CMS, Practice Management, Chief Medical Officer at the CMS Dallas office, Dr. David Nilasena
Exclusive interview with Dr. David Nilasena - Chief Medical Officer at the CMS Dallas office
September 08, 2017
Dr. David Nilasena, MSPH, MS, Chief Medical Officer, Region IV, Centers for
Medicare and Medicaid recently spoke at the Practice Management Institute’s
national conference in Dallas, TX, and took some time to respond to some questions
about MIPS and APMs, MACRA, the Affordable Care Act (ACA), CMS, and much more.
Photo: David Womack (L), President and CEO of Practice Management Institute
and Dr. David Nilasena (R), MSPH, MS, at the PMI National Conference in Dallas,
BC Advantage (BCA): What is your primary role as Chief Medical Officer
at the CMS Dallas office?
Dr. David Nilasena (DN): Probably the most important thing that I do
is to serve as a liaison and point of contact for the clinicians and providers
in our five state region for a variety of CMS programs. This includes giving
educational presentations and helping to address questions and issues that arise
in the field. I also am a clinical and technical resource for the CMS staff
in our office.
BCA: Your industry experience is very impressive by anyone's standards.
Can you just tell us a little about yourself and the roles you have held throughout
your career and how they have helped you in your current position?
DN: I began my career at CMS in 1995 after completing my training in
General Preventive Medicine/Public Health and Medical Informatics. Initially,
I worked with Peer Review Organizations (PROs, now known as Quality Improvement
Organizations or QIOs) as they were beginning to move into their quality improvement
work with local providers. I was a national lead for their projects related
to patients with AMI, Heart Failure, and Stroke. I have been very involved in
outreach related to many of our quality reporting programs as well as for the
EHR Incentive Programs and the Health Insurance Marketplace. Recently, my time
has been very much occupied with the development and rollout of the Quality
BCA: Not many people understand that CMS and the HHS are not agencies
that set laws. Can you explain to BC Advantage readers how and when new laws
like QPP are implemented?
DN: You're right. Many people think that CMS comes up with new programs
all on our own, but this is not the case. Using the Quality Payment Program
as an example, this program was authorized under the Medicare and CHIP Reauthorization
Act of 2015. Pretty much everything we do at CMS has some basis in statute,
so Congress tells us at some level what we are required to do and gives us the
authority to carry out the law as part of the Executive Branch. In the case
of MACRA, there were quite a few specific requirements in terms of the timeline
for implementation, the structure of the program, special considerations that
had to be made, and the size of the payment adjustments. In administering the
program, we use the formal rulemaking process where we propose the program requirements
in regulation, solicit and respond to public comments, and then finalize the
program rules based on those comments. For the Quality Payment Program, we have
been very engaged with the clinical community both before the proposed rule
and on an ongoing basis to get feedback about the best way to implement the
program. So really Congress and the public are key to the way these programs
are designed and implemented.
BCA: Does "repeal and replace" of the Affordable Care Act
(ACA) have any impact of the QPP roll-out?
DN: As I mentioned, the Quality Payment Program was authorized under
MACRA, which is a separate piece of legislation that was passed after the ACA.
MACRA enjoyed strong bipartisan support during its passage, so we have no reason
to believe that it will be impacted by the current activities related to the
BCA: What key factors should be addressed when choosing between MIPS
DN: In the first year of the Quality Payment Program, we anticipate
that the majority of eligible clinicians will be participating under MIPS. Probably
the most important factor in determining whether a clinician should be in an
Advanced APM is if the APM already exists and if the clinician is already participating
in 2017. While it is possible to join an existing APM mid-year, the opportunities
to create new APM entities are restricted by each model and may not be possible
until 2018. If an APM is available to a clinician, they will need to look at
the specific APM model requirements and see if their current practice is prepared
to meet the specific requirements, so they can be successful both in the APM
and in the Quality Payment Program. We have several types of technical assistance
that are available to clinicians to assist with moving towards APM participation.
Go to QPP.CMS.GOV to learn more about technical assistance available.
BCA: Of the four MIPS performance categories-Quality, Cost, Improvement
Activities, and Advancing Care Information, are all categories given the same
weight within the calculation or do they all have different percentages?
DN: The contribution of each category toward the MIPS Final Score is
determined by the category weight. These are established to some extent in the
MACRA law, but the Secretary has some discretion in the first two years of the
program to modify these. For the Transition Year (2017), we have set the category
weights at 60% for Quality, 0% for Cost, 15% for Improvement Activities, and
25% for Advancing Care Information. We have recently proposed to keep those
weights the same for Year 2 (2018).
