During a July 13 U.S. Senate Committee on Finance hearing on the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), Centers for Medicare & Medicaid Services (CMS) Acting Administrator Andy Slavitt left open the possibility that the new sweeping changes set to overhaul physician payment could be pushed back from the intended start date of Jan. 1, 2017.
The Congressional hearing, led by Committee Chairman Orrin Hatch (R-UT) and Ranking Member Ron Wyden (D-OR), set out to give Slavitt a chance to describe MACRA’s implementation efforts and give members of Congress a chance to address issues and concerns towards the CMS head. Hatch opened his statement by noting that physicians are greatly concerned about the timeline of MACRA, which as currently scheduled, calls for implementation to begin in 2017 with bonuses being paid out to eligible Medicare doctors in 2019. Indeed, as comments from healthcare stakeholders poured in since the release of the proposed MACRA rule in April, various physician groups have called for a host of greater flexibilities, many which center around pushing the start date back at least six months.
Hatch stated that the MACRA law gives CMS the flexibility to move the start date of the reporting period back. “Physicians are concerned about the timeline. If CMS releases the final rules around Nov. 1, that only leaves two months for them to prepare. It’s a legit concern,” the Utah senator said. Slavitt agreed with Hatch, responding that the program needs to be launched “so it begins on the right foot, so every physician in the country feels that they are set up for success.” He added, “There has been significant feedback received here, and we remain open to options including alternative start dates, looking at shorter [reporting] periods used, and other ways physicians could get help and experience before the program hits them.”
Hatch also proposed that CMS could publish an “interim” final rule this fall, one that would allow for more stakeholder feedback. Likely, this approach would also require a delay of the program’s start date. To that suggestion, Slavitt said, “That option is on the table for us to consider to keep the feedback process open. We know this a long-term process, and this is just the first step. CMS needs to shorten the window and close the gap between the practice of medicine and policy implementation. This process allows us to get closer to that,” he said.
In the past year, many healthcare professional associations have stated outright that they are not well-prepared for the new law. Up until the release of the proposed rule in April, there seemed to be little awareness about the health IT provisions of MACRA amongst the provider community regarding the two new Medicare payment program tracks— the Merit-Based Incentive Payment System (MIPS) and the Alternative Payment Models (APMs).
As such, for these providers, particular small and solo practices, a delay to the start of the program would very likely be well-received. To this end, Slavitt was again asked about potential impact that MACRA might have on smaller physician practices, a group that Wyden referred to as “the backbone of the medical community.” Slavitt said that CMS is focused on helping these smaller practices, and their ability to continue to practice independently is a “high priority” for the agency. “And I would say that’s a priority for all rural practices,” he said. “We need every physician to be set up for success, and challenges are far greater in small practices. Oftentimes in these practices, it’s a physician and his or her spouse, and that’s all.” Slavitt said there have been a number of areas that CMS has received feedback in regards to small and solo practices including: comparing the performance of these practices to others of their ilk rather than larger organizations; lessening reporting periods; reducing program reporting thresholds; and creating virtual groups.
Back in May, during a Subcommittee on Health of the Committee on Ways and Means hearing, the CMS chief was pressed about this same issue, to which he said the federal agency is trying to help out smaller practices in various ways, including providing them technical assistance, providing access through medical home models, and giving them the opportunity to report in groups and in more automated ways.
More recently, the Department of Health and Human Services (HHS) announcing new funding to the tune of $20 million each year over the next five years to support on-the-ground MACRA training and education for Medicare clinicians in individual or small group practices. Nonetheless, according to a May 2016 Black Book survey, 67 percent of high Medicare-volume doctors said they will not have the technology, capital or staffing to sustain under the conditions of MIPS. The same amount of respondents said they foresee the end of their independence due to the physician payment changes set to take place under MACRA.
Under MIPS, solo and small practices may indeed join “virtual groups” and combine their MIPS reporting. CMS has said that it is seeking public comment on how virtual groups should be constructed, and anticipate being able to implement virtual groups in the second year of the program, in 2018. During the hearing, Slavitt said that the virtual groups’ concept has a lot of promise and potential, but it’s very new so there are plenty of details to still work out. When pressed for a more concrete timeframe for when this group reporting could begin, he said “It’s a whole new way of reporting, and physicians would need to make a bunch of new decisions. They’re not used to reporting this way, so we are [currently] asking them what they want. You need the technology and operations to support [the virtual group reporting], so this is not something that’s ready to be launched in months. Our aim would be to get this done in the following year,” Slavitt said.
Further, Slavitt was asked about the ability of physician practices to move into two-sided risk models that the APM track calls for. One senator mentioned that these double-sided risk approaches, in which there is the potential of financial downside for the provider organization, have been largely unsuccessful in accountable care organization (ACO) programs. Slavitt argued that these approaches are beginning to work, and physicians are increasingly moving into two-sided risk models. “We do have to be cautious about how we define two-sided risk,” Slavitt said, noting that the number of Medicare ACOs taking on downside risk is up to nearly 25 percent.