{"id":422,"date":"2017-03-01T05:21:00","date_gmt":"2017-03-01T00:21:00","guid":{"rendered":"http:\/\/www.policymed.com\/oig-reviews-qpp\/"},"modified":"2018-05-05T11:19:49","modified_gmt":"2018-05-05T06:19:49","slug":"oig-reviews-qpp","status":"publish","type":"post","link":"https:\/\/www.policymed.com\/2017\/03\/oig-reviews-qpp.html","title":{"rendered":"OIG Reviews QPP"},"content":{"rendered":"<p><span style=\"font-family: arial, helvetica, sans-serif; font-size: 12pt;\">As we have recently written, <a href=\"http:\/\/www.policymed.com\/2016\/02\/understanding-medicare-access-and-chip-reauthorization-act-of-2015-macra-merit-based-incentive-payment-system-mips-and-a.html\">the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) enacted clinician payment reforms designed to promote quality and value of care<\/a>. These reforms, known as the <a href=\"https:\/\/qpp.cms.gov\/\">Quality Payment Program (QPP)<\/a>, are a significant shift in how Medicare calculates compensation for clinicians and require the Centers for Medicare &amp; Medicaid Services (CMS) to develop a complex system for measuring, reporting, and scoring the value and quality of care. CMS issued final regulations on October 14, 2016, and the first performance year will begin January 1, 2017, with the first payment adjustments taking effect on January 1, 2019. Clinicians may participate in one of two QPP tracks: the Merit-Based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (Advanced APMs). Given the importance and complexity of these reforms and the tight timeline, <a href=\"https:\/\/oig.hhs.gov\/oei\/reports\/oei-12-16-00400.pdf\">the OIG conducted an early implementation review of CMS\u2019s management of the QPP, raising some concerns about the Program<\/a>.<\/span><\/p>\n<p><span style=\"font-family: arial, helvetica, sans-serif; font-size: 12pt;\"><strong>Key Findings<\/strong><\/span><\/p>\n<p><span style=\"font-family: arial, helvetica, sans-serif; font-size: 12pt;\">As written in the OIG report, it found that CMS has made significant progress towards implementing the QPP. However, OIG identified two vulnerabilities that are critical for CMS to address in 2017, because of their potential impact on the program\u2019s success: (1) providing sufficient guidance and technical assistance to ensure that clinicians are ready to participate in the QPP, and (2) developing IT systems to support data reporting, scoring, and payment adjustment.<\/span><\/p>\n<p><span style=\"font-family: arial, helvetica, sans-serif; font-size: 12pt;\"><strong>Stakeholder Concerns<\/strong><\/span><\/p>\n<p><span style=\"font-family: arial, helvetica, sans-serif; font-size: 12pt;\">The OIG\u2019s findings come, as the OIG notes, along with many stakeholder concerns about the program. Specifically, OIG notes that providers, professional associations, and members of Congress have expressed a variety of concerns about the QPP. CMS alone received over 4,000 comments on the proposed rule for the QPP published in May 2016.<\/span><\/p>\n<p><span style=\"font-family: arial, helvetica, sans-serif; font-size: 12pt;\">OIG describes the major concerns of the QPP as follows:<\/span><\/p>\n<ul>\n<li><span style=\"font-family: arial, helvetica, sans-serif; font-size: 12pt;\">Too burdensome for solo, small-practice, and rural providers. Stakeholders questioned whether small and\/or rural providers will succeed under the QPP. Unlike large practices, small providers may not have the resources to hire an administrator or third-party vendor to handle reporting.<\/span><\/li>\n<\/ul>\n<ul>\n<li><span style=\"font-family: arial, helvetica, sans-serif; font-size: 12pt;\">Too complex. Stakeholders raised concerns about the QPP\u2019s complexity\u2014in particular, the complicated formula for calculating MIPS Final Scores and determining payment adjustments. Stakeholders also noted that if clinicians in Advanced APMs do not know until late in the performance period whether they have reached the threshold to be Qualifying APM Participants, they may still need to prepare for MIPS reporting\u2014reducing one of the incentives for participation in the Advanced APM track.<\/span><\/li>\n<\/ul>\n<ul>\n<li><span style=\"font-family: arial, helvetica, sans-serif; font-size: 12pt;\">Applicability and validity of specific MIPS measures. Stakeholders offered feedback about the availability of MIPS measures relevant to different types of clinical practice and whether the measures will accurately reflect clinician performance.