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Now That The Printers Have Cooled, It's Time To Take a Look at MACRA

by Greg Carey, Technology Standards and Policy Manager

Who tries to “simplify” multiple complex programs with 962 pages of regulations and a web of new acronyms?  A government agency of course!

Last week, CMS responded to an industry-wide plea for simplification and consolidation of pay for performance programs with the release of the proposed Medicare Access and CHIP Reauthorization Act, aka the MACRA rule.  Congress’ clear charge to CMS in MACRA was to streamline existing programs under the Medicare Incentive Payment System (MIPS) and Alternative Payment Models (APM) tracks. The highly anticipated proposal sparked a feverish initial evaluation that left health IT wonks listless and baggy-eyed.  Now that the printers have cooled and the dust settled, it’s time to analyze the impact on health IT and clinicians. Is the proposed rule indeed simple, as Congress intended? And does it reduce the burden on physicians?     

To start, let’s be clear: This is a proposed rule.   Comments to CMS are due at the end of June, and there is ample opportunity for stakeholders to respond to and influence the final rule that is expected this November.  It is likely the final rule could look very different from this proposal.

With that, here are the four things providers and industry observers need to know about MIPS, the track which poses the largest immediate impact to clinicians:

In 2017, approximately 90% of practices will fall into the MIPS category, and it will serve as a stepping stone for some of those practices to join APMs in subsequent years.  The data collected during the 2017 calendar year reporting period will be reflected in 2019 payment adjustments.    

1)  It’s clear that CMS made a concentrated effort to simplify requirements in MIPS.  Yet, the spirit of MU lives on in much of the rule, and MIPS is not an end to government mandated check-the-box requirements.  Thankfully, MIPS has two long overdue changes that should not be undersold: fewer measures and more choices for eligible clinicians.  While navigating and selecting the appropriate measures may add some work, eligible clinicians will finally be able to choose metrics relevant to their practice in the Advancing Care Information (ACI) category, affectionately referred to as “the new MU”.  Everyone agrees that no physician should go to work in the morning striving for compliance through mouse clicks, and CMS has taken a small step towards demonstrating that belief.

2)  The proposed scoring model is also an improvement.  The scoring in MIPS, although complex, is a more accurate reflection of a clinician’s performance.  No longer are scoring and incentives determined on an all-or-nothing basis.  Payment adjustments scale with the calculated score a clinician receives.  CMS undoubtedly recognizes that a clinician’s time should be focused on delivering the highest quality of care. 

3)  While MIPS is simpler than its predecessors MU, PQRS, VM, it is not lacking in complexities. MIPS appears to consolidate these programs under four basic scoring categories.  Scratch just below the surface of those categories, however, and multiple subcategories with measures reminiscent of past programs rear their ugly heads. Four categories quickly turns into twenty plus measures with multiple variables. 

4)  Particularly notable in MIPS is the missed opportunity to produce a virtual group model in year 1. CMS balks at an innovative model to support small practices and permit health IT vendors to take on more risk with their clients.  The virtual group model would allow similar independent practices to pool risk while maintaining their independence and spreading performance over a larger group of clinicians. CMS will delay the first performance year for virtual groups until 2018 because their preferred “web-based registration process” does not currently exist, and it would be too difficult and costly to implement before 2017. 

While CMS’ own baseline technology lags behind their regulation, health IT vendors must adapt to a November final rule in short order to prepare for the January 1st, 2017 program start.  At the same time, CMS paradoxically estimates that 87% of solo practitioners will see a negative adjustment after the first year.   The rule is clearly more favorable to large groups, with an estimated 18.3% of groups with 100 or more eligible clinicians penalized.  CMS’ inadequate technology and scant details on implementation of virtual groups will strong arm some small practices into joining large health systems in order to avoid negative adjustments.

Four days after the proposed MACRA rule was released, CMS unveiled a mobile challenge for businesses and entrepreneurs.  The assignment is to develop a program that “reduces burden and [provides] increased satisfaction for the MIPS clinicians and their supporting entities” through access to key information and education.   This solicitation to simplify and reduce administrative burdens--the same principles MIPS should be rooted in--doesn’t elicit stakeholder confidence when the final rule is still months away.

Regardless what appears in the final rule, athenahealth remains steadfast in our commitment to be our clients' most trusted service and guide through an evolving reporting and payment environment.  Our teams will analyze, educate, and influence the final rule to help enable caregivers to focus on their greatest strengths.  The window of opportunity for CMS to empower clinicians by unleashing the full potential of health IT is still open.  In the next few months, CMS should follow the charge set forth by Congress in MACRA to further streamline and simplify performance programs to allow solo practitioners and larger hospital systems alike to focus solely on delivering quality care and better outcomes.

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Comments

Submitted by Sharon MacMillan - Thursday, June 23, 2016

Medicare already reimburses less than the cost of providing the service. Those of us in solo practice may just decide that we will drop Medicare, if reimbursements are decreased. PCPs can't do that easily, but in my specialty it would be quite possible.

Submitted by Michael James Gascoigne - Friday, May 6, 2016

Dear Mister Carey, Thank you for the excellent post. I submit to you 'The Bible', a thousand plus page guide to lifestyle simplification, which people do seem to be pretty fond of. Perhaps some rules require long narratives. Please have a tremendous day. Sincerely, by, Mike

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