AGA Washington Insider

A policy blog for GIs

AGA Advocates for the Needs of GIs in a Changing Health-Care Reimbursement System

AGA provided the following comment letter to the Senate Finance Committee and the House Ways and Means Committee on Nov. 12, 2013.

The American Gastroenterological Association (AGA) is the trusted voice of the GI community. Founded in 1897, the AGA has grown to include 17,000 members from around the globe who are involved in all aspects of the science, practice and advancement of gastroenterology.  We thank you for all of your efforts in reaching out to the physician community to solicit our input on your latest proposal on SGR Reform and Medicare Physician Payment Reform.  AGA appreciates the opportunity to provide feedback and agrees that we need to transition physicians to a more viable system that rewards physicians for improving the quality of care that they provide to their patients and supports the “Triple Aim.”

Over the past decade, the AGA has made considerable investments in the development of clinical guidelines, outcomes measures, patient registries, collaborations with private payors and other quality improvement initiatives to provide gastroenterologists (GIs) with the tools necessary to improve patient outcomes and also prepare them for a changing health‐care marketplace.

The AGA appreciates the bipartisan and bicameral nature of this proposal that repeals the broken SGR system and transitions physicians to a system that rewards quality improvement and appropriate utilization of care.

We offer the following comments and suggestions specific to your proposal.

SGR Repeal and Annual Updates

  • AGA appreciates that the proposal permanently repeals the SGR formula. With all of organized medicine AGA has long argued that meaningful physician payment reform cannot occur unless the SGR is repealed since it does not fairly or accurately update physician payments and has not served physicians, beneficiaries, or the taxpayers well.
  • The proposal’s 10-year freeze in Medicare payments to physicians is very concerning.  While we recognize and appreciate the enormous fiscal constraints that the committee is operating under, Medicare physician payments have trailed inflation for nearly 10 years and extending this freeze for another decade will result in a cumulative gap between Medicare payments and the cost of treating patients of nearly 45 percent.  The SGR must be replaced with a stable and fair mechanism that recognizes reasonable inflationary medical costs and ensures that physician reimbursements are based on the actual cost of providing care.
  • Physicians should be given positive financial incentives for higher quality and more efficient care, not penalties and withholds.  The proposed 10-year freeze, paired with a budget neutral Value-Based Performance (VBP) Program, will result in cuts to many physicians starting as early as 2017.  In fact, this really represents only one year of stability if payment adjustments are based on 2015 performance.
  • We encourage you to include a five-year period of stability following the repeal of the SGR, during which time base payments to physicians should capture the true cost of treating patients.  This five-year period can be used to support the development and testing of alternative measures, clinical improvement activities, and payment models.

Value-Based Performance Payment (VBP) Program

  • AGA appreciates that the proposal streamlines the current quality reporting programs under Medicare into one program, rather than maintaining three distinct programs. We thank the committees for making this change since we have advocated that measures be aligned across programs wherever appropriate and that reporting should be streamlined to enable physicians to report once for multiple programs.  This harmonization will ease the regulatory burden on physician practices and allow them to report through one mechanism, such as a patient registry or through a certified electronic health record (EHR) system. We also appreciate the committee’s recognition that physician specialties are in different places in terms of measure development and support the inclusion of funding to develop additional quality measures.
  • AGA questions to what extent this proposal would alleviate the regulatory burden physicians now face since the newly proposed structure essentially preserves current reporting mandates in addition to holding physicians accountable for clinical practice improvement activities.
  • AGA supports termination of current law incentive program payment reductions and the return of those payments to the physician payment pool.  We strongly encourage the Congress to ensure that the performance period ends as close as possible to the beginning of the year for which an adjustment is applied.
  • AGA does not support the premise of grading physicians on a curve.  We are concerned that making this a budget-neutral program means that there will inevitably be “losers” to finance the “winners,” no matter how reasonable one’s performance is.  Furthermore, this proposal would extend budget neutrality to where it currently does not exist, since PQRS and EHR Incentive Program reporting are not budget neutral.  Although only positive incentives should be included, if the program must include winners and losers then it should only target statistically significant outliers rather than those performing at the mean.

Assistance to Small Practices

  • AGA supports the provision to assist small practices in achieving quality improvement and to provide them with the necessary tools to document them. Small practices continue to struggle with incorporating new regulatory requirements and quality improvement models into their practices due to the lack of administrative support that larger practices and integrated health systems have.  Even small practices that have adopted electronic health records often lack the necessary support to fully integrate their use to adhere to new physician quality improvement programs and regulatory requirements such as PQRS and EHR meaningful use.   It would benefit small practices to have the necessary assistance to help them adopt the infrastructure and support necessary to implement new payment models and programs.

