The California Medical Association (CMA) has submitted comments to the Centers for Medicare and Medicaid Services (CMS) on the proposed changes to the Medicare Quality Payment Program for 2019.

CMA is disappointed that CMS did not reduce the reporting burdens in the Merit-based Incentive Payment System (MIPS) program in a more meaningful way. We also oppose the confusing new scoring tiers (gold, silver and bronze) and have urged CMS to simplify and overhaul the complex MIPS scoring system.

CMA strongly urges CMS to maintain the 10 percent weight of the cost category, rather than increasing it to 15 percent as proposed. Vast methodology improvements should be made to the cost category before its weighting is increased. Otherwise, physicians will be disincentivized from treating the sickest and most vulnerable patients, thereby jeopardizing access to care. CMA has also requested a delay in the new attribution methods for the inpatient condition measures.

CMA continues to urge CMS to expand the number and types of innovative physician-led alternative payment models (APM) and to remove the current administrative and financial barriers to participation. California physicians have been innovators in health care delivery and we cannot emphasize more strongly the need to move forward with more innovative physician-led models. APMs can address the shortcomings of a fee-for-service system that fails to incentivize high-value services, such as chronic care case management or palliative care – services that reduce spending and improve care.

CMA has also urged CMS to:

• Significantly reduce the number of quality measures; restore the topped-out quality measures to give physicians a sufficient number of measures to report; reduce the threshold on patients from 60-50 percent; and only require 90 days of reporting.
• Eliminate the requirement for physicians to report all-payor data.
• Only require yes/no attestations in the electronic health record (EHR) Promoting Interoperability category and allow physicians to choose from a larger menu of measures applicable to their practice.
• Enforce EHR vendor interoperability and accountability
• Require vendors, not physicians, to report on certified EHR technology functionality and to bear the costs for interoperability updates.
• Reward high-performing physicians within 1-2 standard deviations of the national average.
• Restore the Small Practice Bonus to the overall MIPS score, rather than restricting it to the Quality category.
• Reduce the barriers to participation in virtual groups.

CMA has heard from numerous physicians across the state, in all specialties, from solo practice to large, sophisticated medical groups, who made substantial investments in order to participate in the MIPS program. Most of these physicians received high to perfect performance scores for 2017, but have now been told by CMS that they will only receive a 0.2-0.3 percent bonus in 2019 – if they receive a bonus at all. Additionally, APMs are so limited that these physicians cannot participate in the APM track either. Physicians are left without sustainable payment options and few resources to improve the quality of care.

While CMA understands that CMS is not responsible for the budget neutrality requirements of the Medicare Access and CHIP Reauthorization Act, the limited return on investment has discouraged many physicians to the point of withdrawing from MIPS and Medicare altogether. CMA and the American Medical Association have urged CMS to seriously consider these issues and work with physicians on improvements that will allow physicians to continue to participate in the program.