The statement made by Acting Administrator of the federal Centers for Medicare & Medicaid Services (CMS) Andy Slavitt last week, healthcare association advocacy leaders shared with Healthcare Informatics their perspectives on what might happen next, as some elements mandated by the MACRA (Medicare Access and CHIP Reauthorization Act of 2015) come closer to being put into place. As HCI Managing Editor Rajiv Leventhal noted in his July 13 report, Slavitt made a statement during the U.S. Senate Finance Committee’s hearing that day in which he hinted broadly that there might be flexibility around the January 1, 2017 start date that otherwise was expected to be set into motion around physician reporting requirements.
As Leventhal noted in his report, “The Congressional hearing, led by Committee Chairman Orrin Hatch (R-UT) and Ranking Member Ron Wyden (D-OR), set out to give Slavitt a chance to describe MACRA’s implementation efforts and give members of Congress a chance to address issues and concerns towards the CMS head. Hatch opened his statement by noting that physicians are greatly concerned about the timeline of MACRA, which as currently scheduled, calls for implementation to begin in 2017 with bonuses being paid out to eligible Medicare doctors in 2019. Indeed, as comments from healthcare stakeholders poured in since the release of the proposed MACRA rule in April, various physician groups have called for a host of greater flexibilities, many which center around pushing the start date back at least six months.”
During the course of the hearing, Leventhal noted, “Hatch stated that the MACRA law gives CMS the flexibility to move the start date of the reporting period back.” He quoted Sen. Hatch as saying that “Physicians are concerned about the timeline. If CMS releases the final rules around Nov. 1, that only leaves two months for them to prepare. It’s a legit concern.” In response, our report noted, “Slavitt agreed with Hatch, responding that the program needs to be launched ‘so it begins on the right foot, so every physician in the country feels that they are set up for success.’ He added, ‘There has been significant feedback received here, and we remain open to options including alternative start dates, looking at shorter [reporting] periods used, and other ways physicians could get help and experience before the program hits them.’”
Complexities around timing
There are a number of complexities inherent in the current situation in this moment, says Leslie Kriegstein, vice president of congressional affairs at the Ann Arbor, Mich.-based College of Healthcare Information Management Executives (CHIME). To begin with, the Washington, D.C.-based Kriegstein says, the timing of the release of the final rule for this implementation is expected to be sometime in October, or at the very latest, early November; and that would give physicians and organizations with physicians very little time to put into place the information technology and data and reporting systems needed to ensure that they could begin reporting a broad array of data points to CMS beginning on Jan. 1, as was written into the MACRA legislation.
Fundamentally, Kriegstein says, there are two essential possibilities here. “They could change either the start date or the reporting period. The only reporting period proposed explicitly in the legislation was for clinical practice improvement, which carried a 90-day proposal” in the enabling legislation, she notes. Kriegstein who was present at the Finance Committee hearing last week, said, “Acting Administrator Slavitt said, we want to launch this program on the right foot, for clinician success, which might therefore involve alternate start dates, or shortened reporting periods.” Asked what she thinks might happen, she says, “I could see a scenario where CMS clearly has the propensity to leverage shortened reporting periods for program years they think will be challenging, so I could see that as probably the greatest possibility. Last month, the AMA [American Medical Association] came out asking for a delay; some other groups asked for a July 1 start date.”
Asked whether in practice there is a difference between postponing the start date or shortening the reporting period in 2017, Kriegstein says, “In practice, they end up being the same thing. For example, per meaningful use, or in the hospital quality reporting program, they give you quarters to pick from. So it’s possible that they could change the reporting period to 90 days or 120 days, with some flexibility around the length or the start date.”
Jeffrey Smith, vice president of public policy at the Bethesda, Md.-based American Medical Informatics Associations (AMIA), says, “CMS doesn’t usually telegraph what they’re going to do in relation to timing, until the last minute. If you look at meaningful use and the 90-day reporting period, they waited until the last moment to make that announcement,” he says. “I think that Andy Slavitt’s words were really encouraging to providers who felt that this would be a really heavy lift for individuals and organizations. And frankly, I haven’t spoken to any individual or organization that thought that January 1 would be a realistic timeframe.”
Given all that, Smith says, “I suspect that there will be a final rule in October or November, but that final rule might be an interim final rule, which would essentially be a signal to the market saying, here’s what that final rule will look like, but here are also some changes we’ll make. And that seems to me to be a sensible way to do this. It might be put off to July 1. That seems reasonable. I think everybody knows that more time is needed, and CMS probably heard that from almost every organization in the NPRM process.” Further, he says, “It's been an incredibly tight time since the legislation was passed. CMS has been working its tail off on this; it’s just the way the legislation passed and was written.”
