Medicare’s QPP Not Yet Ready for Rheumatologists

July 27, 2016

Rheumatologists face unique challenges not fully addressed in CMS' Quality Payment Program, says CSRO's Dr. Michael Schweitz. Dr. Schweitz addresses these challenges in this blog post.

Changes Essential to Facilitate Meaningful Rheumatology Participation

On June 27, the Coalition of State Rheumatology Organizations submitted formal comments to the Centers for Medicare and Medicaid Services to register our concerns with its proposed Quality Payment Program (QPP).

The Quality Payment Program represents a new, more streamlined approach to paying physicians for the value of health care delivery, rather than the volume of services rendered, through the Merit-Based Incentive Payment System (MIPS) and alternative payment models (APMs).

CSRO emphasized to CMS the unique challenges rheumatologists face in these new programs and we seek modifications that will enable more meaningful engagement.  [[{"type":"media","view_mode":"media_crop","fid":"50563","attributes":{"alt":"Michael Schweitz, M.D","class":"media-image","id":"media_crop_5463682944914","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"%7BMCIID%7D","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"font-size: 13.008px; line-height: 1.538em;","title":"Michael Schweitz, M.D","typeof":"foaf:Image"}}]]

Quality

CSRO opposed the CMS proposal to replace the Rheumatoid Arthritis Measures Group (a set of eight quality measures reported as a group in the current Physician Quality Reporting System (PQRS) program), with a new specialty measure set that combines five of the rheumatoid arthritis quality measures with several allergy and immunology quality measures planned for use in the new MIPS. 

We argued that the measures group was designed to look at rheumatoid arthritis in a more meaningful and comprehensive way, where each measure had a relationship with the other measures in the group. This is particularly important as rheumatoid arthritis is one of the most significant conditions rheumatologists diagnose, treat and manage in the Medicare population.

Removing the rheumatoid arthritis measures group greatly diminishes the value of the individual measures CMS proposes to retain as stand-alone measures or as part of the newly proposed Allergy/Immunology/Rheumatology specialty measure set, and requested that the RA Measures Group be maintained for purposes of the quality performance category in the MIPS.  [[{"type":"media","view_mode":"media_crop","fid":"50564","attributes":{"alt":"Michael Schweitz, M.D.","class":"media-image media-image-right","id":"media_crop_9171489325768","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"6184","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"font-size: 13.008px; line-height: 1.538em; float: right;","title":"Michael Schweitz, M.D.","typeof":"foaf:Image"}}]]

Resource Use

We have long-registered concerns about resource use measures included in CMS’ existing Value-Based Payment Modifier (VM) program, which do not adequately consider the cost of pharmaceutical therapy in evaluating resource use. Unfortunately, CMS proposed to retain these measures, as well as incorporate two new cost measures focused on rheumatoid and osteoporosis, in the resource use performance category of MIPS, which represents 10 percent of the total MIPS composite performance score.

The current cost measures used in the VM program specifically exclude Part D costs, which puts physicians who administer Part B drugs in their office at a significant disadvantage compared to those who order/prescribe drugs covered under Part D, since the former would appear to have higher Medicare expenditures than the latter.

It may also disadvantage beneficiaries, as treatment options could become less available when providers are inappropriately held accountable for costs beyond their control. As a result, CSRO requested that CMS either remove Part B drug costs, or include Part D drug costs, as it evaluates resource use under the resource use performance category.

Regarding the rheumatoid arthritis and osteoporosis episode-based measures, we registered its opposition to the inclusion of these measures, which would only apply if a patient had two office visits in a 30-day time frame and did not include the cost of drugs. Neither measure has been adequately vetted by rheumatologists nor have they been used in any prior quality program. The use of these measures is premature because they have only recently been made public for comment and as such, they are unlikely to yield meaningful data or information because the vast majority of beneficiaries with a rheumatoid arthritis or osteoporosis diagnosis would not fall within the measures.

Clinical Practice Improvement Activities

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Clinical Practice Improvement Activities

CMS has proposed a list of 94 clinical practice improvement activities that are geared toward primary care providers instead of specialty care physicians, making it more difficult for rheumatologists to meet the requirements under this category. As such, we urged CMS to incorporate the Fracture Risk Assessment Tool (FRAX) and advanced blood tests used to assess disease activity, risk of joint damage, and response to pharmaceutical therapy options.

Risk Adjustment for SES

Adjusting for social and economic factors is critical, given their impact overall health and outcomes. CMS indicates that the Department of Health and Human Services (HHS) is conducting studies and making recommendations on the issue of risk adjustment for socioeconomic status (SES) on quality measures and resource use as required under the Improving Medicare Post-Acute Care Transformation Act of 2014 (the IMPACT Act).

CSRO encourages CMS to work with rheumatologists as risk adjustment for SES are implemented in measures used under the MIPS program and in APMs.

Other Concerns

As members of the Alliance of Specialty Medicine, we registered broad concerns with the impact of the new QPP on specialty physicians. These included disparities between the available metrics, how specialties are accounted for in value comparisons and the limited availability of specialty-focused APMs. CSRO, as part of the Alliance, seeks a delay in the 2017 performance period, along with optional shorter performance periods beginning in 2018. 

Medicare’s final rule for the quality payment program is expected later this fall and it could be combined with the 2017 Medicare Physician Fee Schedule final rule.

 

Michael Schweitz, M.D., is the national advocacy chair and past president of the Coalition of State Rheumatology Organizations.