With the nearly 4,000 comments now in for the proposed MACRA rule, we are taking a look at what organizations had to say about including Continuing Medical Education (CME) as a Clinical Practice Improvement Activity (CPIA) under the new Merit-based Incentive Payment System (MIPS). Across the board, medical organizations and physicians were extremely supportive of including CME as a CPIA and strongly encouraged CMS to include CME-related language in the final rule. For example, an article by MeetingsNet highlights the hundreds of comments submitted describing the value of CME. As suggested by the CME Coalition's comments, CMS should "explicitly recognize qualifying CME as a clinical practice improvement activity within MIPS because CME has long been recognized as an effective means by which physicians demonstrate engagement in continued professional development."
As we reported when the MACRA rule was released earlier this year, starting in 2017 (with payments in 2019 being impacted), the proposal outlines the four components of MIPS. MIPS is based on a 100 point score with clinical practice improvement activities (CPIA) representing 15 percent of the score. This is an area where CME should play an important role in helping CMS achieve its quality measure objectives. The proposed rule leaves great discretion to the Secretary of HHS to define what will be included in these activities. As stated in the rule's preamble: "Clinical Practice Improvement Activity (CPIA) means an activity that relevant eligible clinician organizations and other relevant stakeholders identify as improving clinical practice or care delivery and that the Secretary determines, when effectively executed, is likely to result in improved outcomes." We expect the final rule to be released in early November 2016.
Clinical Practice Improvement Activity
The term "Clinical Practice Improvement Activity" is defined as an activity that relevant eligible professional organizations and other stakeholders identify as one that improves clinical practice or care delivery and that the Secretary determines is likely to result in improved outcomes. The CPIA will assess healthcare professionals on their effort to engage in continuing education and working to improve their practices and facilitate future participation in APMs.
The menu of recognized activities will be established in collaboration with professionals, and is expected to be applicable to all specialties and accessible for small and rural area practices. Currently, the eligible professional's activity log must include the following subcategories of activities:
Expanded practice access (includes activities such as: same day appointments for urgent needs, allowing patients with emergencies to walk-in during certain established hours, use of satellite offices to bring services to patients, and serving on call in an emergency department);
Care coordination (includes activities such as timely communicating test results, provide patients with printed copies of test results, and the ability of a practice to receive - and act upon - faxes or emails from referring doctors);
Beneficiary engagement (includes activities such as providing patients with medical history forms to fill out prior to a first appointment, training patients to properly use medicines and medical devices, and nutritional counseling);
Patient safety and practice assessment; such as MOC Part 2 self-assessment and
Participation in an APM. Note special treatment will be assigned to participants in APM's that don't meet the full APM criteria in MACRA; and
Other criteria as determined by the Secretary of HHS.
Comments Received by CMS
Given the sheer number of comments, this is not an exhaustive look at all possible comments submitted to the agency on CME and the new CPIA program. However, across the board, medical organizations and individual physicians were extremely supportive of including CME activities as a CPIA. Three of the larger organizations stand out. Selected quotes from the American Medical Association (AMA), the American Academy of Family Physicians (AAFP), and the American College of Physicians (ACP):
[We] would like CMS to add accredited continuing medical education (CME) and board-certification related activities to the list of CPIAs. These activities take up considerable time for physicians but ensure patient care is of the highest quality and reflects the latest medical knowledge and innovations. While 45 some proposed CPIA activities could be satisfied through CME, we believe a more explicit recognition would help physicians understand whether all CME will count under the CPIA component of MIPS.
Aligning with CPIAs is performance improvement CME, which supports health care transformation by encouraging clinicians to reflect on current practice and engage them to make changes in their practice that ultimately improves the care that is delivered. There are now multiple examples in the literature that proves the value of performance improvement CME as a vehicle for not only promoting change, but also embedding that change into a practices' workflow so that observed improvement is sustained in the long term. Fundamentally, the objectives of CPIAs and performance improvement CME are congruent with the strategic goals of the Administration.
