Providence Health & Services

1801 Lind Avenue SW

Renton, WA 98057-3303

Providence.org

June 27, 2016

Andy Slavitt

Acting Administrator

Centers for Medicare & Medicaid Services

Department of Health and Human Services

7500 Security Boulevard

Baltimore, Maryland 21244-1850

RE: CMS-5517-P Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative

Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused

Payment Models

Dear Administrator Slavitt:

On behalf of Providence Health & Services, thank you for the opportunity to provide comments to the

Centers for Medicare & Medicaid Services regarding the implementation of the quality payment

program under the Medicare Physician Fee Schedule published in the Federal Register on May 9, 2016.

Providence Health & Services is a not-for-profit Catholic health care ministry committed to providing for

the needs of the communities it serves – especially for those who are poor and vulnerable. The

comprehensive scope of services at Providence includes 34 hospitals, 600 physician clinics, home health

and hospice, senior services, supportive housing and many other health and educational services. The

health system and its affiliates employ more than 82,000 people across five states: Alaska, California,

Montana, Oregon and Washington.

As a large, integrated health care system providing services to patients across the continuum of care –

from primary to acute care to home health and hospice – we are committed to clinical excellence with

compassion. We know that quality of life improves when individuals and families have broad access to

high-quality, patient-focused, affordable care. Together, Providence ministries and secular affiliates are

working at scale to improve overall health in every community we serve through innovation in care

delivery, new economic models and expert-to-expert collaboration.

Providence is rapidly moving to new accountable care agreements that support the redesign of care.

Our Providence-Swedish ACO, Health Connect Partners, was approved in December 2013 for the

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Medicare Shared Savings Program and now serves more than 60,000 Medicare beneficiaries in Alaska,

Montana and Washington. Through the ACO, we are bringing together physicians, hospitals and other

partners to more closely coordinate care for patients, focusing on delivering the highest quality care to

patients at a lower cost. In addition, Providence participates in a number of other alternative payment

models with CMS:

Comprehensive Care for Joint Replacement model – 16 hospitals

Comprehensive Primary Care initiative – 13 primary care practices and our health plan

Medicare Care Choices model – two hospice organizations

Oncology Care model – oncologists within a multi-specialty medical group

Providence appreciates the thoughtful drafting of the Quality Payment Program proposed rules and the

goals of Medicare Access and CHIP Reauthorization Act to align historically disparate programs;

streamline reporting; focus energy to high-value activities that center on patients and outcomes; and

credit the work and resources involved in alternative payment models. While HHS and CMS’ aims are

clear – better care, smarter spending, and healthier Americans – the Quality Payment Program is deeply

complex. We hope our recommendations are constructive and useful to CMS in drafting the final rule:

Provide a flexible approach to defining groups for reporting under MIPS.

Consider special accommodations for clinicians that work in critical access hospitals or rural

health centers, such as establishing a higher threshold for low-volume clinicians in the first year

of MIPS to allow more time to prepare.

Finalize a 90-day performance period in 2017 for the Advancing Care Information category.

Provide more frequent and detailed feedback reports to clinicians on the quality and resource

use measures that CMS calculates and allow health systems to receive claims feeds from CMS so

that timely, actionable data reports can guide improvement efforts.

Prioritize and accelerate the development of cross-cutting, outcome oriented, patient-centered

quality measures.

Establish a maximum of four episode-based resource use measures to be attributed to a

clinician or group in the first year of MIPS.

Address the misalignment of the ACI proposal and the Electronic Health Records Incentive

Program requirements for hospitals and CAHs.

Allow clinicians to report once and fairly apply credit in the ACI category of MIPS and the

Medicaid Incentive Program.

Enhance the bonus points for electronic Clinical Quality Measures and public health registries to

better reflect the work required and encourage early adopters.

Award participants of APMs the highest possible score in the Clinical Practice Improvement

Activities category.

Revise the APM entity definition to allow facility-led APMs to qualify by recognizing MIPS-

eligible clinicians on a Participation List or an Affiliated Practitioners List.

Adopt the proposed financial risk standard for medical homes as the standard for all APMs.

Revise the attestation statements for information blocking to align with the statutory language.

