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MACRA Legislation in the Hands of OMB

March 31, 2016
by Rajiv Leventhal
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Industry insiders say a rule could be coming in about a month

The White House’s Office of Management and Budget (OMB) is currently reviewing a proposed rule that will implement the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), a law that will create new options for Medicare physician payment.

Last April, President Barack Obama signed MACRA, a bill that now permanently repeals the long-maligned SGR formula for Medicare physician payment. In broad terms, MACRA ends physician payment incentives under the meaningful use program within the HITECH (Health Information Technology for Economic and Clinical Health) Act, and those under the Physician Quality Reporting System (PQRS), replacing the incentives in those programs with a new program called the Merit-based Incentive Payment Program, or MIPS.

Beginning in 2019, payment adjustments will begin for physicians as they choose between the new MIPS or participate in a qualifying alternative payment model (APM). But, those adjustments will be based on previously reported data starting in 2017. As reported by Healthcare Informatics in one of its Top Ten Tech Trends of 2016, nearly a year after the bill was signed into law, physician leaders find themselves in quite the precarious position—even as the first program year of the law is scheduled to start in less than 12 months, there is little awareness about the health IT provisions of MACRA amongst the provider community.

 “This is a fundamental payment overhaul,” said Leslie Kriegstein vice president of Congressional Affairs at the Ann Arbor, Mich.-based CHIME, in that HCI report. “Folks are pointing to 2019, but that’s the first payment year. As things stand today, we are rapidly approaching the first program year of 2017. There is no rulemaking yet, and it’s still going to be a very expedited timeframe by the time we respond to those proposals and see them finalized. Folks will have to put the pedal to the metal after that,” she said.

Last summer, in the Centers for Medicare & Medicaid Services (CMS)’ first proposed rule since the SGR formula was scrapped, the agency said Medicare transformation focused around person-centered and outcomes-driven care would be key themes in the new legislation. Indeed, MACRA directs CMS to assess physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists (“MIPS Eligible Professionals” or “MIPS EPs”) on four performance categories: 1) Quality; 2) Resource use; 3) Clinical practice improvement activities; and 4) Meaningful use of certified electronic health record (EHR) technology.

Also, according to a Quality Measure Development Plan (MDP) released by CMS later in 2015, MACRA identifies five quality domains (i.e., clinical care, safety, care coordination, patient and caregiver experience, population health and prevention) for measures developed under the MDP, which aims to serve as a strategic framework for the future of clinician quality measure development.

Now, the rule is in the hands of OMB. It is not known how long the office will take to review the legislation, but industry insiders estimate that for a rule this size, about one month would be a fair approximation. The final rule is expected to be completed later this year.

Recently, during a U.S. House Energy Subcommittee on Health hearing on the implementation of Medicare payment reforms, CHIME and the American Hospital Association (AHA) released statements calling for the removal of the existing pass/fall or “all-or-nothing” construct and for additional flexibility under the meaningful use program as CMS develops a regulatory framework for MACRA.  During that hearing, Patrick Conway, M.D., deputy administrator for Innovation and Quality and Chief Medical Officer at CMS, further hinted that MIPS could require quarterly reporting on the part of physicians.

AHA also said that it would like to see CMS allow hospital-based physicians to use their hospital’s quality reporting and pay-for-performance program measure performance in the MIPS. Currently, MACRA does not address payment models for hospitals—just physicians. But according to AHA, hospitals employed nearly 245,000 physicians in 2013, and had individual or group contractual arrangements with at least 296,000 more physicians. “Hospitals that employ physicians directly may bear the cost of the implementation of and ongoing compliance with the new physician performance reporting requirements under MIPS, as well as be at risk for any payment adjustments. Moreover, hospitals may be called upon to participate in APMs so that the physicians with whom they partner can qualify for the bonus payment and exemption from MIPS reporting requirements that accompanies the APM “track,” AHA said in its statement.

Meanwhile, at HIMSS16 in Las Vegas earlier this month, CMS Acting Administrator Andy Slavitt said that the idea is that MACRA will be a legislation intended to bring value-based care to physician practices every day. Slavitt said, "The way we have been spending our time, we have almost written a new playbook as we move towards MACRA. We are thinking and designing from the outside in." He further said that CMS favors a pull versus a push approach to incentives. "[You want to] allow outcomes, not activities, drive the agenda.” He continued, "What you want to do in a perfect world is allow incentives to customize around the practice goals. I have never met a doctor, nor do I want to, whose practice is driven by some incentive. It's about doing what they think is right for their patient."

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