Professionals Eligible for VBP

  • We support exempting from the VBP Program physicians who treat too few Medicare beneficiaries, but request that the exemption categories be expanded to include those new to practice, those nearing retirement and others who may find it challenging to participate.  Alternatives must be considered, however.  While it is reasonable to exclude professionals who treat too few Medicare beneficiaries from the VBP program and its penalties, these physicians would be left with a 10-year freeze in payments that does not keep up with the cost of providing care.

Assessment Categories

  • AGA requests appropriate time for implementation of this program rather than applying it to all physicians beginning with payment year 2017. This proposal includes no mechanisms to ensure careful and incremental implementation or to differentiate between practices that are better equipped with resources and experience to fulfill performance-based reporting mandates versus those that are not.  We support  exempting physicians who receive a significant portion of their revenue from an advanced Alternative Payment Model (APM) from the performance based incentive program and instead providing these physicians with a 5 percent bonus payment starting in 2016 through 2021.

Quality Measurement

  • AGA supports using the quality measures currently in PQRS and other incentive programs as a foundation for the quality component in the VBP program, recognizing the investments made to date.
  • We support funding for measure development to address current gaps in measures, but request language that ensures that measure development is led by relevant medical specialty societies and their clinical experts; that measures are evidence-based and rely on best clinical practices; and that National Quality Forum-endorsement be recognized, but not required in order to allow for the testing of more innovative approaches to quality improvement. 
  • We also appreciate your ongoing recognition and support of the use of clinical data registries to measure and improve health care.  AGA recommends that this legislation preserves the American Tax Relief Act-authorized recognition of physician participation in a qualified registry in lieu of PQRS or other quality measure reporting, as we believe registries should continue to play a key role in quality improvement and measurement.

EHR Meaningful Use

  • AGA supports provisions to prevent duplicative reporting and to recognize professionals who report quality measures through certified EHR systems as satisfying the meaningful use clinical quality measure (CQM) component.  We remind the committee that CQMs are only one component of the EHR Incentive Program and that the program’s remaining objectives and all-or-nothing scoring approach make it largely irrelevant and challenging for specialists by assuming that every measure is absolutely appropriate and of equal value to every practice situation.
  • To realize the full potential of EHRs, the requirements of the current program need to be less prescriptive to allow physicians to be creative in applying the technology to their unique clinical workflows and patient needs.
  • AGA recommends timeline adjustments. The program’s timeline must be more gradual to allow vendors to keep up with certification requirements and to allow physicians more time to learn how to incorporate system functionalities into practice and use them in a meaningful manner that improves patient care, ensures patient safety, and improves workflows.  At present, there is not a single system that has been certified for the full set of Stage 2 MU requirements, which is set to start in 2014.

Resource Use

  • AGA believes that efficient and effective resource use is an important part of the Triple Aim of healthcare and should include a performance measurement model that relies on meeting certain achievable benchmarks rather than pitting physicians against each other. We continue to urge the committee to emphasize the role of professional societies and other relevant clinical experts in determining measure weights and setting thresholds for each peer cohort.
  • AGA supports language to ensure that current resource use metrics and methodologies are enhanced, including the development of more specific episodes of care, but request specific language to ensure that resource use measures not be used for accountability purposes until more specific episodes are defined and until risk adjustments and attribution methodologies are redefined enough to produce accurate and reliable data.  Recently, Robert Berenson, MD, authored a Perspective piece in The New England Journal of Medicine, “Grading a Physician’s Value – The Misapplication of Performance Measurement,” where he recognizes the challenges of “accurately assigning  costs to an individual physician” since “current methods of case-mix adjustments do not accurately capture variations in patients’ illness severity, complicating coexisting conditions, or relevant socioeconomic differences – differences beyond the physician’s control that affect the cost of care. And we currently don’t know how to attribute to an individual physician the costs that Medicare beneficiaries generate across the health care system.”
  • AGA has met with the Centers for Medicare and Medicaid Services (CMS) on several occasions to discuss ways to improve the utility and dissemination of Quality Resource Use Reports (QRURs).  AGA is committed to improving the program, particularly the attribution method and the need for the QRUR to represent meaningfully appropriate subspecialty-specific quality measures for the value-based payment modifier.

