Large health systems say they need MACRA relief just as much as small providers
Large health systems say the CMS's efforts to make MACRA less burdensome on small providers leaves them behind and they're suggesting the agency overhaul how the new payment model tracks physician performance to make it easier.
Providers expressed the concern in comments to the CMS. The agency asked for that feedback on the interim final rule for the second year of the Medicare Access and CHIP Reauthorization Act.
Last fall, the CMS announced that physician practices with less than $90,000 in Medicare revenue or fewer than 200 unique Medicare patients per year did not have to comply with MACRA. That move excluded about 134,000 providers. The original threshold for exemption was $30,000 in Medicare revenue or fewer than 100 Medicare patients.
Providers must follow the new rule in 2018 and will see payments affected in 2020.
Officials with the CMS said they were responding to concerns from practices that said they didn't have enough Medicare patients to justify the cost of overhauling their electronic health record systems or buying new ones to track and report quality measures required to adhere to MACRA.
The new threshold allows a total of 934,000 providers to be exempt from MACRA's Merit-based Incentive Payment System.
One way to help, large player say, is to stop tracking performance through providers' tax-identification numbers.
Mega-systems like Providence St. Joseph Health have been pushing for the CMS to judge providers based on their specialty and care integration practice.
Dr. Rod Hochman, President and CEO Providence St. Joseph Health said in a comment letter that TINs do not represent clinicians who share a patient population, instead the numbers represent various services.
For example, St. Joseph Health is comprised of 50 hospitals and 829 clinics in Alaska, California, Montana, New Mexico, Oregon, Texas and Washington. The system reports under 80 TINs.
Hochman suggests clinicians instead choose a national provider identifier to be grouped under for reporting purposes.
A similar system was in place for the Physician Quality Reporting System, Hochman wrote in his comment.
"That would alleviate many of the challenging dynamics and burden encountered when reporting under MIPs," he wrote.
Karen Wilson, executive director of the University of Utah Health, an academic medical center that performed over 1.4 million patient visits last year agreed. One TIN can group together clinicians that vary as much as primary care doctors and radiologists who don't see patients at all, she said.
Other large systems were less concerned about the burden of MACRA and instead raised concerns about the implications of the CMS letting so many doctors off the hook.
Rev. Dennis Holtschneider, executive vice president of Ascension, for instance, said the move stalls efforts to move Medicare away from fee-for-service system.
"We are concerned that some well-intentioned flexibility may slow the transition from volume-to-value," Holtschneider said in a comment letter. "Excluded providers will fall behind their included counterparts in their day-to-day experience with quality measurement and reporting, their investment in [EHRs], and their ability to understand and manage to total cost of care."
More clinicians might have voluntarily opted-in to MIPS if given the option. But in the final rule, the CMS chose not to allow that, saying it would be too difficult to handle administratively before the effective date of Jan. 1.
Ascension disagreed with the decision and said the more performance years a clinician or group spends outside of MIPS, the more operational challenges and costs to enter it will rise, and these providers may be motivated to delay their transition to value-based care.
The hospital chain urged the CMS to reconsider its decision and suggested allowing low-volume practices to opt-in during the final quarter of a performance year if those doctors felt ready to do so.
The move would mean "more Medicare beneficiaries would be able to receive their care from clinicians programmatically committed to improving quality and lowering costs," Holtschneider said.
An edited version of this story can also be found in Modern Healthcare's Jan. 8 print edition.
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