Community Health Provider Alliance Issues Public Comment on Centers for Medicare & Medicaid Services Proposed Rule
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CHPA's integrated network has 20 FQHCs participating in various payer-specific quality improvement projects in our Medicare, Medicaid and Commercial ACO. The network of providers includes 630 medical providers and mid-levels, 170 behavioral health and 140 dental providers that operate in more than 140 locations across the state of
Members of CHPA must agree to work as an accountable care organization focused on adopting and implementing best practices to improve health and well-being for our patients. Our members agree to adopt and adhere to evidence-based clinical guidelines. Physicians and clinics are required to actively participate in activities and CHPA initiatives to improve the quality, efficiency and coordination of patient care, including:
* Participating in clinical education, care coordination activities and regular clinical and quality improvement meetings.
* Critical review of FQHC performance data and testing and demonstrating improvements and progress toward CHPA goals,
* Implementation of population health management strategies, including the implementation of health information technology to improve systems, care coordination, and population management, and
* Adherence to clinical guidelines, as demonstrated by performance on nationally endorsed measures and defined performance targets.
In addition, CHPA supports the practices in:
* Establishing mechanisms to securely communicate PHI and developing claims-based patient meaningful reporting for members;
* Providing clinical and operational staff with education, tools and resources to be successful with the patient engagement and outreach efforts,
* Consistent measuring of the quality improvement effort and aligning the measurement process with other payer initiatives to streamline internal clinic processes, such as billing and coding;
* Regular and ongoing monthly communication and committee interaction with key operational, billing, and clinical staff to focus on the quality improvements; and
MSSP PROPOSALS
Changes to ACO Quality Scoring and Reporting
Proposals: CMS proposes major structural changes to the way MSSP ACOs are measured and assessed on quality. For 2021 and future performance years, CMS proposes to sunset the current approach of quality measurement for MSSP ACOs and replace it with a new APM Performance Pathway (APP) to better align with the Quality Payment Program (QPP). CMS also notes many ACOs are high performers under the current structure and the agency believes it is appropriate to require a higher standard of care in order for ACOs to continue to share in any savings they achieve. CMS also notes the agency believes holding ACOs to a higher standard is in line with CMS goals of incentivizing value-based care and driving the Medicare system to greater value and quality. Notably, the new APP would include fewer measures and a higher minimum attainment standard, which is the threshold that ACOs would be evaluated on to be eligible to share in savings earned.
Comments: While we appreciate CMS's goal of aligning methodologies across programs, we do not support CMS proposals to make such sweeping changes to how ACO quality is assessed, how quality data is reported, and how ACOs are evaluated on quality for both the Medicare Shared Savings Program (MSSP) and Merit-Based Incentive Payment System (MIPS). Further, these changes come amidst the unprecedented COVID-19 Public Health Emergency (PHE). The timing of these changes is very concerning as ACOs continue to deal with the uncertainty that the COVID-19 PHE is bringing to the health care industry. At a minimum we urge CMS to postpone making any structural changes to the way ACO quality is assessed or reported until at least 2022. Finally, while these proposed changes align more with the way individual clinicians and groups are scored in MIPS, it is a farther departure from the way CMS assesses other non fee-for-service providers, such as Medicare Advantage. Therefore, this effort at alignment is a step backward for ACOs and those committed to value.
