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The days of summer are winding down, but a refreshed Capitol Hill recently got back to work assessing key pieces of healthcare regulations – and the Centers for Medicare & Medicaid Services (CMS) in turn responded quickly. To that end, representatives within the U.S. House of Representatives’ Ways and Means Committee and the House Energy and Commerce Committee penned a letter to U.S. Department of Health and Human Services (HHS) Secretary Sylvia Mathews Burwell calling for more “flexibility” with implementation of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015.

With concern that there may not be enough opportunities for a clinical pathway to MACRA success, House leaders implored CMS to consider the plight of clinicians, especially within small practices, and to put measures in place that would guarantee that all participants are ready for reimbursement changes. This would illuminate for them a pathway to succeed under the new reimbursement structures before the value-based health law goes into effect on Jan. 1, 2017.

In the letter to CMS, lawmakers stated that “with these principles, we urge CMS to ensure that all physicians and practitioners have an equal opportunity to succeed under the Quality Payment Program.” 

Lawmakers also noted to CMS that several flexibilities, including simplified and streamlined requirements for the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) tracks, were necessary, as were more options for participation in the APM as well as more opportunities for all clinicians to earn value-based incentives for meaningful delivery on system reform activities.

While the House committees stopped short of asking CMS to postpone the launch date of MACRA, based on feedback that many clinicians are already ready to make the switch (many a healthcare industry group and association already has that request for delay covered, for a plethora of reasons noted later), they did state that MACRA would be less burdensome to implement if there was time to adjust to the enhanced requirements within the models, setting them up for greater success than was experienced with previous value-based programs.

Without letting the letter go unanswered, CMS announced late last week that clinicians subject to the Physician Fee Schedule (PFS) may select an appropriate level and pace that allows them to comply with the elements of the Quality Payment Program (QPP) that is a part of MACRA. This type of news helps lessen the angst for small and rural practices, which already are experiencing the pain of sequestration and knew undoubtedly that their respective fiscal and operational margins and sustainability would be in jeopardy. One documented source noted that 89 percent of independent physicians would “most likely” be hit with a negative payment adjustment to their PFS payments.
While rural health clinics (RHCs) and federally qualified health centers (FQHCs) are not subject to participation in the QPP, CMS’s announcement will give physicians within PFS the flexibility to select their level of participation.

With an overarching goal of making sure physicians don’t receive a negative payment adjustment in 2019, CMS is setting them up for success beginning Jan. 1, 2017 (their first performance period), at that time allowing them to select one of four options for the first years in MIPS and APMs. These options were put in place primarily to help all clinicians become more ready, equipped, and program-prepared based on their needs.

Option No. 1: Testing the Program
Clinicians must submit data to the Quality Payment Program, including data from after Jan. 1, 2017, to avoid a negative payment adjustment. This category is to help clinicians ensure that their respective systems are working and that they are prepared for broader participation in 2018 and 2019.

Option No. 2: Participate for Part of Calendar Year
Clinicians can choose to submit QPP information for a reduced number of days, with a first performance period that could begin later than Jan. 1, 2017. Of note is that clinicians’ practices could still qualify for a small positive payment adjustment.

To receive a small positive payment adjustment, clinicians would have to submit the following information for a part of the calendar year:

  1. Quality measures
  2. How your practice uses technology
  3. Identified improvement activities being undertaken 

Providers can select from the list quality measures and improvement activities available under the Quality Payment Program.

Option No. 3: Full-Year Calendar Participation
For those clinicians/practices that are ready to participate right away, the first performance period would begin on Jan. 1, 2017.

Requirements for this option would include:

  1. Quality measures
  2. How your practice uses technology
  3. Identified improvement activities being undertaken

Providers could qualify for a modest positive payment adjustment. Some will submit a full year’s worth of quality data.

Option No. 4: Advanced Alternative Payment Model Participation

  1. In this option, rather than reporting quality data and other identified information, clinicians could participate in the QPP by joining an advanced APM such as Medicare Shared Savings Program (MSSP) Track 2 or 3 in 2017.
  2. If clinicians receive enough Medicare payments or enough Medicare patients via the AAPM model in 2017, then those clinicians would qualify for a 5-percent incentive payment in 2019.

According to CMS, whatever option clinicians choose, CMS will provide resources to assist them in preparation and steps to take. Furthermore, additional information on options and other supporting details will be described in the final rule, which is due out Nov. 1, 2017.

CMS also has noted that the baby boom generation is driving the need for change in payment reform and innovation. With 10,000 people entering the Medicare program every day and more focus on population health and patient outcomes, physicians are being challenged to do even more with less time and more demands. Medicare’s approach of offering support to clinicians in delivering high-quality patient care and moving from fee-for-service to fee-for-value has been marked by the birth of some of the new models, especially MACRA.

While every clinician wants a healthcare system that focuses on what is right for the patient, the excessive reporting, technological, and other programmatic details are also keeping clinicians from providing optimized patient care. And now that it’s clear the old system likely won’t return, this has physicians concerned about if these programs will work in the long run – and if not, what could possibly be next? Will burnout take place long before things are fixed? Will there be a retirement exodus? Will clinicians in a variety of disciplines leave the system altogether, causing even more strain within nursing and PT?

