March 5, 2020 

Ms. Seema Verma
Centers for Medicare & Medicaid Services
U.S. Department of Health and Human Services
Hubert H. Humphrey Building
200 Independence Avenue, S.W.
Washington, DC 20201 

Re: MACRA Implementation Issues 

Dear Administrator Verma: 

The National Association of ACOs (NAACOS) would like to bring to your attention several MACRA implementation issues that contribute to regulatory burden for ACOs. As CMS has implemented the Quality Payment Program (QPP), there have been unintended consequences that must be remedied to continue to advance the movement to value based care. NAACOS and its members are leaders in the movement to value based care, with CMS’s various ACO programs comprising the largest proportion of participants across all Alternative Payment Models (APMs). Therefore, it is critical that CMS address these issues and we urge your consideration of these changes as you develop policies for inclusion in the 2021 Medicare Physician Fee Schedule regulation. 

Advanced Alternative Payment Model (APM) Issues 

Revise QP Thresholds
Many ACOs have communicated they will be unable to achieve Qualifying APM Participant (QP) thresholds when they rise in performance year 2021. These ACOs have demonstrated commitment to value and assumed accountability through participation in risk-based APMs, models which the agency has emphasized as central to the shift to value. Unfortunately, despite their commitment and significant investments, rising QP thresholds will mean many will not be able to earn Advanced APM bonuses. These bonuses are very effective in incentivizing participation in voluntary Advanced APMs. 

Further, ACOs in Advanced APMs that are unable to meet unrealistically high QP thresholds will be subject to extreme amounts of additional regulatory burden by needing to comply with MIPS.,NAACOS appreciates CMS’s current policy which sets the patient count QP thresholds lower than the statutorily set payment thresholds, and we request CMS establish even more flexible patient count thresholds, given the full discretion the agency is provided. We also urge CMS to release details on the range of QP scores, including information on previous performance years through performance year 2019. As part of that release, we request CMS provide details on what factors lead to higher or lower QP scores for various ACOs, as it is our understanding that QP scores are driven more by practice patterns and ACO composition than by a “commitment” to the ACO model. 

Align QP Calculations with ACO Definitions
There has been tremendous confusion regarding how CMS calculates QP thresholds for ACOs. Some of this confusion is due to the fact that definitions for key calculation components, such as ‘primary care services’, and providers used for evaluations differ for QP calculations and similar calculations for ACO programs. NAACOS requests that CMS use the program definitions of the respective APM when making QP calculations (ex., align QPP definitions with those used for ACO assigned and assignable beneficiaries). In addition to alleviating confusion about the QP calculation, using ACO program definitions for QP calculations would alleviate duplicative work for CMS and allow ACOs considering Advanced APM participation to calculate their QP thresholds before entering an Advanced APM. Having this information early is important for ACOs evaluating various models. The current uncertainty about what an ACO’s future QP score might be prevents ACOs from moving to Advanced APMs. We also request more education and transparency for the QP calculations, including adding more details and making timely updates to CMS’s step-by-step QP resource and adding FAQs. CMS should release all the necessary details to allow ACOs to replicate QP calculations on their own. In sum, aligning QP definitions/calculations with similar ACO definitions/calculations and increasing transparency and education will notably minimize provider confusion and reduce administrative burdens for ACOs and CMS. 

Base the Advanced APM Bonuses on the Aggregate Allowed Amounts
After a number of references, such as the one cited below, in the commentary of QPP regulations to CMS basing the Advanced APM bonus on the aggregate allowed amounts, the agency in 2019 changed course and noted that the bonus is based on the aggregate paid amounts. This change results in an approximately 20 percent lower payment, which represents a loss of hundreds of millions of dollars to providers over time. Providers have expressed disappointment over the bonuses being lower than expected. NAACOS urges the agency to follow its own language and base the bonus on the aggregate allowed amounts, as previously discussed. 

We believe it is appropriate to maintain consistency across the QP determination and the incentive payment calculation in order to support internal CMS operational consistencies. It also ensures that any unique payment mechanisms within an Advanced APM do not affect the opportunity for an eligible clinician to reach the QP threshold. We solicited comment on whether the claims methodology we use under the Medicare payment method should align with the proposed claims methodology for purposes of calculating the estimated aggregate payment amount for the APM Incentive Payment.[…] 

Response: We do not believe it would be appropriate to use the Medicare paid amount instead of the allowed amount when calculating Threshold Scores.The Medicare paid amount reflects any reductions from the Medicare PFS amount for beneficiary co-payments or coinsurance requirements, and also reflects any payment adjustments that are applied to fee schedule payments, such as positive or negative payment adjustments from the PQRS, MU, VM, or MIPS programs. Including these adjustments is inconsistent with our proposal to exclude payment adjustments from these programs that we finalized in section II.F.8. of this final rule with comment period. We are finalizing that for the QP payment amount method we will use all available claims information for Medicare Part B covered professional services during the applicable QP determination period as described in this section of the final rule with comment period.” Source: 81 Fed. Reg. 77008, 77453 (Nov. 4, 2016). 

Provide Increased Details on Advanced APM Bonus Payments to ACOs
NAACOS requests CMS provide more transparency on how the Advanced APM bonus is calculated, by releasing a more detailed step-by-step methodology paper to allow providers to replicate the calculation and adding FAQs. Following the release of the Advanced APM bonuses in 2019, there was considerable confusion about the bonuses, which would have been mitigated by increased education and transparency. We also request that CMS release more detailed Advanced APM bonus amount information, including providing details about the bonuses to the ACO entity; without this, ACOs are not able to account for who has obtained the bonus. Specifically, CMS should provide the following information: a detailed accounting to accompany an APM incentive payment; the amount paid for each TIN/NPI combination in the ACO entity; in instances where an NPI participates in multiple TINs, which TIN the payment was made to for the NPI. 

