects the attribution method to ensure that costs of care not 

associated with the condition being treated are not attributed to the specialist caring for the patient, 

the cost performance should not be given a weight. 

Additionally, it is very difficult for physicians to look-up their cost score prior to their reporting cycle. 

Physicians are not aware of what this score will be nor what they can do to positively affect cost 

performance. CMS needs to make this scoring process more transparent and not grade 

physicians on their performance without providing details on how they can actually improve their 

cost scores. 

QCDR Measure Approval Process 

Second, improvements to the QCDR measures approval process are needed to achieve 

efficiency, transparency, and connection to clinical evidence. The current process is characterized 

by unreasonable deadlines, unexplained rejection or consolidation of measures, an inconsistent 

review process, and disjointed review. Consideration of time to gather data and provide evidence 

of measure and performance gaps during the review process would allow for continued 

meaningful measures for specialists. Further, the Academy opposes applying the MIPS Call for 

Measures process to OCDR measures. The MIPS process is slow (6 months between measure 

submission and publication of the final list), cumbersome, and ill-suited to specialty care. The 

Measurement Application Partnership (MAP) process hinges on National Quality Forum (NOF) 

endorsement, a separate lengthy process with few standing committees that include Dermatology 

topics. Historically, the Measures Advisory Panel lacks the expertise to review the clinical 

importance and evidence for specialty measures. The measure approval process must be based 

on specialty-relevant clinical expertise and rationale. Instead of applying the MAP process to 

QCDR measures, we have urged CMS to improve the current QCDR measure review by 

implementing a transparent review process with clear criteria about the acceptability of measures 

and clear timelines for CMS review. Harmonization is a worthy goal that should be addressed 
90 


36027.050

July 26, 2018 

Page 3 of 4 

outside the measure approval process. We appreciate that CMS has met with us a number of 

times to hear our concerns on this important issue and hope that needed improvements can be 

made. 

Data Blocking 

The ability of QCDRs to access patient information from electronic health record (EHR) vendors 

is crucial for such registries to not only achieve their missions of improving quality of care, but 

also to foster the development of quality measures that are relevant and meaningful to practicing 

physicians. The passage of provisions in the 21st Century Cures Act (Pub. L. 114-146) (the "Cures 

Act") was instrumental to prevent EHR vendors from blocking the transmission of clinical 

outcomes data to third parties, such as QCDRs. 

While we understand that the DIG and Office of the National Coordinator for Health Information 

Technology ("ONC") are developing rulemaking to implement such information blocking 

requirements, some EHR vendors are creating barriers to access patient information within their 

systems. For example, some EHR vendors require providers to pay a large annual fee to send 

their data from the EHR to the clinical data registry or their software vendor, or require purchasing 

intermediary software systems owned by the EHR. Cost-prohibitive interoperability deters 

physician participation in QCDRs. EHRs also refuse to provide full measure calculations to clinical 

data registries and only provide partial data on various measures. Much of this is also due to 

various EHRs having a stake in their own MIPS reporting modules, which provide incentives to 

their bottom line. Such barriers interfere with and materially discourage access to such information 

by clinical data registries. These obstructive tactics also create inefficiencies for physicians to 

report their data for MIPS. We look forward to working with the DIG and ONC to address these 

data blocking concerns to unlock QCDRs' potential to develop meaningful measures for the QPP. 

Administrative Burden 

MACRA also has increased physician burden through complex scoring and reporting 

requirements. Though much has been done to reduce reporting burdens on physicians who 

participate in MACRA, there is still more to do to ensure our health care system is able to address 

the needs of a growing and diversifying patient population. We believe QCDRs hold the key for 

data-driven policy changes and streamlined physician reporting, and would like to collaborate with 

you in strengthening the reliance on OCDRs as part of the Quality Payment Program. We are 

pleased that CMS has indicated further reduction in physician reporting will come through 

increased credit for the use of QCDRs. We encourage you to further strengthen QCDRs by 

ensuring that participation in QCDR reporting is sufficient for meeting threshold status for MIPS 

providers, This would reduce overall administrative burden on physicians and provide one outlet 

for them to report all of their measures through MIPS. We are pleased that many of the physicians 

we represent were able to avoid the penalty for MIPS in 2017 by reporting through a QCDR, with 

a significant percentage of them being recognized as high performers due to their having reported 

additional measures. This score adjustment would stimulate increased participation in QCDRs 

and accelerate QCDRs' development of quality measures that are relevant and meaningful to 

practicing physicians and their patients. Additionally, this could encourage EHR vendors to more 

readily share patient data, since MIPS credit is a significant selling point for EHRs. 
91 


36027.051

July 26, 2018 

Page 4 of 4 

Again, the Academy appreciates the Subcommittee holding this hearing today, and the Academy 

appreciates the Subcommittee's efforts to address the clinician burdens in implementation of this 

important payment system changes under MACRA. Please feel free to contact Christine 

O'Connor, the Academy's Associate Director, Congressional Policy, at coconnor@aad.org or 

(202) 609-6330 if you have any questions or if we can provide additional information. 
92 


36027.052

July 26, 2018 

The Honorable Michael Burgess, MD 

Chair, House Committee on Energy and 

Commerce 

Health Subcommittee 

U.S. House of Representatives 

Washington, DC 20515 

The Honorable Gene Green 

Ranking Member, House Committee on 

Energy and Commerce 

Health Subcommittee 

U.S. House of Representatives 

Washington, DC 20515 

Dear Chairman Burgess and Ranking Member Green: 

On behalf of the American Academy of Family Physicians (AAFP) and the 131,400 family physicians 

and medical student members we represent, I write to express our continued support for the goals 

and objectives established by the Medicare Access and CHIP Reauthorization Act (MACRA). We 

appreciate your efforts to evaluate the law and its implementation and thank you for seeking 

physician input as part of the Committee's hearing titled, "MACRA and MIPS: An Update on the Meritbased Incentive Payment System." 

While the AAFP continues to support the underlying goals of the law, we do have concerns with the 

implementation of MACRA. As you know, MACRA placed a priority on the transition of physician 

practices from the legacy fee-for-service payment model towards alternative payment models (APM) 

that promote improved quality and efficiency. To date, the number of available APMs is not sufficient 

to achieve this goal. The AAFP has been actively engaged on the development of primary care 

focused APMs and is eager to work with the Centers for Medicare and Medicaid Services (CMS) and 

the Centers for Medicare and Medicaid Innovation (CMMI) to test these models. While we have 

concerns, we are encouraged by the new leadership at CMMI and the focus of their work. 

Regarding the Merit-based Incentive Payment System (MIPS), we are concerned with the continued 

complexity of the scoring methodology, lack of timely and clinically actionable feedback, and 

terminology changes made by the agency. We recognize the administration's efforts to address this 

issue through proposals for 2019 and look forward to providing substantive feedback on those 

proposals and the new physician fee schedule's documentation guidelines. 

To improve the Quality Payment Program (QPP), the AAFP advocates for the following policies: 

An opt-in pathway for those MIPS-eligible clinicians who find themselves below the lowvolume threshold, which the agency proposes to add in 2019. 

Retention of cross-cutting measures in specialty sets with fewer than six measures to ensure 

parity in quality reporting across all eligible clinicians. 

New ways to hold harmless, for purposes of the cost category, physicians who cannot be 

reliably measured against at least one episode-based cost measure, until such time when 

CMS can create a more even and meaningful playing field for cost measurement. 

