(MIPS) and Alternative Payment Model (APM)

61 Pages·2016·1.19 MB·English

by  Christine Grossman

June 23, 2016

Andrew M. Slavitt SUBMITTED ONLINE
Acting Administrator, Centers for Medicare & Medicaid Services
U.S. Department of Health and Human Services
Hubert H. Humphrey Building, Room 445–G
200 Independence Avenue, SW
Washington, DC 20201

Docket CMS-5517-P: Medicare Program; Merit-Based Incentive Payment System (MIPS) and
Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for
Physician-Focused Payment Models

Dear Administrator Slavitt:

The North American Spine Society (NASS) appreciates the opportunity to comment on the proposed rule
for the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive
under the Physician Fee Schedule as well as the proposed criteria for the Physician-Focused Payment
Models. NASS is a multispecialty medical organization dedicated to fostering the highest quality,
evidence-based, ethical spine care by promoting education, research and advocacy. NASS is comprised
of more than 8,000 physician and non-physician members from several disciplines, including orthopedic
surgery, neurosurgery, physiatry, pain management, neurology, radiology, anesthesiology, research,
physical therapy and other spine care professionals.

NASS recognizes that MACRA was passed in order to address issues with funding for Medicare services,
which included (a) a flawed SGR formula; (b) payment that rewarded volume rather than quality; and (c)
few mechanisms to encourage innovation to improve healthcare delivery systems. NASS applauds these
goals for reforming the Medicare payment system. We understand the tremendous task of
implementing a new program that incorporates multiple existing Centers for Medicare and Medicaid
Services (CMS) programs into one. In doing so, we believe that the requirements for the Quality
Payment Program should be streamlined, easy to understand, and more importantly do not distract
from providing care to patients. It is imperative that clinicians are not overburdened to the point where
leaving the program becomes a consideration. All possible efforts need to be made to simplify the
system, empower physicians to understand it, and make administrative compliance with MIPS and
APM’s as feasible as possible, so that physicians do not give up on the Medicare payment reform
process. We encourage CMS to continue to consider the specialty voice when making proposals related
to MIPS. In addition, it is extremely important that adequate time and resources are provided to
educating eligible clinicians on the new requirements prior to start of the performance period for the
success of the program, the clinicians participating in it and for the best possible treatment of patients.
General Comments
o NASS appreciates the complexity of assembling a program like MIPS and the attempts by CMS to
reduce burden and streamline the programs.
o NASS is greatly concerned about the timeline for implementation of MIPS. With the final rule
being released very shortly prior to the performance period (October 2016), we are concerned
that not only will there not be adequate time to educate members on these new programs, but
clinicians will not have time to generate resources and prepare their practices in such a way to
be successful. Funding for measure development and technical assistance is unlikely to be
available before the start of the 2017 performance period. We strongly urge CMS to consider a
change in timeline either shorten the performance period for the first MIPS payment
adjustment, or delay the start of the 12-month performance period.
o The MIPS program is still heavily primary care-based. We would urge to CMS to continue to
make inroads to provide specialists with opportunities to successfully participate. The
encouragement of the paradigm shift from volume to quality specialty care is a principle that
NASS strongly supports.
o Without significant technical assistance, clinicians and their practices will struggle with the
volume and complexity of information. We would encourage CMS to offer various formats of
assistance using both regional and national outreach, to include, but not limited to:
o Easy to read and find FAQs
o Simple process diagrams
o 24 hour telephonic and email hotlines
o Specialty society-level education
o Office administration education
o Use of QIOs to assist in technical assistance outreach
o Importance of considering that most specialists will not be able to participate in APMs because
very few specialty APMs exist. NASS feels strongly that specialty APMs would provide major cost
savings.
o As with any new program, there may be unintended errors or consequences in the initial
implementation. For a reasonable grace period, participants need to be held harmless from the
consequences of any errors or omissions early on, particularly if physicians utilize a third party
for their quality data submissions and the third party submits erroneous information that a MIPS
eligible clinician could be liable for.
o As a medical specialty society, NASS would be pleased to offer its services as a partner to help
identify and solve any reporting challenges that may affect our members.