We believe that performance improvement CME activities that involve assessment and improvement of patient outcomes or care quality, as demonstrated by clinical data or patient experience of care data, including completion of an AAFP's "Performance Navigator" CME module should be included in the list of CPIAs as a high-weight activity. These activities may involve multiple interventions that are focused via an assessment of the current environment on individualized practice needs. They will also likely require redistribution of an existing staff person's time or a dedicated new staff person. Other high-rated activities should include establishment of a patient advisory council, risk-stratified care management, and shared decision-making (with the use of an evidence-based decision aid).
The College urges CMS to recognize credit for certain defined Continuing Medical Education (CME) activities:
- Accredited CME activities that involve assessment and improvement of patient outcomes or care quality, as demonstrated by clinical data or patient experience of care data.
- Accredited CME that teaches the principles of quality improvement and the basic tenets of MACRA implementation, including application of the "three aims," the National Quality Strategy, and the CMS Quality Strategy, with these goals being incorporated into practice.
The American Academy of Neurology's (AAN) comment letter was one of the most substantial and included a thorough legal and policy rationale for the inclusion of quality-related CME as a CPIA:
According to the statute, any CPIA measure must be "relevant to an existing CPIA subcategory (or a proposed new subcategory)" as defined in §414.1365. Unfortunately, those subcategories do not include a specific reference to medical education or a related area. The subcategories outlined in the proposed rule include: (1) expanded practice access; (2) population management; (3) care coordination; (4) beneficiary engagement; (5) patient safety and practice assessment; (6) participation in an APM; (7) achieving health equity; (8) emergency preparedness and response; and (9) integrated behavioral and mental health.
The AAN asks CMS to consider activities of organizations representing physicians and medical groups as practice improvement activities. Specifically, this would include accredited continuing medical education (CME) related to quality improvement, board-certification-related activities, and other initiatives aimed at improving clinical practice. (emphasis added)
In §414.1355, CMS proposes that CPIA be defined on an annual basis and must meet certain criteria, much of which aligns closely with the goals of CME. While CME related to quality improvement may not be directly relevant to an existing CPIA subcategory, it does improve beneficiary outcomes, leads to practice improvement, can be performed by providers of all types, is feasible to implement, can be validated by CMS, and is evidence-based.
Furthermore, the proposed rule leaves great discretion to the Secretary of HHS to define what will be included in these activities. As stated in the rule's preamble: "Clinical Practice Improvement Activity (CPIA) means an activity that relevant eligible clinician organizations and other relevant stakeholders identify as improving clinical practice or care delivery and that the Secretary determines, when effectively executed, is likely to result in improved outcomes." (81 Fed. Reg. at 28380).
Several CPIA subcategories are relevant to CME, such as population management, care coordination, patient safety practice assessment, and beneficiary engagement. All of the subcategories for clinical practice improvement activities would benefit from provider participation in CME in and around those topics. Additionally, many believe that the previous programs included in MACRA such as the Physician Quality Reporting System (PQRS), Meaningful Use, and Value Modifier would have achieved significantly greater success had physicians received the education and training on these topics that certified CME provides.
To understand the breadth of CME for physicians, according to the Accreditation Council for Continuing Medical Education (ACCME), in 2014 there were 147,024 courses that offered 1,033,615 hours of instruction, and 13,599,687 physician interactions with an additional 11 million other healthcare providers participating in accredited CME courses. CME has long been recognized as a means by which physicians demonstrate engagement in continued professional development. This encourages physicians to develop and maintain the knowledge, skills, and practice performance that leads to optimal patient outcomes.
Lifelong learning, assessment, and improvement are integrally related. Learning is a necessary component of the change process that results in meaningful, sustained clinical performance improvement. Without this professional development, the measurement of adherence to quality metrics and use of health information technology are insufficient to produce clinical performance improvement.
CMS and private payers can also reduce burdens on physicians by counting CME and continuing education related to quality improvement as progress toward program goals. Eligible professionals should be credited for their effort to stay current with clinical practice and quality measures by utilizing CME. The inclusion of CME related to quality improvement as a clinical practice improvement activity recognized by CMS will help these professionals retain credit for the time they invest in learning about practice improvement.
