Five weeks ago, Eric Cragun and Rivka Friedman of The Advisory Board Company authored a very insightful and useful analysis of the proposed rule issued on April 27 by the Department of Health and Human Services (HHS)/Centers for Medicare & Medicaid Services (CMS) recently around physician payment under MACRA/MIPS (the Medicare Access and CHIP Reauthorization Act/the Merit-based Incentive Payment Program).
As Cragun and Friedman noted in their analysis, “The law will fundamentally change how Medicare pays physicians and other clinicians who participate in the program. It will establish a two-track system for Medicare reimbursement: one, called MIPS, for providers who are reimbursed largely through fee-for-service, and an alternative payment model (APM) track for physicians who take on a significant portfolio of APMs.”
The consultants made ten key points, with much analysis and annotation of them. Here are the ten:
> The rule underscores the complexity of MACRA.
> CMS has heard the call to streamline this rule and minimize the burden on participants.
> MIPS will push medical groups of all sizes to invest in reporting and tracking performance on PQRS.
> CMS set a high bar on requirements for APM track.
> CMS expects most eligible clinicians to be in MIPS
> Most clinicians qualifying for the APM track will do so as a group.”
> The proposed rule reflects a belief and expectation that medical home models have potential to drive significant value for Medicare.
> Providers must decide whether to submit MIPS data before they know if they will quality for APM track.
> Performance periods are rapidly approaching.
> The rule’s complexity (and its high stake) are likely to elicit concern and comments from various stakeholders.
Point number one was an essential one to make, and it is gratifying that the authors made it in their analysis. MACRA is indeed complex, and even MIPS is complex. But what’s important is not so much the complexity itself as its implications for physicians. As I noted in a blog early last month, John Halamka, M.D., the CIO of Beth Israel Deaconess Hospital in Boston, and a respected industry leader, after reading and analyzing the April 27 Notice of Proposed Rulemaking (NPRM), wrote this: “After spending 20 hours reading the MACRA NPRM, I had one overwhelming thought. Sometimes when you remodel a house, there is a point when additional improvements are impossible and you need to start again with a new structure. The 962 pages of MACRA are so overwhelmingly complex,” Dr. Halamka wrote, “that no mere human will be able to understand them. Above, I have only covered the HIT related concepts, which are a small subset of all the changes to payment processes. This may sound cynical, but there are probably only two rational choices for clinicians going forward –become a salaried employee delivering clinical care or become a hospital-based clinician exempted from the madness.”
Dr. Halamka’s cri de coeur notwithstanding, the core concepts embedded in the MIPS physician quality program are relatively straightforward. As explained by Kyle Murphy, Ph.D., in EHR Intelligence, “MIPS comprises four performance categories used to score a MIPS-eligible clinician's quality, use of services, EHR use, and quality improvements to care coordination and delivery: quality (90 percent); resource use (10 percent); advancing care information (25 percent); clinical practice improvement activities (15 percent). Whether a MIPS-eligible clinician's composite performance score exceeds, meets, or falls short of the threshold set by CMS determines a positive, neutral, or negative payment adjustment in later years,” he explained. “Beginning in 2019, the payment adjustment is four percent, following five percent in 2020, seven percent in 2021, and nine percent in 2022 and beyond.”
Still, the reporting and quality requirements to appear to be relatively rigorous—and that is a good thing. Only time will tell whether the combination of various requirements, and their weighting, per what Dr. Murphy outlined, will be precisely the right combination and weighting. It is virtually certain that the entire set of MIPS requirements will be tweaked at least slightly over time—and that really is to be expected.
The fundamental reality is this: CMS officials have made it clear that all Medicare-participating physicians, whether they are participating in alternative payment models or not, will have no choice going forward about whether they participate in some form of accountable care delivery in the broadest sense of the term “accountable,” as all those Medicare-participating physicians not participation in APMs will be held accountable for outcomes and processes through the MIPS program.
So what does this mean for hospitals, integrated health systems, and large medical groups, and for their leaders, including their physician leaders and their IT leaders? A lot. Practicing physicians are going to be clamoring for help in their practices with managing this new welter of different sets of requirements, and the only entities that will be able to help them, apart from individual consultants, will be the large medical groups, hospitals, and integrated health systems with whom the practicing physicians are affiliated or by whom they’re salaried.