Regulatory Impact Analysis: Burden Estimates
For the estimates related to the quality performance category, the burden estimates are derived from
existing Physician Quality Reporting System (PQRS) estimates. Unfortunately, NASS believes this is an
extremely conservative estimate, particularly as the MIPS program is new. Regardless of who performs
the quality activities, the person performing those duties will need to, at the very least, either attend a
MIPS webinar or read the requirements to determine how to participate in MIPS, select measures for
the quality performance category (including determining a cross-cutting and outcome or high priority
measure), and report. The proposed scoring methodology of the MIPS is particularly complicated, so
significant time would have to be invested understanding how to maximize composite performance
scores (CPS).

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In general, we request CMS provide estimates to include the following:
- The time and costs associated with:
o reading educational materials and attending educational sessions on the new MIPS
program;
o determining whether to participate as an individual eligible clinician or as a group under
the MIPS; and
o determining whether an eligible clinician is required to participate in MIPS, is a qualified
APM professional (QP) in an advanced APM, or is a partial QP as well as the time and
cost it would take to determine what requirements would need to be met under the
Quality Payment Program based on status;
- The costs for practices with Certified Electronic Health Record Technology (CEHRT) vs. those
without CEHRT.

For the quality performance category, we ask CMS to provide estimates to include the following:
- The time and cost associated with:
o reviewing the measures list to determine which measures have been deemed topped
out and which have not;
o determining whether an eligible clinician should use a specialty measure set or use
measures in the general quality MIPS set;
o reviewing benchmarks that will be implemented for the measures, which will relate to
scoring for the quality performance category; and
o reporting on an increased number of patients, as CMS is proposing to increase the
reporting data threshold to require reporting of 80% of Medicare patients or 90% of ALL
patients

For the resource use performance category, we urge CMS to provide estimates to include the following:
- The time and cost associated with learning how the measures under the resource use category
are applied for eligible clinicians not previously participating in the Value-based Payment
Modifier and therefore who have no experience with this category.

For the advancing care information (ACI) performance category, we urge CMS to provide estimates to
include the following:
- The time and cost associated with understanding the requirements for this performance
category for eligible clinicians not previously participating in the EHR Incentive Program to fulfill
the requirements for the ACI performance category; and
- The time and cost associated with applying for a hardship to have the ACI performance category
reweighted to zero, if applicable.

Meaningful Use Prevention of Information Blocking and Surveillance Demonstration for MIPS Eligible
Clinicians, EPs, Eligible Hospitals, and Critical Access Hospitals (CAHs)
Cooperation with Surveillance and Direct Review of Certified EHR Technology: CMS proposes to require
EPs, eligible hospitals, and CAHs to attest (as part of their demonstration of meaningful use under the
EHR Incentive Programs) that they have cooperated with the surveillance of certified EHR technology
under the ONC Health IT Certification Program. Similarly, CMS proposes to require such an attestation
from all eligible clinicians under the ACI performance category of MIPS, including eligible clinicians who
report on the ACI performance category as part of an APM Entity group under the APM Scoring
Standard, as discussed later in this proposed rule summary.

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NASS opposes the proposed requirement that clinicians attest to having cooperated with the
surveillance of certified EHR technology under the ONC Health IT Certification Program, as it seems
redundant to require this attestation when the eligible clinician would already be attesting to multiple
objectives and measures under the ACI performance category. In addition, information blocking by an
individual provider is difficult in an EMR setting. While we understand the need to assure information
blocking is not taking place, if eligible clinicians are required to attest that they are not engaging in or
aware of information blocking from the clinician/hospital side, a similar requirement should be made of
IT vendors, in addition to hospitals and healthcare networks. There have been a known issues and
impediments to interoperability and data sharing by some IT vendors. In addition, we seek clarification
as to how often attestation would be required. Does CMS anticipate that EPs, eligible hospitals, and
CAHs would attest once a year?