Decreased complexity of scoring in MIPS performance categories. 

www.aafp.org 

, N.\"1, WJO ! WOOl 
93 


36027.053

Support for the Physician-Focused Payment Model Technical Advisory Committee's role in 

evaluating physician-focused payment models (PFPMs). We see significant value in 

broadening the PFPM definition to include any public and private payment modeL 

For the past two decades, the AAFP has been a leading voice for reforms that move our delivery and 

payment systems away from the episodic, fee-for-service regime that has defined our health care 

system for much of the past 60 years. While fee-for-service will always have a role, we are convinced 

that it is, in most instances, not congruent with the delivery of patient-centered, comprehensive, and 

continuous advanced primary care. 

Again, we appreciate the opportunity to offer our thoughts on this important issue and help set a 

specific, measurable, achievable, relevant, and time-bound goal to reduce administrative burden and 

focus on patients over paperwork. The AAFP stands ready to assist in achieving this important goaL 

For more information, please contact Sonya Clay, Government Relations Representative, at 202-232-

9033 or sclay@aafp.org. 

Sincerely, 

John Meigs, Jr., MD, FAAFP 

Board Chair 

2 
94 


36027.054

Statement for the Record 

American College of Physicians 

Hearing before the Energy and Commerce Health Subcommittee 

On 

MACRA and MIPS: An Update on the Merit-based Incentive Payment System 

July 26, 2018 

The American College of Physicians (ACP) is pleased to submit this statement for the record and 

appreciates the efforts of Chairman Burgess and Ranking Member Green in convening this 

hearing on the Merit-based Incentive Payment System (MIPS). Thank you for your shared 

commitment in wanting to ensure that the payment and delivery system reforms created under 

the Medicare Access and CHIP Reauthorization Act (MACRA) are implemented successfully and 

as intended by Congress. We also appreciate the subcommittee and full committee inviting 

input from the physician community throughout the implementation process, and for your 

continued oversight of the Quality Payment Program (QPP). We wish to assist in these efforts 

by offering our input and suggestions on the ongoing implementation of MIPS, as noted in 

detail below. 

ACP is the largest medical specialty organization and the second-largest physician group in the 

United States. ACP members include 1S4,000 internal medicine physicians (internists), related 

subspecialists, and medical students. Internal medicine physicians are specialists who apply 

scientific knowledge and clinical expertise to the diagnosis, treatment, and compassionate care 

of adults across the spectrum from health to complex illness. 

OVERVIEW OF ACP's VIEWS ON MACRA 

To reiterate what ACP has stated in its many communications to Congress on MACRA and the 

QPP, the College has been a strong supporter of MACRA and embraces its goal of creating 
95 


36027.055

incentives for physicians and other clinicians to improve quality and to adopt alternative 

payment models (APMs) aligned with the result in better value for patients and the program. 

MACRA remains a major improvement over the preceding fee-for-service (FFS) system with 

yearly adjustments based on Medicare's Sustainable Growth Rate (SGR) formula, to one of 

value, accountability, and patient-centered care. However, continued improvements are 

needed for the QPP, as created by MACRA, to fully deliver on its intent. 

The College has been active in providing feedback on the QPP via its comment letters to the 

Centers for Medicare and Medicaid Services (CMS) on both the 2017 and 2018 final rules, the 

Center for Medicare and Medicaid Innovation's (CMMI's) request for information on a "new 

direction," and the Measure Development Plan, as well as numerous other requests for 

information and feedback from the Agency. 

The Merit-based Incentive Payment System (MIPS) 

The College believes that MIPS plays an important and essential role in offering a pathway for 

physicians who continue to be reimbursed under the traditional Medicare FFS system to make 

changes in their practices to improve the value of care provided to patients as a step toward 

participating in more transformative APMs. That said, despite important steps being taken by 

the current and previous administrations to make MIPS as effective as possible, many ACP 

members remain concerned that reporting on many of the measures used by MIPS is overly 

burdensome, measures the wrong things, and is not likely to bring about real improvements in 

outcomes. Indeed, ACP's Performance Measurement Committee has reviewed many of the 

measures currently being used by MIPS and has determined that they lack validity, or are of 

uncertain validity. Other aspects of MIPS could also be simplified and improved. ACP 

specifically believes MIPS could be more effective if the following changes were made: 

1. Simplify MIPS 

Congress envisioned MIPS as a solution to the discounted and siloed legacy programs of the 

past. MIPS was designed to be a single, consolidated, and streamlined federal quality reporting 

program that aligned reporting objectives and measures into straight-forward requirements 

2 
96 


36027.056

that minimize burden on clinicians and practices. Unfortunately, certain aspects of MIPS' 

original design have led to unexpected challenges, resulting in ongoing complexity and little 

improvement in the harmonization of reporting requirements. Therefore, the College 

appreciates that Congress recognized the need for CMS to have additional flexibilities in certain 

areas to allow for a number of improvements and updates via several technical changes in the 

Bipartisan Budget Act of 2018 (H.R. 1892). This law enabled CMS to adjust the weighting of the 

Cost Performance category and make important changes to the methodology for establishing 

the performance threshold. 

ACP offered the following additional suggestions to further simplify the program: 

• CMS must simplify the overall scoring approach so that the point value for each measure or 

activity reflects its relative value within the composite performance score (CPS). For 

example, the points within the Quality component would total 50 points, which reflects the 

current weight of that category. 

• CMS should remove the weighting of individual Improvement Activities, as it adds 

unnecessary complexity and it is unclear what evidence might indicate why certain activities 

might be considered "medium" versus "highly" weighted. 

• The Promoting lnteroperability category of the program should be even further simplified. 

Currently, clinicians must contend with a scoring methodology that divides the category 

into three separate components, each scored a different way, that add up to a total of 155 

points, while the category is actually scored out of 100 points. Of note, in the recently 

released notice of proposed rulemaking with changes to the QPP for the 2019 performance 

year, CMS does propose to "overhaul" scoring for this category, including getting rid of the 

separate "base" and "performance" scores, evaluating all measures on the same 

performance basis, and creating alignment between MIPS and other Medicare programs. 

ACP is encouraged by these proposals and will be reviewing them closely in order to provide 

feedback to the Agency. 

2. Increase support for small practices and those in rural and underserved areas 

3 
97 


36027.057

Small practices and those in rural and underserved areas are repeatedly outperformed by their 

larger and more integrated counterparts on MIPS metrics. Often however, this is more a 

reflection of their lack of resources and ability to strategize than a true reflection of their value 

of care. To help address these concerns, we offer the following recommendations: 

• Support CMS' recent proposal in the 2019 QPP rule to allow clinicians who would otherwise 

qualify for exemption from MIPS under the low-volume threshold, the option to "opt in" to 

MIPS. This would increase participation in the program without imposing additional undue 

burden on physicians and is strongly supported by the ACP. 

• Increase assistance specifically geared to small practices, including possibly financial 

assistance for purchasing technologies such as Electronic Health Record (EHR) systems or 

registries, which can be instrumental in leveraging access to real-time data to drive highvalue care, but can often be prohibitively expensive, particularly for small and rural 

practices. Even for practices that already have implemented an EHR and/or other 

technology solutions, there are significant costs associated with paying for the necessary 

upgrades due to the annual changes in the MIPS program requirements. 

