Physicians and their advocates say the government's new Medicare payment rule is too narrow and too complex to achieve its overarching goal of boosting value of care over volume.
This article first appeared October 13, 2016 on MedPage Today.
By Shannon Firth
In interviews with MedPage Today, physicians and their advocates said the government's new Medicare payment rule is too narrow and too complex to achieve its overarching goal of boosting value of care over volume.
Congress repealed the loathed Sustainable Growth Rate formula in April 2015, via the Medicare Access and Chip Reauthorization Act (MACRA), setting the stage for the first major overhaul of physician payment in a quarter-century.
A year later, the Centers for Medicare and Medicaid Services (CMS) released a draft MACRA rule outlining specific plans for payment reform.
Under one payment channel, called advanced alternative payment models (APMs), clinicians meeting specific requirements would earn incentive payments of approximately 5% for 5 years in a "lump-sum payment" every year from 2019 to 2024.
Those ineligible for the advanced APMs will be assigned to a default framework, the Merit-Based Incentive Payment System (MIPS). From 2019 to 2024, these providers would receive small bonuses or penalties based on their ability to meet a series of metrics across four categories: quality improvement, performance, resource use and appropriate use of electronic health records.
The final rule is expected next month.
'Limited Options'
Regarding the advanced alternative payment models, "right now it's a pretty limited number of options for at least the upcoming year," said Laura Wooster, MPH, of the American Osteopathic Association. In particular the AOA has lobbied for including patient centered medical homes (PCMH) in the advanced APM pathway.
Wooster argued that some PCMHs and accountable care organizations (ACOs) are more stringent and more advanced than the track 2 Medicare shared saving programs that have been included. Nevertheless, under the preliminary rule, they were locked out of the advanced APMs and therefore blocked from receiving that 5% bonus.
"That's one of the first things that we're intending to look at as soon as we get the final rule," she said.
Another more sweeping concern is that the draft MACRA rule did not offer an even playing field for small practices in the MIPS track.
Wooster said one of the questions she hears most often from members relates to how small providers are supposed to outperform larger practices in a MIPS environment.
"They don't have the resources or a broad risk pool even, they feel like they'll be at a competitive disadvantage," she said.
Losers Pay Winners
MACRA was designed to be budget neutral, which in this case means "the losers essentially pay the bonuses for the winners," said Rob Tennant, health information technology policy director for the Medical Group Management Association.
One of the major initial concerns of the rule dealt with timing. Initially the rule was expected to be released in November 2016 with reporting requirements slated to begin January 2017.
Acting CMS Administrator Andy Slavitt mitigated some of those worries by announcing a "pick your pace" format, offering graduated options for those who want to delay full participation in the program while still allowing those early adopters to jump in head-long to the program with its original reporting requirements in anticipation of bonuses.
"Assuming that blog post is accurate, we think that it's a good start in terms of really having all providers, all sizes all specialties at least having the chance at avoiding the penalty," Tennant said.
However, because of the budget-neutral aspect of the law, the more providers who avoid penalties, the smaller the potential bonus will be.
This raises the question of how much physicians should invest to get that small bonus, Tennant said. For example, if the bonus is 2%, a physician paid $20,000 through Medicare will earn just $400 for his efforts in the MIPS track, but he might have to invest $10,000 in the technology he needs to succeed in the MIPS.
"We want to make sure that there's not a disincentive for practices to participate," he said.
Bias Against Primary Care?
In addition to the potential challenges of small provider versus large employers, MACRA also could pit primary care against specialty providers.
"So far a lot of those [MIPS] measures apply just to primary care," said John Meigs, Jr. MD, president of the American Academy of Family Physicians who practices in Centerville, Ala.
"If you're going to hold primary care to certain metrics, then you need to have the same or similar metrics that the subspecialties have to comply with.... That's where a lot of the cost in the system is. They do not need a free ride," he said, noting that CMS said it is in the process of developing measures for specialty providers.
Others, like Katie Orrico, JD, director of the Washington office for the American Association of Neurological Surgeons (AANS), said topline issues for her members include provisions around the reporting burden, the low-volume threshold and participation in qualified clinical registries.
Orrico said that under the preliminary rule, most practices would be required to report data on 80-90% of their Medicare patients, AANS has recommended CMS limit that requirement to 50% of applicable patients.
Immediately after the final rule is released, she'll also be scrutinizing it for changes to the low-volume threshold exemption. Under the proposed rule, providers who care for fewer than 100 Medicare beneficiaries and bill less than $10,000 in allowable charges, would not have to participate in MIPS.
For surgeons, a single complex spinal surgery could push them over the $10,000 benchmark.
AANS and several other medical groups have recommended that CMS delink the two criteria -- both the number of patients and the dollar amount charged -- shifting from an "and" to an "or" statement and increase the allowable charge amounts, some groups say to $30,000.