The CMS is poised to release the final rule on Medicare's new physician payment system, and doctors are anxious for details as tight deadlines under the law close in.
The agency will drop its final rule on the Medicare Access and CHIP Reauthorization Act of 2015, or MACRA, by Nov. 1, but some expect it to fall within the week, maybe even Friday.
“We are anxious about seeing the final rule and seeing what's actually there,” said Dr. John Meigs Jr., president of the American Academy of Family Physicians. “We are hopeful from some of the comments by CMS…but the devil's in the details.”
“This is a near reality...and change is always hard, so I think a lot of clinicians are really worried about what it's going to require of them,” Blair Childs, vice president of public affairs at the healthcare consulting and group purchasing organization Premier, said of MACRA. “It starts off fairly gradually but it definitely is going to change health care in a very fundamental way in the long-term.”
The CMS in April released the proposed rule on MACRA, which replaced the old and flawed sustainable growth-rate formula for physician pay with a new method meant to shift physicians away from the fee-for-service model and onto a value-based payment system. To avoid penalties under MACRA, physicians will participate in one of two reimbursement tracks: a merit-based incentive payment system or advanced alternative payment models.
In the merit-based incentive payment system, known as MIPS, physician pay will be based on success in four performance categories, including quality, resource use, clinical practice improvement and “advancing care information,” which is based on the meaningful use program the government has used to decide whether doctors should be rewarded for using electronic health records.
Physicians will have some flexibility on which measures to report. On the MIPS track, physicians can earn plus or minus 4% of reimbursement in 2019, 5% in 2020, 7% in 2021 and 9% in 2022. Reporting on MIPS begins January 2017, and payments based on those reports would come two years later. Most providers are expected to go this route.
Physicians can opt out of the MIPS track if they participate in an alternative payment model, such as an accountable care organization or patient-centered medical home. To qualify, providers are required to “bear more than a nominal amount of risk for monetary loses,” the proposed rule states, but many don't have the capital to set an alternative payment model up or take on risk. Physicians that do choose this path can earn annual bonuses of 5%, and they will also be exempt from the MIPS reporting measures.
Many provider groups have said the timeline for reporting is much too short, and many physicians, especially small and rural groups that lack technological infrastructure, aren't ready.
Indeed, a Deloitte study released in July found that half of non-pediatric physicians surveyed had never heard of the MACRA. And just 21% of self-employed or small-group physicians and 9% of physicians employed by hospitals or larger groups were somewhat familiar with the law, the survey showed.
Advocacy groups have pushed for the CMS to delay MACRA implementation. To address physician concerns, the CMS in September introduced two “pick your pace” options for avoiding penalties for the first performance period beginning in January. The first option allows physicians to avoid a negative payment adjustment in 2019 as long as they submit some data to the program—but they will forgo any pay increase under the program. Under the second option, physicians can choose to submit data for part of the year and still qualify for a small positive payment adjustment.
Additionally, the CMS on Thursday announced a new initiative that seeks to ease physicians' administrative burdens as they implement MACRA. The agency said it would review regulations and policies to minimize administrative tasks, starting with an 18-month pilot to reduce medical review for certain physicians participating in advanced alternative payment models.
Meigs said his group is encouraged by the pick-your-pace concept, but hopes for more details in the final rule on how it will work. He also said the effort announced Thursday to lessen paperwork and other administrative burdens is a step in the right direction but he is hoping “it will be expanded to include practices of all sizes.”
Childs said Premier hopes the final rule reduces the risk requirement to be eligible for the 5% bonus in the advanced alternative payment model track. “The threshold they have in the proposed rule is very high,” he said.
Premier has also been working with the CMS on including certain bundled payment programs under the eligible alternative payment models that qualify physicians for bonus payments, he said.