The focus on quality-related CME was echoed by the American Board of Medical Specialties in their comment letter:
ABMS makes the following recommendations for revisions to Table H, the inventory of Clinical Practice Improvement Activities acceptable to satisfy that component of a physician's quality score:
• Recognize participation in MOC as a high-value clinical practice improvement activity;
• Recognize other forms of assessment and feedback, including peer review and practice assessments through on-line Performance Improvement modules;
• Recognize high-fidelity simulations, which are effective mechanisms for assessment, learning, and improvement of technical and procedural skills;
• Recognize continuing professional development activities as "Clinical Practice Improvement Activities" as long as they are practice relevant; accredited by ACCME; involve assessment and improvement of patient outcomes or care quality, as demonstrated by clinical data or patient experience of care data, such as PI-CME or QI-CME;
• Recognize CME that involves instruction in quality and/or safety science to improve the ability of physicians to participate fully in quality and safety improvement activities; and,
• Recognize activities completed and authenticated under the auspices of the ABMS Multi-Specialty Portfolio Approval Program.
From industry, the Pharmaceutical Research and Manufacturers of America (PhRMA) writes:
In addition to the activities referenced above, we urge CMS to consider including certain continuing medical education CME activities, provided by a nationally-recognized accreditor, as CPIAs within MIPS. CME promotes lifelong learning, assessment, and improvement in practice. Physicians are familiar with CME activities, and so their inclusion in MIPS would be consistent with CMS' goal of minimizing the reporting burden associated with the MIPS program.
Council for Medical Specialty Societies:
The CMSS letter urges CMS to recognize credit for "certain defined" CME activities. They further specify:
One issue potentially complicating CMS's recognition of accredited CME pertains to the 90 day rule. According to the Proposed Rule, MIPS eligible clinicians or groups must perform CPIAs for at least 90 days during the performance period to earn CPIA credit. To allow for accredited CME to count toward CPIA, we urge CMS to allow approved CME activities that incorporate a 90-day survey or evaluation period into the program as having met the 90 day requirements.
The American College of Rheumatology (ACR) concurred with CMSS:
The ACR also concurs with the Council of Medical Specialty Societies that the following CME activities are appropriate for consideration as CPIAs:
- Accredited CME activities that involve assessment and improvement of patient outcomes or care quality, as demonstrated by clinical data or patient experience of care data, such as Performance Assessment and/or Improvement CME, Quality Improvement CME
- Accredited CME that teaches the principles of and hopefully aids in the application of quality improvement and the basic tenets of MACRA implementation, including application of the "three aims," the National Quality Standards and the CMS Quality Strategy The ACR believes accredited CME activities that further physician awareness and compliance with best practices, thus meeting MACRA objectives, should be included as CPIAs.
- Just as QCDRs report to CMS, the ACCME's PARS system could be enhanced and integrated into the CMS MIPS reporting system to ensure consistent reporting. Further, because these systems are already in use, it would not complicate the process for users and remains an efficient process and reliable data source for CMS.
- Additionally, the proposal currently requires approved CME activities to last at least 90 days. We request that inclusion of surveys, interviews, or testing at or beyond 90 days following an activity should meet compliance requirements.
CME-interested groups like the ACCME and CME Coalition also added their comments to the MACRA rule. The ACCME specifically requested:
CMS recognize relevant performance and quality improvement accredited continuing medical education (CME) as a clinical practice improvement activity within MIPS.
CMS designate ACCME's Program and Activity Reporting System (PARS) as a reporting mechanism for clinical practice improvement activities.
The CME Coalition is pushing for the explicit recognition of qualifying CME as a CPIA as CME has long been recognized as an effective means for physicians to demonstrate engagement in continued professional development. They write:
Consistent with the intent of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), and with focus on the "three aims", the National Quality Strategy (NQS) and the CMS Quality Strategy, CME encourages physicians to develop and maintain the knowledge, skills, and practice performance that leads to improved performance with optimal patient outcomes. Simply put, without translating the new payment system into meaningful actions for physicians, the promise of MACRA will never be fully achieved. Because they have the ability to make a measurable difference in the way physicians practice their trade, accredited CME activities that are designed to further the objectives of MACRA, the "three aims," and the NQS should result in credit as clinical practice improvement activities within the MIPS.
