PCPCC Letter to CMS Calls for Simplified MACRA Regulations, Offers Recommendations to More Strongly Support Patient-Centered Primary Care

June 28, 2016

PCPCC Letter to CMS Calls for Simplified MACRA Regulations, Offers Recommendations to More Strongly Support Patient-Centered Primary Care

WASHINGTON — In an official comment letter submitted yesterday to the Centers for Medicare & Medicaid Services (CMS), the Patient-Centered Primary Care Collaborative (PCPCC) commended CMS for its efforts to overhaul health care payment and better reward patient-centered primary care through the Medicare Access and CHIP Reauthorization Act (MACRA). But the Collaborative offered several specific recommendations for strengthening the proposed regulations in order to simplify, spread, and scale high-performing primary care.

“As key supporters of payment reform embodied in MACRA, we appreciate the substantial work of CMS in trying to craft proposed regulations that will successfully implement the critically important and complex provisions in MACRA,” Marci Nielsen, PhD, MPH, president and CEO of PCPCC, wrote in a letter responding to CMS proposed rules implementing the law. “Leading a careful, clear, and workable process to implement MACRA is a tremendous challenge, but its importance cannot be overstated.” 

“The PCPCC has several concerns about the MACRA proposed rule. Despite the complexity of the law itself, the proposed rule in its current form is cumbersome and ill-timed, misses the mark on opportunities to simplify and streamline aspects of performance measurement, and unnecessarily limits the scope and spread of the medical home model of care that could enhance health care delivery to beneficiaries across the United States,” Nielsen wrote.

The PCPCC offered its strong support for several specific provisions in the proposed rule, as well as its recommendations for needed improvements. Specifically, the PCPCC encourages CMS to:

  • Expand Recognition of Patient-Centered Medical Homes - We strongly recommend expansion beyond the four nationally recognized medical home programs outlined in the regulation, and we recommend that CMS broaden the definition of patient-centered medical home specifically to include programs that have a demonstrated track record of support by non-Medicare payers, state Medicaid programs, employers, or others in a region or state.
    • The PCPCC also recommends that CMS closely review and adopt the recommendations of the PCPCC Accreditation Workgroup – a broad stakeholder group convened to assess the purpose of and improvements to current PCMH accreditation – to inform CMS criteria for certification (or recognition) of the patient-centered medical home.
  • Medical Homes as Advanced Alternative Payment Models – The PCPCC firmly supports multiple pathways by which high-performing primary care practices can be recognized and rewarded as medical homes, specifically as (advanced) APMs.
    • Together with the American Academy of Family Physicians (AAFP), the American College of Physicians (ACP), and the American Osteopathic Association (AOA), the PCPCC strongly recommends that CMS undertake an expedited analysis of the Comprehensive Primary Care initiative (CPC) to determine whether CPC meets statutory requirements for expansion (and thus qualify as an advanced APM).
    • We also recommend establishing and implementing a new medical home deeming program that enables high-performing practices enrolled in medical home programs run by states (including state Medicaid programs), other non-Medicare payers, and employers to be deemed as having met the criteria.
    • Finally, while the PCPCC appreciates CMS’ acknowledgement that medical homes have limited ability to assume significant financial risk in comparison to larger health care organizations, we question whether Congress intended any financial risk requirement for the Medical Home Model based on the statute, and thus encourage CMS to revisit this.
  • Acknowledge the Challenges of Solo and Small Group Practices - Given the requisite investment in infrastructure, the cost of practice transformation, the lack of ability to spread risk throughout a larger patient panel, and a patient population that is disproportionately medically underserved, solo and small group practices warrant special consideration in the proposed rule.
    • The PCPCC strongly encourages CMS to better support solo and small group practices by revisiting the proposed creation of virtual groups, which are essential to begin building networks that would encourage small practices to progress toward more sophisticated delivery models such as medical homes and accountable care organizations.
    • The PCPCC recommends a “safe harbor exemption” for any solo clinician or small group that participates in the MIPS program, making them eligible for positive payment updates if their performance yields such payments, but exempt from any negative payment update until such time that the virtual group option is available.
  • Revise the Implementation Timeline –The PCPCC is concerned that the proposed rule outlines an implementation timeframe that is too aggressive for many clinicians, especially solo and small practices. We urge CMS to start the initial period of assessment no earlier than July 1, 2017. While setting the performance period in 2018 is preferable, delaying it until at least July 1, 2017, will provide additional, much needed time for practices to prepare.
  • Strengthen Beneficiary Engagement - The PCPCC echoes the comments of the National Partnership of Women and Families, Community Catalyst, and other patient and consumer organizations to encourage CMS to move beyond the current definition of beneficiary engagement that too often limits patient engagement to the point of care.
    • We recommend that the regulation include measures that encourage partnership with beneficiaries across all six CPIA subcategories. Many of the promising activities and measures link to the work we are doing through our Support and Alignment Network grant, including community-based supports that integrate social determinants of health and promote social and community involvement by linking electronic health records to community and social services, the creation of Patient and Family Advisory Councils (PFACs), and the inclusion of beneficiary/family caregiver representatives on key governance and decision-making bodies. 
  • Streamline Quality Measurement by including the Core Measure Set - The PCPCC recommends that the proposed rule identify and adopt measures that encourage all providers to report on a parsimonious unified set of quality measures. CMS should consider adoption of the recommendations from the Core Quality Measures Collaborative, developed through a multi-stakeholder process intent on reducing administrative burden and clinician burnout. Creating core sets of measures for primary care and subspecialists is essential for comparing clinicians across payment models.
    • The proposed rule for the Advancing Care Information (ACI) performance category, based on the legacy meaningful use (MU) program, appears to have missed the mark on streamlining and simplifying performance reporting, and appears to be another complex and burdensome program, representing only marginal improvements, if any, on the original program. 

In its recent report, “The Patient-Centered Medical Home's Impact on Cost and Quality: Annual Review of Evidence, 2014-2015,” the PCPCC reiterated that the medical home is the crux of a value-based health care system. Published in February 2016, the report found – from the programs that met inclusion criteria for the study – 21 of 23 programs that reported on cost measures found reductions in one or more measures, and 23 of 25 that reported on utilization measures found reductions in one or more measures.

“MACRA makes significant steps toward a more value-based health care system, built on a foundation of advanced primary care,” Nielsen said. “Given Medicare’s influence on the U.S. health care marketplace, MACRA’s reach will extend far beyond the confines of CMS and Medicare. As a unique coalition representing health care providers, patients, and payers, the PCPCC stands ready to assist CMS in engaging the diversity of organizations keenly interested in supporting payment reform that supports high-performing team-based patient-centered primary care for all.”


Editor's Note: Access the PCPCC’s full comment letter here. To arrange an interview with Marci Nielsen, contact Amanda Holt, 202-640-1212, or amanda@pcpcc.org.

About the PCPCC
Founded in 2006, the PCPCC is a not-for-profit membership organization dedicated to advancing an effective and efficient health care system built on a strong foundation of primary care and the patient-centered medical home (PCMH). The PCPCC achieves its mission through the work of its volunteer members, Stakeholder Centers, experts, and thought leaders focused on key issues of delivery reform, payment reform, patient engagement, and benefit design to drive health system transformation. For more information, or to become an executive member, visit www.pcpcc.org.

[1] PCPCC Board of Directors (November 2015) “Improving Patient-Centered Medical Home (PCMH) Recognition: Board Endorsed Recommendations of the Accreditation Work Group” Patient-Centered Primary Care Collaborative, published June 2016.

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