Blair Childs, senior vice president of public affairs at the Charlotte-based Premier Inc., definitely sees the complexity in this situation as well. “We’ve been working with our members for some time to understand what’s involved,” says the Washington, D.C.-based Childs. “But it’s the smaller physician practices that are the concern. What’s confusing is that a lot of people are talking about is a delay for MACRA, and what’s being considered is not really a delay, it’s just a pushing back of the start date for reporting. And the issue might be with the truncated period for 2017, it will be necessary to make sure that they have sufficient data, enough procedures done, so that the measures are accurate enough,” referring to the fact that CMS officials will use the data reported in 2017 to establish payment changes for Medicare-reimbursed physicians beginning 2018.” As a result, he says, “What they probably will do is to reduce the reporting year by some period of time, such as 3 or 6 months, and thereby give people more time to get themselves prepared for the change.”
Did Acting Administrator Slavitt’s comments on July 13 during the Senate Finance Committee hearing represent a major shift in CMS’s intentions towards healthcare providers? “I was personally surprised that he said what he said in a Senate Finance hearing, but I was also encouraged by it,” says AMIA’s Smith. “It shows that he’s trying to be responsive. CMS has been showing itself to be more responsive recently,” he adds, saying that he sees a number of statements and actions on the part of senior CMS officials in the past year or so as pointing to a more flexible stance overall in terms of the agency’s interactions with physicians and hospitals.
CHIME’s Kriegstein definitely sees changes at CMS. “I’m not surprised” by Slavitt’s comments during the Senate Finance Committee hearing,” she says. “He’s definitely been a breath of fresh air. He’s stressed simplicity and flexibility since he took over the job. And the fact that they’re willing to take a step back and make sure this program launches successfully, is significant.”
Kriegstein says she sees CMS officials becoming more flexible generally under Slavitt’s management. “They just made some changes in the meaningful program when they granted the 90-day reporting, so looking through the lens of their technology programs, and especially meaningful use, there has been an appetite for flexibility, and making sure we keep as many hospitals and physicians involved as possible,” she says.
The time to prepare is now
Regardless of the ultimate specifics involved for physicians to report data to the Medicare program, either through the MIPS (Merit-based Incentive Payment System) program, or through alternative payment models (APMs), all the advocacy leaders interviewed for this article agree that the CIOs, CMIOs, and other healthcare IT leaders in medical groups, hospitals, and health systems should be working now to prepare for changes that will impact all their Medicare-participating physicians.
“CMS’s message is, we’re not changing a lot, especially with the assumption that most doctors are going to be on the MIPS side,” says CHIME’s Kriegstein. “They’re already acknowledging that very few alternative payment models, will be ready to go right away—there’s a high bar to participate in those, and you have to use certified technology—so CMS is assuming that most eligible physicians will be under MIPS for the first few years. We know that quality outcomes, resource use, and meaningful use, will all be emphasized” under MIPS. “So staying the course on existing programs and educating staff on what’s available, and beginning those conversations with your vendors, are all going to be important” in the next several months. What’s more, she says, “The whole CPIA bucket—clinical practice improvement activities—there will be a lot of technological requirements inherent in that. There are some non-tech options, but there are also a lot of tech options, to improve your practice. And that’s where there’s a lot of uncertainty involved in what the vendor and tech choices will be,” she says. “So beginning chose conversations will be imperative.”
“I think everybody needs to be thinking about what your measurement strategy is across the continuum; and that’s a multi-faceted set of considerations, as you know,” says Premier’s Childs, who says that medical group, hospital and health system leaders, including IT leaders, will inevitably be drawn fully into all the reporting work required of their physicians by the Medicare program, because of physicians’ reliance on them and their broader organizations in these areas.
Childs says he was aware of the recent Deloitte Center for Health Solutions’ survey of practicing physicians that found that fully 50 percent of non-pediatric physicians have never even heard of MACRA, and only 32 percent recognize the name “MACRA.” Indeed, as HCI’s July 14 report on the Deloitte survey noted, only 21 percent of self-employed physicians, and only 9 percent of employed physicians, reported that they were “somewhat familiar” with MACRA, despite its impending impact on their practices—and on their Medicare revenues.
“Yes, that’s correct,” Childs says, in response to a comment that practicing physicians remain woefully unaware of the full impact that the provisions of the MACRA legislation will have on their practices. “We’ve been out talking to doctors since it passed. And I’ve just been shocked at how little people know about it.”
It’s very clear where policymakers and federal healthcare officials are headed overall, in any case, Childs emphasizes. “We’ve been saying this for years. We predicted mandatory bundled payments in 2010, and it happened in 2016. So we’ve actually kind of nailed all the steps” along the way to the present moment in federal reimbursement policy. “It certainly is moving, and there’s kind of no question about it. And irrespective of the administration, we’re on this path, and it’s going to continue. There are so many questions and issues that healthcare and healthcare IT leaders need to begin tackling: what are they going to report on, how are they going to do it, are their data and information systems organized as they should be, and do they want to go into alternative payment models? The assessment processes are very important for people to undertake.”
AMIA’s Smith says that CIOs, CMIOs, and other healthcare IT leaders should absolutely be “planning for this. I think the final rule will look almost exactly like the NPRM,” he says, referring to the proposed rule, or notice of proposed rulemaking. “And they should be planning for January 1. It would be foolish to think a delay is in the bag. So if you’re a CIO or CMIO, you should plan for this to be full-speed ahead.”
Healthcare Informatics will continue to update readers on this story as new developments take place.