When the Centers for Medicare & Medicaid Services (CMS) announced on Sept. 8 that it will allow eligible Medicare physicians to pick their pace of participation for the first performance period of Medicare Access and CHIP Reauthorization Act (MACRA) that begins Jan. 1, 2017, the initial industry reaction seemed to be a collective sigh of long-awaited relief.
After all, ever since the MACRA proposed rule, which is set to overhaul physician payment as the healthcare industry shifts to paying doctors for value rather than volume, was released in April, many doctors were wondering how they would be able to learn all of the regulations and be able to comply with just a few months’ time to prepare. And, smaller physician practices were even more concerned; a Black Book survey from June revealed that two-thirds of high Medicare-volume small practices said they foresee the end of their independence due to the physician payment changes that will take place under MACRA.
But then came the program flexibility news last week, delivered via a blog post on CMS’ website by the agency’s Acting Administrator, Andy Slavitt. Slavitt, while previously leaving the door open for a delay to the outcomes-based program, implied in his blog that the Jan. 1 reporting period start date (which would affect payment adjustments for eligible doctors in 2019) would stay intact, but that other flexibilities would be granted. Although no final rule on MACRA has been published to date, with most healthcare policy experts targeting sometime this fall as when it will come, Slavitt said participating providers will have four pathways to choose from for the first year of MACRA in 2017. These pathways range from sending in only some data to MACRA’s Quality Payment Program, which includes two paths—the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs); to sending in more data but for a reduced period of time; to “going all in” as is. The idea, CMS said, is to allow doctors to choose their pace for easing into a brand new physician payment program full of complexities, while at the same time avoiding negative payment adjustments in 2019.
In an in-depth analysis of the CMS announcement from last week, Healthcare Informatics Editor-in-Chief Mark Hagland cited multiple healthcare association groups, who at the very least, were appreciative of the government’s efforts to ease the burden on Medicare doctors. But what are providers on the ground saying? John David Goodson, M.D., staff internist at Massachusetts General Hospital (MGH) and associate professor at Harvard Medical School, for one, says that CMS’ message was a strategic move to get doctors to be involved in reporting their data starting next year. Goodson notes how the Physician Quality Reporting System, or PQRS, has been around for a long time, “but many doctors decided to take the financial hit rather than comply with it.” He says that the reporting required in MACRA’s Quality Payment Program will require good, solid data which CMS will never get unless they get doctors to buy into the reporting mechanisms. As such, the pathways laid out by the federal agency are attempts to at the least, get the community of providers engaged at a minor level, Goodson says.
Goodson adds that much of MACRA is baked into Congressional law, and the government is ready to move forward with physician payment adjustments based on quality beginning in 2019. As such, “Congress doesn’t have an appetite for readdressing this program,” Goodson attests. “They want to see this played out, as value-based payment has become so universally accepted,” he says. He adds that at some point, doctors will have to make the choice between staying in Medicare or getting out. “There is a fear that this whole system will implode because doctors won’t want to play this game anymore. They think it’s too demanding and crazy.” However, Goodson believes that in the end, most providers want to partake in Medicare, and the key will be to be able to obtain the meaningful data that these programs under MACRA will inevitably require.
Weighing the Options
Meanwhile, on the policy front, Mari Savickis, vice president of federal affairs at the Ann Arbor, Mich-based College of Healthcare Information Management Executives (CHIME), is pleased with the flexibilities announced by CMS, noting that it shows that the agency is “listening and reacting” to provider concerns. “Anything that points in the direction of increased flexibility for providers so that they would avoid financial penalties is a good thing from our perspective,” says Savickis.
Savickis herself won’t rule out a delay to the start of the program still, as last week’s news came in the form of a blog post rather than an official final rule. “We appreciate that they want to make sure the program is a success, but you have to operate within the parameters of reality, she says. “Finalizing a rule so close to the end of the calendar rule makes it incredibly hard for vendors and providers to meet a full year of reporting.”
Savickis notes the possibility that CMS is using the pathway flexibility in lieu of saying that providers don’t have to start reporting right away. “It’s an option,” she says, referring to the pathways that will allow providers to either “submit some data to the Quality Payment Program, including data from after Jan. 1, 2017,” or “submit Quality Payment Program information for a reduced number of days,” as outlined by CMS. Savickis says, “Obviously your ability to obtain a higher incentive payment would be mitigated if you can’t report to anything or start right away. It’s possible that this is their solution to the full-year reporting period.”