It is also proposed that demonstration of these requirements would apply to meaningful EHR users as of
April 16, 2016. This date is not appropriate as it pre-dates the publication of the proposed rule and users
would have no way of knowing of its existence.

Identifying MIPS Eligible Clinicians
CMS proposes to define a group as a single Taxpayer Identification Number (TIN) with two or more MIPS
eligible clinicians, as identified by their individual National Provider Identifier (NPI), who have reassigned
their Medicare billing rights to the TIN. CMS proposes to use a combination of billing TIN/NPI as the
identifier to assess performance of an individual MIPS eligible clinician. Furthermore, CMS proposes that
each eligible clinician who is a participant of an APM Entity would be identified by a unique APM
participant identifier.

NASS supports CMS’ proposal to allow for participation in the MIPS under both the individual (TIN/NPI
combination) and group practice (TIN) level. NASS also supports identifying participants of an APM
Entity by a unique APM participant identifier.

CMS proposes to use multiple identifiers that allow MIPS eligible clinicians to be measured as an
individual or collectively through a group’s performance. However, while CMS has multiple identifiers for
participation and performance, CMS proposes to use a single identifier, TIN/NPI, for applying the
payment adjustment, regardless of how the MIPS eligible clinician is assessed. Specifically, if the MIPS
eligible clinician is identified for performance only using the TIN, when applying the payment adjustment,
CMS proposes to use the TIN/NPI.

NASS supports the use of the TIN/NPI to apply the MIPS payment adjustment. However, it is unclear
how a MIPS eligible clinician being identified for performance only using the TIN will then be scored and
have his/her payment adjustment based on the TIN/NPI. Since CMS is proposing not to provide for a
registration process for group reporting but instead is choosing an election process, how will the new
process differ from previous registration under the PQRS?

Group Reporting
CMS proposes that a group must meet the proposed definition of a group at all times during the
performance period. Individual MIPS eligible clinicians within a group must aggregate their performance
data across the TIN. A group that elects to have its performance assessed as a group would be assessed
as a group across all four MIPS performance categories.

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NASS supports these proposals. However, NASS seeks more clarification on how participation as a group
practice, particularly within the ACI performance category, where EPs were traditionally only assessed
by NPI under the Medicare EHR Incentive Program, or the CPIA performance category, where the
activities seem to lend itself towards individual participation. NASS requests that CMS provide more
information in the rule as to how participation as a group would differ from participation as an
individual in each of the performance categories.

CMS proposes to eliminate a registration process for groups submitting data using third party entities,
such as a qualified registry, heath IT vendor, or QCDR, since CMS is able to obtain information from the
third party entity to discern whether the data submitted represents group submission or individual
submission. However, if a group elects to use the CMS web interface or report the CAHPS for MIPS
survey, the group practice would be required to register as a group by June 30 of the applicable 12-
month performance period (that is, June 30, 2017, for performance periods occurring in 2017).

NASS supports CMS’ proposal to eliminate the requirement to register as a group for groups using third
party data submitters. Furthermore, we support CMS’ proposal to require registration for group
practices using the CMS web interface and reporting CAHPS for MIPS. However, as we request that CMS
delay implementation of the MIPS, we request that, for the 2019 MIPS payment adjustment, CMS
extend the deadline to register as a group to September 1, 2017 based on a suggested performance
period start date of July 1, 2017 for the 2019 MIPS payment adjustment.

Virtual Groups: CMS is not proposing an option to participate in the MIPS as part of a virtual group for
the proposed performance period in 2017.

While we understand the need for CMS to take time to ensure the proposals for virtual groups are well
thought out, we urge CMS to work to operationalize the virtual group option. The virtual group concept
better recognizes multiple factors about modern day medical practice than the current system. This
includes the facts that: a) physicians often work for multiple organizations at the same time; b) those in
smaller or independent practice do not have the resources, negotiating power, or overall influence over
more comprehensive care decisions that larger group practices and systems have; and c) the multi-
specialty makeup of many groups makes performance assessment challenging and often results in
performance scores that do not reflect the quality of all of the individuals in that group.

