WASHINGTON, D.C.—On April 27, 2016, the Centers for Medicare and Medicaid Services (CMS) took a historic step when it released a proposed rule that would implement value and quality-based provisions of a new Medicare health reform law beginning in January 2017.
The Obama administration had already announced that it wanted 30 percent of Medicare payments to be value-based by 2016, and 50 percent of payments to be tied to quality or value by 2018.
For more than 10 years, the controversial Sustainable Growth Rate (SGR) mechanism for paying physicians under Medicare drew criticism for creating instability and leading to last-ditch Congressional action to avoid deep cuts in reimbursement. On April 16, 2015, President Obama repealed the SGR and signed its replacement, the Medicare Access and CHIP Reauthorization Act (MACRA).
A key goal of the 900-page MACRA is to reimburse physicians equitably for treating Medicare patients while promoting efficient, effective, high-quality care that uses medical resources wisely, said speakers at a news briefing on Capitol Hill sponsored by the Alliance for Health Reform with support from the Commonwealth Fund.
Physicians can choose one of two payment paths based on performance and quality measures: the Merit Based Alternative Payment System (MIPS) or an alternative payment model such as an advanced Accountable Care Organization or patient-centered medical home.
Three existing CMS payment incentive and quality improvement programs, including meaningful use, will be folded into MIPS, which is envisioned as the dominant payment track. Practice performance during 2017 will dictate the Medicare payment impact in 2019.
At the news briefing, speakers noted that while clinicians have hailed repeal of the SGR as a significant victory, making the complicated MACRA quality incentive provisions work in clinical practice presents major challenges.
“This is a very hot topic for all of us,” said Elizabeth Mitchell, President and CEO of the Network for Regional Healthcare Improvement, Portland, Maine. “It is going to take all stakeholders” to implement MACRA successfully, she said, a process “requiring new relationships across communities...This is a major shift.” Mitchell predicted that MACRA could have even more of an impact on U.S. health care delivery than the Affordable Care Act.
“I think we're going to be living with MACRA for a long time,” she said, noting that the law is “clearly part of a much broader push towards value and quality.” One of the most significant aspects of the new law is that it is bipartisan, Mitchell noted; another key aspect is that it is budget neutral.
“We've done a lot of listening...to really meet physicians where they are,” said Kate Goodrich, MD, MHS, Director of CMS's Center for Clinical Standards and Quality. “I don't want to minimize that this is going to be difficult for individual doctors and small practices. It's a big law, it's a big rule.”
However, she noted, “We've got to be paying for what works...we can't waste our precious dollars.” Additionally, Goodrich explained that MACRA has allotted $100 million over 5 years for technical assistance to small and rural practices, aid which will be tailored to their needs.
According to Goodrich, CMS sees MACRA as “an important tool.” She noted that MIPS “provides clinicians the flexibility to choose the activities and measures that are most meaningful to their practice to demonstrate performance.” Goodrich conceded that MACRA is very complex in part because of the choices it gives physicians who treat Medicare patients. “What you sacrifice with a lot of flexibility is simplicity,” she said.
“We must be really vigilant as we implement this program,” cautioned Timothy Ferris, Senior Vice President for Population Health at Massachusetts General Hospital and Partners HealthCare, and leader of the Partners HealthCare Pioneer Accountable Care Organization. He warned that while MACRA is a big advance forward, “it will have unintended consequences.”
Ferris also warned that the pace of MACRA implementation could be difficult: “It's about speed...all of us can only tolerate so much speed so quickly.” Put bluntly, will clinicians be ready for MACRA this January?
Ferris noted that “MACRA does something very clever,” which is to allow practices to propose what value is in order to qualify for an alternative payment model (APM), thus putting the metrics in the hands of physicians. He added that MACRA has provisions that will impose downside risk, and that some physicians in APMs will lose money by taking on too much downside risk.
On the positive side, Ferris said that under MACRA “small incentives can go a long way” if the quality and value metrics used align with what physicians think is the right thing to do for patients.
The quality of health care in the U.S. is “unacceptably variable,” and MACRA has the power to ameliorate that variability, according to Ferris.
“If we can do that systematically, we will improve the health of Americans,” he noted. Additionally, Ferris explained that in order for MACRA implementation provisions to be well received by the medical community, “the time frame from performance to reward needs to be as short as possible.”
Since hospitals employ and contract with many physicians, “physicians and hospitals must partner in moving to value-based care,” said Ashley Thompson, MHA, Senior Vice President of Public Policy Analysis & Development for the American Hospital Association (AHA). She noted that MACRA, which the AHA supported, could result in more employed physicians, could lead to physician retirements, and could pressure physicians to participate in risk-bearing arrangements.
Thompson advised that CMS should “adopt a system that is fair, focused on important issues and sustainable,” and that it should be “as inclusive as possible in defining APMs.”
Impact of Politics
When asked by Oncology Times and others at the briefing whether the coming election of a new U.S. president is likely to affect MACRA, Ferris said, “The problems that MACRA is intended to address are fundamental and have nothing to do with politics.”
“This is one of the highest priorities for CMS,” Goodrich emphasized. “It is hard for me to think that will change. There could be legislative tweaks; I would anticipate that.”
Thompson noted, “I think they're not going to roll back MACRA.” Mitchell agreed, “We have to change the system. These are really pragmatic issues.”
ASCO on MACRA
In a letter to CMS Acting Administrator, Andrew M. Slavitt, written in cooperation with other health organizations including the American Medical Association, ASCO stated that it is concerned that MACRA implementation “does not disrupt the positive effect APMs are having on beneficiaries' health in both the public and private sectors.”
ASCO also noted “there should a clear, non-burdensome pathway for private sector models to meet the threshold for qualifying APMs under MACRA.”
“CMS should ensure that virtual groups in MIPS are defined in such a way that helps small, independent practices remain viable (as independent practices) and supports the potential impact that virtual groups can have to improve patient care,” the letter stated.
Finally, ASCO said that “physicians should have ample opportunity to receive credit for existing clinical quality improvement activities in the MIPS track.”
ASCO and its collaborating groups summed up their conclusion in their letter to CMS by stating that since “the rollout of MIPS begins in less than a year, maximum flexibility and timely, clear guidance is imperative to ensure a smooth transition for all stakeholders.”
Peggy Eastman is a contributing writer.