Pay 2020 Advanced APM Bonuses by June 30 of the Payment Adjustment Year
The first Advanced APM bonuses were distributed late in 2019, many in the fourth quarter. ACOs took the necessary steps and made significant investments to prepare for participation in Advanced APMs, including hiring additional staff to improve care coordination within and across clinical care teams and investing in new technologies to support advanced care processes and performance data submission. As noted previously, those participating in Advanced APMs assumed financial risk, which further illustrates their commitment to value-based care. They took these steps and assumed financial risk with the expectation that some of these investments would be recouped in part by the five percent Advanced APM bonus. The almost three-year delay between the performance year, which began January 1, 2017 and the payment distribution in late 2019 is unacceptable. We urge CMS to distribute Advanced APM bonuses before the end of the second quarter of the payment adjustment year, if not earlier. 

Remove Promoting Interoperability (PI) for Advanced APM ACOs
ACOs who meet QP thresholds are not subject to MIPS, however, many ACOs have had to implement a policy to continue to report PI measures regardless, due to the fact that they will not know whether they met the necessary QP thresholds until it would be too late to report PI for MIPS. This adds burden to ACOs and detracts from the patient care and population health efforts they should be focusing on. As such, NAACOS requests CMS eliminate the PI requirements for Advanced APM ACOs. As an alternative, CMS should provide at a minimum automatic 50 percent credit in this performance category to ensure ACOs are not harmed by this flawed policy. 

Merit-Based Incentive Payment System (MIPS) Issues 

Alter MIPS Eligibility and QP Snapshot Date Calculations
Due to the fact that CMS policy leads to a calculation of MIPS eligibility for each QP snapshot date, it is our understanding that ACOs are expected to use the QPP lookup tool for each QP snapshot date for each unique NPI participating in an ACO to determine who will be subject to MIPS. This is unreasonable and not operationally feasible given the capabilities of the QPP lookup tool. This was not an issue in early years of the QPP, however, as QP thresholds rise and more ACOs miss QP thresholds, this has become a larger issue. Our recommendation is for CMS to establish a policy whereby once an ACO entity meets the QP threshold, any NPI in the ACO for that performance year should earn the Advanced APM bonus and be exempt from MIPS unless they are added after the third snapshot date. 

Clarify How MIPS Exclusions and Exemptions for PI Apply to ACOs
ACOs continue to be provided with conflicting information regarding how certain exemptions and exclusions for PI apply to ACOs in particular. CMS should establish public guidance in this area and be very clear and consistent with the policy, so it is understood by ACOs as well as QPP Help Desk staff. ACOs continue to receive conflicting information from Help Desk staff regarding how such exemptions and exclusions apply, and when a practice in an ACO is eligible to apply for such exclusions. As an example, ACOs continue to receive conflicting information regarding whether or not practices in an ACO may apply for the small practice exclusion for the Promoting Interoperability performance category. We urge CMS to issue clear regulatory language and additional sub-regulatory guidance on these issues. 

Communicate Quality Measure Specification Changes
NAACOs has concerns that CMS continues to change measure specifications or interpretations late in the performance year, without any clear communication to ACOs of such changes until it is too late to act. A recent example of this is the interpretation change on ACO-18 (Depression Screening and Follow Up), which was not communicated publicly until late in 2019 during the question and answer session of a Web Interface support webinar. While we are pleased that MSSP and Next Generation Model staff have decided to make the measure pay-for-reporting retroactively for 2019, this causes extensive confusion and therefore wasted resources. Another recent example of this poor communication was the ACO-17 (Smoking Cessation) measure changes in 2018 which resulted in changes to the measure in 2019. CMS must communicate clearly and publicly to ACOs when significant measure specification or interpretation changes take place. We recommend this communication through MSSP and Next Generation Model program materials such as the ACO-Management System as well as the ACO Spotlight Newsletter. 

Ensure Accuracy of Information Contained on the QPP Portal
ACOs continue to report inaccuracies with the information displayed on the QPP portal (lookup tool). CMS must provide more transparency on how QP calculations are completed, as described above, as well as how MIPS status for clinicians in ACOs will be reported to ACO Entities to reduce confusion in this area. 

QPP Education Issues 

Provide Detailed Guidance and Education Tailored Specifically to ACOs on QPP Policies
ACOs have communicated ongoing frustration with the lack of education on how QPP policies apply to ACOs specifically. According to CMS data, there are almost 500,000 physicians and non-physician providers and over 17,000 TINs participating in the MSSP in 2020. Given this large portion of providers in ACOs, it’s essential that QPP policies and education be adequately geared towards ACOs. CMS should provide tailored educational materials and sub-regulatory guidance in this area. ACOs cannot be successful unless they clearly understand the rules of the program. ACOs also express concerns with the accuracy of information provided to them by the QPP Help Desk staff. ACOs have shared inaccurate or incomplete answers from QPP Help Desk staff due to a lack of knowledge on how QPP policies apply to ACOs specifically (and practices in an ACO). CMS must invest in more tailored education of QPP Help Desk staff or more re-direction to the program leads that would be able to inform ACOs on how QPP policies affect ACOs specifically. QPP policies as they apply to ACOs specifically should be addressed in regulation and through published sub-regulatory guidance. 

NAACOS and the ACO community are very supportive of MACRA and the transition to value. We look forward to working with CMS on QPP implementation and appreciate your attention to these important issues. In order for ACOs to continue to participate in value based programs, particularly those that involve substantial risk, it is critical that CMS resolve the problems described above to reduce regulatory burdens and allow ACOs to focus on care transformation rather than wasting limited resources complying with flawed regulatory policies. 


Clif Gaus, Sc.D.
President and CEO
National Association of ACOs