Value-Based Care News

As MACRA Implementation Turns 2, Industry Leaders Call for Change

At a hearing on MACRA implementation, industry leaders from the AMA, AMGA, and more called for greater incentive payments and streamlined quality reporting.

MACRA implementation

Source: Getty Images

By Jacqueline LaPointe

- For the past two years, MACRA has been shifting providers away from fee-for-service to value. But industry leaders still have reservations about MACRA implementation and the law’s value-based reimbursement programs, including the Merit-Based Incentive Payment System (MIPS).

In a recent Senate Committee on Finance hearing, leaders from the American Medical Association (AMA), American Academy of Family Physicians (AAFP), American College of Surgeons, American Medical Group Association (AMGA), and the Brookings Institution shared how providers are making the shift to value under MACRA.

The industry leaders generally agreed that MACRA is a step in the right direction when it comes to eliminating fee-for-service and moving past the Sustainable Growth Rate (SGR) methodology of the recent past.

However, MACRA is not perfect and Congress should update the law’s value-based reimbursement programs to incent meaningful change across providers, the leaders added.

For example, John Cullen, MD, FAAFP, president of AAFP, expressed concerns that MIPS is overly complex for providers, which takes away from patient care.

READ MORE: What We Know About Value-Based Care Under MACRA, MIPS, APMs

“We are concerned that MIPS is created a burdensome and extremely complex program that has increased practice costs and contributed to physician burnout,” he told policymakers. “Understanding the requirements and scoring for each MIPS performance category and reporting the required data to CMS is a complex task and detracts from the physician’s ability to focus on patients.”

Matthew Fielder, PhD, a fellow at USC-Brookings Schaeffer Initiative for Health Policy at the Brookings Institution, added that CMS estimates MIPS reporting to cost providers approximately $482 million in 2019.

“It’s hard to justify incurring these costs for a program that is unlikely to meaningfully improve care,” he said.

Fielder explained that MIPS’ approach to adjusting payments, which is based on clinical or practice-level performance, does not create strong, coherent incentives to improve quality and patient care efficiency. The approach does not account for other providers influencing a patient’s outcomes and allowing clinicians to choose which measures to report on makes quality comparisons impossible, he continued.

Congress should eliminate MIPS in light of the program’s issues, Fielder suggested.

READ MORE: How Can CMS Improve MACRA’s Quality Payment Program, MIPS?

Other industry leaders testifying at the hearing also criticized incentive payments and quality reporting under MIPS but did not go as far as recommending the program’s repeal. Instead, witnesses like Barbara L. McAneny, MD, AMA president, suggested that Congress improve MIPS policies to make the program more cohesive and meaningful to providers and patients. She suggested allowing clinicians to focus their participation around specific procedures, conditions, or public health priorities.

“By allowing physicians to focus on activities that fit within their workflow and address their patient population needs, rather than focusing on segregated activities that fit into the four disparate MIPS categories, the program could improve the quality of care and be more meaningful and less burdensome for physicians,” she wrote in her testimony.

Frank Opelka, MD, FACS, medical director for quality and health policy at American College of Surgeons, also called for quality measure sets in MIPS that align with specialty workflows and care delivery.

MIPS quality measures center around screening, preventive care, and diabetes management, he explained.

“In other words, surgeons receive credit for how well their group practice immunizes a population instead of ensuring a patient has safe surgical care,” he said.

READ MORE: The Pros and Cons of Quality Measure Choices In MACRA, MIPS

Scott Hines, MD, director at AMGA, took issue with MIPS exclusions and incentive payments. CMS has excluded nearly half of clinicians from participating in MIPS in order to ease providers into the value-based reimbursement program.

But the magnitude of exclusions is resulting in “insignificant payment adjustments to high-performers” because MIPS is budget neutral, Hines said. Consequently, high-performing clinicians are only receiving a 1.5 to 2 percent payment increase in 2020 and 2021 rather than the five and seven percent maximum payment adjustments detailed in the original MACRA implementation regulation.

“By excluding nearly half of providers from MIPS, the program has devolved into an expensive regulatory compliance exercise with little impact on quality or cost,” Hines said.

Several other of the witnesses at the hearing also called for greater incentive payments. The AMA urged Congress to replace the upcoming physician payment freeze with annual positive payment updates, so providers are incentivized to make investments in Advanced Alternative Payment Model (APM) participation.

MACRA intends to move as many clinicians as possible to alternative payment models that make providers accountable for patient care. But eliminating the five percent bonus payment that comes with Advanced APM participation will not encourage clinicians to adopt risk-based models, the industry leaders agreed.

“Unfortunately, through the first three participation years – half the time this bonus was to be available – few physicians have had the opportunity to participate in Advanced APMs,” McAneny said. “Consequently, the AMA is urging Congress to extend the Advanced APM bonus payments to fulfill Congress’ original intent and provide support to physicians as they transition to new payment models.”

Fiedler advised Congress to make the five percent Advanced APM bonus permanent, while others called for at least a three- to five-year extension. The bonus encourages clinicians to make long-term investments in alternative payment model participation, the industry leaders agreed.

Congress may even want to consider increasing the bonus amount in a budget-neutral manner to strengthen the program’s incentives and encourage greater participation, Fielder added.

Advanced APM participation rates are not meeting expectations, especially considering MACRA intends for all clinicians to eventually participate in the track, industry leaders explained. Unrealistic and unattainable eligibility thresholds are keeping clinicians from joining an Advanced APM, several of the witnesses explained.

“AMGA members feel that the requirements are unrealistic, unlikely to be met, and will not attract the physicians and medical groups necessary to ensure the program’s success,” Hines elaborate. “In fact, these arbitrary thresholds serve as a disincentive for AMGA members to make the multi-million-dollar investments needed to move to value.”

The AMA recommended that Congress specifically reconsider the payment thresholds set by MACRA for Advanced APM participation.

“Under current law, these thresholds escalate from 25 percent to 75 percent of APM participant revenues over a five-year period. Many APM participants are concerned that these thresholds are too high, especially for episode-based APMs,” McAneny stated.

MACRA is a landmark regulation that breathed new life into the value-based reimbursement transition. The program is tying a significant portion of Medicare payments to patient outcomes, care quality, and costs.

But the regulation’s value-based reimbursement programs are still in their infancy and policymakers should consider updating the programs to ensure MACRA meaningfully changes provider behavior without becoming a check-the-box program.