When the senior officials of the Centers for Medicare and Medicaid Services (CMS) released the final rule around the MACRA (Medicare Access and CHIP Reauthorization Act of 2015) law, including for its component MIPS (Merit-based Incentive Payment System), on October 14, that action has generated a great deal of analysis and commentary in the healthcare professional press, including by Healthcare Informatics Senior Contributing Editor David Raths.
In the month since the publication of the MACRA final rule, the editors of Healthcare Informatics have interviewed a number of industry experts about it. Recently, Editor-in-Chief Mark Hagland interviewed Mara McDermott, a Washington, D.C.-based attorney and the vice president of federal affairs at the Los Angeles-based CAPG, about the final rule and its impact on healthcare providers. CAPG, which describes itself as “the voice of accountable physician groups,” is a national association of nearly 300 medical groups and independent practice associations (IPAs) involved in accountable care organization (ACO) development and other risk-based contracts, across 41 states. Below are excerpts from that interview.
What are the most important features of the final MACRA rule, in your view?
What we see in the final rule is that CMS has really tried to strike a balance for physicians who are new to MACRA, to create a soft landing for the first year of MACRA implementation; that’s number one. Number two, we see a framework in the final rule for MACRA to ramp up over time. So there’s this immediate softening and flexibility for physicians, along with some of CMS’s intentions for MACRA in the future.
How would you describe those?
We see a pretty low initial bar for MIPS, in terms of its scaling back on the number of measures to report on, in order to avoid a penalty—in order to help physicians get familiar with MACRA and MIPS, to figure it out. One of the questions we have is, is there some burden on physicians before MACRA takes effect? Under current law, before the MACRA performance period of 2017, physicians are participating in PQRS [the Physician Quality Reporting System], the value-based payment modifier program, and Stage 3 of meaningful use; and each of those programs has reporting and data collection requirements associated it that is more than what’s required under MACRA in 2017 to avoid a penalty. We’ve been thinking about that a lot. For the 2016 4eporting period, physicians still need to do that reporting, and it will impact their payment in 2018 before MACRA takes effect. So that’s something we’ve been kicking around a bit to figure out, what the application of those programs looks like for the 2017 and 2018 payment years, before the 2019 first year of MACRA payment.
What are your biggest concerns about MACRA and MIPS?
CAPG has come at this looking at the advanced payment model [APM] options. I know you’ve spoken to Don Crane. One of the things we’ve been concerned about is achieving a reasonable balance between a framework that is functional for MACRA and MIPS, on the one hand—balancing meaningful measurement in MIPS and moving folks along the continuum from FFS to advanced alternative payment models. So what does MIPS need to look like to prepare physicians to move into advanced APMs? What are the things you can do in MIPS to move folks into a CPC-Plus or Next-Generation ACO, and to move to those forms of payment that are alternative to fee-for-service payment?
One of the biggest issues is the treatment of Medicare Advantage: many of our members take risk downstream in Medicare Advantage. CMS pays the health plans capitation under MA, and then the plans can choose how to pay the physicians. And many of our physicians are in risk-based contracts with plans. They’re taking on risk to provide care for populations of patients. And we’ve argued that that type of risk, where you’re having a physician taking risk under a plan, should be afforded the same credit as working under MACRA. There won’t be any credit under the first two years under MACRA for physicians taking on risk through health plans.
Is there any possibility that CMS could alter that, under the terms of MACRA?
We’ve been trying to encourage CMS to count or somehow give credit for those relationships. We’re also working with Congress on a piece of legislation to afford credit for those contracts under Medicare Advantage.
Might that legislation be introduced soon?
We hope so. There’s sensitivity, because MACRA was passed in such a huge bipartisan fashion, and if you reopen it, could that cause the flood gates to open?
Do you believe that the number and rigor of data points to be reported under MIPS, will be increased over time?
Yes. I think for the first year of MACRA, we really see an on-ramp situation, where you have a pretty low number of data points involved. They’re not going to weight the cost component; in the proposed rule, there was a 10-percent weight of your score around your cost component, and that was eliminated in the final rule. But CMS has said that the cost component will come into play in 2018. So we see CMS being responsive to the concerns of physicians, especially in small practices, that the requirements were initially too burdensome. So CMS is saying, OK, we’re going to make it easier to be MACRA-compliant in the first year, but now is the time to look at your feedback reports and look at your strategy. Do you want to play in MIPS or in APMs? Because in 2018, we plan to make MIPS more rigorous over time. And the potential penalty goes from 4 percent to 5 percent. You have a 4-percent penalty from the 2017 calendar year if you don’t report, and that would apply to your 2019 payments.
The bottom-line question is, you see MIPS becoming considerably more rigorous over time?
I think so; that’s what I read into it. I certainly wouldn’t want physicians to be scared by that. It’s not a doom-and-gloom scenario, but the direction is clear, based on what Congress intended when it enacted MACRA, to have a phase-in of requirements over time. They might not have imagined this much phasing.
Do you believe that more practicing physicians will seek direct employment by large medical groups or hospitals, because of MACRA?
We hear that all the time, and it’s easy to blame MACRA for that. What I believe is that there’s a convergence of factors involved here. And PQRS and the payment modifier program, those programs have been around for more than a decade. So, per the consolidation discussion, how much of this was baked in even before MACRA, and then, what’s the impact of MACRA after that? Because it seems to me that if the measurement and component aspects of MACRA—if those are driving consolidation, the reality is that complying with MACRA’s requirements are fairly easy compared to what was going on before. So the cause and effect question to me is still unresolved.
What would you advise CIOs and CMIOs to be thinking about in all of this?
Without knowing the technical answer to that question, I think the biggest thing right now is to get educated. It’s very important to know what’s in the final rule and what’s required in year one. But it’s also important to read between the liens with CMS and say, OK, they’ve scaled back the requirements for this year, and to plan ahead and ask, not what do we need to skate by for this year, but rather, what do we need for our long-term journey? Are we planning to stay in MIPS, or are we planning to move into advanced APMs, and what do we need to pursue our strategy? And what are the technological needs to support any strategy? And part of it is, what are the advanced APMs that will come into being that aren’t even in existence yet now? And CMS has probably put that into the calculus as well.
Is there anything you’d like to add?
One thing that’s attracted the attention of a lot of our members is that the rule talks about the introduction of a Medicare ACO Track One Plus, with lower risk. What is that model going to look like? What gap will that model fill? Will that model allow more organizations to gradually move into risk? That’s something we’re looking at, and our members are intrigued by that.