• Urge CMS to extend the small practice bonus to clinicians in rural and underserved areas. 

• Urge CMS to establish a separate, lower nominal risk amount standard for small and rural 

APM entities, such as one that aligns with the medical home model nominal risk standard. 

This will allow practices that do not have the same sophistication of infrastructure or liquid 

financial resources as larger practices the opportunity to participate in innovative APMs to 

improve care and reduce costs for their patient populations. 

3. Reduce administrative burden 

Physician practices spend $15.4 billion per year, or approximately $40,000 per physician, to 

report on performance. In addition to costing practices financial resources and hours of staff 

time, the administrative burden created by MIPS and other federal programs is a leading 

contributor to physician burnout. ACP has made reducing the burdens of regulatory and 

administrative tasks one of our top advocacy priorities, as evidenced in the launch of our 

Patients before Paperwork initiative in 2015. We strongly support CMS' "Meaningful Measures" 

4 
98 


36027.058

and "Patients over Paperwork" initiatives but believe there is more opportunity for 

improvement in this area. Congress can help to support these important, ongoing efforts to 

reduce administrative burden in the following ways: 

• Urge CMS to award cross-category credit, where one high priority activity or measure could 

earn points in multiple performance categories. This would allow practices to focus in on 

meaningfully driving improvement in key strategy priority areas. For instance, practices 

could report through their EHR system that they began participating in a prescription drug 

monitoring program, which could potentially earn that practice points in the Improvement 

Activities, Quality, and Promoting lnteroperability categories while helping to combat the 

nation's opioid epidemic. 

• Urge CMS to reduce the minimum quality reporting period from a full year to 90 

consecutive days to align with the Promoting lnteroperability and Improvement Activities 

categories. This will have an immediate impact on reporting burden, will create consistency 

across the performance categories, and will allow for much-needed flexibility. Should 

practices experience any difficulties throughout the reporting year, such as technical 

malfunctions by their EHR product, which are reported commonly by our members, rather 

than claiming a hardship exception for an entire performance year, the practice would 

simply report on another 90-day window unaffected by the technical glitch. 

Urge CMS to move the performance period closer to the payment adjustment year as soon 

as possible. As it stands currently, clinicians receive performance feedback six months after 

the performance year has concluded. Payments are impacted two years later. Such a 

delayed cycle can hardly be considered to drive quality and generates mass confusion 

because reporting requirements and scoring rules change year-to-year. Shortening the 

reporting, feedback and payment cycle will allow clinicians to receive more timely feedback 

so that they can truly leverage that information to drive improvement in their practices, 

rather than simply engaging in a reporting exercise after the fact. Ideally, CMS would 

provide access to real-time Medicare claims data. 

• Urge CMS to allow for an appropriate amount of time for practices to transition to new 

2015 Edition CEHRT. The College supports the transition to the new 2015 Edition Certified 

5 
99 


36027.059

EHR Technology (CEHRT) to place greater emphasis on improved interoperability between 

EHR systems. However, upgrading this technology takes time and comes at a significant 

expense to practices. It cannot occur overnight. It will take time for vendors to reconfigure 

the systems to accommodate the new standards, as well as for practices to train clinical and 

administrative staff on the new requirements and system functionalities. Allowing only a 

few months between the release of the final rule and the proposed implementation date of 

Jan. 1, 2019 is likely to result in widespread software glitches that could pose risks to 

patients' health. The College recommends a minimum of six months for vendors and 

practices to perform the necessary system upgrades and staff training to ensure a smooth 

transition on such a massive scale. 

• Under the Promoting lnteroperability category, CMS currently scores certain measures on 

an "ali-or-nothing" basis, where clinicians must report on all required measures or be given 

a score of zero for the entire performance category. In the recently proposed rule with 

changes to the QPP for the 2019 performance year, CMS proposes to overhaul the scoring 

methodology for the Promoting lnteroperability category, as noted previously. However, 

the proposals technically expand the number of required measures that, if not reported, 

would lead to a total score of zero in this category. ACP has expressed serious concerns 

about this approach in the past and the burden it imposes on physician practices that could 

report the vast majority of measures, but may struggle with a single measure for any 

number of reasons, including relevant patient population, EHR functionalities, etc. One of 

the improvements that Congress had the foresight to make to the QPP under MACRA 

compared to the legacy programs was to stop using this cliff-based scoring approach under 

which a clinician could fulfill the majority of requirements but be awarded zero credit for 

failing to report a single measure. Instead, MACRA specifically calls on CMS to implement a 

"sliding scale" scoring approach that rewards clinicians proportionally for the amount of 

data they report. We urge Congress to use its oversight authority to impress upon CMS that 

this ali-or-nothing scoring approach that continues to be used for the Promoting 

lnteroperability category conflicts with Congressional intent under MACRA and subjects 

practices to undue administrative burden and financial risk, given the substantial expense of 

EHR systems. 

6 
100 


36027.060

• We understand the need to collect meaningful data, but only in the case where it is pulled 

from the EHR without additional steps required by the physician. 

4. Improve the accuracy of MIPS measures and data 

Nearly two thirds of practices reported that the current measures do not accurately capture the 

quality of care they provide. ACP has strongly advocated for CMS and other payers to ensure 

that reported measures are evidence-based, outcomes-focused, and aligned within the existing 

clinical workflow, and that they undergo a multi-stakeholder evaluation process. We offer the 

following specific recommendations to further refine and improve the accuracy of MIPS data: 

• Urge CMS to collaborate in a multi-stakeholder evaluation process to develop, test and 

implement both new and existing measures to create a streamlined set of evidence-based, 

outcomes-focused quality measures that align within existing clinical workflows, thereby 

minimizing clinician burden. This not only includes filling critical measure gaps, but also 

removing measures that are poor quality as needed. Our Performance Measurement 

Committee conducted an in-depth scientific review of the validity of 86 QPP quality 

measures relevant to ambulatory general internal medicine and found that just one third 

were valid (35 percent were not valid and 28 percent were of uncertain validity). We urge 

Congress and the administration to look to these recommendations first when considering 

internal medicine measures. Next, Congress and the administration should look to 

measures endorsed by the Core Measures Collaborative and recommended by the Measure 

Application Partnership. Of note, in the proposed 2019 QPP rule, CMS proposes to retire 34 

and add 10 new quality measures. While ACP is still closely analyzing the impact of these 

proposed measure additions and removals, we are encouraged that CMS is taking steps to 

remove what it considers to be low-value measures. However, we underscore the 

importance of taking concrete actions to ensure specialty clinicians have a sufficient 

number of measures to report so that they can successfully participate in the program. 

• Urge CMS not to increase the weight of the Cost category in the same year that new 

measures are being introduced. ACP appreciates that Congress added an additional three 

years of flexibility in setting the weight of the Cost (formerly Resource Use) Performance 

7 
101 


36027.061

category in Sec. 51003 of the Bipartisan Budget Act of 2018 (H.R. 1892), which will provide 

much-needed time for CMS to continue developing and refining new episode groups, 

patient relationship categories, and patient condition categories. However, next year, CMS 

proposes to introduce eight new episode-based cost measures while simultaneously 

increasing the weight of the Cost category from 10 percent to 15 percent. The Cost category 

should not increase above its current weight of 10 percent until CMS is able to fully evaluate 

the reliability and accuracy of these new measures. 

