CMS Hits the Brakes on MACRA Reforms

Andy Slavitt

CMS has scaled back the implementation of physician reporting requirements under the Quality Payment Program (QPP) of medical value improvement created under the Medicare Access and CHIP Reauthorization Act (MACRA) legislation. In a blog post Thursday, CMS Acting Administrator Andy Slavitt outlined a number of phase-in adjustments to the program that would allow practices more time to adjust to the new reporting requirements before penalties would start to apply.¹

The adjustments come in advance of a final rule on the program anticipated November 1 and in response to roughly 4000 comments received by CMS from the physician community, many of them calling for large-scale revisions in the MACRA reforms intended to spur higher quality medicine.

“Universally, the clinician community wants a system that begins and ends with what’s right for the patient,” Slavitt said in remarking on the comments received. “We heard from physicians and other clinicians on how technology can help with patient care and how excessive reporting can distract from patient care.”

Members of Congress in hearings this summer with members of CMS stated that they were strongly concerned about how these reforms would affect smaller and rural practices, and it appears that CMS has responded to those comments. “In recognition of the wide diversity of physician practices, we intend for the Quality Payment Program to allow physicians to pick their pace of participation for the first performance period that begins January 1, 2017,” Slavitt said.

That’s a different tack from the previous path outlined by CMS. Previously, CMS had intended for 2017 to constitute the first full year of reporting by which practices would be judged and potentially penalized or rewarded financially based on their performance as graded by CMS. “During 2017, eligible physicians and other clinicians will have multiple options for participation,”Slavitt said in his blog Thursday.

“Choosing one of these options would ensure you do not receive a negative payment adjustment in 2019. These options and other supporting details will be described fully in the final rule.”

The first option would give practices the choice of submitting only a little data to CMS in order to demonstrate readiness for “broader participation in 2018 and 2019.” Choosing this option and getting started with data submission would enable practices to avoid a negative payment adjustment, Slavitt said.

The second option allows practices to participate in the QPP for a reduced number of days in 2017 rather than a full calendar year. “This means your first performance period could begin later than January 1, 2017 and your practice could still qualify for a small positive payment adjustment,” Slavitt wrote.

Under the third option, practices that are ready to get started could participate for a full calendar year in 2017. Slavitt said he expects that many practices are already prepared to take this step and he is expecting many to do so.

The fourth and final option is to join an Advanced Alternative Payment Model (APM) in 2017. Whereas oncology group representatives have stated that no “advanced” APMs have been approved so far by CMS, Slavitt indicated that participating in the Medicare Shared Savings Program through an Accountable Care Organization (ACO) would be considered acceptable. The Shared Savings Program allows providers to be paid under a fee-for-service plan for Medicare beneficiaries, but also allows them to receive shared savings payments if their ACO meets quality performance standards and has generated “shareable savings” under CMS performance-based payment standards.

The QPP incorporates the Merit-based Incentive Payment System (MIPS) under which physicians could eventually be subject to hefty cuts in Medicare payments for failure to meet expectations or potentially receive bonuses and other incremental payments for meeting savings, quality, and efficiency standards.

Many large oncology groups had submitted comments to CMS about the quality improvement program. Those comments universally expressed deep concerns about the complexity, pace, and potential harm that could result to quality of care and practice economic viability based on the many adjustments in practice procedures and management that would be needed.

Among those groups was the American Society for Radiation Oncology, which stated in a letter to CMS dated June 23 that whereas it shares CMS’s goals for quality improvement in medicine, the organization “is very concerned that the pace with which CMS is transitioning to the new MIPS and APM programs is much too fast.”

In urging CMS to consider a more cautious and measured approach to reform, the group called for a reduction in “the complexity of the programs [to] better ensure chances for successful participation for many physicians, especially those in solo and small practices.”²

Similarly, the American Urological Association (AUA) pleaded for more time for practices to get adjusted to the new program of performance measurement. The group noted that with the final rule to be published on November 1, practices would have only 2 full months to make final preparations before the first full year of the program was to begin. “CMS should be mindful of the fundamental changes that MIPS will have on physician reimbursement and the substantial penalties it will impose in 2019 if physicians fail to achieve specific measures and activities,” AUA wrote in its letter dated June 27.³

ASCO, in a letter also dated June 27, called the data reporting requirements under the QPP “overly ambitious and burdensome, especially given the costs, disruptions, and confusion associated with transitioning to MIPS reporting in 2017.” The group suggested numerous revisions to the reform program, although it agreed with CMS that “movement to a reimbursement system based on value rather than volume is essential to ensuring patient access to cancer services and the long-term sustainability of the Medicare program.”⁴

According to the April proposal under which CMS outlined the QPP plan, quality measures would count for 50% of a practice’s MIPS score in the first year. The use of technology (advancing care), with a particular emphasis on interoperability and information exchange, would account for 25% of the score. Care coordination, beneficiary engagement, patient safety, and other forms of clinical practice improvement would amount to 15% of a practice’s score. Cost (Medicare claims) would account for the remaining 10% of the score.

References

1. Slavitt A. Plans for the Quality Payment Program in 2017: pick your pace. Available at: The CMS Blog. http://blog.cms.gov/2016/09/08/QualityPaymentProgram-PickYourPace. Published September 8, 2016. Accessed September 9, 2016.
2. American Society of Radiation Oncologists. ASTRO comments on MIPS APM proposed rule 06-23-16. https://www.regulations.gov/document?D=CMS-2016-0060-2383. June 23, 2016.
3. American Urological Association. AUA comments on MIPS APM proposed rule 6-27-2016. https://www.regulations.gov/document?D=CMS-2016-0060-3657. June 27, 2016.
4. ASCO. ASCO_CMS-5517-P MACRA comments. https://www.regulations.gov/document?D=CMS-2016-0060-2881. June 27, 2016.