In a press conference on the morning of Oct. 14, senior officials at the federal Centers for Medicare and Medicaid Services (CMS) discussed the details of the new final rule that the agency had just released on its website, for the finalized and highly anticipated finale rule for the provisions of the new Quality Payment Program under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Final Rule, which has been finalized by the Department of Health & Human Services (HHS). The MACRA legislation, passed in the spring of 2015, replaced the provisions of the Sustainable Growth Rate (SGR) formula for physician payment under Medicare that had been prevailing for years.
(For an analysis of some of the provisions of the final rule, please turn to this article by Healthcare Informatics Senior Contributing Editor David Raths.)
Three senior federal healthcare officials spoke at the telephonic press conference. First to speak was Kristie Canegallo, White House Deputy Chief of Staff for Implementation in the Obama administration. “I want to talk briefly about the President’s enthusiasm for the work represented in the final MACRA rule,” Canegallo said. “Today’s announcement is an important step in this Administration’s commitment to improving quality, affordability and accessibility of US healthcare system. Most of you know that this Administration has worked aggressively to move our healthcare system to one that provides better patient care, spends taxpayer dollars in a smarter way and ultimately leads to healthier individuals, healthier communities and a healthier nation.” Referencing a speech given on Thursday by President Barack Obama, she said, “As you may have heard him talk about just yesterday when we were in Pittsburgh at the Frontiers conference, [the President] spoke about the imperative of incentivizing our healthcare system to look holistically at patients and moving that system to one that provides the right incentives to doctors to think this way.”
Canegallo went on to note that, “Thanks to the incentives in the ACA, hospital-acquired conditions have fallen 17 percent since 2010, saving 87,000 lives and $20 billion in healthcare costs. Over 75 percent of physicians and 95 percent of hospitals have adopted and are using electronic health records. And, 30 percent of Medicare payments are in alternative payment arrangements.”
After Canegallo had concluded her comments, CMS Acting Administrator Andy Slavitt then spoke at length about the philosophy and strategy behind the development of the final rule, saying that “This is a landmark effort to move the healthcare system forward. The Medicare program not only serves 55 million people and works with the vast majority of the nation’s clinicians, but it’s also a promise to the millions of taxpayers, including the 10,000 people who turn 65 every day, to be here when we need it. So transforming something of this size is something that we focused on with great care,” he said.
Slavitt continued, saying that “The policy we’ve finalized is the result of a user-driven policy effort, where our staff put down our pens and went into the field to hear from physicians and patients. Overall, many of us traveled the country and received more than 4,000 comments on our proposed rule, and nearly 100,000 people attended our outreach sessions. This was a good opportunity for us to understand the realities of practices today and what we can do to best support care for their patients, how Medicare and other payers interact with their daily practice, how much time they spend on reporting requirements and how burden takes time away from the practice of medicine.”
Highlighting what he considers to be key elements of the final rule, Slavitt said, “First of all, physicians will be able to pick their own pace of beginning to participate in the program and decide how to gradually increase their involvement in the first several years. We will continue to take comment on the rule so that we can make sure that the program evolves as the healthcare system evolves. Second, we’re offering choices to allow physicians to tailor many elements of the program for their specialty and even their practice.”
In fact, he noted, “Based on significant feedback on how physicians want to interact with the program, we’ve launched today a new one-stop shop portal and service center. The portal, which is at qpp.cms.gov, is designed side by side with physicians and with CMS and the great technology team at U.S. Digital Services, the same team that worked on the relaunch of healthcare.gov. We heard critical feedback to make it easier for physicians to join advanced payment models [APMs], which are locally formed, physician-led approaches to care delivery, like medical homes and bundled payments that pay a 5 percent bonus under MACRA. So, the CMS Innovation Center undertook a number of steps.”
Among other elements, Slavitt noted, “We’re announcing today that we will be adding a significant new option in 2018 that will appeal to smaller practices, called ACO Track 1. It will have lower levels of risk to qualify as an advanced payment model. We’re now in the middle of reviewing and opening other popular models in the CMS Innovation Center to be announced shortly. The Innovation Center is also developing opportunities for specialists to participate in advanced APMs. As already announced, we are opening up episode-based models in cardiology and orthopedics to count as advanced APMs, in addition to the oncology and nephrology models that the Innovation Center has already developed.”
In that context, Slavitt said, “In 2018, we expect approximately 20 percent of physicians to participate in an advanced APM and expect that to be on a significant growth trajectory. The Innovation Center and the ability that it has to move quickly and expand models we make advanced APMs available to most interested physicians over the next several years.”
What’s more, Slavitt said, “We’ve also received feedback to simplify how the scorekeeping, the rules, and the reporting work in what is known as the MIPS program, which is the program that will determine bonus payments in the core Medicare program, so that physicians can focus on patient care, not paperwork. We’ve made major steps, which will continue over the coming year, by cutting the number of measures in half, and simplifying how the program works.” In addition, he said, “We announced a major permanent effort yesterday to reduce physician burden. And, in 2017, we estimate that we will pay approximately $1 billion in bonuses for high-quality care to commissions in both advanced APMs and MIPs, in addition to positive payment adjustment of 0.5 percent, under MACRA.”
