September 13, 2021 

The Honorable Chiquita Brooks-LaSure
Administrator
Centers for Medicare and Medicaid Services
U.S. Department of Health and Human Services
Hubert H. Humphrey Building
200 Independence Avenue, S.W.
Washington, DC 20201

Re: (CMS-1751-P) Medicare Program; CY 2022 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment Policies; Medicare Shared Savings Program Requirements; Provider Enrollment Regulation Updates; Provider and Supplier Prepayment and Post-payment Medical Review Requirements.

Dear Administrator Brooks-LaSure: 

The National Association of ACOs (NAACOS) appreciates the opportunity to submit comments in response to the proposed rule, Medicare Program; CY 2022 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment Policies; Medicare Shared Savings Program Requirements; Provider Enrollment Regulation Updates; Provider and Supplier Prepayment and Post-payment Medical Review Requirements, as published in the Federal Register on July 23, 2021.  NAACOS and our members are deeply committed to advancing value-based care, and this notable annual regulation plays an important role in shaping ACOs and the broader shift to value-based payment. 

NAACOS represents more than 370 ACOs participating in a variety of value-based payment and delivery models in Medicare, Medicaid, and commercial insurers. Serving more than 12 million beneficiaries, our ACOs participate in models such as the Medicare Shared Savings Program (MSSP), the Next Generation Model, the Direct Contracting Model, and other Alternative Payment Models (APMs). NAACOS is a member-led and member-owned nonprofit organization that works to improve quality of care, health outcomes and healthcare cost efficiency. 

We are pleased to provide detailed comments on many aspects of the proposed 2022 Medicare Physician Fee Schedule (MPFS) rule, which follow our summary of key recommendations below.

Summary of Key Recommendations

In response to MSSP proposals, NAACOS urges CMS to:

• Work with ACOs and the electronic health record (EHR) vendor community to find solutions to data aggregation problems, and until these solutions are widely available, electronic clinical quality measures (eCQMs) should not be mandated for ACOs. Aggregating eCQM data at the ACO level is not appropriate and, in some cases, not technically feasible at this time.
• Abandon the strategy of aligning ACO quality with the Merit-Based Incentive Payment System (MIPS) quality assessments.
• Revise the new MSSP quality performance standard. It is inappropriate to compare ACO quality performance to MIPS quality performance.
• Remove the all-payor requirement for ACOs reporting eCQMs and instead urge Centers for Medicare & Medicaid Services (CMS) to require reporting on a sample of ACO assigned patients meeting the denominator criteria.
• Identify ways to evaluate quality within APMs in a more strategic manner.
• Identify ways to evaluate quality within APMs in a more strategic manner.
• Reinstate the previous policy to provide a pay-for-reporting year for measures that are new and/or undergo significant changes mid-year.
• Improve education and guidance provided to ACOs to support their successful transition to eCQM/MIPS CQM reporting and the new APM Performance Pathway (APP) reporting and assessments that have been created to evaluate their quality performance in the MSSP.
• Correct ongoing ACO benchmarking flaws including the “rural glitch” by removing ACO assigned beneficiaries from the regional portion of benchmarks.
• Align the use of a risk adjustment cap for the ACO and its region.
• Finalize the proposal to cut in half ACO required repayment mechanism amounts.
• Reduce burden for ACOs by removing the beneficiary notification requirement altogether.
• Absent a full repeal of the beneficiary notification requirement, finalize the proposal to amend the requirement such that ACOs that have selected prospective assignment do not have to send notification to beneficiaries that are not prospectively assigned to them.
• Finalize the proposals to streamline and simplify the MSSP application process.
• Move the deadline for ACOs to add participants until later in the year.
• Grant ACOs access to view the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) from the ACO Management System (ACO-MS).

In response to Quality Payment Program (QPP) and Medicare PFS payment policies, NAACOS urges CMS to:

• Grant ACOs access to view the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) from the ACO Management System (ACO-MS).
• Modify policies for Advanced APM incentives to pay bonuses to APM Entities, such as ACOs
• Finalize proposed payment increases for care management services and implement CPT codes instead of temporary G-codes
• Continue to improve billing and payment for Evaluation and Management (E/M) services and finalize policies such as clarifications for billing split/shared visits and critical care services
• Reduce the data completeness level to no more than 40 percent with a gradual increase to a maximum of 50 percent for those reporting eCQMs or MIPS CQMs
• Use CMS’s statutory authority to allow all ACOs, regardless of risk level or choice of attribution, the freedom to use telehealth in broader circumstances. This includes expanding waivers beyond the patient’s site of care and geographic location.
• Refrain from putting a specific date by which CMS plans to move to full digital quality measurement for value-based purchasing programs.