Stakeholders Agree: CME Belongs in the Merit-Based Incentive Payment System (MIPS) - CME Coalition
Several local physicans included a number of comments, including those from members at the American Academy of Physical Medicine and Rehabilitation:
Furthermore, I also urge CMS to explicitly recognize continuing medical education (CME) activities provided by a nationally‐recognized accreditor as a clinical practice improvement activity within MIPS.
Another interesting comment came from an individual working in a Track 1 ACO:
I have been involved with an MSSP Track 1 ACO since early 2013 and have overseen the annual quality measure abstraction process each year since.
As another commenter has suggested, include approved CME activities to the Clinical Performance Improvement Activities category. Even if you restrict the CME content to population health or education content related to MIPS performance categories, this would help educate clinicians regarding the move toward pay for value initiatives and show a good-will effort on the part of CMS to ensure that providers are getting credit for relevant practice improvement education.
Rockpointe's comments can be found here:
Physicians have a professional responsibility to keep up-to-date through CME and there is a preexisting infrastructure to record participation in CME activities. Currently 45 states plus the District of Columbia require participation in CME to maintain licensure. CME is a familiar activity for physicians and giving CPIA credit for participation in CME will help to align the interests of physicians with the value being driven by alternative payment models.
The mechanisms already in place ensure that accredited/certified CME activities are designed to address clinicians' practice-relevant learning needs and practice gaps. The programs are also measured to evaluate the educational and clinical impact of the activity. Finally, they are planned and provided independent from commercial influence or other biases.
There are two ways in which CME should be recognized as a CPIA. First, if that activity teaches the principles of MACRA, APM's and Quality Improvement. Second should be CME that shows outcomes that improve quality.
If MACRA is to succeed, it will require significant buy in from clinicians. By recognizing CME as a CPIA for learning about MACRA and for implementing clinical practice improvement through CME, CMS will help to foster clinical improvement that clinicians understand.
Furthermore, the Society for Academic CME added:
SACME strongly urges CMS to leverage the existing CME infrastructure to help engage clinicians in activities that facilitate learning and quality improvement. Utilizing accredited CME to further physician awareness and compliance with best practices in clinical performance improvement serves to strategically align the educational efforts in a manner that further reinforces the key focus on patient outcomes. Reliance on CME to drive greater clinical practice improvement activity participation has the advantage of incorporating an existing reporting system that has been proven effective in addition to efficiently leveraging the nation's network of CME providers.
In closing, SACME specifically requests you include in your final ruling a role for CME accreditors to facilitate the engagement, attestation, and auditing of eligible clinician's participation in CPIAs that are consistent with the aims of the MACRA Quality Payment Program.
From state medical societies, the Washington State Medical Society wrote in:
Include additional activities We would like CMS to add accredited continuing medical education (CME) and board-certification related activities to the list of CPIAs.
The South Carolina Medical Association:
In accordance with the ACCME, the SCMA believes that in order to achieve the promise of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), clinicians should receive credit for participating in accredited CME activities that are designed to further the objectives of MACRA as clinical practice improvement activities. Utilizing accredited CME to further physician awareness and compliance with best practices represents an efficient use of our nation's network of CME providers.
Ultimately, this will help to:
- Create awareness amongst our clinician community about MIPS and MACRA.
- Teach the fundamentals of meaningful performance improvement.
- Use data to help clinicians choose an improvement target and approach.
- Develop activities that support the clinician through their change process.
- Identify and navigate local implementation barriers and solutions.
- Help the clinician measure the impact of their change.
- Report the results through ACCME's Program and Activity Reporting System (PARS).