NASS encourages CMS to work through the establishment of a virtual group option, as we believe this
will be an advantageous option for eligible clinicians as there are many ways in which clinicians outside
of a TIN collaborate. Regarding requirements for virtual groups, as CMS finalizes requirements for this
option, it should not place arbitrary limits on minimum or maximum size, geography proximity or
specialty of virtual groups. The virtual group should have the authority to determine the appropriate size
of its group, geographic affiliations and group make-up in order to manage categorical activities and
successfully meet reporting requirements. NASS suggests that CMS hold a listening session to poll
specialties and other interested parties to determine how best to establish the virtual group option in
the MIPS.

Exclusions
New Medicare-enrolled eligible clinician: In the case of a professional who first becomes a Medicare-
enrolled eligible clinician during the performance period for a year (and had not previously submitted
claims under Medicare either as an individual, an entity, or a part of a physician group or under a
different billing number or tax identifier), that the eligible clinician will not be treated as a MIPS eligible
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clinician until the subsequent year and performance period for that year. CMS proposes to define a new
Medicare-enrolled eligible clinician as a professional who first becomes a Medicare-enrolled eligible
clinician within the PECOS during the performance period for a year and who has not previously
submitted claims as a Medicare-enrolled eligible clinician either as an individual, an entity, or a part of a
physician group or under a different billing number or tax identifier.

Under CMS’ proposal, a physician who newly enrolls in Medicare in, for example, November 2017,
would be required to begin participation in MIPS beginning January 1, 2018, just 2 months following
their enrollment. We strongly oppose CMS’ proposal. Instead, we request that CMS extend this window
such that a physician who enrolls in Medicare in 2017 would not be expected to begin participation in
the program until January 1, 2019.

Low-Volume Threshold Exclusions: CMS proposes that the definition of a MIPS eligible clinician does not
include MIPS eligible clinicians who are below the low-volume threshold selected by the Secretary for a
given year. CMS proposes to define MIPS eligible clinicians or groups who do not exceed the low-volume
threshold as an individual MIPS eligible clinician or group who, during the performance period, have
Medicare billing charges less than or equal to $10,000 and provides care for 100 or fewer Part B-enrolled
Medicare beneficiaries.

While NASS supports establishing a low-volume threshold, NASS believes the $10,000 threshold is too
low, particularly for eligible clinicians who perform high cost procedures. For example, surgeons would
easily meet the $10,000 threshold from performing one or two procedures. Therefore, NASS suggests
that CMS exclude MIPS eligible clinicians who either have Medicare billing charges less than or equal to
$75,000 OR provide care for 100 or fewer Part B-enrolled Medicare beneficiaries.

In addition, we believe the thresholds set are too low for a group. We believe the low-volume threshold
should be modified for a group practice. Possible alternatives could include having certain exclusion
thresholds based on group size or excluding a group as long as a majority (over 50%) of clinicians meet
the low-volume threshold.

MIPS Performance Period
Proposed Performance Period for the 2019 MIPS Payment Adjustment: CMS proposes that, for 2019 and
subsequent years, the performance period under MIPS would be the calendar year (January 1 through
December 31) 2 years prior to the year in which the MIPS adjustment is applied.

For the first year of MIPS, NASS opposes the proposed performance period for the 2019 MIPS payment
adjustment. The breadth of the MIPS program is large, and it will be difficult to adequately educate our
members in time for the start of the proposed performance period for the 2019 MIPS payment
adjustment, which is January 1, 2017. NASS requests that CMS either shorten the performance period
for the first MIPS payment adjustment, or delay the start of the 12-month performance period.

Alternative Performance Period: For example, for the first performance period, CMS could implement a
shortened performance period of March 1 – December 31, 2017, in which CMS would receive 9 months
of data. We believe this is an adequate amount of time, as the CMS web interface only collects
information on 9 months of data (January – October).

Alternative Performance Period: Alternatively, CMS could still collect 12 months of data but delay the
start date of the performance period, so that the performance period would start in March 1, 2017 and
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end March 31, 2018 or July 1, 2017 through July 31, 2018.