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Merit-based Incentive Payment System

MIPS reporting options – clinician, group TIN or APM entity

Providence supports the proposed unified MIPS reporting and scoring approach, but we are concerned

that the options for group reporting are too restrictive. CMS has authority under the statute to define

groups and proposes to recognize groups by tax identification numbers or APM entities. TIN level

reporting is currently used by CMS for other programs, however, it is far from ideal for performance-

based payment adjustments, especially for multi-specialty groups, and changing TINs may have

significant business implications. APMs are designed for performance measurement and the entities are

structured to either cluster multiple TINs or recognize a cohort of clinicians within a TIN depending on

the scope and objective of the model. APM entities are an ideal framework for performance

measurement; however, APMs are limited in numbers and not currently available to all clinicians.

The creation of APMs by CMS should not be a rate-limiting factor for defining groups of clinicians that

want to be held to common performance measures and scoring under MIPS – there should be other

options available. Providence urges CMS to provide clinicians with the flexibility to define MIPS

groups by submitting a roster of TIN/NPI combinations to CMS. Such flexibility is critical for large

health systems and multi-specialty groups, and also a very useful precursor to future APM

participation.

We foresee a number of problems with MIPS group reporting for multi-specialty TINs, under the

structure proposed by CMS:

Quality: multi-specialty groups will be challenged to select clinically-relevant measures across

diverse specialties.

Resource Use: multi-specialty groups will have a higher number of measures attributed to the

group making it more difficult to achieve high performance and drive improvement.

Clinical Practice Improvement Activities: activity reporting is required at a TIN level, but multi-

specialty groups include hospital-based and ambulatory clinicians that are engaged in activities

specific to their care setting.

Advancing Care Information: it is unclear how performance will be scored and weighted when a

group includes hospital-based clinicians (exempt from reporting ACI) and non-hospital-based

(must report ACI).

The composition of MIPS reporting groups should be rational and logical in the eyes of clinicians

impacted in order to have the intended result across all of the MIPS categories. CMS risks losing the

hearts and minds of clinicians if the basic structure of the program is seen as irrational and a perception

that performance scoring is arbitrary.

We also anticipate problems with reporting overlap due to APM entities that only make up a portion of

a TIN. In these situations, the clinicians that are not participating in an APM must either report

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individually, or report as a TIN group. As a TIN group, the performance data will include the APM entity

clinicians, which could have a negative impact on the TIN group performance if the measure sets do not

overlap. Alternatively, there may be pressure for the APM entity clinicians to support measures selected

for the TIN group, which may distract from their success in the APM and detract from the goal of

streamlined reporting. We recognize that the submission of rosters to define groups for MIPS may be

operationally challenging for CMS, however, we implore CMS to take this issue seriously in the final rule.

If operational constraints prevent solutions for 2019, we ask that CMS pursue changes in 2020 and

leverage the operational capacity required to support virtual groups and the rapid growth in APM

participation.

Clinicians practicing in rural areas, CAHs, Rural Health Clinics, or FQHCs

Under the proposed rule, CMS recognizes the special challenges that clinicians working in critical access

hospitals, rural health clinics, and federally qualified health centers face given the limited resources and

unique patient populations. Providence supports the proposal to reduce the number of activities

required in the CPIA category for clinicians practicing in rural areas and encourages CMS to consider

additional policies to ease the way for clinicians working in underserved communities, such as

establishing a higher threshold for low-volume clinicians in the first year of MIPS to allow more time

to prepare.

Providence also joins other stakeholders to urge CMS to address data capture issues for CAHs that

may be required to participate in the MIPS. As is the case with the current physician quality reporting

system, CMS proposes that the MIPS would apply to CAHs billing under Method II whose clinicians have

reassigned their billing rights to the CAH. Under Method II, CAHs bill and are paid for facility services at

101 percent of reasonable cost, and for professional services at 115 percent of such amounts as would

otherwise be paid if such services were not included in outpatient [CAH] hospital services. Some CAHs

have reported issues with capturing full information about eligible clinicians from the institutional billing

form used by CAHs (UB-04/CMS-1450). Under existing billing rules, CAHs may bill one CMS-1450 per

day. The claims from multiple providers are combined into one. The claims often do not include all

national provider identifier (NPI) numbers, and as a result, not all of the clinicians on the bill would

receive credit for participation. Thus, we ask CMS to examine whether there are mechanisms for better

capturing information on eligible clinicians from the CMS-1450 form.

