3 Ways to Prep Physicians for MACRA's Unknowns

With a complete roadmap unavailable, and rank-and-file physicians not really paying attention, the next-best guides for physician practice leaders include existing programs such as PQRS, the value-based modifier, and meaningful use.

The future of physicians isn't much clearer than it was before the Centers for Medicare & Medicaid Services (CMS) released proposed rules for the Medicare Access and Children's Health Insurance Program Reauthorization Act (MACRA)  last week.

Despite medical groups' pleas to delay the January 1, 2017, start date of the first reporting period under MACRA's Merit-Based Payment Incentive System (MIPS), CMS has so far stuck to its guns, leaving medical groups just a month or so after the release of its final rule—expected in late fall of 2016—to prepare.

Physicians will need to digest the regulatory information, figure out their quality measures, and get their systems ready to report data that won't result in a penalty or reward until 2019.

Related: Physicians Stymied by MACRA's Unknowns

So with the timelines firmly set, healthcare leaders should not wait to prepare for changes.

But that lag time potentially undermines the purpose of the program, and represents one of many problems the Medical Group Management Association (MGMA) intends to share with CMS during the public comment period ending June 27.

"The feedback mechanisms are too removed from the performance years," says Anders Gilberg, MGMA's senior vice president of government affairs.

"If you're really going to attempt to improve quality through these programs—not have them just be reporting programs with incentives tied to reporting—you need feedback.

You need timely, actionable information. And you need incentives to be closer to when you're actually providing and measuring that care."

Good News, Bad News

A less obvious issue, according to Gilberg, is CMS's proposal to reduce the total number of quality measures practices will need to report under MIPS to six from the nine currently required under the Physician Quality Reporting System (PQRS).

"On first blush, that looks like an improvement," he says.

"But at the same time, CMS proposed to raise the threshold you need to achieve those measures as high as 90% for some… while for some, 50% has been hard to achieve, either because of the nature of the measures or difficulty in reporting."

More positive, however, is CMS's willingness to allow medical groups to select a set of quality measures (which account for half of the total score in year one of the program) that applies to their specific practice, says Chet Speed, JD, LLM, vice president of public policy for the American Medical Group Association.

Overall, Speed rates CMS's proposal as fairly positive.

"They heard from us, and through the house of medicine, that a quality measures program regime is challenging…  They listened to stakeholders and did a nice job there."

Nonetheless, CMS's proposal also unwittingly helps most practices solve the dilemma of whether to participate in MIPS or attempt an exemption via an Advanced Alternative Payment Model (APM).

The "advanced" qualifier appears nowhere in the MACRA legislation, Gilberg notes. "And the list of what would qualify as an advanced APM is so narrow, that virtually no physicians are going to be advanced APMs anytime soon."

So while select practices that participate in the challenging Comprehensive Primary Care Plus (CPC+) program will qualify as advanced APMs, the 95% of Medicare accountable care organizations that have invested in becoming Track 1 ACOs will be left out.

As a result of the difficulty in qualifying as an advanced APM, almost all groups will begin 2017 in MIPS.

That may not appreciably lessen practices' current burden of reporting for PQRS, the value-based modifier, and meaningful use (with clinical practice-improvement activities added to the mix).

How to Prepare

While it's still possible CMS will dial back some of its more significant requirements in its final rule, leadership's current strategy should consist of three parts:

1. Read Up
Based on strategic planning sessions Speed has attended with AMGA members groups', the first step is to process all the information that's currently available about MACRA and figure out what it means to them and to their physicians.

2. Communicate Implications to Physicians
"Quite frankly, the rank-and-file physicians aren't really paying attention, at least with our member groups," says Speed. "They're just practicing medicine with the idea that the group practice leadership will take care of the details."

The key message physicians need to hear, according to Speed, is that risk is happening.

"It's not going to be a repeat of the 1990s, when managed care came and went. Risk is now literally etched in statutory stone: MACRA. And the commercial payers typically follow Medicare, so risk is going to be interjected into all payment models."

3. Study Current Quality Programs
With a complete roadmap unavailable, the next-best guide for practices include existing programs such as PQRS, the value-based modifier, and meaningful use, for which they must still report until the end of 2016. In particular, groups will be wise to study CMS's interim (mid-year) quality and resource use reports (QRURs), released in April 2015, says Gilberg.

"It's not a perfect picture, but at least you'll get a general sense of how CMS is looking at physicians within the practice relative to both quality and resource use," Gilberg says. "Those types of measurements are likely going to be similar in the final rule."