Alternative Performance Period: CMS could also, for the first performance period, implement a
performance period starting in July, thereby allowing for a 6 month-performance period for the start of
the MIPS. We note that there is past precedent for establishing a shortened performance period. When
the Physician Quality Reporting Initiative (PQRI) was first established, the first reporting period for the
PQRI was a shortened 6-month period from July 1, 2007 through December 31, 2007. We believe a
shortened period is necessary in this situation, as there is not enough time to adequately prepare
eligible clinicians.

Partial Year Participation: For individual MIPS eligible clinicians and group practices with less than 12
months of performance data to report, such as when a MIPS eligible clinician switches practices during
the performance period or when a MIPS eligible clinician may have stopped practicing for some portion
of the performance period, CMS proposes that the individual MIPS eligible clinician or group would be
required to report all performance data available from the performance period. Specifically, if a MIPS
eligible clinician is reporting as an individual, they would report all partial year performance data.
Alternatively, if the MIPS eligible clinician is reporting with a group, then the group would report all
performance data available from the performance period, including partial year performance data
available for the individual MIPS eligible clinician.

NASS supports not holding MIPS eligible clinicians accountable for times in which the eligible clinician is
not practicing. NASS requests more information in the final rule as to how eligible clinicians who
participate for only part of the performance period will be assessed against eligible clinicians who
participate for the full performance period. We would particularly caution against penalizing of
physicians who are not practicing for reasons beyond their control (health reasons, etc.). Quality should
be measured through reporting; not the process of whether someone can successfully report metrics.

CMS seeks comment on what a reasonable threshold for considering performance to be less 12-months,
as well as comments on how to account for MIPS eligible clinicians with extended leave that may affect
measure sample size. For example, some clinicians may take leave related to illness, vacation and
holidays. CMS would not anticipate applying special policies for lack of performance related to these
common and expected absences assuming the clinicians’ quality reporting includes measures with
sufficient sample size to generate valid and reliable scores. We would consider a threshold of 9 months
reporting with a documented reason (maternity, illness, vacation, etc.) for not reporting the remaining
quarter should sufficiently meet the reporting requirement. If this does not yield sufficient data, the
clinician could receive a 0 payment adjustment.

Submission Mechanisms:
For the quality performance category, CMS proposes to retain the submission mechanisms currently
available in the PQRS – claims, qualified clinical data registry (QCDR), qualified registry, EHR, and CMS
Web Interface (groups of 25 or more), CMS-approved survey vendor for CAHPS for MIPS, and
administrative claims (no submission required) to calculate certain population-based measures.
Furthermore, CMS is proposing to only allow use of one submission mechanism per category.

NASS supports CMS’ proposal to retain the reporting mechanisms currently available in the PQRS,
particularly the QCDR and claims-based reporting mechanisms. In general, NASS supports offering
physicians the widest range of reporting mechanisms in order to give everyone an opportunity to
determine which are most relevant to their practice. However, we oppose CMS’ proposal to only allow
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use of one submission mechanism per category. We note that there may be a need for a clinician to
report independent measures through multiple reporting mechanisms. For example, an EP might
identify a handful of clinically relevant e-specified measures that can be reported through an EHR, but
also might identify a few other relevant measures that are not yet e-specified and can only be reported
through a registry.

For the ACI performance category, CMS proposes the following submission mechanisms – Attestation;
QCDR; Qualified Registry; EHR; and CMS Web Interface (groups of 25+).

NASS supports the proposed submission mechanisms for the ACI performance category.

For the CPIA performance category, CMS proposes the following submission mechanisms -- Attestation
QCDR; Qualified Registry; EHR; Administrative Data (no submission required); and CMS Web Interface
(groups of 25+).

NASS supports the proposed submission mechanisms for the CPIA performance category.

CMS proposes that eligible clinicians and groups may elect to submit information via multiple
mechanisms; however, they must use the same identifier for all performance categories and, unless a
group practice is using a certified survey vendor to administer the CAHPS for MIPS survey, they may only
use one submission mechanism per category.