• Urge CMS to address current flaws in risk adjustment methodologies that fail to accurately 

account for socioeconomic status, which create a system that inappropriately penalizes 

physicians with higher numbers of lower income or frailer patients. It is vitally important 

that MIPS help to reduce, rather than exacerbate, current disparities in care due to social 

inequities. Properly controlling for socioeconomic factors is critical to both learning more 

about these populations and understanding ways to help reduce this gap, and ensuring 

clinicians are not adversely penalized for caring for at-risk or more complex patient 

populations, which could result in access issues for vulnerable patients. 

Urge CMS to address flawed patient attribution methodologies for the total per-capita cost 

and Medicare Spending per Beneficiary (MSPB) measures, which were carried over from the 

Value-Based Payment Modifier legacy program and inappropriately attribute broad-based 

costs to physicians for services that are outside of their control and that they do not have 

the ability to impact, such as costs associated with care settings outside of the physician's 

practice. 

• Encourage CMS to allow practices to subdivide into smaller groupings (i.e., specialties, 

practice sites, etc.) for performance assessment purposes to allow for selection of 

performance measures and activities that are most relevant to a clinician's scope of practice 

and patient population. 

ACP TOOLS AND RESOURCES ON MACRA 

ACP wants to give internists and subspecialists the best chance possible to succeed in the QPP, 

be it through the MIPS or APM pathway. To that end, ACP has developed tools and resources 

8 
102 


36027.062

for its members to help them navigate through the QPP; chief among them is the Quality 

Payment Advisor®. 

Quality Payment Advisor® 

The Quality Payment Advisor® is an educational tool that is intuitive to the needs of clinicians 

participating in the QPP. This tool provides a systematic approach to succeed in the QPP by 

helping to determine who is eligible for the QPP, which reporting pathway is best, as well as 

assistance with quality measure/activity selection and implementation. Each question offers 

information and resources to guide the user through the algorithm toward understanding 

which pathway is most appropriate for their practice. The modules provide guidance and 

resources to select and implement measures and activities. It should be noted that this tool 

cannot help with all measures or activities but to the extent possible the ACP hopes that it 

proves to be useful in implementing quality measures and activities most commonly applicable 

to internal medicine and sub-specialty practices. 

Top Ten Ways to Succeed under the QPP 

In addition, ACP has created a host of resources on the QPP, including a Top Ten list of things 

that clinicians should be doing to be successful under the QPP. This list provides ACP members 

with a road map to understanding and complying with all the demands and opportunities within 

the MIPS and APM pathways. 

Conclusion 

ACP greatly appreciates the subcommittee convening this hearing and for its continued desire 

to see that the value-based system, as established under MACRA, is successfully implemented. 

We very much want to be part of this process as implementation continues and to provide 

feedback whenever needed. Please contact Jonni McCrann at jmccrann@acponline.org with 

any questions or if additional information is needed. 

9 
103 


36027.063

The Honorable Michael Burgess, MD 

Chairman 

Committee on Energy and Commerce 

Subcommittee on Health 

July 25, 2018 

U.S. House of Representatives 

Washington, District of Columbia 20515 

The Honorable Gene Green 

Ranking Member 

Committee on Energy and Commerce 

Subcommittee on Health 

U.S. House of Representatives 

Washington, District of Columbia 20515 

Dear Chairman Burgess and Ranking Member Green, 

We applaud this Subcommittee for reviewing the progress of the Center for Medicare and 

Medicaid Services (CMS) as it works to implement the Medicare Access and CHIP 

Reauthorization Act (MACRA). We share Congress' overarching goal to move the 

Medicare system from a largely fee-for-service model to one that rewards the value and 

cost-effectiveness of healthcare. We note that MACRA is driving these changes, including 

through the implementation of telehealth and remote monitoring technologies.' 

The Connected Health Initiative (CHI) represents a broad consensus of stakeholders in the 

connected health sector. As part of ACT I The App Association, CHI represents a large 

community of small app developers and connected device companies that create the 

innovations that improve the lives and health of patients across America. We offer several 

observations and recommendations as the Subcommittee considers the next step for 

value-based care and the role of technology-driven tools in advancing this goal. 

CHI urges this Subcommrttee to recognize the strong evidence base that demonstrates 

the efficacy and cost savings associated with the use of cutting-edge remote monitoring 

tools. Several studies have shown that providing remote care results in fewer 

hospitalizations, cost savings, and improved health outcomes. For example, a randomized 

control trial of telehealth and telecare services concluded that, "if used correctly telehealth 

can deliver a 15 percent reduction in A&E visits, a 20 percent reduction in emergency 

1 E.g., 42 U.S.C. 1395w·4(q)(2)(B)(iii)(lll) (requiring CMS, for care coordination, to ensure the use of remote 

monitoring or teleheal\h). 
104 


36027.064

admissions, a 14 percent reduction in elective admissions, a 14 percent reduction in bed 

days and an 8 percent reduction in tariff costs. More strikingly they also demonstrate a 45 

percent reduction in mortality rates."' One of the most promising applications for remote 

monitoring is for patients with chronic conditions. A University of Ottawa Heart Institute 

study supports this proposition, finding that "telehome monitoring" cut hospital 

readmission for heart failure by 54 percent, and secured savings up to $20,000.3 

Nowhere are the potential benefits of connected care more pronounced than in rural 

America. In a pioneering diabetes self-management study, CHI steering committee 

member University of Mississippi Medical Center (UMMC) found that the program's first 

100 patients saved an impressive $339,184 in healthcare costs by using remote 

monitoring and telehealth tools. Cost analyses predict that if 20 percent of Mississippi's 

diabetic population was enrolled in the program, it would bring $189 million in Medicaid 

savings to Mississippi each year. 4 

Under this Subcommittee's guidance, CMS has already taken important steps to 

incorporate connected health tools that save lives and reduce costs. Specifically, the 

Physician Fee Schedule (PFS) rulemaking introduced unbundled current procedural 

terminology (CPT) code 99091 to support the use of remote monitoring tech. As the 

Medicare system makes strides to move past its legacy of fee-for-service payment, CMS 

has also been shaping its Quality Payment Program (OPP), pursuant to MACRA 

provisions. As part of the QPP's merit-based incentive payment system (MIPS) rules rolled 

out last year, CMS adopted an Improvement Activity (lA) proposed by CHI-IA_BE_14 : 

Engage Patients and Families to Guide Improvement in the System of Care-which incents 

providers to leverage digital tools for patient care and assessment outside the four walls of 

the doctor's office. The lA urges providers to ensure that any devices they use to collect 

patient-generated health data (PGHD) do so as part of an active feedback loop. CHI is 

especially encouraged that CMS assigned high weight and linkage to an Advancing Care 

Information (ACI) bonus to this lA, which signals to healthcare providers that CMS 

acknowledges the important role connected health tools can play in improving health 

outcomes and controlling costs. We commend CMS for taking these and steps in support 

of connected health solutions that will improve the care of every Medicare beneficiary while 

reducing program costs. We urge this Subcommittee to ensure CMS continues in this 

direction. 

While good progress has been made, it is important that this Subcommittee recognize that 

much work remains to be done to realize MACRA's vision of a value-based Medicare 

system. With CMS currently contemplating its next steps as far as needed changes to 

2 
105 


36027.065

both the PFS and OPP, tllis Subcommittee's hearing is taking place at a crucial time. 