MIPS Exclusions

CMS proposes to exclude new Medicare-enrolled clinicians (who would otherwise be MIPS-eligible),

clinicians that meet the low-volume threshold, and clinicians that meet the criteria as a qualifying

Advanced APM participant or partial qualifying Advanced APM participant from MIPS. Providence

supports these exclusions.

MIPS performance measurements and scoring

Performance period

CMS proposes that calendar year 2017 will be the performance period for payment adjustments in

2019. Providence is concerned with the proposed timeline, especially given the system changes

required to streamline and unify what have been up to this point, disparate programs (PQRS, meaningful

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use, value modifier) and the limited information about baseline and relative performance. Additional

time is essential for group reporting and other changes in the ACI category due to the lead time required

for changes to our EHR.

While we support a uniform performance period for all MIPS categories in the future, we recommend an

interim solution for the 2019 payment adjustment. Quality and resource use measurement can be

significantly impacted by seasonality and for purposes of integrity needs to be a 12-month performance

period. However, for the MIPS categories of ACI, Providence urges CMS to align the ACI category with

the CPIA category and adopt a 90-day performance period.

Quality category

Providence appreciates that CMS proposed to lower the number of quality measures for reporting from

nine in PQRS to six under MIPS.

Although we appreciate the effort CMS has made to create specialty measure sets to aid clinicians in

selecting clinically-relevant measures, from a system perspective, we are concerned that this approach

may reinforce clinical silos rather than focus on patient outcomes. Providence endorses adopting more

patient-centric, outcome-oriented, cross-cutting quality measures. In particular, we support the

development of measures that focus on patient values, preferences, and goals of care. We appreciate

that the CMS Measure Development Plan also stresses these priorities, but would like to see more

aggressive development and rapid progress in this area. Over time, CMS might consider increasing the

minimum number of cross-cutting measures beyond the one measure required for 2019 reporting.

Providence strongly supports measuring patient experience and commends CMS for the proposal to

provide bonus points under MIPS for Consumer Assessment of Healthcare Providers & Systems

reporting. CAHPS survey administration adds expense and complexity to quality reporting, making the

bonus points very appropriate. For this reason, we recommend CAHPS be voluntary for clinician groups

of all sizes. CMS should also consider allowing providers to report more than six CAHPS measures and

be scored on a composite of the six highest-performing measures. Like many groups, we are challenged

to improve our CAHPS scores because the scores are generally high, making the absolute performance

between deciles quite slight and measureable improvement very challenging. For this reason, we also

urge CMS to consider alternate methods for scoring the CAHPS (e.g. scoring based on absolute

performance rather than relative performance or awarding scores based on maintaining a threshold) to

avoid discouraging clinicians from selecting CAHPS. In addition to the six measures that clinicians or

groups report under the quality category, CMS proposes to include three population-based measures

that CMS will calculate using claims data: acute conditions composite, chronic conditions composite and

all-cause hospital readmissions. We are concerned that the current frequency of data reports from CMS

on the population-based measures (annual and mid-year, with a significant data lag) is not sufficient for

performance tracking and driving improvement. We urge CMS to provide more granular and frequent

data to all clinicians and groups, comparable to the data available to participants of APMs – e.g.

quarterly feedback reports and the opportunity to enter into data use agreements with CMS to access

claims data. More detailed, timely, and actionable data is critically important to direct improvement

activities. As an interim step, we request that CMS publish the deciles breakdown of the population-

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based and PQRS measure performance from prior years so that clinician groups have a better

understanding of relative performance and trending.

Providence appreciates the CMS proposal to maintain the current quality reporting mechanisms. We

agree that it is necessary and appropriate to establish different benchmarks for different reporting

methods. We also fully support the transition to all-payer quality measurement.

Regarding the bonus points proposed for submitting quality measure data per the eCQMs criteria, we

agree that the extra resources, testing, and validation required for eCQMs is worthy of extra credit.

However, Providence recommends CMS provide two extra points for eCQM submissions, rather than

the one point proposed, as a more fair recognition of the level of effort required.