NASS opposes CMS’ proposal to only allow the use of one submission mechanism per category,
particularly for the quality performance category. We believe this is a limitation that is proposed to be
carried over from PQRS that hinders an eligible clinician’s choice to report the most meaningful
measures to his/her practice in the event that the measures are reportable via different submission
mechanisms. Of note, this proposal may disadvantage clinicians who choose to use CMS’ proposed
specialty measure sets that contain measures of different submission mechanisms.

For example, in the proposed Physical Medicine specialty measure set, there is only 1 EHR measure and
3 claims measures available within the set. If an eligible clinician were to choose the claims submission
mechanism, the eligible clinician would only be allowed to report on 3 measures within the specialty set.
Based on CMS’ proposal, given this proposed limitation, it is unclear whether the eligible clinician would
receive full credit for reporting the specialty measure set or whether the eligible clinician would have to
look for other measures to meet the 6 measure requirement (thus defeating the purpose of directing
the eligible clinician towards a specialty set). In addition, what if the eligible clinician would like to
report the registry-based measures within the Physical Medicine specialty set as well as the EHR
measure in order to receive additional bonus points for CEHRT?

MIPS: The Quality Performance Category

Reporting Criteria: For most submission mechanisms, CMS proposes the following criteria for reporting
quality measures under the quality performance category: Report at least six measures including one
crosscutting measure and at least one outcome measure, or if an outcome measure is not available
report another high priority measure (appropriate use, patient safety, efficiency, patient experience, and
care coordination measures); if less than six measures apply then report on each measure that is
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applicable. With respect to data completeness, for the claims, qualified registry, and EHR submission
mechanisms, CMS proposes that a MIPS eligible clinician or group would be required to report quality
measures data on at least 80% of its Medicare Part B patients. For the QCDR option, CMS proposes that
a MIPS eligible clinician or group would be required to report quality measures data on at least 90% of all
its patients.

NASS supports CMS’ general proposal to have MIPS eligible clinicians report six measures, as this is a
lower threshold than the PQRS, which currently requires that a MIPS eligible clinician or group generally
report on at least 9 measures covering 3 National Quality Strategy (NQS) domains. NASS also supports
CMS’ decision to remove the NQS domain requirement and instead use these domains as a guide for
selecting measures and to guide measuring national quality goals.

Reporting on Outcomes and High Priority Measures: NASS opposes the requirement to report on
outcomes and high priority measures. While we believe in the importance of collecting data based on
these measures, the availability of these measures is highly dependent on the nature of a clinician’s
practice, so the clinician or group should be free to determine which measures they report. While we
agree that outcome measures will more closely represent the actual quality of care provided to patients,
flexibility needs to be in place to ensure that specialties that still do not have outcome measures are not
unfairly penalized as there are many specialties without access to outcome measures. The availability of
outcome measures is dependent on many things including the depth of the medical literature on specific
diseases and conditions. Availability of these measures is beyond the control of the average EP.
Outcomes measures at the physician level can also be particularly challenging to construct for two
primary reasons— small sample sizes and the difficulty of identifying outcomes for which the physician
can and should be held accountable (ie, outcomes that are largely dependent on the quality of care
received, not other factors). Under MACRA, there is funding set aside to assist societies with
development of measures and we encourage CMS to give preference to those specialties with limited
measures.

It is also important to not underestimate the value of clinical process measures. These measures often
lead to sought after outcomes; additionally, they are under the control of the individual clinician and
represent a more accurate measure of actual physician driven improvement.