<\/span><\/li>\n<\/ul>\n<ul>\n<li><span style=\"font-family: arial, helvetica, sans-serif; font-size: 12pt;\">Limited number of Advanced APM opportunities currently available. Stakeholders stated that more Advanced APM opportunities for clinicians, particularly specialists, are needed. Some recommended that CMS simplify and lower the financial-risk standards for Advanced APMs.<\/span><\/li>\n<\/ul>\n<p><span style=\"font-family: arial, helvetica, sans-serif; font-size: 12pt;\"><strong>HealthCare.Gov Fiasco<\/strong><\/span><\/p>\n<p><span style=\"font-family: arial, helvetica, sans-serif; font-size: 12pt;\">The OIG report addresses the proverbial elephant in the room: the problems with the Healthcare.gov website during the Obamacare roll out. \u201cHealthCare.gov was a really low moment for the agency, but it was a learning moment, which allowed us to learn the lessons of how to build new muscles [from the turnaround of] HealthCare.gov and apply them to the MACRA program,\u201d said a candid CMS employee.<\/span><\/p>\n<p><span style=\"font-family: arial, helvetica, sans-serif; font-size: 12pt;\">OIG says that CMS staff reported that they drew on experiences from HealthCare.gov to rethink the agency\u2019s approach to launching complex initiatives such as the QPP. Like HealthCare.gov, the QPP requires coordination on policy, operational, and technological issues, as well as extensive collaboration across different components within CMS. In its report, OIG noted points at which CMS staff reported applying the lessons learned from HealthCare.gov to CMS\u2019s management of the QPP.<\/span><\/p>\n<p><span style=\"font-family: arial, helvetica, sans-serif; font-size: 12pt;\"><strong>Key Management Principles<\/strong><\/span><\/p>\n<p><span style=\"font-family: arial, helvetica, sans-serif; font-size: 12pt;\">From interviews with CMS leadership and staff and analysis of key documents, OIG identified CMS\u2019 five key management priorities regarding the planning and early implementation of the QPP. These priorities include:<\/span><\/p>\n<ul>\n<li><span style=\"font-family: arial, helvetica, sans-serif; font-size: 12pt;\">fostering clinician acceptance and readiness to participate;<\/span><\/li>\n<li><span style=\"font-family: arial, helvetica, sans-serif; font-size: 12pt;\">adopting integrated internal business practices to accommodate a flexible, user-centric approach;<\/span><\/li>\n<li><span style=\"font-family: arial, helvetica, sans-serif; font-size: 12pt;\">developing IT systems that support and streamline clinician participation;<\/span><\/li>\n<li><span style=\"font-family: arial, helvetica, sans-serif; font-size: 12pt;\">developing flexible and transparent MIPS policies; and<\/span><\/li>\n<li><span style=\"font-family: arial, helvetica, sans-serif; font-size: 12pt;\">facilitating participation in Advanced APMs.<\/span><\/li>\n<\/ul>\n<p><span style=\"font-family: arial, helvetica, sans-serif; font-size: 12pt;\"><u>Fostering Clinician Acceptance<\/u><\/span><\/p>\n<p><span style=\"font-family: arial, helvetica, sans-serif; font-size: 12pt;\">The OIG found that CMS has taken a number of steps to foster clinician acceptance and readiness, including engaging clinicians and stakeholders, conducting user testing of the QPP Portal, establishing \u201cClinician Champions,\u201d creating a transition year, and awarding contracts for education, <a href=\"https:\/\/www.cms.gov\/Medicare\/Quality-Initiatives-Patient-Assessment-Instruments\/Value-Based-Programs\/MACRA-MIPS-and-APMs\/Small-Practices-Fact-Sheet.pdf\">support and technical assistance<\/a>. Of the two vulnerabilities identified in the report, one is found within this management priority. The vulnerability relates to CMS ability to conduct outreach and provide technical assistance so that providers\u2013especially solo, small-practice, and rural providers\u2013have the information they need.<\/span><\/p>\n<p><span style=\"font-family: arial, helvetica, sans-serif; font-size: 12pt;\">OIG writes: \u201cIf providers lack the knowledge, tools, or skills to participate, they will struggle to meet the QPP reporting requirements. Frustrated providers may even opt not to participate in the QPP despite the payment penalty, limiting the program\u2019s ability to meet its goals.