In order to better align the efforts for clinicians who will qualify under a MIPS APM, we urge CMS to

provide electronic specifications for the MSSP program and allow these measures to be reported under

the same Quality Reporting Document Architecture electronic process as is currently in place for the

meaningful use program.

Resource Use category

CMS proposes to equally weight all measures in the resource use category, which includes:

Medicare total per capita cost measure (Measures total Part A and B costs of patients attributed

to clinician or group)

Medicare spending per beneficiary measure (Evaluates hospitals’ efficiency and includes Part A

and B costs spanning 3 days prior to and 30 days after an inpatient hospitalization)

Episode-based measures that can be attributed to a clinician or group

Providence recommends that CMS revise the weights to place a greater emphasis on the total per

capita cost measure. While measuring resource use for specific episodes of care or conditions are

important metrics, they do not reflect whether the episode itself was appropriate or aligned with clinical

guidelines. CMS notes that measures need to be developed to address appropriate use criteria and

clinical guidelines. As these measures are adopted, CMS could revisit the measure weights and re-

establish equal weights in the future.

CMS proposes over 40 episode-based measures, some of which have been reported on the

Supplemental Quality and Resource Use Reports, but many are new and have never been reported to

clinicians or groups. Even those measures that have been reported to clinicians and groups have never

been used as a basis for payment adjustments. Given stakeholder’s lack of familiarity with these

measures and the aggressive timeline for adoption in MIPS, Providence has three recommendations for

CMS to consider.

First, Providence asks that CMS not finalize a measure for use in the MIPS Cost/Resource Use category

if it has never been previously reported to clinicians or groups. For 2019 payment adjustments and

onward, clinicians and groups should receive their baseline data before a measure is incorporated into

MIPS scoring. This approach is consistent with the Hospital Value-based Purchasing Program.

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Second, we recommend that CMS adopt a maximum number of episode measures to be attributed to

a clinician or group. A manageable number of episode measures will allow clinicians and groups to

focus efforts as they become more familiar with resource use measures and strategies for positively

impacting performance. For 2019 payment adjustments, four episode-based measures are a reasonable

starting place and when combined with the total per capita cost measure and Medicare spending per

beneficiary measure, reflect a consistent number of measures used in the value-based modifier.

And third, clinicians and groups need better data on resource use and cost to manage performance

under MIPS. We urge CMS to re-process previously published Quality and Resource Use Reports to

include information on national performance deciles so that clinicians and groups gain a better

understanding of their relative baseline performance and trending in advance of the MIPS

adjustments. More detailed breakdowns of each episode measure would also be helpful, e.g. the

ability to view breakdowns of service categories within an episode. In addition, we ask CMS to

increase the frequency of future feedback reports to quarterly and extend options for groups to sign

data use agreements with CMS to receive claims data through which providers can develop their own

reports for tracking and managing performance.

Clinical Practice Improvement Activities category

CMS proposed over 90 activities for the CPIA category and to receive full credit, clinicians or groups

must attest that 3-6 activities were performed for a minimum of 90-days. Providence noted the effort

CMS made to identify high-value activities with a proven association with improved health outcomes

and found that a number of proposed activities align with quality improvement initiatives already

underway across our system.

We appreciate that CMS aimed to keep reporting for CPIA simple through an attestation process, which

can be done through various reporting mechanisms. Providence supports this policy, but requests that

CMS publish guidance related to internal documentation that clinicians and groups should maintain

for purposes of an audit. As we have found with CMS-contracted auditors for other programs, it is

critically important that clinicians and auditors have a common understanding of adequate

documentation. CMS audit contractors should not develop their own standards or requirements that

are not based on regulatory requirements or CMS published guidance.

CMS asked for recommendations on how to score medical home accreditation for TIN groups that

include designated and non-designated sites. This issue relates to a broader challenge in this category

for TIN-level reporting. As we noted earlier, multi-specialty TIN groups may include clinicians of diverse

specialties and potentially working in different care settings. This means providers will be involved in

activities that are related to their specialty and setting, but may not be common for the entire TIN.

Providence recommends that CMS allow groups to collect CPIA information at the individual clinician

level to aggregate and average across the group. This approach is consistent with the policy CMS

proposed for scoring APM entity participants.