Quality improvement is a cornerstone of the ACO model. In addition to reducing spending, ACOs must meet certain quality performance standards to be eligible to receive shared savings payments. ACOs continue to improve quality year over year, which improves patient care and helps to control costs. It is critical that CMS policies to evaluate ACO quality are fair, appropriate and accurately reflect the work ACOs undertake to improve patient care. CMS's proposals to change the way ACO quality is assessed, reported and scored for the purpose of shared savings calculation are significant and more feedback should be collected before moving forward with such drastic changes. Further, as stated in previous comments, CHPA strongly believes ACOs should not be evaluated and assessed in the same manner as all other APMs or individual MIPS clinicians. ACOs are high-quality performers, however, this should not serve as a reason for CMS to overhaul the entire quality performance assessment approach for the MSSP. Instead, we urge CMS to work with CHPA and other stakeholders to make changes to the current quality measure performance evaluation criteria and measure set for ACOs to further refine the measures and criteria as appropriate for a group of providers who are responsible for total cost of care for the populations they serve. Clinicians in MIPS who are not participating in total cost of care and full accountability payment models should not necessarily have the same quality measure set and scoring approach as ACOs. Likewise, each APM has specific goals and objectives, and the one size fits all approach under the proposed APP structure does not account for those differences.
The proposed APP attempts to apply one approach to a multitude of providers and APMs. The current MIPS APM Scoring Standard, in comparison, allows each APM to have its own set of unique quality measures and scoring approaches that best fit a particular model. This approach allows specific APMs to have meaningful quality measures tailored to their model's goals while still providing credit for quality improvement efforts to those who are also subject to MIPS. The proposed APP approach would instead apply one set of quality measures for all APMs subject to MIPS. Therefore, each model participant would need to report not only their APM's specific quality measures, but also the APP quality measures (or other measures). This one size fits all approach results in more burden for APM participants and further may require the model participants to report on measures that are not applicable or appropriate.
Finally, CHPA has concerns that this policy, which may allow APMs to choose to select measures to report outside the APP instead of relying on the APM's own quality measures as is currently done, would allow certain organizations to select measures for which they have the highest historical performance, not allowing for a true and fair assessment of quality improvement efforts. We instead urge CMS to maintain the APM Scoring Standard approach.
Proposed APP Measure Set
Proposals: CMS proposes to dramatically decrease the number of measures ACOs are evaluated on for purposes of MSSP quality assessments. These measure scores would also be used to evaluate ACOs subject to MIPS for purposes of quality assessments. Table 36 on page 50233 of the proposed rule outlines the proposed new measure set for MSSP ACOs, which includes 10 Consumer Assessment of Healthcare Providers and Systems (CAHPS) measures (counted as one measure under the APP), two administrative claims measures, and three clinical quality measures.
Comments: The proposed six APP measures are a drastic reduction from the 23 measures ACOs are currently assessed on. While CHPA supports reducing reporting burdens and efforts to eliminate low value measures, we feel these proposals go too far by reducing the number of clinical quality measures to a mere three measures. Quality improvement is a critical and core component of an ACO's work. We therefore recommend CMS consider maintaining several key clinical quality measures that are foundational to an ACO's quality improvement work and have been proven to improve outcomes including: ACO-14, Influenza Immunization; ACO-19, Colorectal Cancer Screening; ACO-20, Breast Cancer Screening; and the previously used Pneumonia Vaccination measure. While ACOs can choose to continue to work on these preventive measures whether or not they are included in the MSSP's official measure list, we think it is critical for CMS to evaluate both individual ACOs and the program as a whole on these foundational prevention measures. Further, since the ACO program already gives ACOs a direct financial incentive to reduce avoidable admissions and readmissions, we do not feel it is appropriate to have one third of the total measure set focused on utilization measures. We also urge CMS to do more comparative research on how ACO quality on these core measures and improvement areas contrasts to non-ACO quality and to make the data and research findings public. This type of comparison cannot fairly be done if ACOs are only measured on one diabetes measure, one blood pressure measure, and one depression screening measure as proposed in the APP, nor does it reflect the true purpose and work ACOs do in the quality improvement space.
