Changes seek to address burdens on solo and small practices
On June 21, 2017, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule that includes participation requirements for the second year of the Quality Payment Program.

The Quality Payment Program—which replaces the flawed Sustainable Growth Rate (SGR) formula as required by the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015—includes two tracks: the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (Advanced APMs).

The American Association of Orthopaedic Surgeons (AAOS) has been working closely with CMS to address a number of concerns related to the Quality Payment Program, including the need for additional flexibility and simplification, as well as protection for small, solo, and rural practices. CMS has taken significant steps to respond to these concerns in the proposed rule.

"AAOS is pleased CMS has listened to physician feedback, and we commend the agency for incorporating changes that will address a number of our concerns," said Wilford K. Gibson, MD, chair of the AAOS Council on Advocacy. "The program remains overly complex and there are continued issues regarding access to data and Advanced APM qualification for specialists, but we are extremely encouraged by proposals that improve the program for providers and ensure quality care for Medicare beneficiaries. The provisions related to virtual groups, expanding the low-volume threshold, and delaying 2015 CEHRT [certified electronic health record technology] requirements are especially welcomed.

"Further, we applaud the agency for continuing the transition period, allowing physicians to more successfully meet the challenges of implementation and participation," Dr. Gibson continued. "We look forward to continuing our work with CMS to further improve the Quality Payment Program and ensure that physician payment reform ultimately improves the care of musculoskeletal patients."

"We've heard the concerns that too many quality programs, technology requirements, and measures get between the doctor and the patient," said CMS Administrator Seema Verma. "That's why we're taking a hard look at reducing burdens. By proposing this rule, we aim to improve Medicare by helping doctors and clinicians concentrate on caring for their patients rather than filling out paperwork. CMS will continue to listen and take actionable steps toward alleviating burdens and improving health outcomes for all Americans that we serve."

Decreasing burdens on solo and small practices
CMS has included a number of provisions in the MIPS track to decrease the burdens on solo and small practices (defined as 15 or fewer eligible clinicians). These provisions include the following:

• higher low-volume threshold
• significant hardship exemption from Advancing Care Information
• a 5-point bonus to the MIPS final score
• ability to form virtual groups
• 3-point scoring for measures that do not meet data completeness

Under the proposed rule, MIPS-eligible clinicians include physicians, physician assistants, nurse practitioners, certified nurse anesthetists, and clinical nurse specialists. Exceptions include those who are in their first year of enrollment as a Medicare provider, participate significantly in an APM or Advanced APMs, or are under the low-volume threshold.

Providers may participate in MIPS as individuals or in groups. The change in the low-volume threshold would mean that providers with less than $90,000 in Part B allowed charges or fewer than 200 Part B beneficiaries would be exempt from MIPS.

AAOS had previously urged CMS to address the burdens on solo and small practices, commenting that "the new scoring design will disproportionately disadvantage the solo, small, and even medium-sized practices."

"Patient care is of the utmost importance," said then-AAOS President Gerald R. Williams Jr, MD, in 2016. "While many provisions in the proposed rule are improvements over the current system, there are a number of steps that would better protect specialty physicians along with small and solo practices so that Medicare patients have access to the timely, high-quality, affordable specialty care that they need."

Additionally, CMS is proposing that a MIPS-eligible clinician may work with others as a virtual group starting in performance year 2018. Performance assessment and payment adjustments for virtual groups would be scored in a manner similar to regular groups. CMS is requesting comments on how group-related activities may or may not apply to virtual groups.

AAOS will provide CMS with further comments on these and all other applicable proposals by the Aug. 21, 2017, deadline. Email questions or concerns to macra@aaos.org

For more information and resources, visit https://www.aaos.org/MACRA-DeliveryReform

Elizabeth Fassbender is the communications manager in the AAOS office of government relations. She can be reached at fassbender@aaos.org

CMS Issues Proposed Rules
On July 13, the Centers for Medicare and Medicaid Services (CMS) issued two more proposed rules—one that updates payment rates and policy changes in the Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System and another that would update Medicare payment and policies for doctors and other clinicians who treat Medicare patients in calendar year (CY) 2018.

According to CMS, the proposed rules are a part of a broader strategy to relieve regulatory burdens for providers, support the patient-doctor relationship in health care, and promote transparency, flexibility, and innovation in the delivery of care. AAOS will submit comments on all proposed rules.

"Doctors want to spend less time on burdensome regulations from Washington, D.C., and more time with their patients," said CMS Administrator Seema Verma. "We believe this new approach will improve quality of care and result in better health outcomes. CMS is committed to giving providers and beneficiaries alike more flexibility and choice in health care and is eager to hear comments on our proposed rule. We look forward to addressing the feedback we receive in our final rule later this year."