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Making the Next Move in MACRA

September 13, 2016
by Rajiv Leventhal
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Health IT experts discuss: Which MACRA pathway is best for providers in 2017? And what could they be doing to get ready for Jan.1, 2017?

When the Centers for Medicare & Medicaid Services (CMS) announced on Sept. 8 that it will allow eligible Medicare physicians to pick their pace of participation for the first performance period of Medicare Access and CHIP Reauthorization Act (MACRA) that begins Jan. 1, 2017, the initial industry reaction seemed to be a collective sigh of long-awaited relief.

After all, ever since the MACRA proposed rule, which is set to overhaul physician payment as the healthcare industry shifts to paying doctors for value rather than volume, was released in April, many doctors were wondering how they would be able to learn all of the regulations and be able to comply with just a few months’ time to prepare. And, smaller physician practices were even more concerned; a Black Book survey from June revealed that two-thirds of high Medicare-volume small practices said they foresee the end of their independence due to the physician payment changes that will take place under MACRA.

But then came the program flexibility news last week, delivered via a blog post on CMS’ website by the agency’s Acting Administrator, Andy Slavitt. Slavitt, while previously leaving the door open for a delay to the outcomes-based program, implied in his blog that the Jan. 1 reporting period start date (which would affect payment adjustments for eligible doctors in 2019) would stay intact, but that other flexibilities would be granted. Although no final rule on MACRA has been published to date, with most healthcare policy experts targeting sometime this fall as when it will come, Slavitt said participating providers will have four pathways to choose from for the first year of MACRA in 2017. These pathways range from sending in only some data to MACRA’s Quality Payment Program, which includes two paths—the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs); to sending in more data but for a reduced period of time; to “going all in” as is. The idea, CMS said, is to allow doctors to choose their pace for easing into a brand new physician payment program full of complexities, while at the same time avoiding negative payment adjustments in 2019.

In an in-depth analysis of the CMS announcement from last week, Healthcare Informatics Editor-in-Chief Mark Hagland cited multiple healthcare association groups, who at the very least, were appreciative of the government’s efforts to ease the burden on Medicare doctors. But what are providers on the ground saying? John David Goodson, M.D., staff internist at Massachusetts General Hospital (MGH) and associate professor at Harvard Medical School, for one, says that CMS’ message was a strategic move to get doctors to be involved in reporting their data starting next year. Goodson notes how the Physician Quality Reporting System, or PQRS, has been around for a long time, “but many doctors decided to take the financial hit rather than comply with it.” He says that the reporting required in MACRA’s Quality Payment Program will require good, solid data which CMS will never get unless they get doctors to buy into the reporting mechanisms. As such, the pathways laid out by the federal agency are attempts to at the least, get the community of providers engaged at a minor level, Goodson says.

Goodson adds that much of MACRA is baked into Congressional law, and the government is ready to move forward with physician payment adjustments based on quality beginning in 2019. As such, “Congress doesn’t have an appetite for readdressing this program,” Goodson attests. “They want to see this played out, as value-based payment has become so universally accepted,” he says. He adds that at some point, doctors will have to make the choice between staying in Medicare or getting out. “There is a fear that this whole system will implode because doctors won’t want to play this game anymore.  They think it’s too demanding and crazy.” However, Goodson believes that in the end, most providers want to partake in Medicare, and the key will be to be able to obtain the meaningful data that these programs under MACRA will inevitably require.

Weighing the Options

Meanwhile, on the policy front, Mari Savickis, vice president of federal affairs at the Ann Arbor, Mich-based College of Healthcare Information Management Executives (CHIME), is pleased with the flexibilities announced by CMS, noting that it shows that the agency is “listening and reacting” to provider concerns. “Anything that points in the direction of increased flexibility for providers so that they would avoid financial penalties is a good thing from our perspective,” says Savickis.

Savickis herself won’t rule out a delay to the start of the program still, as last week’s news came in the form of a blog post rather than an official final rule. “We appreciate that they want to make sure the program is a success, but you have to operate within the parameters of reality, she says. “Finalizing a rule so close to the end of the calendar rule makes it incredibly hard for vendors and providers to meet a full year of reporting.”