Making MACRA better, in intent and implementation

Congress, in enacting the Medicare Access and CHIP Reauthorization Act (MACRA) last year by huge bipartisan majorities in both the House and Senate, expressly intended for Medicare to reduce the burden on physicians and their practices associated with reporting on measures while bringing greater value—better care at lower cost—to patients. Congressional intent is one thing, but implementation is another.

Will CMS actually implement the law in a way that truly simplifies reporting, or will it just replicate the current flawed approach of requiring physicians to report on poorly designed and burdensome measures that do not help improve patient care? As I wrote in this column last issue (“Setting the record straight on MACRA,” ACP Internist, July/August 2016), MACRA makes significant improvements in how Medicare links payment to reporting of quality measures. They include:

• consolidating the currently “siloed” Physician Quality Reporting System (PQRS), Meaningful Use, and Value Modifier programs into 1 reporting program, called the Merit-Based Incentive Payment System (MIPS),
• adding a new category, Clinical Practice Improvement Activities, that would recognize physicians' own efforts to improve care in their offices,
• giving physicians the opportunity to earn positive adjustments rather than at best avoiding cuts, and
• providing multiple opportunities for physicians in medical homes and other alternative payment models (APMs) to earn bonus payments.

CMS's proposed MACRA implementation rules suggest that the agency wants to get to a place where quality reporting is better and easier, but when it gets down to the specifics, it's not quite there yet. ACP, in its comments on the more than 900-page proposed rule, recommended dozens of improvements to simplify the MIPS program and provide more choices and opportunities for physician-led APMs. Our recommendations included the following:

Push back MIPS reporting. CMS proposed that physicians begin reporting on measures starting on Jan. 1, 2017, even though its final rule likely won't be published until late October or early November. Giving physicians 60 or so days to get ready to successfully participate in MIPS isn't realistic or reasonable, we told CMS. Alternatively, we proposed that the initial reporting period begin no earlier than July 1, 2017.

Simplify reporting. ACP proposed an alternative, less complicated scoring methodology for quality reporting that, unlike CMS's overly complex proposal, would allow physicians to readily know in advance how their proactive efforts to improve quality, use health information technology, and implement practice innovations would affect their overall performance score and Medicare payments. We proposed other specific changes to reduce the burden of reporting. In addition, we offered ways that practices could be “certified” as patient-centered medical homes (PCMHs) in addition to getting accredited by the National Committee for Quality Assurance, URAC, or The Joint Commission, such as being recognized for participating in Medicaid or private-payer PCMH programs. Under MACRA, certified PCMHs will automatically qualify for the highest possible score for clinical practice improvement activities, 1 of the 4 categories to be assessed under MIPS.

Revamp Meaningful Use reporting to ensure clinical relevance. Although CMS proposed a new Advancing Care Information program to replace the current Meaningful Use rules for electronic health records, it still relies too much on requiring physicians to do check-box reporting on activities with little or no benefit. Our alternative would make it easier for physicians to report on and be successful in this category and would help ensure that health information technology is used in a way that is clinically meaningful to physicians.

Help small practices. ACP urged CMS to create safe harbors that would protect smaller practices of 9 or fewer clinicians from any negative payment adjustments until there is an option to join together with other small practices to report quality data to CMS. Under our alternative, smaller practices could still qualify for positive adjustments.

Expand options for physician-led APMs, like medical homes. ACP proposed multiple options so that medical homes nationwide could qualify as APMs, in contrast to CMS's proposal, which limited the number of medical homes that would qualify as APMs to only 5,000 practices in 20 communities. If our proposal is accepted, tens of thousands more primary care practices across the country potentially could qualify for a 5% Medicare bonus payment, plus other enhanced payments. ACP urged CMS to make additional APMs available for physicians in all specialties, including internal medicine subspecialties.

We won't know until the final rule comes out whether CMS accepts most of ACP's recommendations. However, if it does, MACRA will live up to its billing of providing more options to recognize and support physicians' efforts to improve care to their patients, reducing the administrative burden associated with quality reporting, and creating more opportunities for physicians to develop and lead new models of delivery and payment, like PCMHs, all while bringing greater value to patients and the Medicare program.