MACRA Final Rule Expected Soon: What are the Considerations?

Oct. 11, 2016
With rumors swirling that the MACRA final rule could drop from CMS sooner rather than later, now is a good time to take a look back at what was proposed and what key elements might be changed.

With rumors swirling that the Medicare Access and CHIP Reauthorization Act (MACRA) final rule could drop from the Centers for Medicare & Medicaid Services (CMS) sooner rather than later (a source close to Washington D.C. has told Healthcare Informatics that the rule could come down as early as Oct. 11 and probably no later than next week), now is a good time to take a look back at what was proposed and what key elements might be changed.

As the industry knows already, CMS last month announced flexibilities that will allow eligible Medicare physicians to pick their pace of participation for the first performance period of the outcomes-based program that begins Jan. 1, 2017. CMS Acting Administrator, Andy Slavitt said in a blog post announcing the program flexibilities that 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. But even with these flexibilities in place, there is more to consider regarding what might change from the 962-page proposal to the final rule.

Timing—Given the four paths that participating providers could choose from, there are different timelines in place for program involvement in 2017. As reported in a story last month from Healthcare Informatics, policy experts noted that physicians do not have to start reporting right away on Jan. 1 if they choose the either of two pathways that allow them to “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.” Essentially speaking, this is a “delay” without using the word. But, as Tom Lee, Ph.D., founder and CEO of Chicago-based consulting and software firm SA Ignite, said in that same story, “For ‘incentive seekers,’ the true start date for MACRA is indeed Jan. 1, 2017.” Indeed, while physicians and healthcare associations have asked for a delay to MACRA since the release of the proposed rule, most of the timeframe questions have likely been put to bed with CMS’ announcement last month.

Concern for small practices—There has been no shortage of conversation about solo and small practices’ ability to thrive, and even survive, under MACRA’s rules. 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. In a projection of what’s to come regarding payment adjustments, CMS estimated itself in the proposed rule that 87 percent of eligible solo practitioners and 70 percent of practices with two to nine physicians could get hit with a negative payment adjustment early on in the program. In terms of dollars, these negative hits could be in the range of $100 million to $300 million.

So what could be done to help these types of practices? During a Congressional hearing in May, Slavitt provided further detail on how CMS plans to help out smaller practices, noting that if they are already participating in clinical data registries, for example, that can be used for MIPS rather than requiring physicians to send information in again. Also, he said, “Small practices can report in groups in many categories where they weren’t able to before, and others won’t have to report at all if they don’t meet the minimum Medicare threshold for patients.” In another hearing in June, Slavitt said that the creation of virtual groups is something the agency has received significant feedback on, although that wouldn't take place until 2018.

Nominal risk—The MACRA proposed rule calls for the streamlining of various quality reporting programs into a single framework. It does this by guiding providers down one of two paths—MIPS or APMs. Most policy folks expect the overwhelming majority (90 percent or more) of eligible doctors to choose the MIPS path as the two-sided risk models as part of the advanced APM track are very aggressive for many. Simply put, the APM path is a huge gamble for many organizations who are not set up well to be in danger of losing money as a result of poor quality performance.

But for those who are ready for the advanced APM track, they must bear “more than nominal financial risk.” The Charlotte, N.C.-based Premier Inc., for one, has taken issue that CMS did not include any bundled payment models or Track 1 Medicare Shared Savings Program (MSSP) ACOs as qualifying advanced payment programs under MACRA. Under Track 1, CMS and the participating ACO will reconcile savings and allow the ACO to share in those savings without the risk of the ACO sharing in any losses. In other words, this single-sided model only has upside—no downside for the ACO. Blair Childs, senior vice president, public policy for Premier, has told Healthcare Informatics that he hopes CMS will rethink the proposed rule in terms of who they will recognize as qualified APMs as Track 1 ACOs have still made real investments to take on risk. Other organizations have done the same. During the recent National Association of ACOs Summit, CMS officials hinted at this change could be in store.

Reduced complexities and reporting periods— The American Medical Informatics Association (AMIA) and others have called for the simplification of reporting burdens and to improve chances of success by creating more opportunities for partial credit and fewer required measures within MIPS. Groups have also called for the reduction of thresholds for reporting on quality measures. The Congressional Doctors Caucus recently urged CMS to make MIPS far less complex. It noted that as proposed, many physician practices would have to “expend finite resources on measuring and monitoring their performance on at least 22 measures." The letter to the agency added, “In order to be successful, MIPS must engage clinicians with a reporting system that is not overly burdensome, a scoring system that is simple and transparent, attainable thresholds, and a short enough quality/payment feedback loop to allow physicians to learn to and make necessary changes to avoid further penalty.”

What’s more, the lawmakers, and others, have asked for a 90-day reporting period for the Advancing Care Information (ACI), which replaces the Meaningful Use program for Medicare physicians, for at least the first year of MIPS. This is something the feds have granted in the past for the MU program, but have waited until the last minute to do so. Further regarding the ACI program, the College of Healthcare Information Management Executives (CHIME) has asked CMS not to require Stage 3 attestation any earlier than the 2019 reporting year.

Data blocking—CHIME further took issue with data blocking monitoring. MACRA requires both clinicians and hospitals to attest they are not “data blockers,” while CMS calls on providers to demonstrate that they have not knowingly and willfully taken action (such as disabling functionality) to limit or restrict the compatibility or interoperability of certified EHR technology. However, CHIME has called for modifications to the data blocking attestation statements.  The group has said that CMS’ proposal, as outlined in the regulation, “does not recognize the limitations of current technology, regulatory barriers, and challenges some resource-strapped providers face,” in its continued push for better patient identification across healthcare.

Regarding the attestation on the part of providers, CHIME has said that “If providers are being asked to attest that they have been compliant with the standards applicable to exchange information, it’s imperative that such standards are clearly defined and appropriately matured to facilitate meaningful data exchange.” CHIME’s comments continued, “Because the work underway at the Office of the National Coordinator for Health IT (ONC) to tackle these challenges is not yet complete, CMS is inadvertently asking providers to attest to more than they reasonably can at this time. The attestations in the final rule should be modified to recognize this.”

Healthcare Informatics will have more coverage on MACRA once the final rule hits.