\u00a0 To mitigate this risk, CMS must continue to monitor clinician readiness\u2014especially as the first reporting deadline approaches\u2014to identify and address any problems early on. CMS has begun its technical assistance and training efforts, but these activities must quickly be ramped up to full scale and continued throughout 2017 to support Medicare clinicians\u2019 participation in the QPP.\u201d<\/span><\/p>\n<p><span style=\"font-family: arial, helvetica, sans-serif; font-size: 12pt;\"><u>Adopting Integrated, Flexible Business Practices<\/u><\/span><\/p>\n<p><span style=\"font-family: arial, helvetica, sans-serif; font-size: 12pt;\">As the OIG notes, implementing the QPP requires CMS to coordinate policy, technology, communications, and operations activities. Additionally, because the legacy programs on which the QPP is based are dispersed among various CMS components, staff with necessary expertise and experience are similarly dispersed. Staff working with many of the APMs, for example, report to the CMS Center for Medicare &amp; Medicaid Innovation, while those involved in the Value-Based Payment Modifier program are located in the CMS Center for Medicare.<\/span><\/p>\n<p><span style=\"font-family: arial, helvetica, sans-serif; font-size: 12pt;\">To address this logistical and organizational complexity, the report describes how CMS sought to learn from the problems of HealthCare.gov by adopting an integrated, flexible approach to both program management and IT development. To create this flexible management approach, CMS developed an overall QPP strategy, assigned executive leadership to each program component, established integrated project teams with shared office space, adopted agile IT development methods, adopted a new contracting approach, and awarded a systems integrator contract. According to the report, CMS is still planning on awarding additional contracts, expanding oversight of contractors, and hiring staff with expertise in agile development.<\/span><\/p>\n<p><span style=\"font-family: arial, helvetica, sans-serif; font-size: 12pt;\"><u>Developing IT Systems<\/u><\/span><\/p>\n<p><span style=\"font-family: arial, helvetica, sans-serif; font-size: 12pt;\">Information technology is arguably CMS\u2019 greatest challenge in the roll out. Front and center to CMS\u2019 IT efforts is the QPP Portal. This portal will consist of three major components: a public-facing informational website, individualized accounts for clinicians, and backend systems necessary to receive and validate clinicians\u2019 data, provide individualized performance feedback, calculate clinicians\u2019 MIPS scores, and adjust Part B payments accordingly.\u00a0\u00a0\u00a0<\/span><\/p>\n<p><span style=\"font-family: arial, helvetica, sans-serif; font-size: 12pt;\"><u>QPP Portal<\/u><\/span><\/p>\n<p><span style=\"font-family: arial, helvetica, sans-serif; font-size: 12pt;\">CMS launched the informational website in October 2016. However, CMS has yet to enable the individualized accounts or set up the backend systems. CMS staff have reported to OIG that individualized accounts will indeed be available in January 2017. These accounts will ultimately enable CMS to verify the user\u2019s identity, inform clinicians of their eligibility for the Advanced APM track versus the MIPS track (so that clinicians know whether they must select and report MIPS measures), and provide individualized performance feedback.<\/span><\/p>\n<p><span style=\"font-family: arial, helvetica, sans-serif; font-size: 12pt;\">OIG identified the development of the backend IT system as the second of the two vulnerabilities to the QPP\u2019s roll out. OIG writes: \u201cBuilding and testing the extensive IT systems necessary to support critical QPP operations will require significant and sustained effort over the forthcoming year. In the past, CMS has sometimes experienced delays and complications related to major IT initiatives, such as those required for the continued operation of Medicare Part D and HealthCare.gov. If the complex systems underlying the QPP are not operational on schedule, the program will struggle to meet its goal of improving value and quality.\u201d<\/span><\/p>\n<p><span style=\"font-family: arial, helvetica, sans-serif; font-size: 12pt;\">According to OIG, CMS plans to partially mitigate this risk by using the legacy systems for the existing reporting programs as a backup option for MIPS data submission.