BCA: What is the deadline for submitting data?
DN: In general, the MIPS measures and activities for the 2017 performance
year need to be submitted to CMS by the end of the submission deadline, which
is March 31, 2018. For claims-based quality measures, the data is submitted
throughout the year on Medicare claims. The submission of quality data using
the CMS Web Interface for MIPS and the CAHPS for MIPS survey are a little different
but still occur in the first quarter of 2018.
BCA: During your keynote presentation for Practice Management Institute's
Dallas Conference, you share information on the structure, eligibility,
participation, performance categories, and scoring of the merit-based incentive
payment system. What kinds of questions from the attendees did you address during
or after your presentation and the answers provided?
DN: There were a number of questions related to the low-volume threshold,
which is one of the exclusions for MIPS participation. For 2017, individual
clinicians that have Medicare Part B allowed charges that do not exceed $30,000
OR have no more than 100 Medicare patients will not be required to participate.
Groups of clinicians under a single taxpayer ID number (TIN) can participate
if the group exceeds both of these threshold numbers. Excluded individuals or
groups may voluntarily participate in MIPS, but their Medicare payments will
not be affected in 2019-meaning they will not receive a negative or positive
payment adjustment. There were some questions about how MIPS affects Medicare
Advantage plans. Since these plans do not bill under the Part B Physician Fee
Schedule, those payments will not be affected by MIPS, and clinicians that practice
exclusively in Medicare Advantage plans do not need to participate in MIPS.
We have, however, proposed to include Medicare Advantage plans in the All-Payer
Combination Option beginning in the the third performance year of the program.
There were also some questions related to any registration requirements for
MIPS. With two exceptions, there is no need for eligible clinicians or groups
to register with CMS about how they plan to participate in MIPS. Those exceptions
are if they plan to use the CMS Web Interface for MIPS or the CAHPS for MIPS
survey data submission methods. Both of these require registration that occurs
between April 1 and June 30 of the performance year.
BCA: How are physician benchmarks determined (i.e. local/national standards/practice
size, etc.) for MACRA? What are the reporting methods?
DN: For the MIPS quality category, benchmarks are created for each
measure using historically reported data from clinicians and groups where the
submitted data meets the data completeness criteria of at least 50%, meets the
case minimum of at least 20 cases, and has a performance rate above 0%. This
data is used to define deciles of performance which are the basis of the benchmarks
used to assign points based on performance. Separate benchmarks are created
for different reporting mechanisms, and these include claims submission, qualified
registries, qualified clinical data registries (QCDRs), EHR data submission,
the CMS Web Interface for MIPS, and CAHPS for MIPS. We plan to use a similar
approach to define benchmarks for the cost category in the future.
BCA: How will this affect large multispecialty groups compared to rural
DN: We have a number of provisions in the requirements for the Quality
Payment Program that will make it easier for smaller practices to participate.
Some of these are flexibilities that will assist groups of all sizes. In the
Transition Year, we are allowing clinicians to begin participating at the time
and level at which they are ready under Pick Your Pace. This allows all participants
to avoid a negative payment adjustment in the first year. We also have an exclusion
for clinicians that fall below a low-volume threshold ($30,000 in Medicare Part
B payments OR 100 Medicare patients) that will affect many small practices.
We allow group reporting in all categories and this will help to reduce the
reporting burden. In the Improvement Activities category, small, rural, and
underserved practices have a reduced reporting requirement to still get the
maximum score. Finally, MACRA provides funding for special technical assistance
to small and rural practices. In our recently published proposed rule
for the second year of QPP, we have also made a number of proposals that would
provide additional help to small practices participating in QPP.
BCA: For those without any previous reporting experience, how can CMS
DN: CMS has a variety of technical assistance that is offered free
to clinicians to help them participate and be successful in the Quality Payment
Program. The best starting place is our Quality Payment Program website at https://qpp.cms.gov/
. This website has a wealth of information, resources, and tools to assist clinicians
in participating. On the site, there is a Technical Assistance Resource Guide
that covers several key, in-person options for help. There is special support
for small practices with 15 or fewer clinicians that has been funded under MACRA.
For larger practices, we have our network of Quality Innovation Networks-Quality
Improvement Organizations (QIN-QIOs). Practices interested in moving towards
APM participation can join the Transforming Clinical Practice Initiative (TCPI)
and work with one of the Practice Transformation Networks (PTNs). Those that
are already in an APM can get tailored support through the appropriate APM Learning
BCA: What tips on MIPS implementation could you share with medical office
coders and billing services?