Originally, the American Medical Association (AMA) advised CMS to delay the start date until July 1, 2017, asking for a “transitional period” designed to help eligible clinicians move away from prior Medicare reporting requirements and then easing them into the learning of MACRA’s reimbursement tracks (and having them work on strategic workflows and system changes best suited within MACRA). Layered within that would be a later go-live date so that health IT companies could update product offerings and be MACRA-ready.

Additionally, many specialist groups, including the ACR (American College of Rheumatology) requested a later MACRA implementation date in order to comply, noting that more time was necessary to best prepare for the new program as well as to shrink the 2017 reporting period.

It will be very interesting to see, prior to the Nov. 1, 2016 release of the final rule, if these new revisions create the necessary positive response and readiness to launch MACRA.

Given the enormity of scope within IT for meaningful use and other related situations and stresses over the last few years, it would be extraordinary to think that the technology for the largest program reimbursement change ever would actually be ready by Jan. 1, 2017.

While these new CMS announcements of options and flexibility might bring degrees of success for clinicians, it doesn’t change the enormous amount of messaging still necessary for program preparation. Remember the old rule of thumb – it takes seven repetitions under near-perfect conditions to apply information. And it was just July when The Deliotte Center for Health Solutions noted that 50 percent of non-pediatric physicians reported that they had never heard of MACRA, with only 32 percent of the 600 physicians surveyed recognizing the name of the legislation.

There is an enormous body of work and preparation yet to be done to meet the new challenges associated with MACRA.

A few steps to consider:

  1. Still providing simple MACRA messaging to the masses, including evaluating current payment processes and understanding how physicians are organized within their hospitals or practices.
  2. Additionally, allowing adequate time for option analysis, programmatic selections, and review of impact.
  3. Getting all pieces in place, from clinicians to team members to data to technology.
  4. Ensuring commitment and continued energy to practice medicine. 
  5. Recognizing short-term and long-term implications and realities of MACRA impacts within each practice, system, CIN, and/or ACO.
  6. Creating adequate messaging regarding MACRA and otherwise ensuring strategic planning regarding short- and long-term impacts on rural health. While being “exempt” is often helpful in one or many ways, operationally and financially, it doesn’t best position rural healthcare long-term because it creates gaps where there are already barriers to access, care, and margins.
  7. As mentioned, considering what long-term impact this will have on recruitment and retention of clinicians, especially for rural healthcare. Will the programs of MACRA reach the ears of med school students in the classroom, or will the challenges of practicing medicine be shared as part of the new reality?
  8. Keeping track of what CMS is doing to train and inform IT vendors so that there can be a more seamless launch versus stopping and starting.
  9. Ensuring that the necessary infrastructure support and funding are available, allowing you to focus on areas of care coordination, beneficiary engagement, and patient safety.
  10. Understanding MIPS principles.

According to HHS, between 30,658 and 90,000 providers will become qualifying APM participants in AAPMs, and they are estimated to receive between $146 million and $429 million in APM incentive payments in 2019.

Lastly, a few questions to consider:

  1. Will the aforementioned efforts help get the system of care delivery where it really should be – in terms of policy, law, and reality?
  2. Being as CMS has stressed that MACRA implementation is first and foremost about patient-centric care, will it really deliver on improved care and quality of care? What is the impact of care at the individual and population level?
  3. To that end, in this new era of population health, will individuals finally achieve optimal outcomes?
  4. Will this stabilize Medicare?
  5. What will happen to rural healthcare? Remember the MACRA language: “the proposed rule includes provisions aimed at supporting critical access hospitals and federally qualified health centers, which won’t face the pressure to gain a high a MIPS score because they won’t be required to. CMS has also proposed that services provided at Critical Access Hospitals, Rural Health Clinics, and Federally Qualified Health Centers that meet certain criteria be counted towards the Qualifying APM Professional determination.”

Stay tuned, because as with the final days of summer, we are in a transition, and as with the campaign races, we will see what happens at the finish line.

About the Author

Janelle Ali-Dinar, PhD is a rural healthcare expert and advocate with more than 15 years of healthcare executive experience in many key areas addressing critical access hospitals (CAHs), rural health clinics (RHCs), physicians, and patients. Dr. Ali-Dinar is a sought-after speaker on Capitol Hill. A former hospital CEO and regional rural strategy executive, Janelle is also a past National Rural Health Association rural fellow, Rural Congress member, and Nebraska Rural Health Association president.  She is currently the Nebraska DHHS chair of The Office of Minority Health Statewide Council, addressing needs of rural, public, minority, tribal, and refugee health, and she serves on the Regional Health Equity Region VII council as co-chair of Rural Health and Partnerships. Janelle holds a master’s degree and doctorate in communications and is a recent graduate in public health leadership. Janelle is currently the vice president of rural health for MyGenetx

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