Additionally, we have concerns with the Screening for Depression and Follow-Up Plan measure, as well as the Days at Home measure discussed but not formally proposed. Understanding the degree to which individuals spend their time at home is a useful indicator to determine if the healthcare system is achieving one of its primary goals. While this indicator provides a viewpoint broader than measures such as admissions or readmissions, the many different factors that can affect patients' "healthy days at home" raise serious concerns about whether differences in performance on this measure can be reliably attributed to the services delivered by ACOs and whether it would truly distinguish the quality of care ACO participants deliver. We also are concerned with the controlling high blood pressure measure in its current state, which determines performance based on a single reading rather than taking into account the level of control over a period of time. There are also limitations in accepting patient reported home readings that can be more reflective of true control of high blood pressure than office-based readings.
Further, the MIPS Unplanned Admissions for Multiple Chronic Conditions measure does not meet the required 0.7 reliability threshold, and therefore we urge CMS to increase testing, particularly for risk adjustment, and increase case minimums for this measure before including it in the proposed APP measure set. Finally, the Unplanned Readmissions measure and CAHPS measures have very narrow bands, meaning very small differences in quality can result in very drastic quality score differences that are not meaningful and do not truly measure an ACO's quality improvement efforts. We recommend CMS work with stakeholders to make improvements to the specifications for these measures before using them as part of such a limited quality measure set as proposed in the APP.
Finally, while we support the inclusion of patient satisfaction measures, we have concerns that the number of CAHPS measures included in the APP is disproportionate to clinical quality and outcomes measures. There are several issues with the CAHPS measures as currently collected. As an example, the CAHPS measures use a very small sampling of patients and rely on patient recollection of experience that took place months prior. CMS should consider altering surveys to accept results from shorter surveys provided closer to real time and to a much larger population.
Removing the Web Interface Reporting Mechanism
Proposals: CMS proposes to eliminate the Web Interface as a reporting method for ACOs and all MIPS reporters beginning in 2021, citing low uptake of use outside the ACO program. In place of the Web Interface, the APP would require ACOs to actively report on three clinical quality measures, which could be reported using a registry or direct via electronic health records (EHRs) using electronic clinical quality measure (eCQM) standards. These eCQMs must be reported for all patients, regardless of payer.
Comments: CMS proposes to abruptly end the use of the Web Interface reporting mechanism, a tool that has been used since the MSSP's inception. Removing this option for all ACOs with little notice is illtimed and unfair. Further, CMS has not been clear regarding how the alternative MIPS reporting options will be utilized for ACOs (as APM Entities) specifically. There are several key questions and obstacles to moving away from this reporting method in this timeframe. For example, the current remaining MIPS reporting options available under the APP would be registry (MIPS CQMs) and EHR (eCQMs). Using these reporting options would result in the ACO being evaluated on quality for all patients the ACO's providers serve, not only ACO assigned patients. This is not a true evaluation of the ACO's quality efforts and, additionally, raises contractual and legal concerns, as an ACO may not have the ability to access patient data for non-ACO patients. This would also make quality evaluations challenging. In effect, assessing ACOs on their quality actions for all patients rather than ACO patients would be evaluating the ACO's spillover effects and would not directly evaluate the true impact of their work on their ACO patients.
Further, a goal of APMs is to promote provider investment in processes and tools to improve outcomes. Many ACOs have invested significant resources for development of reporting processes and workflows to optimize this process; removing this option altogether would undermine these investments, thus diverting critical resources away from improving patient care.
Additionally, making the switch to these alternative reporting options will cost many ACOs considerable time, money and effort in changing workflows, paying for registries and adapting and modifying EHRs to comply with eCQM standards. As an example, some ACOs would need to pay large fees for modifying EHRs to capture the appropriate quality data and to change performance dashboards. These fees can be significant, and a large hardship particularly for smaller ACOs. Other ACOs may need to explore working with registries, which again, could come with additional fees to the ACO. For these reasons, we urge CMS to provide a more gradual transition away from the use of the Web Interface reporting option to give more time and thought to how this will practically be implemented and to give ACOs more time to assess their alternatives. While CHPA supports the movement toward more automated reporting, the timeline CMS proposes is unreasonable and creates a hardship for ACOs. Specifically, we urge CMS to allow the Web Interface to be continued as an option for the foreseeable future while carefully considering additional reporting options for ACOs.