Providence recommends that CMS be more direct in providing credit in the CPIA category of MIPS for

APM participants. The statute requires that APM participants be awarded at least half of the highest

score, which provide CMS with the ability to credit APM participation even higher. APMs are a

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significant commitment and they require very specific activities and/or regular reporting to the Center

for Medicare and Medicaid Innovation on performance. We urge CMS to award participants of APMs

the highest possible score in the CPIA category.

Advancing Care Information category

CMS proposed a number of changes to the reporting, requirements and scoring under for the

meaningful use program, now rebranded as the Advancing Care Information category of MIPS. While

we support many of the proposed changes, we urge CMS to address the misalignment of the ACI

proposal and the EHR Incentive Program requirements for hospitals and CAHs.

Providence commends CMS for honoring the final rule published last year on meaningful use reporting

and the option for modified Stage 2 reporting in 2017. We urge CMS to further align the modified

Stage 2 with the changes proposed for ACI category by simplifying the public health and clinical data

registry reporting for modified Stage 2 to require only the immunization registry. This approach aligns

with the requirements for Stage 3.

CMS proposes to award bonus points for connecting to additional public health registries. On a point

scale of 0-100, a bonus of one point per registry does not appear to be a significant incentive, nor does it

reflect the resources and effort required to connect to external registries. Providence urges CMS to

reconsider the bonus point allocation for public health registries and finalize 5 points per registry to

provide a more meaningful incentive.

Providence strongly supports the group reporting option proposed by CMS under the MIPS uniform

scoring method, which would reduce the reporting burden associated with eligible provider level

reporting under the current meaningful use program. However, this new policy raises additional

questions. A TIN group may include both hospital-based clinicians and non-hospital-based clinicians, so

how will the MIPS reporting, scoring, and weighting work in this situation? This is another illustration of

the need for MIPS reporting groups constructed by roster rather than using TINs as a default. In

addition, under the structure of eligible-provider reporting, performance measures and attestations

were required to include data from all care settings in which the provider worked, which required

reaching out to the clinician’s former practice, or second practice if the clinician concurrently works for

two organizations. In our experience, CMS auditors have demanded patient-level information to

validate attested performance measures, but sharing that level of information is not medically necessary

or required under the regulations. Providence urges CMS to clarify in the final rule that MIPS group

reporting for ACI will be based only on the TIN group Certified EHR Technology data.

CMS recognizes that there may not be sufficient measures in the ACI category under MIPS for hospital-

based clinicians, so the proposed rule would reweight the MIPS categories for these clinicians. CMS

currently defines hospital-based eligible providers in the EHR Incentive Program as providers that have

90 percent or more of payment for covered professional services associated with place of service codes

21 (inpatient hospital) or 23 (emergency department), however there are additional service areas in

which this analysis is warranted. Providence urges CMS to also include POS-22 (outpatient hospital)

and POS-51 (inpatient psych) as the clinicians in these departments also rely upon hospital EHR

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systems, therefore the adoption and use of EHR technology is reflected by the meaningful use

reporting conducted by the hospital.

While we support many of the proposed changes, they will disrupt the alignment of objectives and

measures for eligible hospital reporting and the Medicaid EHR Incentive Program, which causes concern

for health systems like Providence. Furthermore, CMS explicitly states that double reporting would be

required for the Medicaid EHR Incentive Program:

In this rule, [CMS does] not propose any changes to the objectives and measures previously

established in rulemaking for the Medicaid EHR Incentive Program, and thus EPs participating in

that program must continue to report on the objectives and measures under the guidelines and

regulations of that program…Therefore, MIPS eligible clinicians who are also participating in the

Medicaid EHR Incentive Programs must report their data for the advancing care information

performance category through the submission methods established for MIPS in order to earn a

score for the advancing care information performance category under MIPS and must separately

demonstrate meaningful use in their state's Medicaid EHR Incentive Program in order to earn

a Medicaid incentive payment.

