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Released on Mar 21, 2018

Implementation of MACRA’s Physician Payment Policies - Statement for the Hearing Record submitted by ASGE

When Congress passed the Medicare Access and CHIP Reauthorization Act (MACRA) in 2015, it represented a cumulative, bipartisan body work that involved the input of hundreds of stakeholders over the course of roughly three years. Through the implementation of the law rests the opportunity to identify areas for improvement. The American Society for Gastrointestinal Endoscopy (ASGE), representing more than 8,000 gastroenterologists throughout the country, commends the U.S. House Ways and Means Subcommittee on Health for holding a hearing on the implementation of MACRA’s physician payment policies, specifically the Quality Payment Program (QPP).

The ASGE appreciates the action by Congress this year to provide the Centers for Medicare and Medicaid Services (CMS) with continued flexibility for MIPS implementation. ASGE thanks this Subcommittee for its leadership that led to the enactment of these technical changes. When physicians participate in quality improvement activities, patients benefit and the potential exists for cost savings to accrue to the health care system. However, to realize these positive outgrowths, physicians must be first given the opportunity to succeed within the new MIPS and Alternative Payment Model (APM) payment structures.

Give MIPS Time to Succeed

The ASGE asks Congress to reject recommendations issued by the Medicare Payment Advisory Commission (MedPAC) to eliminate MIPS and to establish a new Voluntary Value Program (VVP). It is too soon to arrive at the conclusion, as MedPAC has done, that MIPS will not succeed at improving quality and encouraging cost-effective use of health care resources. ASGE also firmly rejects MedPAC’s position that all clinicians, regardless of specialty, should have their performance assessed on a set of broad population-based quality measures. Such a move would disenfranchise physician specialists and damage the quality improvement infrastructure that physicians and their professional societies have worked to build around actionable quality metrics that can have a demonstrable effect on quality and patient outcomes.

Minimizing Regulatory Burden on Physicians

Administrative and regulatory burden is a major driver of consolidation in the health care marketplace. Consolidation, in turn, can lead to increased health care costs, as well as to poorer patient quality and access to care. As highlighted by MedPAC in its March 2018 report, an increasing number of physicians have joined larger groups, hospitals, and health systems. As an example, MedPAC highlighted in its report that the share of physicians working in practices with more than 50 physicians grew between 2009 and 2014 from 16 percent to 22 percent, and that recent studies show that commercial prices for physician services are higher in markets with larger physician practices and in markets with greater physician–hospital consolidation. Minimizing regulatory burden can help small and mid-sized practices remain agile and competitive which in turn, can achieve improved quality and access to care without scale effects driving up health care cost.

ASGE concurs with MedPAC’s assessment that the burden on clinician practices to participate in MIPS is significant. Immediate steps must be taken to minimize this burden. MedPAC has proposed a simplified value-based purchasing program. While MedPAC’s approach might reduce clinician burden, it would simultaneously eliminate the flexibility of clinicians to report on measures that are meaningful to their practice and scope of services.

ASGE instead proposes that CMS adopt recommendations put forth by the American Medical Association that were developed in collaboration with several medical societies, including the ASGE, to revise the MIPS scoring approach and requirements with the goal of reducing the administrative burden of MIPS and enhancing the existing program. The recommendations, developed to work within the confines of the MACRA statute, aim to remove the category silos and harmonize the four categories to produce a more cohesive and holistic program and sharpen the focus on outcomes as opposed to just reporting. Importantly, clinicians would maintain the ability to select quality measures that are best suited for their scope of practice. In theory, reducing the burden of MIPS will free resources for physicians and practices to make the investments required for eventually moving into APMs.

Creating a Pathway to APMs

According to MedPAC, roughly 12-16 percent of Part B billing clinicians will be Advanced APM qualifying participants in 2018. MedPAC’s goal with the VVP is to make it unattractive for clinicians to remain in traditional Medicare fee for service. Yet, it is going to be extremely difficult to move the roughly 85 percent of remaining clinicians to Advanced APMs in the foreseeable future for a variety of reasons, including the lack of accessibility to Advanced APMs for many clinicians.

Another limitation to eligible clinicians pursuing participation in an Advanced APM is the threshold limitations for reaching the status of Qualifying APM Participant. To become a Qualifying APM Participant, a clinician must meet a specific Medicare payment or patient count threshold, which may not be easily attainable depending on a practice’s mix of services. For example, gastroenterologists may be interested in participating in CMS’ new Bundled Payments for Care Improvement Advanced model, which is an Advanced APM, but because all the gastroenterology-related bundles are inpatient bundles, gastroenterologists are unlikely to meet either the required revenue or patient count thresholds. Only Advanced APM participants that meet the thresholds qualify for the APM bonus payment and a guaranteed exemption from MIPS.

To encourage development and participation in Advanced APMs, ASGE supports and encourages Congress to act on the proposal in the President’s Fiscal Year 2019 Budget that would allow clinicians to receive a five percent bonus on physician fee schedule revenue received through the APMs in which they participate regardless of whether they meet or exceed the payment or patient thresholds. As explained in budget documents, this change would reward clinicians along a continuum for their participation in Advanced APMs without imposing arbitrary participation thresholds. Removing the thresholds would also simplify the QPP.

ASGE also suggests that clinicians who participate in Other Payer Advanced APMs should also be allowed to claim an exemption from MIPS until more Medicare Advanced APMs become available for physician specialists.

Lastly, Congress can facilitate the movement of clinicians to APMs by waiving the Stark and Anti-kickback laws for physician practices that are developing or operating an APM. ASGE supports the Medicare Care Coordination Improvement Act of 2017 (H.R. 4206) as introduced by Reps. Bucshon, Ruiz, Marchant and Kind, which would remove the “value or volume” prohibitions in the Stark law. These Stark law prohibitions pose barriers to the participation of physician group practices in APMs.

Even the mere threat of violating Stark impedes innovative payment arrangements.
By granting physician practices the same waivers that were provided to Accountable Care Organizations in the Affordable Care Act, there will be more flexibility to move money around in the APM to create incentive structures designed to improve quality and encourage appropriate resource use.


The ASGE appreciates the Subcommittee’s engagement and oversight of MACRA throughout its implementation. The ASGE asks the Subcommittee to support physicians as they transition to new value-based payment models by fostering early opportunities for success and eliminating barriers that impede advancement toward new payment and delivery designs. Congress can support physicians during this transition by:

  • encouraging CMS to adopt the recommendations put forth by the physician community to revise the MIPS scoring approach and requirements within the confines of current MACRA statute;

  • removing reference of payment or patient count thresholds from the definition of a Qualifying APM Participant at Section 1833(z)(2) of MACRA; and

  • removing Stark law barriers to APM development and physician participation by passage of the Medicare Care Coordination Improvement Act of 2017 (H.R. 4206).