There are several encouraging proposals in the draft calendar year (CY) 2019 PFS/OPP 

that this Subcommittee should ensure CMS adopts, such as CMS' proposal to activate 

three additional remote monitoring codes. CHI contributed to the development of these 

codes, which if adopted, will support the use of remote monitoring innovations in the 

Medicare program. Further, CMS is considering additional changes to the MIPS program 

to give due credit for using connected health technology innovations in care delivery when 

calculating a MIPS score. Such proposals should move forward, incorporating the 

thoughtful feedback of the connected health stakeholder community. Other areas, like 

Alternative Payment Models (APMs) under the OPP, merit greater attention from by CMS 

so that a clear message is sent to all stakeholders that remote monitoring tools should 

serve a key role in the success of future innovative APMs. CHI continues to examine CMS' 

proposed rule to identify additional opportunities to realize Congress' vision of a valuebased Medicare system. We commit to continue to assist this Subcommittee in this 

respect. 

We appreciate the Subcommittee's continued focus to ensure that CMS carries out its 

statutory mandate under MACRA. With your oversight, we believe CMS can stay on track 

to bring Medicare into the 21st century to ensure health providers have the tools they need 

to succeed and better serve patients. 

3 

Sincerely, 

~ Graham Dufault 

Connected Health Initiative 

Brian Scarpelli 

Connected Health Initiative 
106 


36027.066

I 

ASCO' AMERICAN SOCIETY Of CLINICAL ONCOLOGY 

www oscoorg 

July 26, 2018 

The Honorable Greg Walden 

Chairman 

Energy & Commerce Committee 

U.S House of Representatives 

Washington, DC 20515 

The Honorable Michael Burgess, MD 

Chairman 

Energy & Commerce 

Subcommittee on Health 

U.S. House of Representatives 

Washington, DC 20515 

The Honorable Frank Pallone 

Ranking Member 

Energy & Commerce Committee 

U.S House of Representatives 

Washington, DC 20515 

The Honorable Gene Green 

Ranking Member 

Energy & Commerce 

Subcommittee on Health 

U.S. House of Representatives 

Washington, DC 20515 

Dear Chairman Walden and Ranking Member Pallone, Chairman Burgess and Ranking 

Member Green, 

The American Society of Clinical Oncology (ASCO) is pleased to submit this statement in 

relation to the hearing, "MACRA and MIPS: An Update on the Merit-based Incentive 

Payment System." ASCO supported the passage of MACRA as a replacement to the 

flawed Sustainable Growth Rate and we applaud this committee for your shared 

commitment to its success. 

ASCO continues to educate Its members on how to make MACRA work for their 

practices and the Medicare beneficiaries they serve. Practice tools and webinar 

resources are readily available on asco.org/MACRA, and in July 2017, ASCO updated its 

Quality Oncology Practice Initiative Quality Clinical Data Registry (QOPI • QCDR) to allow 

practices to seam!ess!y report MIPS data via electronic medica! record data. 

Further, we thank the committee for its leadership in the passage of critical technical 

fixes to the legislation passed in February of this year. Specifically, we appredate the 

indusion of language to remove Part B drugs from the low volume threshold and scoring 

adjustments in MIPS and the additional f!exibi!ities in the cost category provided to 

CMS. 

Making a world o( dijference in cancer care 
107 


36027.067

The recently released 2019 Quality Payment Program (QPP) rule in combination with the Medicare 

Physician Fee Schedule (MPFS) raises several questions about how oncology practices will be able to 

continue to provide the highest quality care for Medicare beneficiaries. The QPP rule proposes an 

increase in weight for the cost category from 10% to 15% but lacks an updated methodology, including 

risk adjustment for the severity and variation of high cost therapies and potential hospitalization at 

times necessary to treat cancer patients. 

Additionally, the MPFS proposes a 4% overall cut in reimbursement for oncology services, a decrease in 

reimbursement for new Part B drugs, and an overhaul of evaluation and management (E&M) coding that 

does not reflect accurately services and resources practices deliver to complex patients. To offset the 

reduction in reimbursement, oncology practices may be forced to reduce unpaid or underpaid but 

important services currently provided to patients with cancer. ASCO opposes the cuts in the proposed 

MPFS and believes they will harm Medicare beneficiaries with cancer, impede MIPS implementation, 

and risk access to appropriate anti-cancer therapies. 

The proposed MPFS reimbursement cuts would diminish the reward to high performing providers 

Congress intended under MACRA in this first year the MIPS adjustments will be applied. Coupled with 

the MPFS, the best performers would only receive a 2% bonus. This is much lower than the 4% 

authorized by law. Providers and practices meeting all the necessary quality improvement/value 

requirements will still have an overall decrease in reimbursement for the 2019 year. 

Over the coming months, ASCO will be in touch with the Center for Medicare and Medicaid Services 

(CMS) as well as this Committee about the impact of these proposals on cancer care. 

ASCO thanks the Committee for its commitment to improving the Medicare program. If you have 

questions about this or any issue affecting cancer care, feel free to reach out to Amanda Schwartz at 

amanda.schwartz@asco.org or 571-483-1647. 

Sincerely, 

Monica M. Bertagnolli, MD, FACS, FASCO 

President, American Society of Clinical Oncology 
108 


36027.068

July 25,2018 

The Honorable Michael Burgess, MD 

Chairman 

Subcommittee on Health Committee on Energy & Commerce 

United States House of Representatives 

2336 Rayburn Bouse Office Building 

Washington, DC 20515 

The Honorable Gene Green 

Ranking Member 

Subcommittee on Health Committee on Energy & Commerce 

United States House of Representatives 

24 70 Rayburn House Office Building 

Washington, DC 20515 

Dear Chairman Burgess and Ranking Member Green, 

The Infectious Diseases Society of America thanks you for scheduling the 

hearing, "MACRA and MIPS: An Update on the Merit-Based Incentive Payment 

System." IDSA represents more than 11,000 infectious diseases (!D) physicians 

and scientists devoted to patient care, prevention, public health, education, and 

research in infectious diseases. Our members care for patients with serious 

infections, including HIV/AIDS, viral hepatitis, hcalthcare-associated infections, 

antibiotic-resistant infections, as well as emerging infections such as the Middle 

East Respiratory Syndrome coronavims (MERS-Co V), Ebola vims and Zika vims 

diseases. IDSA provided detailed comm_ents to the Centers for Medicare and 

Medicaid Services on the 2018 final rule of the Merit-Based Incentive Payment 

System (MIPS) and Alternative Payment Model (APM) Incentive Programs, 

collectively known as the Quality Payment Program (QPP). 

Outlined below, we arc pleased to describe the important roles of ID physicians. 

Please note several provisions of the 2018 final mle that we support. W c also 

strongly recommend important changes to MIPS related to antibiotic resistance 

and antibiotic stewardship and highlight an underlying ID physician 

compensation issue that is hampering our ability to meaningfully participate in 

new payment models and indeed may threaten the future of our subspecialty. 