We ask that CMS keep in mind that the primary policy goal of the EHR Incentive Program is to

“encourage and promote the adoption and use of certified EHR technology among Medicare and

Medicaid health care providers to help drive the industry as a whole toward the use of certified EHR

technology.” Requiring double reporting is not necessary to meet this policy objective. CMS does not

cite any statutory restriction that would prevent CMS or a state from honoring comparable reporting

completed under another program. Providence implores CMS to address this burdensome

requirement in the final rule or if necessary, in separate rulemaking or guidance, to permit clinicians

to report once and fairly apply credit for that reporting in MIPS or the Medicaid EHR Incentive

Program. Reporting twice creates waste and adds no value to patients, clinicians, or the integrity of

government programs.

Under the statute, the Secretary has the authority to reduce the weight of the ACI category in any year

in which the proportion of meaningful users is 75 percent or greater. CMS sought comments on defining

a meaningful user for purposes of this determination. Providence urges CMS to estimate the

proportion of physicians who are meaningful EHR users as those physician MIPS eligible clinicians who

earn an ACI performance category score of at least 75 percent under the proposed scoring

methodology for the ACI performance category for a performance period. This would require

clinicians to perform beyond the based score and demonstrate higher capabilities.

And finally, given all the changing structure and performance scoring in the ACI category, we feel it is

very appropriate to delay the onset of full calendar year reporting once again. Providence understands

CMS has been eager to move to full year reporting, but the annual program modifications create very

real challenges to complete the necessary programming, testing and validation. We ask that CMS

consider the totality of changes occurring under the Quality Payment Program and the complexity for

providers. The meaningful use program has a history of 90-day performance periods and CMS also

proposed a 90-day performance period for the CPIA category. Therefore, Providence urges CMS to

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finalize a 90-day performance period for the ACI category for the 2019 payment adjustment to allow

sufficient time for development and testing of changes to do group level reporting and incorporate

the other program changes.

Review and correction of composite performance score

MACRA requires the establishment of a process under which a MIPS-eligible clinician may seek an

informal, targeted review of the calculation of the MIPS adjustment factor (or factors) applicable to such

MIPS eligible clinician a payment year. Transparency and clarity about MIPS scoring and corresponding

payment adjustments are critically important and CMS should consider broader communications, such

as webinars to help clinicians and groups understand their own composite performance score and the

broader, national context of performance under MIPS. Providence agrees that a targeted review is

warranted in the circumstances described by CMS:

A clinician believes that measures or activities submitted to CMS during the submission period

and used in the calculations of the CPS and determination of the adjustment factors have

calculation errors or data quality issues.

A clinician believes that there are certain errors made by CMS, such as performance category

scores were wrongly assigned to the MIPS eligible clinician.

Given the complexity of the MIPS program, it is important CMS provide an opportunity to correct

inaccurate data submissions when they are discovered. We are concerned that the language only

references a clinician and not a group. Since clinicians reporting under the MIPS group reporting

option will have the same composite scoring and adjustment factor(s), we urge CMS to revise the

language to make clear that a representative of a group may request a targeted review for the entire

group and that reviews do not need to be evaluated at the clinician level.

For the first year of MIPS adjustments, Providence recommends a longer review period of 90-days,

rather than the 60-days proposed so that providers have time to sort through the data and determine

if a targeted review is necessary. We urge CMS to adequately staff the MIPS helpdesk during the

review period to respond to questions and direct providers through the process.

APM scoring standard in MIPS

CMS proposes to use its waiver authority to waive certain statutory provisions related to MIPS reporting

and scoring for APM participants reporting in MIPS. The proposed APM scoring standard for MIPS

provides different reporting, category weights, and scoring for APM participants. Providence supports

CMS’ use of its waiver authority and agrees that CMS should establish special scoring under MIPS to

reflect the program structure and incentives from APMs.

Criteria for MIPS APM

CMS proposes to define a MIPS APM as one that:

(1) participates in the APM under an agreement with CMS;

(2) includes one or more MIPS-eligible clinicians on a participation list; and,

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(3) bases payment incentives on performance (either at the APM Entity or eligible clinician level) on

cost/utilization and quality measures.

Providence agrees with other stakeholders that this definition is too narrow and simplistic in defining

the participants of an APM model. We are concerned that under the proposed definition, all models in

which a facility is the direct “participant” in the eyes of CMS would be excluded as a MIPS APM (e.g. the

Comprehensive Care for Joint Replacement model), which may create a disincentive for clinicians to

participate in these models. The proposed definition is also contrary to the purpose of an APM, which is

intended to create incentives for collaboration across provider types and settings to achieve success

under the model. Such a policy sets the stage for models to compete with one another in undesirable,

potentially counterproductive ways.

