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SHM Signs Onto MACRA Letter to CMS

April 18, 2016

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Andrew M. Slavitt
Acting Administrator
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Washington, DC 20201

Dear Acting Administrator Slavitt:

With the upcoming release of the proposed rule regarding implementation of the Medicare
Access and CHIP Reauthorization Act (MACRA), we are writing to ensure that activities in the
private sector continue, and have a defined pathway to meet the Alternative Payment Model
(APM) criteria. The undersigned organizations reflect a wide breadth of companies and
organizations that share your commitment to a strong Medicare payment system that better
meets the healthcare needs of its beneficiaries through the adoption of a framework that
rewards clinicians for value over volume, and streamlines other existing quality reporting
programs into one new system.

Our collective goal is to ensure the implementation of MACRA does not create an overly
prescriptive, time-consuming and complex federal approval process for clinical quality
improvement and APMs as this could undermine existing programs that are already
extraordinarily effective in improving care and containing costs. While each undersigned
organization has unique perspectives and concerns regarding the rollout of MACRA, there are
overarching topics on which we are unanimous and urge CMS to strongly consider adopting the
following recommendations when developing policies for both the MIPS and APM tracks:

First, it is important the implementation of MACRA does not disrupt the positive effect
APMs are having on beneficiaries' health in both the public and private sectors. As you
know, APMs such as Patient-Centered Medical Homes (PCMHs) and Accountable Care
Organizations (ACOs) have shown great promise and proven potential in improving quality while maintaining or reducing costs to the healthcare system. There are diverse approaches being taken by physicians, private payers, and CMMI that have demonstrated that there is no one way to achieve the shared goals of building a health care delivery system that is better, smarter and healthier. CMS should allow for maximum flexibility on the public and private sector sides and not inadvertently create rules around participation that have a chilling effect on the ability to innovate—for both physicians and payers. Maximum flexibility would help enable both private sector and public sector APMs to work in concert, as opposed to the potential for confusion or conflicting requirements. Ensuring a broad variety of APMs that suit local markets and the diversity of physician practice – including both primary care and other specialties -- is essential to achieving the goals of this program.

Second, there should be a clear, non-burdensome pathway for private sector models to
meet the threshold for qualifying APMs under MACRA. There has been a significant
amount of success over the last decade in developing APMs in the private sector among health
plans, employers and physicians – we fear that this work risks coming undone by creating
stringent rules on APMs that make it impractical or untenable for clinicians to participate in both private sector and Medicare APMs. Having a clear pathway to become a qualified APM under the all-payer threshold as well as the Physician-Focused Payment Model Technical Advisory Committee (PTAC) will be a significant step forward for creating synergies between public and private sector delivery system reform efforts.

Third, CMS should ensure that virtual groups in MIPS are defined in such a way that
helps small, independent physician practices remain viable (as independent practices)
and supports the potential impact that virtual groups can have to improve patient care.
The opportunity for physicians to form virtual groups and build organized systems of care is an
essential piece that can help sustain their ability to remain independent while mitigating further
consolidation under MACRA.

Finally, physicians should have ample opportunity to receive credit for existing clinical
quality improvement activities in the MIPS track. Clinical improvement activities that
physicians have worked on in the private sector should also earn them credit under MIPS.
These successful collaborations between physicians and health plans can serve as a first step
for physicians that are not able to be part of a larger APM, but do want to be part of a valuebased care model.

Given that the proposed rule currently resides at The Office of Management and Budget for
review (CMS-5517-P) and the rollout of MIPS begins in less than a year, maximum flexibility
and timely, clear guidance is imperative to ensure a smooth transition for all stakeholders. We
welcome the opportunity to discuss this with you in greater detail so we can jointly construct
meaningful solutions to this complex, yet transformative law. We look forward to working with
you to help meet the needs of current and future Medicare beneficiaries.


Advocacy Council of the American College of Allergy, Asthma and Immunology
AMDA – The Society for Post-Acute and Long-Term Care Medicine
American Academy of Allergy, Asthma & Immunology
American Academy of Dermatology Association
American Academy of Facial Plastic and Reconstructive Surgery
American Academy of Family Physicians
American Academy of Home Care Medicine
American Academy of Neurology
American Academy of Otolaryngic Allergy
American Academy of Pediatrics
American Academy of Physical Medicine and Rehabilitation
American Association of Neurological Surgeons
American College of Cardiology
American College of Emergency Physicians
American College of Osteopathic Internists
American College of Physicians
American College of Rheumatology
American College of Surgeons
American Congress of Obstetricians and Gynecologists
American Gastroenterological Association
American Medical Association
American Osteopathic Association
American Psychiatric Association
American Society for Dermatologic Surgery Association
American Society for Gastrointestinal Endoscopy
American Society of Anesthesiologists
American Society of Clinical Oncology
American Society of Nuclear Cardiology
American Society of Plastic Surgery
American Society of Radiation Oncology
American Urological Association
Association of American Medical Colleges
BlueCross BlueShield Association
College of American Pathologists
Congress of Neurological Surgeons
Endocrine Society
Heart Rhythm Society
Infectious Diseases Society of America
Society for Cardiovascular Angiography and Interventions
Society of Hospital Medicine
The Society of Thoracic Surgeons