The Value of ID Physicians 

IDSA members are committed to improving the quality and the safety of patient 

care in hospitals and health systems across the nation. Many lead the "on-theground" efforts to address healthcare-associated infections, antimicrobial 

resistance, and bio-emergencies. The specialty of infectious diseases is unique in 

that it is the only specialty that routinely emphasizes the linkage between 

individual patient care and the impact on the larger patient population. ID 
109 


36027.069

PAGE 2-IDSA Comments to E&C Subcommittee on Health Re AfACRA and MIPS 

physician involvement in patient care is associated with significantly lower rates of mortality and 

30-day readmission rates in hospitalized patients, shorter lengths of hospital stay, fewer intensive 

care unit (ICU) days, and lower Medicare charges and payments. ID physicians care for some of 

the most complex patients and are essential to the safety and effectiveness of many life-saving 

medical interventions, including organ and bone marrow transplants, complex surgeries and 

cancer chemotherapy. ID physicians also conduct research leading to breakthroughs in the origin 

and transmission of emerging and re-emerging diseases, factors that make these diseases 

virulent, and the development of urgently needed new antimicrobial drugs and other therapies, 

diagnostics, and vaccines. 

2018 final rule of the Merit-Based Incentive Payment System (MIPS) and Alternative 

Payment Model (AP:W) Incentive Programs, collectively known as the Quality Payment 

Program (QPP) 

IDSA appreciates that the 2018 final rule of the Merit-Based Incentive Payment System (MIPS) 

and Alternative Payment Model (APM) Incentive Programs, collectively known as the Quality 

Payment Program (QPP) included many improvements and recommendations we made in 

response to the proposed rule. We also reiterate some concerns and recommendations below. 

• IDSA appreciates that the final rule includes the facility-based measurement option as a 

proxy for MIPS quality and cost measurement for facility-based physicians. We remain 

concerned that many lD physicians who are facility-based will have difficulty 

participating in MIPS in a meaningful way until the facility-based scoring is finalized. 

• !DSA is pleased that the final rule includes a five-point complex patient bonus (as lD 

physicians often treat the "sickest of the sick" on a regular basis) and includes a small 

practice bonus. 

• !DSA supports the final low volume threshold of $90,000 in Part H-allowed charges and 

200 Medicare Part B beneficiaries, which we believe will lower administrative burden, 

particularly for small practices and practices in rural and underserved areas, allowing 

them to focus their limited resources on patient care. 

IDSA supports the finalized options for the implementation of virtual groups for 

participation in MIPS, but we await further details as to how virtual groups will be 

constructed. If CMS is committed to relieving administrative burden, then we believe 

CMS should assist physicians in forming their virtual groups. 

• IDSA appreciates the CMS decision not to finalize the requirement for eligible clinicians 

to report cross-cutting measures. We encourage CMS to remove the requirement entirely, 

as it would intensify administrative burden and increase the likelihood that our members 

would not be able to report to MIPS satisfactorily. 

• IDSA appreciates the inclusion of an infectious disease specialty measure set for MIPS. 

Nonetheless, we continue to have strong reservations regarding the clinical relevance of 

the majority of the measures to the practice scope for many ID physicians. Of the 

proposed measures, IDS A recommends that only those that align with the practice of an 

ID physician be included. Specifically, we support the inclusion of measures regarding 

inf1ucnza immunization, pneumococcal vaccination, documentation of current 

medications, and appropriate treatment of Methicillin-Sensitive Staphylococcus Aureus 

(MSSA) bacteremia. 

• Recognizing that there are significant financial incentives participation in an Alternative 

Payment Model (APMs), we call attention to the challenges that exist for ID physician 

participation. Unlike procedure-based care, ID and other cognitive care typically docs not 
110 


36027.070

PAGE 3-IDSA Comments to E&C Subcommittee on Health Re MACRA and MIPS 

have easily identifiable episodes of care that result in easily measured patient outcomes. 

Even when there is an easily identifiable episode of care, (i.e. patient with cellulitis 

within the Bundled Payment Care Improvement Advanced Program), the program 

design has made it impossible for ID physicians to design a value-based care plan for the 

episode, (i.e. the BPCl-Advanced program required that a patient with cellulitis be 

admitted to the hospital to "trigger" the episode). ID physicians would like to be able to 

demonstrate their value by designing episode bundles that avoid having a patient 

admitted to the hospital. 

Improvement Activities: Implementation of an Antibiotic Stewardship Program 

IDSA would like to highlight for the Subcommittee the improvement activity entitled 

"Implementation of an Antibiotic Stewardship Program (ASP)," for three key reasons: First, we 

greatly appreciate this subcommittee's strong attention to the national and global crisis of 

antibiotic resistance and the subcommittee's leadership in driving solutions. Second, we believe 

this component of MIPS represents a key area where lD physicians will be particularly able to 

participate in a meaningful way. Third, we believe changes to CMS policy are necessary to 

maximize the impact of this component of MIPS. 

IDSA believes that the listed example conditions in this improvement activity (lA) should either 

be removed entirely or revised to note that antibiotic stewardship applies to any infectious 

disease condition, and not just those listed in the improvement activity. We remain concerned 

that the listed conditions may be interpreted as the only conditions for which this improvement 

activity is applicable, therefore making this improvement activity overly prescriptive and subject 

to misinterpretation. 

High Weight for implementation of an Antimicrobial Stewardship Program 

We continue to urge the Agency to make the Implementation of an ASP a high weighted 

improvement activity. IDSA believes that implementation of an ASP would meet the parameters 

set by the Agency when determining if an IA should be of high weight. In the QPP Final Rule for 

2017, CMS stated, "we believe that high weighting should be used for activities that directly 

address areas with the greatest impact on beneficiary care, safety, health, and well-being'' 

Antibiotic stewardship directly provides an impact on beneficiary care, safety, health, and wellbeing by assisting providers and facilities in prescribing the correct antibiotic, using the correct 

dose, and for the correct amount of time. Antibiotic stewardship programs have been 

demonstrated to reduce inappropriate antibiotic usc that drives the development of resistance and 

to reduce adverse events associated with antibiotic usc, such as C. difficile infection. 

Finally, as this Subcommittee is well aware, antibiotic stewardship programs play a central role 

in combating antibiotic resistance nationally and globally. Expert national and international 

bodies including CMS, the Centers for Disease Control and Prevention, the National Institutes of 

Health, the Food and Dmg Administration, the President's Council of Advisors on Science and 

Technology and the World Health Organization have all emphasized ASP as a priority 

recommendation. Given the societal and population health impact of using antibiotics 

appropriately, the work involved in the implementation of an ASP, and the work involved in 

continually supporting and administering an ASP, we believe that this should be a high weighted 

!A. 
111 


36027.071

PAGE 4---!DSA Comments to E&C Subcommittee on Health Re }.IACRA and MIPS 

Undervaluing ID: Jeopardizing the Next Generation of ID Physicians 

We want to highlight for the Subcommittee that MACRA implementation is occurring against a 

complex backdrop in which compensation issues arc driving young physicians away from the 

field of infectious diseases. Data from the National Residency Match Program (NRMP) indicate 

a disturbing 21.6% decline in the number of applicants to infectious disease fellowship training 

programs over a 5-year period ending in 2016. These data indicate a broader problem-the 

undervaluation oflD. 

In 2014, an IDSA survey of nearly 600 Internal Medicine residents revealed that salary was the 

most often cited reason for not choosing !D. Average salaries for ID physicians are significantly 

lower than those for most other specialties. Young physicians' significant debt burden ($200,000 

average for the class of2014) is understandably driving many individuals toward more lucrative 

specialties. 