In all this, Slavitt said, “The bottom line is we’re trying to get doctors back to doing what they do best, care for patients, through a lot of simplification and support. We view the coming years as just the first steps into a program that will continue to improve, not an attempt to create a perfect system.”
Then Slavitt turned the microphone over to CMS Principal Deputy Administrator and Chief Medical Officer Patrick Conway, M.D., who shared some more granular information with the telephonically assembled press. “First of all,” Dr. Conway said, “very few things change for physicians in the first year, other than a 0.5 percent positive payment adjustment. If you participate in an advanced APM, that continues. If you don’t, many more options are becoming available. If you participate in the standard Medicare quality reporting and HER incentive programs, you will find those programs got far simpler with MIPS. And if you see Medicare patients but have never participated in a quality program, there are a number of paths to choose from to get you started, you can pick your pace.”
With regard to the burden on physicians in smaller practices, Conway said, “We understand in particular the challenge any changes and any burden that is placed on smaller and independent practices. That’s why we include important support for physicians and other clinicians, especially for smaller practices and those in rural areas or serving vulnerable patients. We know small practices can provide the same high-quality care as larger ones and can be just as successful in MACRA. Based on a lot of feedback we received, we made a number of adjustments.” He noted the following broad changes:
> reducing the time and cost to participate
> raising the threshold to exclude more small practices
> increasing the number of APMs available to small practices, including the new ACO Track 1+ and CPC Plus, both of which will provide opportunities for small practices to join
> allowing practices to begin participation based on their own pace
> allowing the qualification for participation in advanced APMs to be revenue-based, based on the practice, rather than total cost-of-care-based
> conducting significant technical support and outreach to small practices, using $20 million per year over the next five years
“We have updated our assumptions from our original proposal, where we estimated that many small practice physicians would only participate in QPP at the same level of participation in the precursor PQRS program to a rate closer to that of all other practice sizes.” Following these adjustments, Conway said, “We think the vast majority of small practices can succeed.”
Conway went on to say, “II would also add that in addition to the positive payment adjustment that as Andy said, we expect to award approximately $1 billion in additional Medicare payments to clinicians for providing high quality care in the first payment year of the program. And we made avoiding negative adjustments incredibly easy. In summation,” he said, “today’s rule protects small practices, reduces administrative burden and jumpstarts all of our desires to transform our healthcare system that supports healthier people and value.”
With regard to the forward evolution of the Quality Payment Program, Conway said that “We all recognize that that this will be a gradual implementation and involve a lot more listening and learning and adjusting along the way. We fully intend to keep the lines of communication open. We want to get this right. We want to partner with physicians and other clinicians across the country to achieve smarter spending, better care and better health for all people.”
Former National Coordinator Mostashari shares some initial thoughts
Shortly after the final rule had been posted to the CMS website, Farzad Mostashari, M.D., founder of Aledade, a company that focuses on physician-led accountable care organizations (ACOs), and former National Coordinator for Health IT, shared some initial thoughts with Healthcare Informatics. According to Dr. Mostashari, the single most important part of today’s final rule revolves around the changing one of the qualifications for participation in advanced APMs to be practice-based as an alternative to total cost-based. Mostashari takes particular interest in how CMS redefined what counts as “nominal risk,” stating that, given how the proposed rule had been outlined, participating physicians would have to take on total cost of care downside risk, meaning payments to Medicare totaling millions of dollars. For small and solo practices, this was considered detrimental to their independence.
But Mostashari says that’s no longer the case. “The most significant thing they did was create a smart way of defining what nominal risk was based on your income for Medicare Part A and Part B,” he says. So it starts at 8 percent and goes up to 15 percent, meaning if more than that number of your Medicare revenue is at risk, in a two-sided risk model, then that is more than nominal risk for you. This will absolutely shift the equation in terms of how many doctors will be in advanced APMs and out of MIPS,” he says. Indeed, previous estimates had 5 percent of eligible Medicare physicians patriating in the APM path early on—a small estimation that Mostashari says “was generous”—and now CMS has said that as soon as 2018, as many as 250,000 doctors could be in the APM track. “This is right; we want physicians to be focused on outcomes, not checking boxes,” he says.
Core to this is CMS’ new ACO Track 1+ model to begin in 2018, which the agency said has lower levels of risk than other ACOs. According to the final rule, the model would be voluntary for ACOs currently participating in Track 1 of the Shared Savings Program or ACOs seeking to participate in the Shared Savings Program for the first time. It would test a payment model that incorporates more limited downside risk than is currently present in Tracks 2 or 3 of the Shared Savings Program but sufficient financial risk in order to be an advanced APM. Mostashari says “separate rulemaking will be required to create this program.”