This week has been a week of intensified activity on the healthcare policy front. With just hours to go, numerous healthcare professional associations sent comments into senior officials at the federal Centers for Medicare & Medicaid Services (CMS), as the door was about to close for them to comment on the proposed rule related to physician payment requirements under the MACRA (Medicare Access and CHIP Reauthorization Act of 2015) legislation, which created the MIPS (Merit-based Incentive Payment System) system for physician reimbursement under Medicare.
As Assistant Editor Heather Landi and I reported in separate articles this week, numerous comments came from such associations as the Englewood, Colo.-based Medical Group Management Association (MGMA), the Philadelphia-based American Academy of Family Physicians (AAFP), the Alexandria, Va.-based American Medical Group Association (AMGA), the Chicago- and Washington, D.C.-based American Medical Association (AMA), the Bethesda, Md.-based American Medical Informatics Association (AMIA), and the Charlotte-based Premier health alliance, among others.
The recommendations of these and other healthcare professional associations are quite diverse, and touch on a very wide range of issues. Fundamentally, they revolve around issues of timing and timeframes, many specific aspects of measurement of quality and outcomes, many IT-related requirements in the program, concerns over the program’s complexity, and concerns over the impact of the MIPS/alternative payment model participation requirements on small and rural providers.
As has been well-noted, the meaningful use program for physicians is being folded into the new MACRA/MIPS program, meaning that whether practicing physicians participate in an alternative payment model (APM) or in the MIPS program, the kinds of requirements that doctors faced under meaningful use will continue, in modified forms. What’s more, most of the measurements around healthcare IT, going forward, are focused on achieving success in broad areas that CMS officials have been pushing more generally: health information exchange and data exchange, care management and population health management, and patient engagement.
If there’s a single area in which nearly all of the associations agree on, it is their strong recommendation that CMS officials delay the onset of physician requirements from January 1, 2017, as referenced in the proposed rule, to at least July 1, 2017. As association leaders have pointed out in their comments, the January 1 start date obligating physicians to collect data for the Quality Payment Program, is one that healthcare professional association leaders almost universally believe would be too difficult for physicians to adhere to.
Meanwhile, among the statements made by association executives in their comments to CMS that most stood out, are the following:
Ø Halee Fischer-Wright, M.D., the MGMA’s president and CEO, in her letter to CMS Acting Administrator Andy Slavitt, was openly critical along numerous dimensions. Among other things, she wrote that CMS’s “narrow definition of APM [advanced payment models] provides almost no opportunities for medical groups to begin the shift away from fee-for-service reimbursement,” and further, “strongly opposes” the overly-narrow and restrictive Advanced APMs criteria proposed by CMS,” she wrote in her association’s letter, adding that, “While MACRA established a requirement that APMs bear more than nominal financial risk, CMS would establish a rigorous risk standard that requires strict repayment of losses—a criterion that excludes the vast majority of legitimate APMs, such as Track 1 MSSP ACOs and the Bundled Payments for Care Improvement models.”
Ø Meanwhile, the AMA’s CEO James L. Madara, M.D., offered a whole laundry list of requests/recommendations for Acting Administrator Slavitt, among them, that CMS “provide more flexibility for solo physicians and small group practices, including raising the low volume threshold”; that CMS “provide physicians with more timely and actionable feedback in a more usable and clear format”; that CMS “align the different components of MIPS so that it operates as a single program rather than four separate parts, such as creating a common definition for small practices”; that CMS “simplify reporting burdens and improve chances of success by creating more opportunities for partial credit and fewer required measures within MIPS”; that the agency “reduce the thresholds for reporting on quality measures”; and that the agency “reward reporting of outcome or cross-cutting measures under a bonus point structure rather than a requirement in order to achieve the maximum quality score.”
Ø Meanwhile, the comments from the AAFP laid it all out very simply, with the primary care physicians’ association’s key point being this: “Given the significant complexity of the rule, we strongly encourage CMS to issue an interim final rule with comment period rather than to issue a final rule.” The association also quoted the commentary of an individual family physician, who wrote, “I am a Texas physician who is extremely disappointed and disillusioned with the Centers for Medicare & Medicaid Services' draft rule… Physicians as a profession and individually are dedicated to constantly improving the quality of care we provide. But as I read it, this rule will wreak havoc with my practice while offering absolutely no evidence that it will do anything to improve patient care. Here is how you can help this problem,” that doctor wrote. “Since you won't finalize the rules until on or around Nov. 1, 2016, the Jan. 1, 2017, start date is completely unreasonable. Physicians need at least a six-month deferment to prepare our practices and processes for all the changes MACRA is demanding. Please begin the first period on July 1 and end it on Dec. 31. This deferment will be particularly critical for small practices.”
Ø And AMIA’s core recommendations were summarized neatly in the following points. “In order to improve the current proposal and to help guide future proposals, AMIA established several principles CMS should consider related to QPP [the Quality Payment Program],” AMIA wrote, including “use data reporting requirements to learn, not simply to grade; focus on defining clear, expected outcomes, rather than prescriptive process measures; engage organizations and experts to perform scientifically rigorous, peer-review studies to determine which requirements should be retained in future years; develop feedback loops that are accurate, timely and meaningful”; and “encourage increased data exchange and interoperability whenever possible.”
These key points from those associations, as well as others, clearly reflect the broad concerns of the associations in this area. They point to some serious tweaking that senior CMS officials might consider. Perhaps the most intriguing of all of these is the AAFP’s strong suggestion that CMS officials put in place an interim final rule rather than a plain-old final rule.
There would be some real strategic and tactical risk in doing so, of course; because once one begins to tweak something, the tweaking could become endless. And let’s face it, no one is ever going to be 100-percent satisfied with the final outcome.
But these recommendations are well-thought-out, and reflect considerations that appear to be very reasonable. Above all, it seems clear to me that it is incumbent on senior officials at CMS to truly thoughtfully consider some of these suggestions and recommendations, if they want the full cooperation of physicians and other providers, and of these provider associations, going forward into this emerging world of intensified data collection and reporting around value-based care delivery and payment, with broadly intensified quality, outcomes, efficiency, and data and IT elements in so many areas.
Now, what will actually happen…? It really is anybody’s guess. We really have entered uncharted territory here. But one thing that I think is rather clear, is this: for better or worse for everyone, given the tremendous imperatives facing the U.S. healthcare delivery system to bend its own cost curve and to improve all of the outcomes around care delivery—the quality-of-care outcomes, the patient, family, and community satisfaction outcomes, and the financial and operational outcomes—we are inevitably being drawn into rather a new dynamic here. It is one in which CMS officials will necessarily need to iterate concepts forward in a more collaborative way, with physicians, hospitals, and other providers. There are now so many programs and requirements, and the pace of change and of anticipated change is such that one simply cannot imagine things working out without a huge dose of cooperation, collaboration, coming together, whatever one might want to call it.
So, perhaps more even than at other key moments in the past, this feels like a true inflection point for U.S. healthcare; because this headlong plunge into the new healthcare is one that is unprecedented in both its complexity and in the need for all the stakeholders around healthcare to be able to come together in good faith to make this all work. The next few years are going to be determinative in more ways than one. And it will be interesting to see whether the path ahead feels more like a 19th-century stagecoach ride over rutted roads, or like the smooth path of a high-speed train on shock-absorbing bumpers—or maybe some combination of the two. Stay tuned, and we’ll all find out, together.