NASS also continues to believe that patient experience and satisfaction should not be a required
element of reporting for providers since these are often subjective in nature, often not directly under
the control of the physician (e.g., physician wait times in a hospital setting), and not necessarily true
indicators of quality. Spine care providers see many patients with chronic pain, and many of these
patients do not have surgically correctable or other remediable conditions. Often times, their level of
pain will determine their patient satisfaction. Recent research also suggests that recommendations
against surgical intervention may negatively affect patient satisfaction scores in patients with spinal
disorders. Appeasing any patient in the name of patient satisfaction rather than providing clinically
effective, evidence-based care is dangerous and costly. When used for accountability purposes, patient
satisfaction measures can incentivize bad medicine and discourage clinically and cost effective
strategies. We fully recognize the need to evaluate and ensure high standards in regards to patient
experience. However, this could be accomplished most effectively through confidential feedback to
physicians. We would support CMS recognizing the use of patient satisfaction surveys under the Clinical
Practice Improvement Activities category so long as performance was based only on actions such as
administering a survey, evaluating the results, and potentially implementing an intervention that
addresses the findings of the survey. Physicians should not be held directly accountable for the results of
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patient experience surveys due to their subjective and non-evidence based nature.

Data Completeness Threshold: NASS opposes CMS’ proposed thresholds for data completeness,
requiring that a MIPS eligible clinician or group would be required to report quality measures data on at
least 80% of its Medicare Part B patients for claims or, if using a qualified registry, QCDR, or EHR, a MIPS
eligible clinician or group would be required to report quality measures data on at least 90% of ALL their
patients. This is a significantly higher bar than the 50% data completeness threshold that is currently
required under the PQRS. NASS is concerned that this threshold may cause a larger number of clinicians
to fail the reporting requirements under the quality performance category. We also believe that 50%
provides an adequate sample of quality measures data.

With respect to proposing an 90% threshold for the qualified registry submission mechanism, NASS
notes that, in the past, CMS required that EPs report measures data for at least 80% of patients using
the qualified registry option in PQRS. However, this threshold was established in PQRS when CMS was
only requiring the reporting on 3 measures. We also note that when CMS finalized increasing the
number of measures that would be reported in PQRS from 3 to 9 in the 2014 PFS final rule (78 FR 74459-
74461), CMS lowered the reporting threshold for data completeness to 50% of patients to compensate
for the increase in the reporting threshold. While CMS is proposing to lower the number of measures
required to be reported under the MIPS from 9 to 6 measures, the reporting burden is still significantly
higher than when the 80% threshold was used for PQRS. The proposed requirement to report 6
measures is double the prior requirement in PQRS of reporting 3 measures. In addition, CMS is now
proposing that eligible clinicians and groups report on a cross-cutting measure as well as an outcome or
high priority measure. Further, the measures used to complete the 80% reporting threshold were much
lower bar than the measure set currently being proposed. Within the past few years, CMS has removed
many check box and topped out measures. As such, it is harder to meet the reporting threshold for
these higher quality measures than in the past.

With respect to proposing an 80% data completeness threshold for the qualified claims-based
submission mechanism, we note that CMS has NEVER required this high of a threshold for the claims-
based reporting mechanism under the PQRS. CMS has maintained a data completeness threshold of
50%. We believe increasing the data completeness threshold for the claims-based reporting mechanism
will result a significant increased burden for clinicians. Unlike the other data submission mechanisms,
the clinician practice is responsible for entering QDCs onto the claim form for each reported patient.
There are no third party intermediaries that perform this task for the clinician.

NASS is particularly concerned with CMS’s proposal to require that clinicians and groups using the QCDR
option report on 90% of ALL their patients. CMS has NEVER required this high of a reporting threshold
for the QCDR option, and therefore it was not foreseeable that CMS would increase the data
completeness threshold by almost twofold. The QCDR option is still a relatively new option under the
PQRS. In fact, there are 18 new QCDRs on the 2016 PQRS QCDR list (50 QCDRs in 2015 vs. 68 QCDRs in
2016). Both existing and new QCDRs will find the 90% reporting threshold difficult to obtain in addition
to other requirements and aspects that CMS intends the QCDR to be able to handle either starting in
2017 or in future years. For example, in addition to being able to submit data on quality measures data
for the quality performance category, CMS is also requesting, if feasible, that a QCDR be able to submit
data for the ACI and CPIA performance categories. In addition, collecting data on patients from other
third party payers is not within the purview of the Medicare program and make reporting within the
tight timelines for the first performance period even more difficult. These thresholds are particularly
high if the January 1, 2017 deadline is held firm. Without adequate time to prepare for a new program,
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