The MACRA QPP 2018 Final Rule: Is It a Glass Half-Empty or a Glass Half-Full?

Nov. 7, 2017
What one thinks of the QPP CY 2018 final rule could depend at least partly on a number of factors, including where one “sits” in the healthcare stakeholder constellation—and what one might have to do to respond to it, as a result

The release last Thursday by the Centers for Medicare and Medicaid Services (CMS) of the final rule for the Quality Payment Program (QPP) for calendar year 2018 under the MACRA (Medicare Access and CHIP Reauthorization Act of 2015) law—including its MIPS (Merit-based Incentive Payment System) component—has unleashed a predictable mix of reactions and responses from healthcare leaders and organizations.

Many are upset at the 365-day reporting period for cost and quality, while others are delighted at the exceptions being made for low thresholds of Medicare participation, and for the numerous provisions allowing for the participation of “virtual groups.” And various responses have been elicited around the gradual ramping up of cost as a proportion of total scoring for participating physicians.

In fact, Jeff Smith, vice president at AMIA (the American Medical Informatics Association), told Associate Editor Heather Landi, “There weren’t a whole lot of surprises” with the final rule. “When you focus on the quality payment program in MIPS, I think CMS telegraphed that they want to provide much more flexibility and are looking for ways to make the program more feasible for docs, and I think the final rule really does follow through with that intention.”

Meanwhile, Adaeze Enekwechi, Ph.D., vice president of McDermott + Consulting, a Washington, D.C.-based healthcare consulting firm, who previously worked at the White House Office of Management and Budget (OMB) under the Obama Administration as the associate director for health programs, told Landi that CMS designed year 2 of the MACRA QPP as a gradual ramp-up to full implementation in 2020.

Per that, Tom Lee, Ph.D., CEO of the Chicago-based SA Ignite consulting and software services firm, told Managing Editor Rajiv Leventhal that he believes that, by raising the cost category weight in MIPS to 10 percent in 2018—from 0 percent in the proposal—and then to 30 percent in 2019 (which is mandated in the MACRA law), government officials are telling clinicians that “they are very serious about the cost category.” As he put it, “If they kept it at 0 percent for next year, it would be a disservice to clinicians since they won’t have the right level of motivation to take a close look at that category.”

Some industry leaders had complicated, multi-factorial reactions to the various elements in the final rule. For example, Mari Savickis, vice president of federal affairs for CHIME (the Ann Arbor, Mich.-based College of Healthcare Information Management Executives), told Leventhal, as they both were participating in the CHIME Fall Forum in San Antonio last week, as the news broke, that CHIME likes some aspects of the final rule, and dislikes others. On the one hand, she said, “The ability to keep using 2014 CEHRT [certified electronic health record technology] is a big deal for our members. That syncs up with what CMS finalized for hospitals and it gives clinicians more time [to implement 2015 CEHRT]. It also means that when you look at the ACI category, that’s the part that revolves around 2014 CEHRT. So that means that the transition measures under MIPS (modified Stage 2 ‘like’ measures) are still intact for another year. This is what we advocated for and supported.”

On the other hand, she and her colleagues at CHIME were disappointed that the cost category in MIPS will go up from a 0-percent weight in the interim rule, to a 10-percent weight in the final rule, calling that change “a significant concern.” CHIME is also very concerned about the shift to a full-year reporting period for cost and quality. “Yes, there are some clinicians out there who can report for a full year, but making it mandatory is not supported,” she said. “It should be voluntary.”

Still, for all of the challenges, John Halamka, M.D., the CIO of Beth Israel Deaconess Hospital in Boston, and an industry luminary, told Leventhal that that his comments on previous iterations of the rule were based on its incredible complexity, which he now sees as having been refined significantly. “There are now so many exceptions for who has to participate and what they have to do, and there is so much more choice involved. The [regulation] isn’t quite the nature of how it used to be,” he said. “I believe that most practices can either say that they simply won’t participate; or they will be exempt; or the practices will participate and just focus on two or three things. So that is what has changed.”

