The MACRA Final Rule: More Options for MDs, More To-Do’s for IT Leaders

Oct. 18, 2016
Initial responses to the release of the MACRA final rule have mostly been positive—and in any case point to more to-do’s on the to-do lists of healthcare IT leaders

In his excellent reaction story published on Monday, our Managing Editor, Rajiv Leventhal, was able to reach a broad range of healthcare association leaders regarding the news that came out of the Centers for Medicare and Medicaid Services (CMS) last Friday, with its release of its final rule under the MACRA (Medicare Access and CHIP Reauthorization Act of 2015) law, one of the most highly anticipated regulatory releases in the healthcare industry in years.

As Leventhal noted in his article today, a large number of adjustments were made to the proposed rule before the Oct. 14 release of the final rule, many of them apparently in response to stakeholder feedback, “as provider-led associations pushed the government to: reduce burdens, help ease them into the new program, lower risk thresholds for what qualifies as advanced alternative payment models (APMs), and provide plenty more flexibilities so smaller physician practices don’t get penalized for not having the tools or resources to thrive under MACRA.”

Indeed, as we reported last week, CMS Acting Administrator Andy Slavitt and CMS Principal Deputy Administrator and Chief Medical Officer Patrick Conway, M.D., both referred to industry input when they briefed reporters on the final rule in a telephonic press conference on Friday. “The policy we’ve finalized is the result of a user-driven policy effort, where our staff put down our pens and went into the field to hear from physicians and patients,” Slavitt told reporters last week. “Overall, many of us traveled the country and received more than 4,000 comments on our proposed rule, and nearly 100,000 people attended our outreach sessions. This was a good opportunity for us to understand the realities of practices today and what we can do to best support care for their patients, how Medicare and other payers interact with their daily practice, how much time they spend on reporting requirements and how burden takes time away from the practice of medicine.”

Moving from volume to value--with transitions

Some provider associations expressed a mix of cautious optimism, sometimes mixed with mild criticism. For example, the Englewood, Col.-based Medical Group Management Association (MGMA) released a statement that said that it is “pleased with the significant burden reduction for physician practices in the first year of the MIPS program and new alternative payment model options outlined in the final rule. It’s disappointing that flexibility provided for quality reporting in 2017 largely disappears in 2018 and beyond,” the MGMA statement continued. “The Centers for Medicare & Medicaid Services missed an opportunity to close the two-year gap between the measurement and payment periods, which would facilitate improved patient care by providing actionable feedback to physicians and more timely incentives.”

But Farzad Mostashari, M.D., the former National Coordinator for Health IT, in an interview with Leventhal, disagreed with the MGMA’s assessment. Dr. Mostashari believes that much of the flexibilities granted in the final rule essentially make both 2017 and 2018 “transition years.” As he told Leventhal, “They would do rulemaking in 2017 to see what 2018 will be like. I tend to be in the camp that feels you don’t want to push everything back; there should be rewards for the early majority and first movers. You wouldn’t want to see this increased flexibility come at the expense of those who are ready to go more aggressively. They will have to balance that,” he added.

Meanwhile, the Washington, D.C.-based Advisory Board Company released a statement applauding the relief that the Final Rule afforded in the first year. “Most—if not all—clinicians should be able to avoid a negative payment adjustment for performance year 2017. CMS proposes three options for providers subject to MIPS [Merit-Based Incentive Payment System] in 2017, the easiest of which providers can meet by reporting a single metric. CMS has also raised the low-volume threshold, exempting more small practices from MIPS,” The Advisory Board’s statement read.

There are also specialist physician perspectives, including that of Rasu Shrestha, M.D., the chief innovation officer at the 20-plus-hospital UPMC health system in Pittsburgh. Asked about Dr. Mostashari’s comments on the final rule’s release, Dr. Shrestha, who continues to practice as a radiologist, told me, “Farzad said that MACRA is about moving to a continuum of scoring versus an all-or-nothing system, and I think that’s spot-on. Meaningful use has been about looking at quantity—the numerator-denominator game we’ve been playing. Now we’re actually looking at quality, so there’s a movement and a validation, and a push, for us to actually get to value.”

That concerted push will be very powerful, Dr. Shrestha believes. What’s more, with regard to his own clinical specialty, he told me, “I think this is actually awesome for radiology and radiologists. This basically substantiates a lot of the discussion that radiology has been leading in the last couple of years, moving from volume-based to value-based imaging.” In fact, he said, “I think radiology has also been the bellwether for healthcare on this.”

Indeed, Shrestha says, his one concern is this: “About a third of physicians could be exempted from MACRA. And you can never build a system that can catch everyone and everything, but then, how do we incentivize and allow for that third to move towards the things we’re pushing for, on value? I think that’s the big thing. But otherwise, I think it’s movement in the right direction.”

Some breathing room for doctors—but not infinite outs

Considering all these thoughtful comments, it seems clear that there is a mood of cautious optimism in healthcare right now around release of the final rule for the implementation of MACRA. There is much still to be digested here—the rule itself is, after all, a 2,398-page document—but CMS officials should probably feel relieved that provider leaders feel at least to some extent relieved about the outcome of this rulemaking process, with genuine flexibility, both in terms of the timeline options being given to physicians around how and when they begin to be measured—as well as some breaks in terms of the reduction in the number of measures on which they will be graded going forward.

All that having been said, there is no question that CIOs, CMIOs, and other healthcare IT leaders are going to be hit with a tsunami of to-do’s on their already-overwhelming to-do lists going forward. And, in that context, what Tom S. Lee, Ph.D., founder of SA Ignite, a Chicago-based vendor firm whose software platform is focused on reimbursement analytics, told Leventhal, seemed particularly apropos at this moment.

Asked when asked by Leventhal what he thinks CIOs should be doing right now, given all this, Dr. Lee said, “I think the first thing is what we have continued to hammer home is to get educated about this final rule, especially the c-suite. The c-suite has even more reason to make budgetary and staffing decisions based on what’s in the Final Rule compared to what was proposed. Second,” he said, “is try to estimate what your MIPS baseline score based on the rules in the final rule. You can leverage your existing PQRS [Physician Quality Reporting System] and meaningful use data to get a read on Quality and ACI, which are now 85 percent of the score since they set cost equal to 0 percent under MIPS. Also, look at what practice improvement activities seem attractive to you.” Above all, he counsels, “Avoid complacency in 2017, even though it’s a transition year, [as] the majority of those relaxation points will disappear in 2018, and it will go back to how it was originally planned. That treadmill is continuing to accurate, so if you jump on the treadmill that’s already moving fast in 2018, you will get swept away by your competition.”

And I think that pretty much says it all when it comes down to what healthcare IT leaders should take away from the release of this final rule. Because if ever there was a clear bottom line for healthcare IT leaders in a policy and payment situation it is this one: it now is time for CIOs and other healthcare leaders to plunge fully into understanding a major policy and payment change, and to prepare their organizations to react to it. And that particularly means preparing to help physicians move forward under this new reimbursement regimen, because its implications are vast and extremely important for U.S. doctors—and for everyone in healthcare.

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