Finally, moving to a registry or EHR-based reporting method will significantly increase the number of patients an ACO must report on and be evaluated on under CMS proposals. Currently, ACOs must report on 248 ACO patients included in the Web Interface. Under the registry option, an ACO would have to report on 60 percent of their patients, both Medicare and non-Medicare patients as well as ACO and non-ACO patients. For the EHR reporting method, ACOs would be required to report on 70 percent of patients, both Medicare and non-Medicare as well as ACO and non-ACO patients. For some ACOs this could be a drastic increase and will therefore add significant administrative burden for the ACO. Should CMS finalize this approach, the agency should be requiring the ACO to report on, at a maximum, 50 percent of exclusively ACO patients. These specification issues and differences demonstrate why CHPA feels an ACO-tailored approach to quality measurement and assessment is more appropriate than trying to make the MIPS program and standards apply to ACOs. This will be increasingly important as CHPA predicts many ACOs will not be able to meet the increasing QP thresholds in the coming years and will therefore find themselves subject to MIPS, even those taking on the most advanced levels of risk.
Quality Benchmarks
Proposals: CMS proposes to use all MIPS reporters to establish benchmarks for ACOs under the new APP scoring approach. Further, due to anomalies in data due to COVID-19, CMS proposes to use PY 2021 information to establish 2021 quality benchmarks.
Comments: It is unfair to hold providers accountable for performance against a benchmark that would not be set until after the performance period has closed. Alternatively, we recommend CMS continue to monitor the data submitted by Web Interface reporters in 2019 and continue to evaluate the impact of COVID-19 on 2021 quality performance. As is the case for 2020, we suspect there will be a significant impact on quality improvement efforts in 2021 as a result of the COVID-19 pandemic, and we urge CMS to consider using alternative policies such as reverting all measures to pay-for-reporting or providing ACOs with historical performance scores.
Quality Scoring Methodology Changes
Proposals: CMS proposes to alter the scoring methodology currently used to assess MSSP ACO quality. As proposed, CMS would award a score of three-to-ten points for each measure in the APP that meets the data completeness and case minimum requirements, which would be determined by comparing measure performance to established benchmarks. Benchmarks would no longer be determined by looking at all Web Interface reporters, but rather, benchmarks would be established based on all MIPS reporters and would also vary based on the reporting method chosen by the ACO. Notably, CMS is proposing to remove the pay-for-reporting year currently provided to ACOs in their initial contract year or for new or substantively revised measures. CMS also proposes to change the minimum attainment standard to require ACOs to meet or exceed the 40th percentile among all MIPS reporters. Finally, as is currently the case, ACOs must also report on all measures in order to meet the minimum attainment standard.
In regard to how quality scores determine shared savings/loss rates, CMS proposes that ACOs must meet the minimum attainment standard to be eligible to share in any savings earned, however, once the minimum standard is met an ACO would receive the maximum shared savings rate automatically regardless of the ACO's final quality score. If an ACO does not meet the minimum attainment standard, the ACO would not be eligible for shared savings. To determine shared loss rates, CMS proposes to use an approach that would award ACOs with higher quality scores a lower shared loss rate (and vice versa), except for risk-based Basic
Comments: CHPA opposes the proposal to remove the pay-for-reporting year currently provided to ACOs beginning an initial MSSP contract, as well as individual measures that are newly introduced to the measure set. This change would also remove the ability of CMS to provide a pay-for-reporting year when measures undergo significant changes, such as guideline and specification changes. Providing the pay-for-reporting year is critical to an ACO's success. This flexibility in scoring when a measure undergoes significant changes allows an ACO to evaluate their current workflows, data capture processes and other operational strategies to see where changes are needed and what areas to focus on. Further, providing a newly introduced measure with a pay-for-reporting year ensures there are no unintended consequences or flaws in the measure specifications before holding an ACO accountable for performance on the measure. Allowing this time to assess workflows and operations before ACOs are held accountable for performance on measures allows ACOs to be successful in getting credit for the good quality improvement work they are already engaged in, as often times a measure is not only assessing true quality but also how the quality data are captured. We urge CMS to not finalize this approach and instead maintain the pay-for-reporting year provided to ACOs in their initial contract year, as well as new quality measures when they are introduced or significantly changed. The current MIPS policy would allow for suppression of a measure that undergoes significant specification changes: under the proposed new APP scoring approach this would significantly disadvantage ACOs who could see drastic swings in their performance based on suppression of just one measure.
