CMS to make MACRA less painful with 'pick your pace' options

A week ago, physicians and health system leaders were sweating a waning number of days to figure out and prepare for Medicare's new incentive payment framework in time to report performance data to the CMS. Now they face a lower-stakes set of decisions but the same mandate to wean themselves off of fee-for-service pay.

The CMS was flooded with nearly 4,000 comment letters after issuing its draft rule for carrying out the Medicare Access and CHIP Reauthorization Act. Many of them asked for flexibility, and last week acting CMS Administrator Andy Slavitt answered with a blog post promising two new “pick your pace” options for avoiding penalties.

“We're making the consequences of not being ready more modest as these models start up,” Slavitt told Modern Healthcare. “The bull's-eye for us isn't what will happen with this program in 2017, it's about what will lead to the best patient care in the long term.”

The physician community welcomed Slavitt's gesture, but they're also continuing to press him for a more expansive opportunity to duck that system altogether.

To avoid penalties and qualify for bonuses under MACRA, physicians must participate in the new Merit-based Incentive Payment System (MIPS, for short) unless they have a substantial amount of their revenue at risk under a qualifying alternative payment model—and the vast majority of physicians do not.

Physicians were supposed to start reporting performance data next year, and many complained that smaller practices in particular wouldn't be ready. The framework calls for them to choose from an array of measures in four categories: quality, resource use, clinical practice improvement and meaningful use of electronic health records. The final rule on those measures, however, isn't expected to arrive until November.

Slavitt wrote last week that providers will be able to avoid negative payment adjustments in 2019 by submitting a limited amount of data next year to simply “ensure that your system is working.” That also means, however, that those practices won't qualify for a performance-based pay increase.

A second new option allows providers to start submitting data later in the year and still qualify for a small pay increase.

“This is the flexibility that physicians were seeking all along,” American Medical Association President Dr. Andrew Gurman said in a statement. The new options, he said, would give physicians a “fair shot” in MACRA's first year.

But the industry still wants more flexibility on MACRA's other track: one that encourages participation in a value-based payment model with downside financial risk, quality measures and requirements for EHR use.

The CMS does, in fact, want to get more providers on that track. In July, the agency announced a new bundled-payment demonstration for cardiac care and also expanded its existing bundled-pay demo for joint surgeries. Both programs, it said in the regulations, would count as an advanced alternative payment model.

Provider groups, however, want the CMS to reduce the level of risk required and find a way for more of the accountable care organizations participating in the Medicare Shared Savings Program—the government's most popular value-based pay initiative—to get out of MIPS.

Nearly all of the 433 ACOs in that program have chosen not to assume financial risk. That is, they get bonuses if they save money and meet quality targets but don't lose money if they fail.

And even with the new flexibility, MIPS will be a heavy lift for some practices, especially ones that don't have EHR systems or haven't previously reported performance data, said Braden Lang, senior consultant of research at the Advisory Board. Last week's adjustments may not be the last, he said. “I'm sure that some of those organizations will see this as welcome news and be anxious to see the final details released in the final rule.”