Sending Office: Honorable Suzan K. DelBene
Sent By:

        Request for Signature(s)

Supporting Organizations:

  • American Medical Group Association (AMGA)
  • National Association of ACOs
  • Americas Physician Groups
  • Premier Healthcare Alliance


Dear Colleague:

By passing the Medicare Access and CHIP Reauthorization Act (MACRA) in 2015, Congress revved up our health care system’s shift to value-based care, so that doctors and clinicians are reimbursed based on the quality of the care they provide to Medicare beneficiaries.
Unfortunately, the way CMS has implemented MACRA leaves nearly half of all providers out of MACRA, which means continuing the current fee-for-service system we have now. If we fail to make a meaningful shift toward value-based health care, we are missing a
critical opportunity to reduce costs for Medicare and improve care for patients.

Under MACRA, CMS is required to implement a quality incentive program, referred to as the Quality Payment Program, which rewards value and positive patient outcomes. Providers can either participate in the Merit-based Incentive Payment System (MIPS) or through
an Advanced Alternative Payment Model (APM) like certain Accountable Care Organizations. If a provider participates in an APM, they are exempt from MIPS.

Clinicians participating in MIPS are scored in four categories – Quality, Improvement Activities, Promoting Interoperability (electronic health records use), and Cost. Based on their performance, providers will receive an adjustment to their payments. Those
providers that perform well will receive a positive payment adjustment, ultimately resulting in higher reimbursements, compared to those with lower scores, who will be paid slightly less.

To protect small physician practices, CMS created a low-volume threshold for participation. To meet the current low-volume threshold and be excluded from participation in MIPS, providers must see no more than 200 Medicare beneficiaries or receive no more
than $90,000 in Medicare reimbursement annually. This threshold, along with other provisions, would exclude 58% of providers. Because 10-16% of providers are expected to participate in an APM, and are already excluded from MIPS, that means 42-48% are expected
to not participate in any form of value-based care model.  

With nearly half of all providers not participating in either MIPS or an APM, how can we expect a meaningful movement from fee-for-service to value-based care to occur? Medicare will keep paying more without the benefit of quality improvements for patients.

Join me in urging CMS to adjust the current low-volume threshold in order to shift more providers toward value-based care. Seniors depend on Medicare and we take seriously efforts to rein in costs and improve quality.

If you have questions or would like to join this letter, please contact Kyle Hill (, 202-225-6311) in my office.  



Suzan DelBene

Member of Congress




Dear Administrator Verma,


We are writing to you regarding the recently released proposed rule for the third year of the Quality Payment Program (QPP) in the Medicare Access and CHIP Reauthorization Act (MACRA). MACRA has been and continues to be, a bipartisan effort to shift Medicare
to a system based on the value of care provided by improving quality and lowering costs – a system that will ultimately benefit seniors who depend on Medicare.  We are concerned that the implementation of the Merit-Based Incentive Payment System (MIPS) fails
to make a meaningful effort toward that goal.

As you finalize the 2019 proposed rule, we urge CMS to adjust the low-volume threshold to bring more providers into MIPS for the 2019 performance year.  Currently, CMS projects that for the 2019 performance year, 58 percent of clinicians will be excluded
from MIPS. We understand that a portion of that number will not be participating in MIPS due to their participation in an Advanced Alternative Payment Model, but most of the exemptions stem from the low volume-threshold.  If CMS continues to exempt a high
number of eligible clinicians from participating in MIPS, this will diminish the payment adjustments for providers invested in value-based care.  These adjustments included in the law rightfully reward providers who have made the substantial investments in
the infrastructure needed to deliver care that achieves the quality and cost goals set out in MACRA. 

To incent reporting quality measures, use of electronic health records, and other care improvement activities, Congress created a mechanism that adjusts Medicare Part B payments based on performance measured against a threshold score. However, the program
is budget neutral and is based on the possibility of positive payment adjustments, coupled with the potential for negative payment adjustments, based on performance, and, importantly, meaningful participation in the program.  By excluding more than half of
providers from participation, CMS has profoundly weakened these payment incentives which are critical to the program’s success.

The contrast between the Part B payment adjustments authorized under MACRA and the payment adjustments to be implemented by CMS cannot be overstated. For example, high-performers are estimated to receive an aggregate payment adjustment in 2019 of 1.1 percent,
based on their performance in 2017.  However, a maximum 4 percent adjustment was authorized.  In 2020, for example, CMS is projecting a 1.5% payment adjustment for high-performers, compared to a potential 5 percent under the law.  This trend continues in 2021,
when a 7 percent adjustment is expected to be reduced to 2 percent for high performers. The pathway to value is an ambitious, necessary goal our health care system needs to achieve, however, it will never come to fruition if CMS fails to properly reward physicians
at the forefront of modernizing health care delivery.

It is worth noting that very little of the MIPS program is new. In fact, MIPS is a continuation of CMS programs that have been in existence for years, specifically the Physician Quality Reporting System (PQRS), the Value-Based Payment Modifier, and the Meaningful
Use program.  While these programs were not without flaws, none of them had mechanisms to exclude providers from participation. We appreciate that CMS moved cautiously to implement MIPS and strived to ensure providers had every opportunity to succeed under
this reformed payment system but we must keep in mind that MACRA was ultimately passed for the benefit of patients.

CMS can correct this problem by more appropriately setting low-volume thresholds to ensure there is significant and meaningful participation in MIPS. As we stated MACRA was approved in a bipartisan manner and we want to ensure this law is implemented in
a way that benefits seniors – as Congress intended.  Seniors deserve a system that encourages and rewards value-based care. We urge CMS to keep those seniors in mind as MACRA implementation advances.


Related Legislative Issues

Selected legislative information:HealthCare

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