MACRA: Easing the Pain?

Medicare's final rule acquiesces to medicine's call for more flexibility for small practices in the first year but moves full speed ahead with the transition to value-based payment. 

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Quality Feature — January 2017

Tex Med. 2017;113(1):41-47.

By Amy Lynn Sorrel 

Bracing for the pain small practices expected with Medicare's new Quality Payment Program (QPP), Kanti Agrawal, MD, found at least some relief in the flexibilities medicine won in the final regulations implementing the Medicare Access and CHIP Reauthorization Act (MACRA). He hopes the reprieve gives his three-physician practice at least a shot at avoiding payment penalties in the higher-stakes pay-for-performance game.

The Garland cardiologist is among the 90 percent of physician practices nationwide that the U.S. Centers for Medicare & Medicaid Services (CMS) predicts will fall into one of two major payment tracks in QPP: the Merit-Based Incentive Payment System (MIPS). 

"It's either do it, or don't. And I and numerous colleagues in my community had more or less given up on being able to meet the MIPS requirements," Dr. Agrawal said. 

But he also knows the one-year transition is just a temporary salve for more aches ahead, as the law that replaced the maligned Sustainable Growth Rate (SGR) payment formula applies pressure on practices to ramp up for the shift from fee-for-service to value-based care.  

Responding to medicine's vehement concerns, CMS said physicians who at least try to comply with the new rules as of Jan. 1 will see no penalty in their payments in 2019, the first year the penalties were set to apply. That's because starting in 2017, physicians' performance on various quality, cost, technology use, and practice improvement measures determines cuts or bonuses in their payments two years later. 

In addition to reduced reporting requirements, the Texas Medical Association and organized medicine won other significant improvements that create a more palatable transition period, including a broader exemption for small practices with few patients or little revenue in Medicare.

Dr. Agrawal anticipates some of his colleagues will absorb the penalty nonetheless, outweighed by the high cost of participation. Nor is he fully convinced of the program's purported benefits, saying the major elements of MIPS are still "very difficult, poorly defined, and poorly implemented."

Given his specialty, Dr. Agrawal has too many Medicare patients to qualify for the new exemption. But after receiving penalties last year, he is now shifting gears.

The recent graduate of TMA's Accountable Care Leadership Program took the year-long course and attended TMA's Texas Quality Summit in November to "learn more about the nuts and bolts" of value-based care programs like MIPS. With that knowledge, "we will make our best efforts to see if we can meet the requirements in 2017 so 2019 payments might not be as bad. But I still foresee a lot of hurdles and difficulties logistically. And the requirements for us to qualify to get a bonus are tremendously onerous." 

Medicine's Voice Heard

As TMA staff pore over the nearly 2,400-page rule CMS released on Oct. 14, physician leaders praised Medicare officials for following through on their promise to listen to physicians' thoughts and concerns and for delivering meaningful improvements for physicians and patients. 

TMA suggested many of those improvements in the 50 recommendations the association submitted to Medicare officials in a June 27, 2016, formal comment letter on the draft rule. The letter stood among more than 4,000 comments CMS received, including those of 656 Texas physicians submitted through TMA's Grassroots Action Center. Of TMA's 50 recommendations, CMS completely adopted 21, partially adopted 13, and rejected just 16.

Among the most significant improvements for 2017 are:  

  • A broader exemption that includes physicians who see fewer than 100 Medicare patients or submit Medicare charges of less than $30,000. The draft rule originally set the low-volume threshold at $10,000. 
  • Reduced reporting requirements to avoid a penalty in 2019. Any physician who successfully reports one quality measure or one of the new improvement activities will earn enough credit to avoid a 4-percent payment cut in 2019. 
  • A simpler system that gives physicians and groups leeway to pick the most meaningful quality measures and reporting mechanisms for their practices and their patients. 
  • Eliminating the cost category in calculating physicians' overall performance scores.
  • A shortened performance period that allows physicians to report quality and technology use data for 90 days, instead of a full calendar year, to be eligible for a bonus.  

The adjustments drew appreciation from across the medical community — even from MACRA's author himself — for giving physicians more options to participate. But TMA leaders caution physicians should not mistake the transitional reprieve for a delay in the law's implementation, as requirements will increase in 2018 and beyond.

TMA will continue to work with CMS and the Texas congressional delegation to rewrite and reform ongoing problems identified in the draft regulations that stuck in the final rule, such as making sure quality measures are evidence-based, costs are appropriately attributed, technology vendors are held accountable for their products' performance, and doctors aren't penalized for factors out of their control.