Over 90% of the care provided by ID physicians is accounted for by evaluation and management 

(E/M) services. These face-to-face, cognitive encounters are undervalued by current payment 

systems compared to procedural patient encounters (e.g., surgery, cardiology, and 

gastroenterology), as current E/M codes fail to reflect the increasing complexity of E/M services. 

This accounts for the significant compensation disparity between ID physicians and physicians 

that provide a greater proportion of procedure-based care. 

Without updated, accurate E/M codes, the payment reform activities included in MACRA will 

have only a limited impact on improving ID patient care and will fail to address the underlying 

problem of undervaluing ID patient care that is driving fewer young physicians to enter the 

specialty. ID physicians often care for more chronic illnesses, including IllY, hepatitis C, and 

recurrent infections. ID care often involves reviewing ill patients with many days of 

hospitalization or complex outpatient case management that arc both time intensive to do well. 

Such care involves preventing complications and exploring complicated diagnostic and 

therapeutic pathways. ID physicians also conduct significant post-visit work, such as care 

coordination, patient counseling and other necessary follow up. IDSA urges the Subcommittee to 

direct CMS to undertake the research needed to better identify and quantify the inputs that 

accurately capture the elements of complex medical decision making. 

Reimbursement for Telemedicine 

ID physicians arc increasingly seeking opportunities to utilize telemedicine to expand access to 

care, particularly in rural and other underserved communities, and to conduct clinical research 

and provide continuing medical education. The Extension for Community Health Outcomes 

(ECHO) program has demonstrated success in treatment of hepatitis C virus. Evidence also 

supports the use oftelemedicine for HIV management, for which subspecialty care can be 

critical. Compared to in-person management by generalists, subspecialty care using telemedicinc 

has been shown to improve virologic suppression and result in a greater rise in CD4+ T-cell 

counts in a large prison population and may prove beneficial for HIV care in other resourcelimited settings. Telemedicinc can also be used to expand 1D physician-led services, including 

antibiotic stewardship programs and infection prevention and control programs, to a wide variety 

ofhcalthcare settings. We appreciate this Subcommittee's ongoing attention to tclemedicine and 

encourage additional efforts to promote use of telemedicine to allow reimbursement for care 

delivered remotely. 
112 


36027.072

PAGE 5~-IDSA Comments to E&C Subcommittee on Health Re MACRA and MIPS 

Once again, we thank the Subcommittee for its attention to physician payment and health care 

quality, and we look forward to continuing to work with you to meet the evolving needs of our 

patients. 

Sincerely, 

Paul 

~~ G. Auwaerter, MD, MBA, FIDSA 

President, IDSA 
113 


36027.073

Medical Group Management Association 

Statement for the record 

Committee on Energy and Commerce 

Subcommittee on Health 

United States House of Representatives 

Re: MACRA and MIPS: An Update on the Merit-based 

Incentive Payment System 

Anders Gilberg, MGA 

Senior Vice President, Government Aft'airs 

agilberg@mgma.org 

1717 Pennsylvania Ave NW Suite 600 

Washington, DC 20006 

202.293.3450 

July 26, 2018 

The Medical Group Management Association (MGMA) commends the Committee on Energy 

and Commerce Subcommittee on Health for convening this hearing on "MACRA and MIPS: An 

Update on the Merit-based Incentive Payment System." MGMA represents 12,500 medical group 

practices of all sizes, specialties, types and structures, which collectively provide almost half of 

the healthcare in the United States. 

MGMA appreciates the Committee's ongoing leadership and oversight efforts to ensure 

successful implementation of the sweeping payment reforms enacted in the Medicare Access and 

CHIP Reauthorization Act (MACRA). We applaud Congress making technical corrections to 

MACRA in the Bipartisan Budget Act, which demonstrated your continued support for the 

innovative care delivery improvements taking place in group practices across the country. We arc 

optimistic that these changes will be a catalyst for improving the Merit-based Incentive Payment 

System (MIPS) beginning in 2019 and expanding Advanced Alternative Payment Model (APM) 

opportunities in the near future. 

Since MACRA passed, MGMA has partnered with Congress and the administration to help 

physician practices succeed in the Quality Payment Program (QPP). We have hosted numerous 

educational events that connect our members directly with Centers for Medicare & Medicaid 

Services (CMS) staff, served as informational and educational resources for our members by 

dispensing news and infonnation related to MIPS, and provided suggestions to policy makers 

based on feedback from our members. We also collaborate with other stakeholder groups as part 
114 


36027.074

of various coalitions, including a MIPS workgroup that submitted to CMS comprehensive 

suggestions for reducing clinician burden, several of which are reflected in these comments. 

We appreciate Congress' work to support physician practices transitioning to value-based 

payment in Medicare by passing MACRA and exercising oversight authority to help facilitate 

implementation. We hope these comments will help Congress and the administration improve 

the QPP, align it with congressional intent in MACRA, and ensure a successful transition to a 

Medicare payment system centered around high-value care. 

Reduce Medicare quality reporting documentation requirements 

Repealing the problematic sustainable growth rate and retiring a hodgepodge of quality reporting 

programs, MACRA charted a value-based trajectory for the Medicare payment system by valuing 

innovative, patient-centric and efficient care delivery over check-the-box bureaucracy. However, 

the final2018 MIPS rule maintains an overly complex set of rules that reward the quantity of 

reporting rather than the quality of care provided to patients. One of the most onerous 

requirements in MIPS is the mandatory 365-day data collection and reporting period. 

CMS' own estimates show full-year quality measure tracking and reporting is estimated to cost 

medical groups close to $700 million in 2018. 1 Based on a study ofMGMA member practices, 

this cost estimate may be low. Our research determined that each year physician practices in four 

common specialties spend, on average, 785 hours per physician and more than $15.4 billion on 

quality measure reporting programs2 Most of the time spent on quality reporting consists of 

"entering information into the medical record only for the purposes of reporting for quality 

measures from extemal entities." 

We urge this Subcommittee to provide immediate relief by working with CMS to shorten the 

current MIPS quality reporting period to 90 consecutive days. There is precedent for this action. 

In response to the introduction of legislation to shorten the Meaningful Use EHR reporting 

period from a full year to three months, CMS retroactively amended its regulations to relieve the 

onerous reporting burden. 3 Congress should consider using its influence in the same way to 

relieve the quality reporting burden in MIPS. 

Put patients over paperwork in MIPS 

MGMA strongly supports CMS' goal to emphasize "high-value care and patient outcomes while 

minimizing burden on eligible clinicians" in MIPS. Unfortunately, rather than relieve the 

burdens of participation, the current MIPS program exacerbates them. Rather than maintain a 

stable, already robust repmiing period minimum of 90 days across all MIPS categories in year 

two, CMS quadrupled the reporting period for quality measures. Rather than realize the goal of 

MACRA to streamline quality reporting under one program, CMS continued the siloed approach 

1 82 fed. Reg. 53577, Medicare Program: CY 2018 Updates to the Quality Payment Program: and Quality Payment 

Program: Ettreme and Uncontrollable Circumstance Poli(T for the Transition Year, CMS-5522-FC and IFC. 2 Lawrence P. Casalino. David Gans, Rachel Weber, Meagan Cea, Amber Tuchovsky, Tara F. Bishop, Yescnia 

Miranda, Brittany A. Frankel, Kristina B. Ziehler. Meghan M. Wong and Todd B. Evenson, "US Physician Practices 

Spend More Than $!5.4 Billion Annually to Report Quality Measures," Health Affairs 35. no.3 (20!6). 3 H.R. 3940. The Meaningful Use Hardship Relief Act of20!5. 

