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Avalere’s Josh Seidman Answers Your Questions on the MACRA Request for Information

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Recently, CMS released a Request for Information (RFI) inviting public comment on three provisions related to the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)-the Merit-based Incentive Payment System (MIPS), Alternative Payment Models (APMs), and Physician-focused Payment Models (PFPMs). Comments are due to CMS by November 17, 2015. We sat down with Avalere's Josh Seidman to discuss what to expect from the RFI.

Q1: What is the significance of the MACRA RFI?

A1: The RFI provides a brief comment period for stakeholders to influence CMS’ implementation of MACRA, which impacts most healthcare professionals receiving Medicare payments. MACRA gives CMS two new levers to drive a more value-based payment system. First, it encourages developing new APMs and greater provider participation through financial rewards. In the near future, CMS will create new APMs or redesign current APMs to support broader provider participation by allowing more providers to qualify for bonus payments under MACRA. Second, clinicians who don’t move into APMs will be subject to MIPS, which will expose an increasing share of Medicare physician payment to clinical, financial, and patient-reported outcomes. As CMS continues to seek partnerships with commercial insurers, these changes will have implications beyond Medicare fee-for-service.

Q2: What types of comments are CMS requesting?

A2: CMS is requesting comments on the MIPS, APMs, and technical assistance for small practices and practices in Health Professional Shortage Areas (HPSAs).

For MIPS, CMS is requesting comments to help identify appropriate measures for each of the MIPS performance categories-quality, resource use, clinical practice improvement activities, and meaningful use of certified electronic health record (EHR) technology. CMS is also taking recommendations for an appropriate MIPS provider identifier (and the use of virtual groups for small group practices), performance standards, and the minimum threshold to publicly report MIPS measures on the Physician Compare website.

For APMs and PFPMs, CMS is asking for comments on the requirements for what constitutes an APM and a qualifying APM participant as well as the definition of and the criteria used by the Technical Advisory Committee for assessing PFPM proposals. Finally, the RFI requests comments on best practices when providing technical assistance to MIPS providers in small practices and in HPSAs.

Q3: Which content requires a decision?

A3: CMS is in need of value-based payment models comprised of

    Measures that rely on trusted data

    Measures that can be used by providers to improve decisions and by beneficiaries to make informed decisions
    Measures that can be collected efficiently

Q4: What should life sciences companies consider prior to submitting comments?

A4: Life sciences companies should consider how the design of APMs and MIPS would support or curtail the use of their products. APMs and MIPS will increasingly influence providers’ care patterns in favor of treatments that improve downstream clinical, financial, and patient-reported outcomes. APM design may affect patient access to innovative treatments, expensive therapies, and specialized care. APMs can either restrict provider flexibility or choice due to payment methodologies or use of pathways, or they can enhance provider flexibility because they generally put greater decision making in the hands of clinicians. CMS aspires to develop measures that truly capture value provided to beneficiaries and the broader delivery system, and life sciences companies should think about how to support that effort relative to the value of their own products.

For an understanding of the impact of the potential financial risks or rewards that MIPS and the growth of new CMS APMs may have on your company, please contact Josh Seidman at

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