In the meantime, "the flexibility for the first year of MACRA that if you do something — anything — you won't be penalized, is a huge step forward from CMS' original proposal," TMA President Don Read, MD, told Texas Medicine at the TMA-sponsored Texas Quality Summit. Nevertheless, he advised against delaying preparation for what he described as "the largest regulatory program physicians have ever had to comply with under CMS," in TMA's comment letter to Medicare officials. 

"Physicians have to be proactive, not reactive, and find out now what is the best thing to do for your practice," Dr. Read told Texas Medicine, pointing to resources like the TMA MACRA Resource Center to get started. (See "TMA Gets You MACRA Ready.") 

Acknowledging potential uncertainties with turnover at the federal level, he says a new president, Congress, and Senate might "nibble at the corners" of existing legislation. "But it's not likely to change the fact that the value-based care train has left the station and is going down the track. It takes some experience and practice, and if you don't keep up with it, you're going to get run over or left behind." 

Despite indications from President-Elect Donald Trump and a Republican-dominated Congress and Senate of plans to undo the Affordable Care Act, TMA Council on Health Care Quality consultant Ronald S. Walters, MD, explained that MACRA is "totally separate legislation" from ACA, and Medicare's shift toward value-based care predates both laws.   

Of the final rule for the MACRA legislation he authored, U.S. Rep. Michael Burgess, MD (R-Lewisville), said, "It is evident that the regulation is responsive to the needs and concerns presented by small, independent, and rural practices. I appreciate that CMS and [Acting CMS] Administrator Andy Slavitt have taken every possible step to maximize and incorporate the input from clinicians."

American Medical Association President Andrew W. Gurman, MD, said CMS' approach "better reflects the diversity of medical practices throughout the country" and "will help give physicians a fair shot in the first year of MACRA implementation. This is the flexibility that physicians were seeking all along."

Pace Yourself in MIPS

Under what CMS has dubbed "Pick Your Pace," physicians have four participation options (see "Pick Your Pace in MIPS"):  

  • Option 1: Don't send any 2017 data, and receive an automatic 4-percent payment cut. 
  • Option 2: Submit a minimum of one quality measure or improvement activity, and avoid the penalty. 
  • Option 3: Submit data for less than a year — at least 90 days' worth — for the chance to earn a small bonus or at least keep payments the same. 
  • Option 4: Submit a full year's worth of data for the chance to earn a larger bonus.   

CMS estimates the final rule will exempt 32.5 percent of MIPS-eligible clinicians, and 95 percent of physicians will get a neutral or positive — up to 4 percent — payment adjustment in 2019. Physician performance is scored in the following four weighted categories meant to consolidate the current tangle of Medicare quality programs:  

  • Quality activities (60 percent): Replacing the Physician Quality Reporting System (PQRS), physicians must report on six measures (down from nine in the PQRS rule) to be considered for a bonus. Reporting a minimum of one measure will avoid a penalty. 
  • Clinical improvement activities (15 percent): The new category requires doctors to attest to completing up to four activities (up to two for small practices or practices in rural or shortage areas) such as care coordination, each weighted differently. Doing just one activity also would erase the possibility of a penalty.
  • Advancing Care Information, or technology use (25 percent): Replacing the meaningful use of electronic health records (EHRs) program, doctors report on four EHR-related measures in 2017 (five in 2018), down from 11 measures in the draft rule. 
  • Resource use (reduced from 30 percent to zero in 2017): Replacing the value-based payment modifier, CMS will factor in how well physicians control costs. The category will make up 10 percent of physicians' scores in 2018 and 30 percent in 2019. 

Dr. Read's practice of 15 colon and rectal surgeons found themselves ahead of the game having hired an information technology expert and having incorporated a specialty registry to "collect what we think is useful quality data." 

Dr. Agrawal and his two cardiology associates started using PQRS in 2011 to track their quality and adopted an EHR system. 

Unable to afford additional resources, however, his practice "gave up" on advancing to the second stage of the old meaningful use EHR program, finding the criteria "too onerous." On top of that, "the systems are not well developed by the vendors, so it makes it difficult for physicians to even meet the criteria because of the deficiency of the system," Dr. Agrawal said.  

He also called the quality measures in his specialty "full of flaws. And I don't believe they reflect quality of care in my specialty." The cost and practice improvement categories, he added, "are still very abstract. And to accept that and rely on that for payment is extremely difficult." 

While the quality measures remain imperfect, Dr. Walters says under the final rule, physicians have more choices to select the ones they feel are most applicable, unlike in PQRS. 

"MACRA is an opportunity compared to the alternative, which is people telling you what to measure," he said. "And if you're in a group that just plain nothing applies to, get involved. There are opportunities as a member of your professional society to come up with ones that matter."

MACRA, for instance, makes way for a physician advisory committee to weigh in on measures development going forward. 

