- Reimbursement based on value, not volume
- IT/EMR focused on real clinical performance not process
- Integrated group practice models not solo providers
The proposal seeks to "streamline" a patchwork of programs into two paths for value based reimbursement, aligning medicare payments with cost and quality of patient care. The law is complex - 962 pages! - and will affect more than 800,000 eligible physicians. The newly proposed rules are intended to address physician concerns about excessively burdensome reporting of quality measures as well as EHR "meaningful use" process metrics of doubtful relevance to patient outcome. While subject to modification and open for comments until June 26, 2016, implementation in 2017 will drive change throughout the health care system beyond simply how caregivers are paid. From accelerating the demise of solo or small group practices to refocusing health IT/EMR on clinician-friendly technology that supports increased patient engagement and caregiver communication the proposal reshapes how health care is delivered in the next decade and beyond. Though many details need to be filled in here's what we know at this point.
The Quality Payment Program: 2 paths to reimbursement
The proposal outlines two reimbursement models for physicians caring for medicare patients:
- Merit-based Incentive Payment System (MIPS)
- Advanced Alternative Payment Models (APMs)
Almost 90% of eligible physicians will likely participate in the MIPS model. Fewer clinicians are involved in alternative payment models which include Accountable Care Organizations (ACOs), the Comprehensive Primary Care Initiative, Patient Centered Medical Home, and newer bundled payment models such as the Comprehensive Center for Joint Replacement CCJR). MIPS applies only to physician office practices unlike some APMs which bundle services provided in acute and post acute hospital and rehabilitation settings.
MIPS scores physicians in 4 categories, weighted as shown in parentheses:
- Quality (50%)
- Advancing Care Information (25%)
- Clinical Practice Improvement Activities (15%)
- Cost (10%)
Meaningful Use (MU) morphs into Advancing Care Information (ACI)
A significant component of the MACRA/MIPS proposal focuses on health IT, specifically the electronic medical record (EMR). In MIPS, the focus is on rewarding providers for using technology to improve patient care, rather than just on using technology. The federal government's EHR - incentive program, "meaningful use" will be significantly revised and re-emerge in MIPS as "advancing care information" beginning in 2017. MU is credited with incentivizing EHR adoption by more than 80% of physicians but widely criticized for focusing heavily on process rather than patient outcomes. The CMS announcement listed three priorities for ACI:
- improved interoperability to facilitate health information exchange
- increased flexibility
- user-friendly technology
Solo and small practices at risk
Initial reaction to the CMS proposal has been mixed. AMA president Dr. Steven Slack commented that the document made "significant improvements by recasting the EHR meaningful use program and by reducing quality reporting burdens." However, many solo and small practice physicians are concerned about the significant negative financial impact forecast for their independent practices. CMS itself projects 87% of solo practices face negative adjustments in reimbursement in 2019 totaling $300 million dollars. Almost 70% of small practices (2-9 physicians) would have negative payment adjustments as well totally $279 million. Since 2008, the number of physicians describing themselves as independent practice owners has declined from 62% to 35%. It's not surprising that many of these physicians feel the program threatens the already shrinking private practice model of health care and really represents a thinly-veiled attempt to reshape the structure of the US health care system at their expense. Smaller practices lack the resources of larger health care systems to meet reporting and technology requirements. It's likely that at least some of these physicians will retire earlier than planned or may opt out of medicare, pursuing concierge-style medical practice. The potential impact on access to health care in rural and under served areas is unknown but would likely be significant.
MACRA/MIPS is about much more than reimbursement. The program drives a continuing restructuring of the American health care system and a new generation of technology to support it. The impact on physicians and patients will be huge.