Will MACRA fizzle under pressure?

  | September 9, 2016

Late Thursday, in a blog post by acting administrator Andy Slavitt, the Centers for Medicare and Medicaid Services finally provided some much-anticipated details — welcome, but also potentially troubling — regarding MACRA performance options for clinicians in 2017.
Reactions to the agency's proposed MACRA implementation rule, which would bring sweeping changes to the way physicians are paid under Medicare, had been almost universally negative. Stakeholders complained of overwhelming complexity and unrealistically aggressive timelines. And perhaps the biggest backlash came from CMS's own declaration that 87 percent of clinicians practicing in small groups would face negative payment adjustments in 2019.
As a result, CMS officials spent much of the summer conducting listening sessions with clinicians, stressing that their concerns were being heard and would be addressed in the final rule, due out by November 1.
This week's announcement outlined four options for clinicians to “pick their pace" for performance in 2017, all of which ensure no negative payment adjustments in 2019.
Option 1 allows clinicians to merely test MACRA's Quality Payment Program (QPP). As long as some data is submitted to demonstrate “that your system is working and that you are prepared for broader participation in 2018 and 2019 as you learn more," clinicians can avoid a negative payment adjustment.
Option 2 qualifies clinicians for the potential of a small positive payment adjustment for submitting QPP data for part of 2017. Clinicians hoping for the prospect of a slightly larger positive payment adjustment can pursue
Option 3, which requires reporting of QPP data for the full calendar year.
And finally, ​Option 4 — participating in an Advanced Alternative Payment Model such as the Medicare Shared Savings Track 2 or 3 — qualifies clinicians for a potential five percent positive payment adjustment.
Clinicians across the country asked for flexibility, and it is hard to think of a way that CMS could have been more responsive to that request. It's a rare and beautiful thing when regulators truly listen to stakeholder input.
But hidden in the details of the four options is an underlying truth that shouldn't be ignored: these changes amount to a free pass for 2017. CMS proposed an incredibly high bar, only to lower it all the way to the ground at the eleventh hour. We've seen this happen enough times, in programs like Meaningful Use and the Physician Quality Reporting System, that a troubling trend is developing.
Responsiveness to feedback is great. But the last minute bar-lowering doesn't just limit the impact of a well-meaning — if overly complex — initiative like MACRA. It also establishes uncertainty around the rules of the road. What other new proposals to bring healthcare into the future will eventually be watered down to nothingness?
CMS seems to understand that clinicians can't move too far, too fast. But the agency also needs to recognize that, in order to thrive, the healthcare system needs certainty — and a clear direction forward.
Stephanie Zaremba is director of government affairs at athenahealth.

Will MACRA fizzle under pressure?