Under the Advanced APM Incentive, CMS proposes to recognize affiliated practitioners (eligible

clinicians who are in a contractual relationship with an Advanced APM Entity) for purposes of the

qualified practitioner determination. CMS may already collect this information for other purposes to

administer the APM, such as for monitoring, evaluation, or administering waivers. Therefore, it seems

both reasonable and feasible to also use these affiliated provider rosters for purposes of defining an

APM entity under MIPS. An important benefit of this approach is the consistency in defining a

participant for both Advanced APMs and MIPS APMs.

In summary, we urge CMS to allow facility-led APM entities to qualify as MIPS APMs by revising the

requirement that the APM entity includes one or more MIPS-eligible clinicians on a Participation List

or an Affiliated Practitioners List.

MIPS APM reporting, scoring and category weights

MSSP

Providence endorses the proposal to use MSSP quality measure data for purposes of MIPS quality

scoring. In comparing the quality reporting to regular MIPS scoring, we also noted that CMS intends to

make the bonus points for eCQM reporting available to APM participants; however, we are not aware of

e-specifications for the MSSP measure sets. We urge CMS to develop and adopt e-specifications for all

APM measure sets so that APM entities may qualify for the eCQM bonus points.

We also agree with the proposal to eliminate the resource use category and reallocate the weighting to

the CPIA and ACI categories. This policy will allow MSSP participants to focus on the performance and

stewardship goals of the ACO rather than be distracted by the various resource use measures proposed

for non-APM participants.

Providence supports the proposal to report the ACI category by TIN. ACOs may include medical groups

that use different EHRs or different instances of the same EHR vendor, so assessing ACI by TIN,

aggregating and weighting for an ACO group score is sound policy.

Other MIPS APMs

CMS proposed different MIPS category weights for participants of Other MIPS APMs. In this variation of

MIPS, both the quality and resource use categories would be weighted at zero and the MIPS composite

score would be heavily weighted by the ACI category (75 percent), with CPIA making up the remainder

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(25 percent). While we support a zero percent weight for the resource use category, based on the

underlying cost and resource use accountability under the APM, we do not believe this approach to

MIPS scoring fully honors and credits the work clinicians are undertaking in quality as part of the APM.

It is concerning that performance under the ACI category takes on such significance, which seems

disproportionate and unbalanced. CMS requested comments on whether a neutral score for quality and

resource use categories would be a better alternative – this alternative also seems unfair because in an

APM structure, clinicians have even more of an incentive to achieve high performance and improvement

over time. We recommend CMS revise the category weights for Other MIPS APMs to include credit for

quality performance.

Advanced APM incentive

Providence supports the financial risk being borne at the APM entity level rather than requiring the

risk to be borne directly at the clinician level.

Designated Advanced APM criterion and models

MACRA requires Advanced APMs to meet three statutorily-defined criteria:

1. Use CEHRT

2. Provide for payment for covered professional services based on quality measures comparable to

those in the quality performance category under MIPS

3. Include more than nominal risk

Based on the criteria definitions proposed by CMS, very few models would be designated as Advanced

APMs. We are particularly concerned that Advanced APM models that include explicit downside

financial risk, such as the CJR model, do not meet the qualifications because the “model” does not

require use of EHR technology, even though participant clinicians and hospitals may in fact be

meaningful users. We encourage CMS to address such barriers by modifying the model agreements for

willing APM participants so that participation in these models may be fairly credited.

Medical home model standard for financial risk for monetary losses

CMS goes beyond the MACRA requirements to define a financial and nominal risk standard specific to

medical home models. In this definition, CMS includes risk from the total funds potentially owed to CMS

or special funds the entity could forego. Providence endorses this definition of nominal risk, but

disagrees with CMS that this definition should only apply to medical home models. We agree with the

recommendation from the Health Care Transformation Task Force that the proposed financial risk

standard for medical homes should also be used for all other APM models. The logic underlying this

behavioral economics theory should apply to physicians regardless of the type of APM they are

participating in, and will be a significant incentive to realizing the desired physician behavior across all

APM models.

