Should CMS Delay Implementation of MACRA?

Thursday, July 21, 2016 | Larry Sobal

Last week, the Centers for Medicare and Medicaid Services’ (CMS) Acting Administrator Andy Slavitt stated that the agency may delay the implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which is currently set to begin Medicare payment reform on January 1, 2017. Slavitt was testifying to the Senate Finance Committee that public comments during the MACRA comment period indicated a need for special consideration for small, rural and independent practices likely to struggle with implementing the new rules. “The focus on small independent practices and their ability to continue practicing independently is a very important priority for us,” Slavitt said.

I should assume that anyone working in health care is already acutely aware of MACRA; however, that is not necessarily a safe assumption, as a recent survey by Deloitte's Center for Health Solutions found that only one in two non-pediatric physicians said they had ever heard of MACRA.

That’s an alarming statistic, given that in less than six months, the pending MACRA rules will start determining how physicians get paid in 2019. Therefore, let me offer a quick breakdown of MACRA. On Wednesday, April 27, CMS released the highly-anticipated proposed rule that would establish key parameters for the new Quality Payment Program, a framework that includes the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). These policies were among the provisions in what can best be described as an overly-complex 962 pages. CMS received more than 4,000 formal comments leading up to the close of the 60-day comment period on June 27.

As things stand, the final rules for MACRA are slated to be published November 1, with implementation on January 1, 2017, giving providers just two months to learn and implement these complex set of rules. As noted above, beginning January 1, physician performance will begin determining whether those physicians who namely see a fair share of Medicare patients in their practices will be penalized or rewarded via Medicare reimbursement in 2019.

If you are a pediatrician, you probably don’t care. For the rest of you, if you are seeking further information on MACRA, please refer to my blog posts from March 31 and May 5, where I offer some insights regarding MACRAnomics 101. MedAxiom also has prepared a comprehensive resource site related to MACRA that can be accessed here.

Let’s get back to the key question. Should MACRA be implemented as planned or delayed? MedPage is actually conducting an online poll where you can even vote for a third option, to dump it altogether. As of the day I was writing this (July 17), “dump” was ahead by a wide margin.

An argument for not delaying MACRA can be made in that it combines three existing (and confusing) programs: the Physician Quality Reporting System (PQRS), the Value-Based Payment Modifier (VBM), and Meaningful Use (MU), along with a new program—clinical practice improvement activities—into a single program, MIPS. That consolidation has the potential to be a good thing. 

Of most importance is that MACRA would avoid Meaningful Use Stage 3. I feel that Meaningful Use has been a wasteful and ineffective disaster from the onset. Although it is not yet clear what aspect of Meaningful Use will survive in the final MACRA rule, my hope is that it is dropped altogether. After all, with a much clearer set of specific quality and cost objectives (PQRS and VBM), MU is no longer needed and gets in the way of more valuable initiatives. Avoiding Meaningful Use Stage 3 is the only logical reason I can think of for moving ahead with MACRA.

The reasons to delay MACRA are far too compelling. I can only believe that Andy Slavitt was being diplomatic in his comments. In reality, he should have said that, aside from being just slightly less confusing than the Affordable Care Act, MACRA reforms are too complex, too onerous on small and solo practices, and lack opportunities for many physicians to participate in alternative payment models. In fact, that’s a good summation of what many of the 4,000 comments about MACRA revealed.

There are some good concepts included in MACRA, but they need further simplification, a longer phase-in period, and additional flexibility to have less impact on small—and large—physician practices.

There are some good concepts included in MACRA, but they need further simplification, a longer phase-in period, and additional flexibility to have less impact on small—and large—physician practices.

So Andy, while I criticized CMS pretty hard in my blog last week (for many CMS efforts you had nothing to do with), I see this as your chance to do the right thing. Slow the MACRA train down and win some huge brownie points by listening and acting on the messages that many have taken the time to send you. Delay, reorganize, and win friends and influence people in the process.

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Larry Sobal is Executive Vice President of Business Development at MedAxiom. He has a 35-year background as a senior executive in medical group leadership, hospital leadership and insurance. As part of his current role, Larry consults, writes and presents on topics relevant to transforming physician practices and health systems.

 

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