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With CMS’s MACRA Announcement, the High-Speed Train Has Already Left the Station for Practicing MDs

September 9, 2016
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CMS’s announcement about the Jan. 1 transition to the new MACRA payment environment has set into motion a series of important developments

As HCI Managing Editor Rajiv Leventhal reported on Thursday afternoon, Andy Slavitt, Acting Administrator of the federal Centers for Medicare & Medicaid Services (CMS), announced yesterday that, on the one hand, there will be no delay in the January 1, 2017 start date for the implementation of the provisions of the Medicare Access and CHIP Reauthorization Act (MACRA); but that, at the same time, CMS was providing physicians in practice with a range of options for complying with MACRA’s provisions.

In the announcement, in the form of a blog on the agency’s website, Slavitt wrote that, during 2017, “eligible physicians and other clinicians will have multiple options for participation. Choosing one of these options would ensure you do not receive a negative payment adjustment in 2019. These options and other supporting details will be described fully in the final rule.” Slavitt said the final rule will be published before November 1. This summer, Slavitt had himself left open the possibility that the sweeping changes set to overhaul physician payment as the healthcare industry shifts to paying doctors for value rather than volume, could be pushed back from the intended start date of Jan. 1.

But that was not to be. Now, instead, as Slavitt laid out for providers in his blogpost, Medicare-participating physicians in the U.S. will have four options:

Ø  The first option is to “test” the Quality Payment Program, which includes two paths—the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). Under this first option, as long as physicians “submit some data to the Quality Payment Program, including data from after Jan. 1, 2017,” they will avoid a negative payment adjustment.” The idea of this option is to ensure that systems are working and that providers are prepared for broader participation in 2018 and 2019 as knowledge is gained.


Ø  The second option is to choose to submit Quality Payment Program information for a reduced number of days. This means that the first performance period could begin later than Jan. 1, 2017 and the physician’s practice could still qualify for a small positive payment adjustment. Slavitt writes, “For example, if you submit information for part of the calendar year for quality measures, how your practice uses technology, and what improvement activities your practice is undertaking, you could qualify for a small positive payment adjustment. You could select from the list of quality measures and improvement activities available under the Quality Payment Program.”


Ø  The third option is to participate for the full calendar year in 2017. This choice is for practices that are ready to go. CMS said that it has “seen physician practices of all sizes successfully submit a full year’s quality data, and expect many will be ready to do so.”


Ø  The fourth option is to participate in an Advanced Alternative Payment Model in 2017. Examples of this include Medicare Shared Savings Track 2 or 3 in 2017. Slavitt writes, “If you receive enough of your Medicare payments or see enough of your Medicare patients through the Advanced Alternative Payment Model in 2017, then you would qualify for a 5 percent incentive payment in 2019.” It should be noted that most policy experts predict eligible physicians to initially pursue MIPS because an APM that qualifies under MACRA will bring with it a significant amount of risk.

So, what does all of this mean?

I would submit that this is a very careful “threading of the needle,” if you will, creating a workable compromise between on the one hand, maintaining rigor in the process of the shift to MACRA-driven changes in physician reimbursement, while on the other hand, giving physicians what most would considerable a reasonable amount of flexibility with which to comply. Many in the provider world will doubtless be shocked that CMS has pushed back hard in not extending the start date for all this activity into mid-2017, as many industry observers had predicted the agency would do.

But those who are most shocked should also consider how much is at stake, on a policy level, in delaying the start of all this much longer, particularly at a time of political uncertainty on Capitol Hill. With Medicare’s actuaries predicting a snowballing of U.S. healthcare spending over the next decade, it would be hard to deny on the broadest policy level the idea that MACRA needs to move forward quickly. As I noted in a blog in July, following the release that month of the Medicare actuaries’ total U.S. healthcare spending projections, the U.S. healthcare system is set to go over a truly enormous cost cliff, with total spending expected to go from $3.3013 trillion, and 17.5 percent of our country’s gross domestic product, in 2014, to $5.631 trillion, and fully 20.1 percent of our GDP, by 2025; in other words, a nearly 70-percent total increase in U.S. healthcare spending across just over a decade. And as I wrote in July, anyone who isn’t astonished by the $5.631 trillion number simply isn’t fully awake.

Keep in mind also that the Medicare actuaries’ projections were released on July 18, and this announcement has come out on September 8; in the context of the pace at which the cogs of federal government agencies’ wheels turn, yesterday’s announcement has come lightning-fast. As in, as relatively quickly as an Olympic runner moves.