All-Payer Option

CMS proposes that APM entities must submit payer contract information to allow CMS to verify

alignment and this would include both details about the payment structure and the patient population.

In addition, CMS proposes that payers must attest to accuracy and the contracts may be subject to audit

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by CMS. Provider contracts with payers are generally considered to be proprietary and closely guarded

by all parties. Providence is concerned that attestation by payers will be burdensome and we

recommend that CMS accept an attestation by the APM entity only, which would be subject to audit.

We also encourage CMS to consider strategies for closer alignment with Medicare Advantage. The

Affordable Care Act sought to achieve parity between MA and traditional Medicare, bringing the MA

benchmarks, on average, to 100 percent of fee-for-service across the country. We believe that MACRA

has inadvertently tipped the balance in favor of traditional Medicare, offering payments above 100

percent of fee-for-service in traditional Medicare, but not in MA. All the while, MA offers a glimpse into

innovative, advanced payment arrangements in Medicare. In the proposed rule, CMS implies that the

five percent bonus payments to Advanced APM participants will not factor into the MA benchmark

determinations because they are made outside of the claims payment system. The MA plans would see

no benefit from the physicians’ involvement in risk-based coordinated care. We believe this

underscores the need for separate incentives in MA that encourage risk-bearing contracts between

physician groups and MA plans.

Information blocking and EHR surveillance

Providence strongly supports the creation of an efficient and effective infrastructure for health

information exchange that facilitates the delivery of high-quality, patient-centered care across health

care settings. However, this shared goal is met with practical limitations to the current state of EHR

technology and exchange networks, as well as the cost and complexity.

Cooperation with surveillance and direct review of Certified EHR Technology

Under MACRA, eligible professionals, eligible hospitals, and CAHs will need to attest that they have

cooperated in good faith with the surveillance of CEHRT under the Office of the National Coordinator of

Health IT Certification Program. In the proposed rule, CMS outlines the attestation requirements, which

commit providers to accommodating data requests and opening access to EHR technology to

certification bodies.

Although CMS notes that ONC has established safeguards to minimize the burden on providers, the in-

the-field surveillance activities are extensive and it is not clear how frequently providers would need to

respond to such requests. We ask that CMS provide more information about the circumstances that

would trigger a direct review and recommend that such requests be part of the program audit process

rather than a separate, unaffiliated process.

Attestation to support health information exchange and prevention of information

blocking

MACRA requires that to be a meaningful user, an eligible professional, hospital or CAH must

demonstrate that they have not knowingly and willingly taken action (such as disabling functionality) to

limit or restrict the compatibility of certified technology. To implement this requirement, CMS proposes

a three-part attestation statement.

Part two of the attestation includes a statement that the EHR is “implemented in a manner that allowed

for the timely, secure, and trusted bi-directional exchange of structured electronic health information

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with other health care providers (as defined by 42 U.S.C. 300jj(3)), including unaffiliated providers, and

with disparate certified EHR technology and vendors.” This statement is essentially guaranteeing

interoperability, which is simply not possible at this time.

Part three of the attestation statement maintains that providers and hospitals must respond to any data

exchange requests:

the eligible clinician, EP, eligible hospital, or CAH would be required to attest that it responded in

good faith and in a timely manner to requests to retrieve or exchange electronic health

information, including from patients, health care providers (as defined by 42 U.S.C. 300jj(3)), and

other persons, regardless of the requestor's affiliation or technology vendor.

Given these challenges with today’s technology and the more limited scope of the statutory

requirement, Providence joins the American Hospital Association and other stakeholders in urging

CMS to keep only first of the three proposed attestations about information blocking: hospitals and

CAHs participating in the meaningful use program and clinicians participating in the Medicare quality

program attest that they have not “knowingly and willfully taken action (such as to disable

functionality) to limit or restrict the compatibility or interoperability of their certified EHR.” We ask

CMS to not finalize the other two attestation statements.

Thank you for the opportunity to provide comments on this important proposed rule. We hope that you

find our input constructive and informative. For more information, please contact Christa Shively,

director, federal regulatory affairs and engagement, at (503) 893-6456 or via email at

christa.shively@providence.org.

Sincerely,

Rod Hochman, MD President and CEO Providence Health & Services