2 
115 


36027.075

ofPQRS, Meaningful Use, and the Value Modifier by drawing bright lines between the four 

MIPS categories, each of which has a unique, complex reporting and scoring scheme. 

Not only does this increase in regulatory burden contradict CMS' initiative to promote patients 

over paperwork, it coincides with growing skepticism that MIPS as implemented neither reflects 

nor incentivizes clinical quality improvements in medical groups. According to a recent study of 

more than 750 MGMA member practices, more than 70% of respondents were very or extremely 

concerned about the lack of clinical relevance to patient care.4 Articulating a theme we hear 

regularly across the country, one practice leader wrote: "We are a GI single specialty clinic. I can 

use the specialty measures for the MDs but not the mid-level providers as they don't apply. I have 

to have two sets of MIPS requirements and measures. It's extremely burdensome." 

To assist CMS in resetting its approach and achieving its stated goals of reducing clinician 

burden in MIPS and enhancing patient care, MGMA encourages Congress to instruct CMS to 

make the following high-impact improvements to MIPS: 

I. Permanently shorten the minimum MIPS quality reporting period to any 90 

consecutive days using sampling and attestation methodologies that ensure 

statistical validity. Participants should have the option to report more data as needed. 

2. Decrease the number of measures across MIPS. Physician group practices' finite 

resources arc spread across at least 15 measures, including a minimum of six quality 

measures, two cost measures, five advancing care infomntion (ACI) measures, and two 

improvement activities. CMS should structure MIPS to allow practices to prioritize 

effective and impactful improvements to patient care, rather than comply with 

sprawling reporting mandates. 

3. Simplify MIPS and reduce redundancies by awarding cross-category credit. As 

implemented, MIPS ret1ects a continuation of the agency's historically siloed approach 

to quality reporting, consisting of four programs under one umbrella. To reduce 

burden, CMS shonld award credit in multiple categories for overlapping efforts. For 

instance, clinicians should receive credit in both the quality and ACT categories when 

they report quality measures via end-to-end electronic reporting using certified 

electronic health records. 

4. Provide clear and actionable feedback about MIPS performance at least every 

calendar quarter, as recommended by the statute. Without timely feedback, MIPS 

is essentially a reporting exercise that enters data into a "black box" only understood 

by CMS, rather than a useful barometer practices can leverage to drive clinical 

improvement. 

5. Release critical MIPS information prior to the start of the performance period. 

To participate successfully and, more importantly, implement evidence-based actions 

at the point of care, groups need time to plan and review key program details, such as 

the quality measure specifications and benchmarks, qualified vendor lists, and clinician 

and group practice eligibility detenninations. 

4 MGMA 2017 Regulatory llurden Survey. Summary of Findings, available at www.mgma.org/regrelief. 
116 


36027.076

Support the development and availability of physician-focused APMs 

MGMA agrees with Congress that APMs arc a key piece of the transition to a value-based 

payment system. However, in the eight years since it was created, the Centers for Medicare and 

Medicaid Innovation (CMMI) has yet to deliver a robust pathway for interested physician 

practices to move away from fee-for-service and take on appropriate financial risk for the care 

within their control. Congress should work with CMS to encourage and support the approval of a 

large and diverse set of new APMs, particularly before the 2022 performance year when the 5% 

lump sum bonus is set to expire under current statute. There are several immediate steps 

Congress could take to work with CMS to significantly expand the APM pathway. 

It is imperative that CMS revisit the unnecessary regulatory restrictions placed on current 

Medicare APMs, such as the arbitrary 50-clinician cap for the Comprehensive Primary Care Plus 

Program and "primary care focus" limitation to qualify as a Medical Home Model. Congress 

should also direct CMS to establish a separate, lower risk threshold for such practices. In many 

cases, small and rural practices interested in joining an APM have limited capital and resources 

to take on financial risk, particularly when compared to larger health systems. Expanding the 

definition of Advanced APMs to include federal payers other than traditional Medicare would 

also quickly expand participation. MGMA is encouraged by CMS' plans to implement a 

Medicare Advantage (MA) demonstration, although we encourage CMS to consider participants 

as qualifying Advanced APM participants as opposed to merely exempt from MIPS. 

We commend Congress for creating the Physician Focused Payment Model Technical Advisory 

Committee (PT AC) and its continuing support of the important role PT AC plays in the 

development of APMs by explicitly permitting PT AC to provide model developers with initial 

feedback under the Balanced Budget Act. However, PTAC's work is only valuable ifHHS acts 

on its recommendations. Unfortunately, in a June 13 letter, the Secretary of the U.S. Department 

of Health and Human Services (HHS) wrote that HHS would not test the APMs that were 

developed by frontline physicians and withstood rigorous review by PTAC. The chair and cochair of PT AC expressed frustration with HHS' lack of direction and inaction during a 

congressional hearing before the Energy and Commerce Health Subcommittee last November. 

We urge Congress to direct HHS to be more collaborative with PTAC and to codify a timeline by 

which the Secretary is expected to respond to PTAC recommendations. MGMA believes sixty or 

ninety days would be appropriate. 

The key features that make APMs less burdensome and a more appealing alternative to one-sizefits-all MIPS are choice and flexibility. These core principles are violated when the federal 

government mandates participation. According to a recent MGMA poll, 72% of over I, I 00 

medical group practices who responded opposed mandatory participation in Medicare APMs, 

citing lack of evidence and a negative impact on practice innovation. 5 Rather than taking a 

shortcut to boosting numbers by mandating participation in certain models, CMS should focus 

on continuing to develop new APMs that meet the needs of a diverse range of practices of 

varying types, sizes and specialties that will inherently drive more widespread pmiicipation. 

Participation in Advanced APMs has been slower than anticipated, due in large part to the slow 

pace at which new models have been developed. Since 2017, just one new Advanced APM has 

'"MGMA Poll: Medical group practices oppose mandatory Medicare altcmative payment models." mgma.com/stat 

4 
117 

Æ 


36027.077

been announced. As a result, CMS estimates less than 250,000 clinicians will participate in 

Advanced APMs nationwide this year6 Many practices, particularly specialty practices, may be 

interested in joining Advanced APMs, but are unable to do so because there arc not yet viable 

options. The 5% bonus Congress instituted under MACRA is a powerful incentive for practices 

to participate in APMs, but it is set to end by 2022. Congress should consider extending it to 

continue incentivizing practices to participate in APMs as more models are developed that may 

offer practices an opportunity to participate in an APM for the first time. 

Conclusion 

Thank you for the opportunity to share our statement regarding implementation ofMACRA's 

physician payment policies. MGMA stands ready to work with Congress, HHS, and other 

stakeholders in ensuring the QPP supports physician practices' transition to value-based care 

delivery models by reducing administrative burden, improving the clinical relevance of MIPS, 

increasing opportunities to move into APMs, and modernizing outdated federal rules impeding 

care coordination. Should you have any questions, please contact me at agilberg@mgma.org or 

202-293-3450. 

Regards, 

/s/ 

Anders Gilberg 

Senior Vice President, Government Affairs 

"82 Fed. Reg. 30011, Medicare Program; CY 2018 Updates to the Quality Payment Program, CMS-5522-P.