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  • Washington Highlights

    AAMC Comments on CMS Episode Groups Comment Letter

    Len Marquez, Senior Director, Government Relations

    The AAMC March 1 submitted a comment letter to the Centers for Medicare and Medicaid Services (CMS) in response to a request for feedback regarding implementation of episode groups as required under the Medicare Access CHIP Reauthorization Act of 2015 (MACRA, P.L. 114-10).

    Beginning in 2019, physicians will either have the option to have their performance assessed under a newly consolidated pay-for-performance program, Merit-based Incentive Payment System (MIPS), or receive incentives for participation in Alternative Payment Models (APMs). The MIPS will assess performance of eligible professionals in four categories: quality, resource use, meaningful use of certified electronic health record (EHR) technology, and clinical practice improvement activities. MACRA requires CMS to establish care episode and patient condition groups to measure resource use under MIPS and APMs.

    The AAMC’s comments include several factors for CMS to consider when identifying specific patient characteristics to classify into care episode and patient condition groups. The association recommends CMS consider the transition from ICD-9 to ICD-10 and notes that CMS needs to provide sufficient time to allow meaningful input from experts on the appropriate ICD 10-CM codes to use in the episode groups.

    The letter states that CMS should use appropriate risk adjustment to account for patient characteristics, as variation in patient severity, rates of patient compliance with treatment, socio-demographic status, patient engagement, and patient preferences for treatment approaches must be accounted for when developing episode groups.

    Additionally, the letter urges CMS to align resource use measures with clinical quality measures. According to the AAMC, quality measures under MIPS should be aligned with measures used by other Medicare programs (e.g., Accountable Care Organization programs) and commercial insurers. This will ensure that health care providers are not overwhelmed with administrative burden and contradictory requirements.

    Finally, the AAMC suggests CMS should ensure that inpatient add-ons, such as Indirect Medical Education (IME) and Disproportionate payments are removed from episode groups.

    CMS will publish more information regarding episode groups in the MIPS and APMs proposed rule in the spring, and the final rule is likely to be released in November 2016.