On April 27, 2016 the Centers for Medicare and Medicaid Services (CMS) published proposed rules for implementation of the Medicare Access and CHIP Reauthorization Act (MACRA). In addition to defining a new value-based reimbursement model, the proposal also refocuses health IT on clinician friendly technology and increased patient engagement and interoperability. MACRA drives a continuing restructuring of the American health care system and a new generation of technology to support it. In a prior post, I described the potential risks MACRA poses to both doctors and patients. The MACRA comment period ended on June 27, 2016. CMS received more than 3,700 comments, some running to more than 100 pages. After review, CMS is scheduled to publish the final rules on October 1, 2016 with implementation beginning in January, 2017. While feedback was wide-ranging and not unexpectedly stakeholder-specific, there are at least 5 clear, consensus messages to CMS:
- Delay implementation - at least until July 1, 2017
- Quality measures need to be fair to both specialists and primary care doctors, practicing in or out of the hospital.
- The Advancing Care Information (ACI) portion of the Merit-based Incentive Payment System (MIPS) needs to significantly revamped.
- Small groups or solo practitioners need special consideration for an even playing field with larger organizations.
- The Advanced Alternative Payment Models (APMs) need to be broadened to include other programs.
MACRA: A brief review
To recap, the MACRA rules published in April outline 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. 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%)
Collection of performance data begins in January, 2017. That data will be used to calculate MIPS scores which will determine whether a physician's reimbursement is adjusted positively or negatively by up to 4% beginning in 2019, increasing to 9% by 2022. There will be winners and losers.
Under the proposed MACRA rules, the federal government's EMR - incentive program, "meaningful use" (MU) will be significantly revised and re-emerge in MIPS as "Advancing Care Information (ACI)" 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
Unlike MU, ACI performance metrics would offer greater flexibility in reporting. The program would encourage physicians to choose performance metrics that better reflect the use of technology in daily practice to improve patient outcomes. The American Medical Association and 36 medical specialty societies including the American College of Physicians, the American College of Surgeons, and the American Academy of Family Physicians have already weighed in to CMS urging the adoption of new benchmarks for interoperability focusing on clinical value to patients rather than just the quantity of information exchanged.
MACRA: next stepsAs CMS sifts through the thousands of pages of comments over the next few months, I think it's likely the next steps in moving ahead with implementation of the law will become clear.
- Delay Implementation
This is a no-brainer. The clear message from multiple organizations including the AMA, American College of Physicians (ACP), American Academy of Family Physicians (AAFP), American Academy of Orthopedic Surgeons (AAOS) and the American Medical Group Association (AMGA) is January 1, 2017 is not a fair or realistic start date for the program. If final rules aren't published until October, physicians and medical groups would have only 3 months to develop quality plans and select metrics, ensure EMR functionality and reporting capability, and select clinical improvement projects. The AMA has suggested a transition year (2017) to allow physicians to get ready without penalty. Other feedback suggests delaying until 2018.
2. Define clinically relevant quality metrics fair to all physicians
Primary care providers are particularly emphatic that parity among all physician groups - specialists and generalists alike - in reporting quality metrics under MIPS is critical. The "devil is in the details" in selecting reportable measures relevant to patient-centered outcomes while not adding to the documentation burden.
3. Redefine ACI based on patient centered metrics
While the proposed rules describe laudable goals of interoperability, flexibility and user-friendly technology, the proposed rules fall short of achieving these objectives. The AAFP suggested an entirely "new construct" for the ACI component of MIPS is required. The AAOS noted that interoperability and infrastructure remain significant barriers to even reporting required performance measures. As noted in my earlier post, the AMA and multiple societies have already expressed concerns about this element of MIPS. The opportunity for innovative health IT is huge. Back to the drawing board.
4. Provide accomodations that protect solo practitioners and small groups
Many solo physicians and smaller group practices are concerned they will get the short end of the reimbursement stick as they are less likely to have the robust data reporting capability of larger groups. CMS itself projects 87% of solo practices will face negative adjustments of reimbursement in 2019 totaling 300 million dollars. The AAFP notes that more than 50% of family physicians currently practice is solo or small group settings. CMS has already tried to address these concerns by providing $100 million in technical assistance to physician groups with 15 or fewer clinicians. AAFP encouraged CMS to continue to pursue the concept of "virtual groups" in which solo or small groups of physicians aggregate their data. This model could remove biases due to reporting on smaller numbers of medicare patients than larger groups. Failure to provide a "safe harbor" for these physicians could lead some physicians to opt out of medicare or even pursue early retirement just as demand for care is increasing.
5. Expand eligibility for APMs
The rules limit APM participation to a select few models, including:
Comprehensive End Stage Renal Disease Care Model (Large Dialysis Organization arrangement)
Comprehensive Primary Care Plus
Medicare Shared Savings Program – Track 2
Medicare Shared Savings Program – Track 3
Next Generation ACO Model
Oncology Care Model (Two-Sided Risk Arrangement) (available in 2018)
It's not clear why participation in other similar existing programs such as Patient Centered Model Homes (PCMH) or bundled pilots such as the Comprehensive Care for Joint Replacement (CCJR) or Bundled Payments for Care Improvement ( BPCI) weren't included. These CMS-sanctioned pilots were designed to drive the transition from fee-based reimbursement to value based care. Restricting the number of clinicians in the APM reimbursement model doesn't make sense.
It's likely that CMS will find many other appropriate suggestions for revising the rules in the thousands of pages of comment. These consensus 5 steps represent more than simply fine-tuning the initial proposal. In some cases, particularly ACI, they require major revision and re-definition. The law will transform health care in the U.S. and impact the care of our patients. We need to take the time to get it right.