Additionally, CHPA opposes the overall approach proposed for ACO quality scoring. With upcoming changes to MIPS through the MIPS Value Pathways and exemptions due to extreme and uncontrollable circumstances such as for COVID-19, the 40th percentile of the Quality Category score could vary greatly from year to year making it a less meaningful indicator of true performance. Instead, should CMS move forward with proposals to re-design the quality assessment structure for ACOs, we urge CMS to utilize a scoring approach that is more similar to the current domain-based scoring approach instead of using an all-or-nothing approach as proposed. As an example, CMS could instead consider a policy that would use a minimum attainment standard that requires 50 percent of the quality measures to meet or exceed the 40th percentile. This must be done in conjunction with our recommendations to add additional clinical quality measures to the measure set beyond the three that CMS has currently proposed. Setting the standard at 50 percent ensures that ACOs perform well on a substantial set of measures to earn savings but does not punish ACOs that miss the mark on a measure that is either not as relevant to their patient population or has a very narrow range of performance rates. Finally, CHPA also urges CMS to better reward high quality performers, as is done in the Medicare Advantage program by providing bonuses or higher shared savings rates to high quality performers or those that notably improve quality scores over time.
Alternative Proposal Allowing ACO Selection of Quality Measures
Proposals: CMS seeks comment on an alternative approach that ACOs could use in the event "the three measures ACOs are required to actively report on are not applicable to their beneficiary population." In this case, the ACO could choose to opt out of the APP and report to MIPS as an APM Entity selecting more appropriate measures available under MIPS. CMS does not include any further details regarding how CMS would determine if the three required measures were not applicable to the ACO.
Comments: CHPA opposes this approach to provide ACOs the option of selecting alternative quality measures to report. First, we cannot contemplate instances when the proposed APP measures listed would be determined to not apply to an ACO. Second, allowing this option would make program evaluation nearly impossible. Evaluating ACO's impact on quality should be a key focus for CMS and, therefore, there should be one standard set of quality measures that apply to all ACOs participating in the model. Finally, CHPA has concerns that this policy would allow certain organizations to select measures for which they have the highest historical performance, not allowing for a true and fair assessment of quality improvement efforts across ACOs.
Awarding the Higher of the 2019 or 2020 ACO Quality Score and CAHPS Changes for 2020 Due to COVID-19 PHE
Proposals: CMS seeks comment on an option that would provide ACOs the higher of their 2019 or 2020 quality scores for PY 2020 due to the impact of the COVID-19 PHE, so long as ACOs fully report on quality measures in 2020. Additionally, due to the negative impact of COVID-19 on sample size and performance scores, CMS proposes to remove the requirement for ACOs to field a CAHPS for ACOs survey for PY 2020. Instead, CMS proposes to provide automatic full points for each of the CAHPS survey measures within the patient/caregiver experience domain for PY 2020.