So, what to make of these diverse reactions to the content of the final rule? Overall, it seems that CMS officials ended up landing somewhere in the middle on numerous decisions, making reasonable judgments about the “ramp-ups” on the weightings of various factors, while also judging issues around CERHT with discernment. The one element around which most industry leaders have reacted uniformly negatively has been around the issue of the 365-day reporting period for cost and quality, versus what could instead have been a 90-day reporting period. One could make arguments in both directions around this, but it does seem clear to me that a full-year reporting period will be quite burdensome to the majority of physicians in practice, even given CMS’s justifications.

Out of fairness, I’m going to quote one piece of the final rule, in which CMS officials respond to concerns about full-year reporting. They wrote, “We understand the commenters’ concerns” regarding the performance period issue. “However, we believe that it would not be in the best interest of MIPS-eligible clinicians to have less than a full calendar year performance period for the quality and cost performance categories, beginning with the 2021 MIPS payment year, as we previously finalized… a full calendar year performance period for the quality and cost performance categories for the 2020 MIPS payment year, which will occur during CY 2018. By finalizing a full calendar year performance period for the quality and cost performance categories for the 2021 MIPS payment year, we are maintaining consistency with the performance period for the 2020 MIPS payment year. We believe this will be less burdensome and confusing for MIPS-eligible clinicians. We also would like to note that a longer performance period for the quality and cost performance categories will likely include more patient encounters, which will increase the denominator of the quality and cost measures. Statistically, large sample sizes provide more accurate and actionable information.”

The CMS officials go on to state that “Additionally, the longer performance period (a year) is consistent with how many of the measures used in our program were designed to be reported and performed, such as Quality #303 (Cataracts: Improvement in Patient’s Visual Function within 90 days Following Cataract Surgery) and quality #304) Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery). Finally, some of the measures do not allow for a 90-day performance period (such as those looking at complications after certain surgeries or improvement in certain conditions after treatment). In regards to the recommendation of providing bonus points to MIPS-eligible clinicians that report for a performance period longer than 90 days, we believe a more appropriate incentive is for MIPS-eligible clinicians to performance on a full year so that they have the ability to improve their performance due to having a larger sample size, etc. We also understand the commenters’ preference of a 90-day performance period, so that there is adequate time to update systems and train staff. We agree that adequate time is needed to update systems, workflows, and train staff. However, we note that the quality measures are finalized as part of this final rule, and the specifications are published on our website by no later than December 1 prior to the performance period.”

The explanation goes on, but the gist of it seems to be that CMS officials believe that the value of robustness of data will outweigh the hassle factor for practicing physicians.

I’m not so sure. Because truly, for many practicing physicians, the year-long reporting period will indeed prove a source of frustration, and even resentment, at CMS. And is that really what CMS officials want, at this moment in the forward evolution of the QPP program?

We’ll have to see how all this plays out. Perhaps physicians will simply become accustomed to all these elements. But I would hope that CMS’s calculations on all these elements turn out to be the right ones, because there is a level at which federal healthcare officials need some level of goodwill from practicing physicians.

In any case, all of these elements will be very important for healthcare IT leaders, as they increasingly become drawn into physicians’ practice issues, because of all the reporting elements in MACRA/MIPS. So going forward, there will be no “down time” for CIOs, CMIOs, and all their colleagues, as they move forward, hopefully rapidly and skillfully, to support their salaried and affiliated physicians to meet the requirements under a law that will inevitably transform in many ways conceptual and practical, how physicians practice medicine in the second and third decades of the 21st century. And in that, there is some certainty: the certainty that the forward evolution of the implementation of the MACRA law will mean definite additions to the to-do lists of CIOs, CMIOs, and all their colleagues in healthcare IT and clinical informatics.

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