    All-cost and per capita resource use metrics used under the current VBM should no longer be used since they inappropriately hold the individual accountable for decisions outside of their control.  Even CMS has admitted that the current set is less than ideal and is being used only as a stopgap measure to satisfy a mandate until more appropriate metrics are developed.  If total per capita costs measures are maintained, they should at least be expanded to include payments under Part A, Part B, and Part D drug expenses, which are currently not being accounted for. If Part D costs are not considered when calculating total beneficiary costs, physicians who prescribe Part B drugs will appear to have significantly higher resource use over their peers who are prescribing Part D drugs for the same condition.  This is a major concern for physicians who treat patients that rely on pharmacotherapy to manage a specific condition and who are faced with a choice between Part B and D drugs. To date, risk adjustment has been unable to address this issue to a degree that limits adverse effects on clinical decision-making and patient choice.
  • AGA is concerned that this proposal lacks specific language to ensure that that both quality and cost measures used under the VBP program are properly adjusted prior to being used for accountability purposes. Sec. 3007 of the Affordable Care Act, which authorizes the Physician Value-Based Payment Modifier, states that quality measures “shall be risk adjusted as determined appropriate by the Secretary,” and that costs shall be evaluated under a mechanism that “eliminate[s] the effect of geographic adjustments in payment rates and take[s] into account risk factors (such as socioeconomic and demographic characteristics, ethnicity, and health status of individuals (such as to recognize that less healthy individuals may require more intensive interventions) and other factors determined appropriate by the Secretary.”

Clinical Practice Improvement Activities

  • AGA supports the array of options that the committee allows physicians to demonstrate clinical practice improvement activities and believes that many AGA initiatives qualify under this section. We have undertaken the development of a number of quality measures that address both high-cost and common high-volume diseases and commonly utilized preventive and surveillance services.  It is critical that the categories used to define Clinical Practice Improvement Activities not limit a physician’s flexibility to choose activities that are most relevant and meaningful to his/her practice.
  • AGA is committed to ensuring that Medicare and private payors measure physicians against standards that are scientifically valid, fair, and realistic and are linked as closely as possible to patient outcomes. As we have indicated in a previous letter to the committees, we have developed, or are in the process of developing, the following quality initiatives, which we believe set a foundation for a payment system that rewards care based on science, avoids waste and inappropriate services, and identifies known opportunities for quality improvement. We envision these initiatives would qualify as clinical practice improvement activities under this section:
  • Clinical Decision Support Tools
  • AGA Digestive Health Recognition Program™ (DHRP), a platform for clinicians to demonstrate and be recognized for superior quality of care in the treatment of various digestive diseases.

Performance Assessment

  • Give greater weight to practice improvement activities. While we support the direction that the committee wants to move in terms of quality and outcomes measures, the proposal weighs EHR meaningful use and resource use higher than clinical practice improvement activities.  We believe this emphasis is wrong. In terms of calculating the composite score, we recommend that greater weight be given to clinical practice improvement activities since this is where physicians have the most flexibility to choose quality improvement activities that are most relevant to their practice and their patient base.  Less weight should be given to EHR Meaningful Use due to the inflexible nature of the program and persistent unavailability of relevant, certified products.  Less weight should be given to resource use until better metrics and methodologies are developed that result in more accurate assessments.
  • AGA supports group-level performance analyses, as well as allowing facility-based professionals to have their quality assessment determined by the performance of their affiliated hospital or facility so long as these professionals are given the choice to decide what is most appropriate for their practice.  We support recognition of group-level reporting to a clinical data registry so long as individual reporting is also preserved. We recommend that confidential feedback be provided to physicians for at least a year prior to holding physicians accountable for performance.