Comments: CHPA is pleased to see CMS providing a fallback option for 2020 quality scores due to the impact of COVID-19. While CHPA prefers to see all measures reverted to pay-for-reporting in 2020, we support this alternative approach that will protect ACOs whose quality scores are affected by the COVID19 pandemic. We are also pleased to see CMS remove the requirement for ACOs to field a CAHPS for ACOs survey in 2020 and provide full points automatically for each of the CAHPS survey measures. We urge CMS to finalize these proposals. We also ask CMS to begin considering alternative polices and exceptions for the COVID-19 PHE for PY 2021, which CMS does not address or discuss in this proposed rule. The COVID-19 pandemic will continue beyond
Quality Measure Specification Changes
Proposals: CMS proposes several notable measure specification changes for the ACO Web Interface quality measures for 2021. CMS proposes to add denominator exclusions for advanced illness and frailty for the breast cancer screening and colorectal cancer screening measures. CMS also proposes to update specifications for certain Web Interface measures to allow telehealth encounters as eligible encounters.
Comments: As noted above, we urge CMS to keep in place the current measure set, reporting mechanism and scoring methods for ACO quality in 2021. Therefore, we support CMS proposals to add denominator exclusions for advanced illness and frailty for the breast cancer and colorectal cancer screening measures, as previously advocated for by CHPA. These important exclusions will ensure unnecessary care is not provided to patients with advanced illness. Additionally, CHPA supports updates to specifications to add telehealth encounters as eligible encounters, however, we note that certain measures do not list these changes as applicable when reporting via the Web Interface. CMS should clarify that all specification updates will apply regardless of reporting method and including measures reported via Web Interface. CMS should also clarify the proposed changes to the influenza immunization measure. CMS notes a qualifying encounter must occur
Additionally, needing an in-person encounter for the flu shot during a predefined timeframe is not practical, whether it is a telehealth encounter or in-person encounter. Many patients will receive the flu shot at a pharmacy, where there is a Part B charge but not an encounter. These patients receiving flu shots in the pharmacy setting should meet the measure criteria as well.
Adjustments to the MSSP Extreme and Uncontrollable Circumstances Policy
Proposals: CMS proposes to make changes to the quality portion of the MSSP Extreme and Uncontrollable Circumstances policy for ACOs to align with the proposed changes to introduce a new APP for ACOs. For PY 2021 and subsequent years, CMS proposes to provide an ACO affected by an extreme and uncontrollable circumstance with the higher of its own quality score or a score equal to the 40th percentile MIPS Quality Performance Category Score. CMS also proposes to use the quarter four list of assigned beneficiaries to determine the portion of patients affected by the extreme and uncontrollable circumstance.
In addition, CMS seeks comment on a potential alternative Extreme and Uncontrollable Circumstances Policy for PY 2022 and subsequent years. Specifically, CMS proposes to adjust the amount of shared savings determined for affected ACOs that complete quality reporting but do not meet the quality performance standard, or that are unable to complete quality reporting. Under this alternative approach, CMS would determine shared savings for an affected ACO by multiplying the maximum possible shared savings the ACO would be eligible to receive based on its financial performance and track (or payment model within a track) by the percentage of the total months in the performance year affected by an extreme and uncontrollable circumstance and the percentage of the ACO's assigned beneficiaries who reside in an area affected by an extreme and uncontrollable circumstance.
Comments: We do not support CMS making further changes to the MSSP Extreme and Uncontrollable Circumstances policy at this time. Given the vast changes proposed to the MSSP Extreme and Uncontrollable Circumstances policy over the last two years and the additional, alternative policies that have been put in place in 2019 and 2020 to account for COVID-19, CMS should refrain from making any significant changes to this policy at this time and continue to assess the COVID-19 pandemic in 2021 before making any further changes to the established policy. As noted above, we also urge CMS to begin considering alternative policies for 2021 due to COVID-19 for both financial and quality assessments for ACOs. As noted above, we do not support CMS proposals to change ACO quality assessments, and therefore we also do not support the proposed changes to the MSSP Extreme and Uncontrollable Circumstances Policy to align with the new APP proposals.