The Medical Society of New Jersey:
CMS Should Recognize ACCME Accredited Activities as Clinical Practice Improvement Activities under MIPS The CME community in New Jersey is passionate about leveraging education to improve and maintain the performance of our clinicians, healthcare teams, and institutions. Our accredited providers already accredit many activities that have been demonstrated to achieve meaningful change in the quality of healthcare being delivered here.
We are requesting that CMS explicitly recognize CME activities provided by an accredited provider in the ACCME System as Clinical Practice Improvement Activities within the Merit-Based Incentive Payment System (MIPS). CME has long been recognized as an effective means by which physicians can pursue their continued professional development. CME encourages physicians to develop and maintain the knowledge, skills, and performance that lead to optimal patient outcomes. In order to realize the promise of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), clinicians should receive credit for participating in accredited CME activities that are designed to further the objectives of MACRA as Clinical Practice Improvement Activities. Utilizing accredited CME to further physician awareness and compliance with best practices represents an efficient use of our nation's network of CME providers.
These professionals are able to:
· Create awareness amongst our clinician community about MIPS and MACRA;
· Teach the fundamentals of meaningful performance improvement;
· Use data to help clinicians choose an improvement target and approach;
· Develop activities that support the clinician through their change process;
· Identify and navigate local implementation barriers and solutions;
· Help the clinician measure the impact of their change; and
· Report the results through ACCME's Program and Activity Reporting System (PARS).
Such a program would leverage existing systems to attain the goals of MACRA. CME professionals are familiar with PARS – they are already routinely registering data in the system. CME professionals can reliably and accurately report this type of information and ACCME has several data systems to ensure appropriate validation and data security. Having already been developed for the purpose of tracking learner participation at accredited CME activities, PARS can be enhanced and integrated into the CMS MIPS reporting system so as to ensure accurate and consistent reporting.
Accredited CME has a mechanism to help clinicians achieve even better patient outcomes, and ultimately improve the health of the nation. MSNJ urges CMS to recognize ACCME accredited activities as Clinical Practice Improvement Activities under MIPS
The Pennsylvania Physician:
Finally, my physician takes his CME credits very seriously. He should receive credit for participating in CME credits to help him meet the requirements for the Clinical Practice Improvement Activities. Accredited CME through a professional organization leads to optimal patient outcomes and compliance with best practices. Patients deserve a physician who is committed to lifelong learning and assessment, so it is important that these activities be recognized and rewarded by CMS.
The California Academy of Family Physicians:
CAFP encourages CMS to include accredited Continuing Medical Education (CME) activities, as defined by the ACCME, AAFP, AMA, AOA, AAPA or other nationally recognized credit systems with formally defined CME, in the CPIA category. Because CME has the ability to make a measurable difference in the way physicians practice, accredited CME activities that are designed to further the objectives of MACRA, support "The Triple Aim" and the National Quality Strategy should result in credit as CPIA activities. Accredited CME can be tracked, via the ACCME, AAFP and AOA systems. The 90-day Compliance rule may also be met with accredited CME activities that incorporate a 90-day survey or evaluation period into programming. Explicit CPIA credit could be awarded for defined CME activities in two of the CMS designed CPIA areas: Accredited CME activities that involve assessment in improvement of patient outcomes or care quality, as demonstrated by clinical data or patient experience, such as PI or QI CME, and Accredited CME that teaches the principles of QI and basic tenets of MACRA implementation, including The Triple Aim and NQS.
Other comments of note:
American Urological Society
American Urogynecologic Society
American Academy of Allergy Asthma and Immunology
Society of Nuclear Medicine and Molecular Imaging
Society of Vascular Surgery
American Society of Nephrology
American Association of Neurological Surgeons
American Society of Plastic Surgery
American Society of Anesthesiologists
American Gastroenterological Association
American College of Gastroenterology
National Kidney Foundation
International Society for the Advancement of Spine Surgery
American Medical Informatics Association
Infectious Disease Society of America
American College of Mohs Surgery
American Association of Neuromuscular& Electrodiagnostic Medicine
Society for Cardiovascular Magnetic Resonance