MACRA’s Quality Payment Program and the “Goldilocks Problem” in Federal Healthcare Policy | Mark Hagland | Healthcare Blogs Skip to content Skip to navigation

MACRA’s Quality Payment Program and the “Goldilocks Problem” in Federal Healthcare Policy

June 23, 2017
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Are CMS officials hitting the right levels of incentives under MACRA’s Quality Payment Program?

All of us have heard the fairytale of “Goldilocks and the Three Bears.” The Wikipedia entry on it has a good plot summary, with lots of interpretations of the myth. In any case, as Wikipedia notes, referencing the version of the tale published in Britain in 1837 by English writer and poet Robert Southey, the story goes like this: "A little girl named Goldilocks, goes for a walk in the forest and comes upon a house where she enters and finds to her delight three bowls of porridge. The first one she tastes is too salty, the next too sweet, but the third one just right so she eats it all up. Goldilocks finds the three different size chairs where she tries them out and finds the first one too high, the next too low, and then the little one just right but it breaks when she sits in it. As she wanders in the home she finds three beds and tries them out. The first bed is too hard, the next too soft but the third is just right and she curls up and falls asleep. Meanwhile the owners come home who happen to be three bears, Papa, Mama and little baby bear. Much to their surprise they discover the outcome of what Goldilocks has done to their porridge, chairs and finally their beds. Goldilocks wakes with a fright when she sees and hears the bears; she jumps from the bed and runs away as fast as she can.”

The Wikipedia entry on “Goldilocks” also offers some fascinating interpretations of the fairytale’s meaning. But for our purposes, let’s focus here instead on the idea of the “just-right measure.” Is the porridge too salty or sweet, or just right? (Most of us grew up with the idea of the porridge being too hot, too cold, or just right, but you get the idea.) Is the chair too high, too low, or at just  the right  height? Is the bed too hard, too soft, or at just the right level of firmness?

The Goldilocks story absolutely sprang to mind for me this week, as officials at the federal Centers for Medicare and Medicaid Services (CMS) on Tuesday afternoon released the proposed rule for 2018 with requirements for providers under what will be the second year of the Quality Payment Program (QPP) under the MACRA (Medicare Access and CHIP Reauthorization Act of 2015) law. The proposed rule, at 1,058 pages in length, is the first major update to MACRA since January, when a new presidential administration was put in place, while the MACRA final rule concretely launching the program had released in October, just a few months before the first reporting year of the QPP—inclusive of two payment paths that eligible Medicare-participating physicians could partake in—MIPS (the Merit-based Incentive Payment System) and the advanced alternative payment models (APM) track—was set to begin in January 2017.

As our team of editors has reported, there has been a full spectrum of reactions to the content of the proposed rule, with regard to some of the core incentives for physicians that are embedded into it—leaders of the Alexandria, Virginia-based AMGA (American Medical Group Association), for example, are seeing unfairness in it, in that they see the work that the leaders of the most innovative medical groups are doing to shift quickly towards value, being insufficiently rewarded—while on the other end of the spectrum, leaders at the Englewood, Colorado-based MGMA (Medical Group Management Association) are expressing concerns that, even with some of the adjustments made to how CMS will calculate rewards and penalties under the QPP, many physicians in the smaller and smallest practices could be heavily penalized within the next two years.

Meanwhile, there were widespread reactions of relief over the fact that, under the proposed rule, even in 2018, the use of 2015-certified electronic health record (EHR) technology would remain optional rather than mandatory, easing major concerns among physicians, hospital executives, and vendors, over the pace of change in terms of IT-related requirements. Advocacy leaders for both HIMSS (the Chicago-based Health Information and Management Systems Society) and CHIME (the Ann Arbor, Michigan-based College of Health Information Management Executives expressed great relief over that element of the proposed rule, even as they reflected on the broad direction of the QPP and of MIPS and MACRA more broadly.