Industry Groups React to Final MACRA Implementation Rule

October 20, 2016 - In the week that the healthcare industry has had to digest the 2,400-page final MACRA implementation rule, many industry groups have come forward to express support for the rule, especially attestation flexibilities, while others have challenged MACRA provisions, such as its Advanced Alternative Payment Model (APM) and small practice support policies.

Under the MACRA implementation rule, CMS finalized flexible attestation tracks for Quality Payment Program participation in 2017. The flexible options range from testing the new value-based reimbursement program by submitting some data to the Merit-Based Payment Incentive System (MIPS) to fully participating in an Advanced APM.

CMS stated that eligible clinicians can avoid a four percent reduction in Medicare payments in 2019 by submitting at least some data to MIPS, but they could earn upwards of four percent in value-based incentive payments by reporting more data.

Many healthcare industry groups stated that using 2017 as a transition year into the Quality Payment Program through flexible MACRA attestation options will help eligible clinicians better understand and succeed under new value-based reimbursement models.

One such group was the American Medical Informatics Association (AMIA), which commended CMS for developing a flexible program that accommodates the needs of all providers.

“CMS has crafted a set of policies that are strategic, flexible and reflective of feedback from the informatics community,” said Douglas B. Fridsma, MD, PhD, FACMI, FACP, AMIA President, in a  statement. “AMIA recommended that CMS provide physicians with an on-ramp to participation in 2017 and they have responded with a strategy that will do just that. Beginning with a much-needed ‘transition year’ for participation, and inclusive of an across-the-board reduction in scope, this final rule with comment period will ensure that success is within reach of every eligible clinician.”

The Medical Group Management Association echoed AMIA’s sentiments, but voiced disappointment that the flexible participation options would only last for a year.

“MGMA 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,” stated Halee Fischer-Wright, MD, MMM, FAAP, CMPE, MGMA President and CEO, in an emailed statement. “It’s disappointing that flexibility provided for quality reporting in 2017 largely disappears in 2018 and beyond.”

On the other hand, the American Medical Group Association (AMGA) stated that flexible attestation tracks would unfairly penalize prepared providers.

“We remain concerned, however, that in its understandable desire to provide flexibility, particularly as the program begins, CMS does not adequately recognize or reward the providers and systems who have made the investments to improve quality and decrease costs,” stated Donald W. Fisher, PhD, CAE, AMGA President and CEO, in a press release, “We believe rewarding performance should be based on the value provided, not on size of the practice.”

AMGA also argued in September that flexible attestation tracks might compromise financial rewards for providers that have already implemented the necessary value-based care capabilities to succeed under the Quality Payment Program. The organization advised CMS to ensure that all eligible clinicians are assessed equally for performance.

While some stakeholders favored a transition year, other groups were less enthusiastic about Advanced Alternative Payment Model (APM) provisions. CMS stated in the final rule that it is considering adding more Advanced APM options, such as some Medicare Shared Savings Program Track 1 participants and other payer models. However, the federal agency will not release a finalized list of approved models until Jan. 1, 2017.

The American Hospital Association (AHA) was discouraged that CMS did not expand Advanced APM participation in the final rule.

“While we are disappointed that CMS continues to narrowly define Advanced Alternative Payment Models, which means that less than ten percent of clinicians will be rewarded for their care transformation efforts, we are encouraged that CMS is exploring a new option that would expand the available advanced APMs that qualify for incentives,” Tom Nickels, AHA Executive Vice President, said in a press release.

The AHA was also concerned that “lack of sociodemographic adjustment to the measures used in the MIPS will unfairly disadvantage clinicians and hospitals caring for the poorest patients.”

In addition, Premier Inc, a healthcare improvement company, contended that financial risk structures under Advanced APMs in the final rule would burden providers and limit participation in the value-based reimbursement track.

In a statement on its website, the organization wrote:

“Although CMS eased the policy defining the Advanced APM to allow additional programs to qualify and has signaled it will increase the number of available models, the nominal risk standard remains way too high. As we have learned from members in our Bundled Payment and Population Health Management Collaboratives, these models require significant investment in redesigning care through new technologies, data analytics, and additional staff. CMS has chosen to ignore these realities. We call on CMS to rethink this risk standard in future rules to incent greater participation.”

Some industry groups also voiced concerns for small practices participating in the Quality Payment Program, especially since the final rule would not implement virtual groups until 2018. CMS developed virtual groups to allow small practices to band together for quality reporting and scoring, but the federal agency has not yet developed a pathway for virtual group implementation.

Premier Inc called on CMS to “accelerate recognition of ‘virtual’ physician groups that would allow small practices to band together using technology to meet the minimum thresholds and comply with reporting requirements.”

Health IT Now, a coalition of patient groups, provider organizations, employers, and payers, also urged the federal agency to overcome technical difficulties with developing virtual groups and implement them as soon as possible.

“We recognize that part of the problem may lie with the CMS legacy IT system, which some suggest are incapable of performing many functions that are commonplace among IT systems today,” Robert James Horne, Health IT Now’s Executive Director wrote in a letter to CMS. “While we believe it imperative that Congress work with the administration to identify ways that the CMS computer systems can be updated to increase Medicare’s efficiency and reduce costs, we do not believe such a barrier need impact the effectiveness of the virtual group concept.”

Despite some pushback on MACRA’s provisions for small practices, the American Academy of Family Physicians applauded CMS for fostering small practice participation in the Quality Payment Program. The organization commended the federal agency for appropriate MIPS exclusion thresholds, which will allow small practices to prepare for the Quality Payment Program without facing financial penalties, and additional financial support for technical assistance.

CMS is accepting comments on the final MACRA implementation rule for the next 60 days.

Dig Deeper:

• CMS Timelines for Stage 3 Meaningful Use, MACRA Implementation

• Impact of Quality Payment Program on Medicare Reimbursement