Tom Lee, Ph.D., founder and CEO of Chicago-based consulting and software firm SA Ignite, who is as familiar as they come regarding health IT reporting requirements and regulations, agrees with Savickis on the intent of CMS. In an emailed response, Lee notes that for “incentive seekers,” the true start date for MACRA is indeed Jan. 1, 2017. “For providers choosing the first option (some data) or the second (partial year), there effectively can be a later start to the performance period,” he says. That’s why, Lee says, the CMS announcement is good for providers in a "penalty-avoidance" mindset by providing more flexible means to avoid penalties.
Navigating the Road Ahead
Regarding the overwhelming concern for small and solo practices’ ability to survive under MACRA—as discussed at length during a Congressional hearing this summer—Goodson isn’t buying the narrative of fear that’s being portrayed. While he acknowledges that he is part of a larger enterprise at MGH, Goodson says that MACRA is only deadly for small practices “if they let themselves be intimidated.” He says, “The guys who run the little practices are agile, inventive and autonomous. They know how to get things done. I live within an enterprise and it drives me crazy sometimes. They just don’t know how to steer this large battleship. [Conversely], the little guys are able to move quickly.”
Goodson notes that the smaller practices also have more equity in their patient panel, leading to good will and trust, which is the way to save money in healthcare, he says. “Trust allows you to use time as a diagnostic tool and a therapeutic intervention. So if you’re close to your patients, live in the community, and have a relationship with them, you can be a high quality, low cost provider.” Goodson adds that the key thing for these small practices is to have complete control over their data. This means that they know exactly who their patients are, what their problems and medications are, and what all their diagnostic codes are, so every single thing that has been identified as a problem with the patient maps to an ICD code.
Nonetheless, John Squire, president and chief operating officer of Amazing Charts, a West Warwick, R.I.-based electronic health record (EHR) software vendor, is less confident in small practices’ ability to succeed under MACRA. Squire, whose company’s provider clients are mainly in the 1 to 10 practice size range, says that most of them aren’t the least bit familiar with MACRA’s rules. He notes how many of them don’t have an IT staff, so no one is perusing the latest CMS regulations, meaning they only hear about them over time from physician association groups. “We are focused on educating these practices since they’re simply not ready,” Squire says. “CMS has a long way to go in terms of educating small practices,” he adds.
Goodson notes another concern of providers: a fear that the system will be “gamed,” meaning people are worried they might not be able to play the game as well as their peers. He explains that there is a lot of fear around attribution and risk adjustment—two issues not brought up at all by Slavitt. Regarding attribution, Goodson ponders, “How will we as providers know who we are responsible for and held accountable for?” And for risk adjustment, he notes, “People worry so much about cherry picking, so if I deal with a complicated group of patients, will I be judged against someone who selects a much less demanding group of patients? If that happens, if people figure out how to cherry pick the system, things could start to melt down,” Goodson speculates.
In the end, how can providers best use this breather offered by CMS? Goodson says that uncertain doctors need to find expert help and get the tools to survive. “You need to know how to use the existing service codes within Medicare that are high value service codes—so the wellness visits and the transitional care management codes in particular—because if you’re not using them, you’re giving away work you should be getting paid for,” he says. “You also need to be able to manage your patients, and keep track of data for your patients. This involves developing systems that allow you to have workstations or dashboards so you can look at all your patients who have given conditions, be able to identify patients who have needs, and then do something on the basis of that.”
SA Ignite’s Lee adds that if an organization “falls too behind on the MIPS performance treadmill that starts and accelerates in 2017,” then, when the "real competitive game" starts the following year in 2018, “wherein winners take more money from losers, an organization could see large negative financial impacts by being too far behind competitors in terms of the MIPS score.” As such, for "penalty avoiders,” as Lee calls them, who are choosing one of the reduced participation options in the first year, he advises to “be cognizant that 2017 is still one where continual MIPS performance improvement is critical as there is currently no plan to provide relief for 2018.”