<\/span><\/p>\n<p><span style=\"font-family: arial, helvetica, sans-serif; font-size: 12pt;\"><u>Develop MIPS Policies<\/u><\/span><\/p>\n<p><span style=\"font-family: arial, helvetica, sans-serif; font-size: 12pt;\">OIG noted that CMS was able to issue a final rule, including policies on MIPS, notwithstanding a challenging deadline and a massive number of public comments. OIG identified three future initiatives under this management priority, including issuing promised subregulatory guidance, finalizing policies for so-called \u201cvirtual groups,\u201d and subsequent rulemaking in 2018 and beyond.<\/span><\/p>\n<p><span style=\"font-family: arial, helvetica, sans-serif; font-size: 12pt;\"><u>Facilitate Participation in Advanced APMs<\/u><\/span><\/p>\n<p><span style=\"font-family: arial, helvetica, sans-serif; font-size: 12pt;\">OIG\u2019s report identifies a number of steps that CMS has taken to address this management priority, including:<\/span><\/p>\n<ul>\n<li><span style=\"font-family: arial, helvetica, sans-serif; font-size: 12pt;\">identifying which existing Medicare models meet criteria for Advanced APMs;<\/span><\/li>\n<li><span style=\"font-family: arial, helvetica, sans-serif; font-size: 12pt;\">establishing policy for determining Qualifying APM Participants;<\/span><\/li>\n<li><span style=\"font-family: arial, helvetica, sans-serif; font-size: 12pt;\">publishing the Final Rule, including Advanced APM policies for 2017; and<\/span><\/li>\n<li><span style=\"font-family: arial, helvetica, sans-serif; font-size: 12pt;\">awarding contracts for technical assistance to prepare clinicians to participate in Advanced APMs.<\/span><\/li>\n<\/ul>\n<p><span style=\"font-family: arial, helvetica, sans-serif; font-size: 12pt;\">The report lists a number of initiatives that remain, including determining which clinicians are Qualifying APM Participants, increasing Advanced APM opportunities, and increasing clinician participation in Advanced APMs over time.<\/span><\/p>\n<p><span style=\"font-family: arial, helvetica, sans-serif; font-size: 12pt;\"><strong>Conclusion<\/strong><\/span><\/p>\n<p><span style=\"font-family: arial, helvetica, sans-serif; font-size: 12pt;\">This report is a mixed bag for CMS and stakeholders of the new QPP. On one hand, CMS is clearly trying to avoid the same kind of problems that impacted the ACA roll out. However, with such a massive undertaking, there are many vulnerabilities and it is not clear that CMS has the track record worth believing the agency\u2019s promises to be ready. There will likely be technical challenges associated with the QPP and that may only further the calls to reform the program, especially with friendly staffers leading HHS and CMS in the Trump Administration.<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>As we have recently written, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) enacted clinician payment reforms designed to promote quality and value of care. These reforms, known as the Quality Payment Program (QPP), are a significant shift in how Medicare calculates compensation for clinicians and require the Centers for Medicare &amp; Medicaid [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":5606,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[20,28,63],"tags":[1101],"class_list":["post-422","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-cms","category-macra","category-quality-improvement","tag-new"],"_links":{"self":[{"href":"https:\/\/www.policymed.com\/wp-json\/wp\/v2\/posts\/422","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.policymed.com\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.policymed.com\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.policymed.com\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.policymed.com\/wp-json\/wp\/v2\/comments?post=422"}],"version-history":[{"count":2,"href":"https:\/\/www.policymed.com\/wp-json\/wp\/v2\/posts\/422\/revisions"}],"predecessor-version":[{"id":5611,"href":"https:\/\/www.policymed.com\/wp-json\/wp\/v2\/posts\/422\/revisions\/5611"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.policymed.com\/wp-json\/wp\/v2\/media\/5606"}],"wp:attachment":[{"href":"https:\/\/www.policymed.com\/wp-json\/wp\/v2\/media?parent=422"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.policymed.com\/wp-json\/wp\/v2\/categories?post=422"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.policymed.com\/wp-json\/wp\/v2\/tags?post=422"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}