Encouraging Alternative Payment Model Participation

  • AGA has been working with national commercial payors on a variety of quality improvement initiatives as well as alternative payment models.  The AGA has developed a bundled payment model for screening and surveillance colonoscopy, which we believe would qualify as an alternative payment model under this section.  The colonoscopy bundle provides a framework for physicians to provide high value, cost-efficient, preventive care to patients. The Centers for Disease Control and Prevention recently announced that a third of the eligible screening population is not being screened for colorectal cancer, despite screening options.  Colonoscopy is a vital screening tool in our fight to prevent colorectal cancer which remains the second leading cancer killer in this country.
  • We believe that a bundled payment model for colonoscopy, starting with services related to colorectal cancer screening and surveillance, will help to improve the quality of services by including quality and outcomes measures, providing financial stability for gastroenterologists by allowing them to accept the financial risk of providing colonoscopy care, improve colorectal cancer screening rates and the detection and removal of pre-cancerous lesions, thus helping to incent physicians to improve the efficiency of that care while tied to quality reporting.  We envision this bundle being used by both Medicare and commercial payors, therefore, we appreciate that the committee includes a second option for physicians to have revenue thresholds be a combination of Medicare and non-Medicare revenue.
  • The requirement that the APM include two-sided financial risk is restrictive and, depending on interpretation, could exclude important models currently being tested, such as bundled payments.  This language should be clarified so that it more broadly reflects accountability for certain (unspecified) losses when a target (again, unspecified) is not reached.
  • Physicians need flexibility to reflect the variance in practice setting of physicians across the country and should be allowed to participate in more than one payment model or arrangements if a physician chooses. For example, because of the current CMS policy, gastroenterologists who provide any evaluation and management (E/M) services are required to be “exclusive” to one accountable care organization (ACO), which fragments subspecialty care and severely limits patient access to specialty care.  This policy is counter to the goal of improved care coordination across all medical subspecialties and will also lead to less competition among providers to participate in various alternative payment models and may lead to complacency once an exclusive relationship is established.

Ensuring Accurate Valuation of Services Under the Physician Fee Schedule

  • AGA appreciates that the committee does redistribute reduced fee schedule changes back into the physician pool.  However, the AGA is concerned that this provision fails to recognize that CMS has addressed several of these issues through its ongoing work on the potentially misvalued code initiative, as well as through its new authority to validate RVUs through the Affordable Care Act.
  • While we appreciate the committee’s efforts to more accurately determine physician values, we are concerned that physician practices will be subject to more regulatory burdens of providing information to CMS.  The steep 10 percent penalty proposed is totally unreasonable and places a significant administrative and financial burden on physician practices. Completing surveys is timely and expensive, and without technical assistance, can be challenging.   This activity should be voluntary and compensated, but never punitive. It is not clear whether physicians who inaccurately complete the survey would be subject to the penalty or if they would be subject to the False Claims Act if they mistakenly or unknowingly provided inaccurate data.
  • It also is not clear whether surveys will be the only mechanism by which CMS would collect data. It has been said that time-motion studies could be carried out. It should be noted that CMS is already using its statutory authority to carry out similar activities through its contracts with RAND and Urban Institute. It is not clear whether these activities will continue under this proposal.  Regardless, any effort should include an element of technical assistance, whether it is with completion of surveys or participation in a time-motion study.
  • We fear the agency may still not receive the most accurate information on physician services under these circumstances.   We are appreciative for efforts to reduce the regulatory burden on smaller practices via an exemption, but are concerned that this could result in larger and potentially more “efficient” practices setting the baseline RVUs and payment being too low for smaller practices that are unable to be as efficient, despite providing high-quality and “relatively” efficient care.

Transparency of Data

  • AGA opposes allowing qualified entities to provide or sell data analyses to health insurers and employers.  This provision ignores current challenges with public reporting. While consumers have a right to informed decision-making, transparency is only valuable if it is meaningful and relevant.  If not, it can actually cause greater harm and confusion.  Utilization and payment data are not indicative of a professional’s quality or efficiency and may create further confusion and inaccurate assumptions among consumers.   There is little evidence that consumers value or to what extent they even use publicly reported data regarding physician quality and costs.

Additional Concerns Not Addressed in Proposal

AGA would like to see the following provisions included in any SGR replacement package:

  • Legal protections for physicians who follow clinical practice guidelines and quality improvement program requirements. At the very least, the rule of construction contained in the Energy and Commerce Committee’s bill should be included.  This states: “RULE OF CONSTRUCTION REGARDING HEALTH CARE PROVIDER STANDARDS OF CARE.—(1) IN GENERAL.—The development, recognition, or implementation of any guideline or other standard under any Federal healthcare provision shall not be construed to establish the standard of care or duty of care owed by a health care provider to a patient in any medical malpractice or medical product liability action or claim.”
  • Repeal of the Independent Payment Advisory Board (IPAB)

The AGA appreciates the opportunity to provide our input on your SGR Repeal and Medicare Physician Payment Reform Proposal and believe our experience with quality and efficiency programs with both Medicare and private payors can be expanded to a wider population base. Again, we share your vision to create a new payment system that rewards physicians for quality improvement and moves the Medicare system to a more stable and viable path.

Should you have any questions or need additional information, please do not hesitate to contact Kathleen Teixeira, AGA’s senior director of government affairs, at (240) 482-3222 or


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