APMs and Everything in Between

At the other end of the spectrum, more sophisticated practices have the option to participate in the advanced alternative payment model (APM) track if they are already in arrangements such as a Medicare Shared Savings Program (MSSP) accountable care organization (ACO). The advanced APM track qualifies participants for a 5-percent lump-sum bonus payment in 2019. 

Luis Delgado, MD, is taking advantage of the law to get rewarded for all the hard work his practice put into forming an ACO. 

The McAllen family physician spearheaded a movement to gather with other colleagues in 2012 to participate in an MSSP. The ACO has since grown to include 18 practices in South Texas and advanced to Track 3, qualifying it as an advanced APM under MACRA.

As such, the ACO must meet higher thresholds than MIPS, including reporting on a broader array of EHR and quality measures, including patient satisfaction, for a larger patient population, and get graded as a whole, not as individuals. 

In the future, APMs will be able to count commercially insured patients toward their performance goals, for which TMA PracticeEdge is helping Dr. Delgado prepare. (See "Prepare for Value-Based Care With TMA PracticeEdge.")

"Back when we started the process, we hadn't even heard of MACRA," Dr. Delgado said. "Fortuitously, we decided to move ahead, and turns out, once the definitions were all spelled out, it became apparent to us we were in a very good position to be able to participate [as an advanced APM] without having to change very much."

He acknowledges the endeavor is intense. "But this is the way medicine is headed, and with regulatory changes coming out, you're seeing more physicians having to group together to accomplish the work that needs to be done. If you make this work for you, the rewards are there, and hopefully everyone in the future can take advantage and get back to what we are trained to do." 

There are numerous practices in between MIPS and advanced APMs still finding their place in the new payment paradigm. Many were disappointed they could not qualify as an advanced APM because they were not taking full risk and therefore would miss out on the additional financial incentives.

In another win for medicine, however, the final rule gives qualifying APMs in MIPS, like medical homes, full credit in the clinical improvement activities category for their extra work (CMS' initial proposal would have given them only half credit), plus the potential for extra points in the technology category. 

Baylor Scott & White Quality Alliance President Cliff Fullerton, MD, says the medical home will strive to be a high performer in MIPS to grab the maximum incentive payments in 2019. Bonuses and penalties grow from 4 percent in 2019 to 9 percent in 2022 and beyond. Exceptional performers can earn an additional 10-percent bonus.

In the meantime, "we'll be assessing the best opportunity to move into an advanced APM," said Dr. Fullerton, a TMA Council on Health Care Quality member. Pointing to the high failure rate among MSSPs, he warns, "If you jump in when you're not ready, you're at risk for poor outcomes." 

Amy Lynn Sorrel is former associate editor of Texas Medicine.


TMA Gets You MACRA Ready

TMA urges physicians to continue to evaluate their practices' readiness to participate in MACRA and to take steps to comply with the complicated program now if they intend to participate. Among the TMA resources available to help physicians in this process: 

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Prepare for Value-Based Care With TMA PracticeEdge

Founded in 2015, TMA PracticeEdge is a physician services organization created by TMA to provide turnkey network solutions that strengthen the independent private practice of medicine in Texas.

Backed by the trusted TMA brand, the company develops scalable platforms for physician practices to improve patient care and quality, while improving practice financial viability. TMA PracticeEdge provides support to more than 500 independent physicians operating a dozen physician-owned and -led value-based care networks serving more than 100,000 patients across Texas. Among them, several Medicare accountable care organizations (ACOs) recently united to pursue commercial opportunities in the Rio Grande Valley. 

Osler Medical Group ACO and TMA PracticeEdge launched a physician-led commercial ACO, which will serve more than 9,000 Blue Cross and Blue Shield of Texas patients under a commercial value-based contract starting in January. Osler is a joint venture company formed by several Medicare ACOs, including Buena Vida y Salud ACO, Rio Grande Valley Health Alliance ACO, and Sunshine ACO. In 2015, two of the ACOs were among the top six performers in generating savings among hundreds nationwide.  

Luis Delgado, MD, president of the new ACO, said the organization's primary goals are addressing rising health care costs while maintaining quality care and working together to keep independent physicians in the health care marketplace.

"We approached TMA PracticeEdge for their help in bringing our organizations together, and they developed a highly customized solution to maximize our strengths and bring additional resources to support growth," he said.

David Spalding, chief operating officer of TMA PracticeEdge, said, "We are truly pleased to bring commercial value-based opportunities to this highly accomplished network of more than 40 independent primary care physicians operating in small practices of one or two clinicians." Independent physicians, he adds, are always in the best position to provide the highest quality, affordable health care to patients in their communities.  

Physicians and office managers interested in learning more about TMA PracticeEdge or the Osler Medical Group ACO can email or call (888) 900-0334. 

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