DN: Coders should continue to provide the most accurate and complete
information that they can on the claims that are submitted. This will benefit
practices not only in getting the appropriate Medicare payment but also in the
way their performance will be assessed under MIPS. Codes are used for most of
the measures for the quality category. They are also used in calculating measures
in the cost category and for risk adjustment for measures such as the all-cause
hospital readmissions measure. Beginning in 2018, a new set of patient relationship
codes will be submitted on Medicare claims, and these may be used for attributing
measures to clinicians and groups. So as you can see, medical office coding
and billing staff are important to the overall success of clinicians under MIPS.
CMS also understands that the medical billers and coders, oftentimes, is the
team responsible for the data required for data submission. It's important to
note that doing nothing will result in a negative 4% payment adjustment for
clinicians. If clinicians are not ready to submit a full year's worth of the
data, there is flexibility, also known as "Pick your Pace," that allows
for minimal data submission and avoidance of a negative payment adjustment.
BCA: How will CMS use clinician performance under MIPS to determine
clinician payment adjustments?
DN: The payment adjustments under MIPS are determined by comparing
each eligible clinician's final score to a performance threshold. Those with
scores below the performance threshold will have a negative payment adjustment,
and those above the performance threshold will have a positive payment adjustment.
A score exactly equal to the performance threshold will result in a neutral
or 0% adjustment to Medicare Part B payments. For the Transition Year (2017),
the performance threshold has been set at 3 points. Clinicians with a score
below 3 (which for the first year will be a score of 0) will get a negative
4% payment adjustment. Those above 3 points will get a positive payment adjustment,
the size of which will increase with higher MIPS scores and the overall percentage
of which will be calculated to maintain budget neutrality. There is also an
additional payment adjustment that is available for exceptional performance.
BCA: CMS has set aside a pool of $500 million for the first six years
of the program, with the intent of providing rewards to exceptional performers
in the MIPS track. Is this taxpayer money and how is it divided?
DN: Under MACRA, clinicians whose MIPS score is above the additional
performance threshold will share incentive money (from the Medicare Trust Fund)
for exceptional performance that totals $500 million per year from 2019 through
2024. For the Transition Year (2017), we have set the additional performance
threshold at a MIPS Final Score of 70 points. Clinicians will get a minimum
of a 0.5% additional upward payment adjustment, and the size of that adjustment
will increase with higher MIPS scores. The maximum additional payment adjustment
is capped at 10%.
BCA: Under the ACI category reporting requirements, clinicians must
possess and use Certified EHR Technology. How is this verified?
DN: For the Advancing Care Information category under MIPS, we are
allowing MIPS eligible clinicians and groups to use technology certified to
either the 2014 Edition or the 2015 Edition or a combination of the two editions
to support their selection of objectives and measures for 2017. Available products
meeting these standards can be found on the Certified Health IT Product List
maintained by the Office of the National Coordinator at https://chpl.healthit.gov/
. During MIPS reporting for this category, clinicians may be asked to submit
their CMS EHR Certification Number to confirm that they are using an approved
BCA: CPC+ targets primary care practices with varying capabilities to
deliver comprehensive primary care. In order to participate, all CPC+ practices
must demonstrate multi-payer support, use Certified Electronic Health Record
(EHR) Technology, and have other capabilities. While not yet an option in Texas,
this is really a question for primary care practices in eligible states; in
your opinion, is it worth joining CPC+ and does that qualify as an Advanced
DN: Strengthening primary care is critical to promoting high quality,
patient-centered care, and reducing overall health care costs in the U.S. The
Comprehensive Primary Care Plus (CPC+) model is an advanced primary care medical
home model that rewards value and quality by offering an innovative payment
structure to support primary care practices to improve quality, access, and
efficiency. CMS believes that the Comprehensive Primary Care Plus model represents
the future of health care that we're striving toward. Earlier this year, we
announced the opportunity for practices to participate in four new regions in
CPC+ Round 2. For Performance Year 2017, practices participating in CPC+ are
considered to be part of an Advanced APM for the Quality Payment Program. Beginning
in Performance Year 2018, only practices participating in CPC+ with fewer than
50 eligible clinicians in their parent organization will be considered to be
part of an Advanced APM for the Quality Payment Program. We have proposed to
exempt the first cohort of the CPC+ model from this requirement, but all future
cohorts will be subject to it.