Repayment Mechanism Requirements
Proposals: CMS proposes to eliminate the requirement that a renewing ACO maintain a higher repayment mechanism amount than would otherwise be required under the new agreement period if the ACO's repayment mechanism amount for the final year of its previous agreement period was greater than the repayment mechanism amount calculated for the new agreement period. CMS also proposes to allow ACOs an option to decrease their repayment mechanism amounts if the recalculated amount is less than the current amount. If finalized, this policy would be in place beginning with Performance Year (PY) 2022. The agency also proposes to allow eligible ACOs that renewed their agreements effective
Comments: Securing a repayment mechanism is a regulatory burden, which is time consuming and costly for ACOs. We appreciate CMS's efforts to minimize burdens associated with the repayment mechanism. Currently, a renewing ACO that wants to use its existing repayment mechanism in the subsequent agreement period is required to maintain a higher repayment mechanism amount than necessary for its new agreement period if the repayment mechanism amount for the last performance year of the previous agreement period is greater than what is needed for the subsequent agreement period. We support CMS's proposal to eliminate this requirement and recommend it be finalized.
Under the Pathways to Success regulations when a recalculated repayment mechanism increases by a certain amount (i.e., the lesser of 50 percent or
We support CMS's proposals in the rule, but we also urge the agency to take additional steps to minimize burdens associated with repayment mechanism requirements. Many ACOs cite the burden and cost of securing a repayment mechanism as reasons not to move to a risk-based ACO model. Instead of requiring a repayment mechanism that pays banks and brokers and takes money away from the ACO executing its core mission of improving patient care, we urge CMS to remove the repayment mechanism requirement when an ACO can prove that it has an investor or financial backer with a demonstrated high credit rating. Financial backers could include outside investors, insurers or hospitals or health systems that are involved with the ACO and providing financial support, which would be available should losses occur. This assurance would protect the
MSSP Beneficiary Assignment
Proposals: CMS proposes to amend the list of primary care services the agency uses to assign beneficiaries to ACOs by adding nine more codes and making technical changes to existing codes used in assignment starting in PY 2021. CMS also proposes to exclude advance care planning services when billed in an inpatient setting from being used to determine beneficiary assignment starting in PY 2021 and to exclude professional services furnished by Federally Qualified Health Centers (FQHCs) or Rural Health Centers (RHCs) when those services are delivered in a skilled nursing facility (SNF).
Comments: CHPA supports updating the definition of primary care codes used for MSSP assignment. Assignment is a critical program methodology that determines the beneficiary population for which an ACO is held accountable. Adding codes such as "e-visits," chronic care management, and principal care management will help create a better picture of where patients receive most of their primary care. CMS should continue to refine the primary care codes used in assignment, and we request that the agency do so in a timely manner. We recommend CMS finalize adding the nine proposed codes to the MSSP assignment methodology.
CHPA also appreciates CMS's desire to ensure that patients are attributed to providers from whom they receive their primary care services. Therefore, we support excluding advance care planning services from MSSP assignment when billed in an inpatient setting and also excluding professional services furnished by FQHCs or RHCs when delivered in a SNF. Both of these changes, while technical in nature, help create more complete and accurate patient assignment lists for ACOs and we recommend the agency finalize these proposals.
While CHPA appreciates CMS's work to refine assignment during the COVID-19 PHE, CHPA recommends that CMS use a two-year assignment window for MSSP to account for potential variations in attribution in 2020 and 2021. Especially in states hit harder by the pandemic, healthy patients may forego routine primary care and throw off assignment for MSSP ACOs who use either retrospective or prospective attribution. Therefore, patient visits from 2019 and 2020 should be considered for ACOs' assignment lists regardless if ACOs choose prospective attribution or retrospective attribution. While the windows for either groups of ACOs will be different, the same general principle applies and would help create more steady and accurate assignment lists. The Next Generation ACO Model uses a two-year assignment window already.
View full comment at: https://www.regulations.gov/contentStreamer?documentId=CMS-2020-0088-16087&attachmentNumber=1&contentType=pdf
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The proposed rule can be viewed at: https://www.regulations.gov/document?D=CMS-2020-0088-1604
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