CMS needs a translator to demystify MACRA models

The CMS and physicians aren't communicating well on what's required under MACRA. So the agency is looking for a contractor that can help.

The agency is in the early stages of finding a new contractor to help providers better understand value-based pay models and how they are performing. The third-party company would develop policy around the Quality Payment Program to make it easier to comply with.

Providers in the Quality Payment Program can take one of two pathways for Medicare reimbursement: the Merit-based Incentive Payment System or the Advanced Alternative Payment Models.

Understanding both pathways is critical. If a provider performs poorly under either, it will face financial penalties. By 2021, the CMS estimates that up to 220,000 clinicians will operate under an alternative payment model and another 798,000 will participate in MIPS.

The new contractor will also create a new IT interface to give physicians more transparent feedback on their performance.

"The feedback needs to remove the shroud of mystery surrounding what clinicians view as very complex, very algebraic measures and scoring," the CMS says in a notice. "We can't change the manner in which legislation, special interest groups and policy decisions have set up the current QPP environment, but we can do our best to implement the appropriate strategies that inject plain language and intuitive explanations of clinician outcomes."

The CMS is most concerned about making sure providers understand the cost measures under MIPS. This is how the agency measures if clinicians are saving Medicare money. Cost savings will account for 30% of a provider's MIPS score in 2021.

"The cost performance category feedback presents the greatest challenge for providing feedback since the measures are highly complex, the data is extracted from claim submissions and is not consciously submitted by clinicians," the CMS said in the notice.

The CMS' efforts are coming just in time, according to policy insiders. Groups like the American Medical Association and the Medical Group Management Association have released surveys in recent weeks in which doctors say the Quality Payment Program has grown too complex to understand.

An MGMA survey released last month found 49% of practices interviewed don't understand how the Medicare MIPS program evaluates them on costs.

"Although we are entering year three under the QPP, many of our provider clients still struggle with understanding, practically, how to meaningfully select measures for their individual practices to directly benefit their patients and achieve the quality metrics" under the Quality Payment Program, said Amy McCullough, a partner at the Akerman law firm's healthcare practice.

Many practices have had to spend thousands of dollars to hire consultants to make sure they understand the Quality Payment Program, due to the program's complex nature.

"Every dollar spent on a consultant because the payment model is so complex is kind of a dead weight loss," said Dr. Mark Friedberg, senior physician policy researcher at RAND Corp. "You could be achieving the same goals without a consultant if you had a model that's simple enough to understand."

Confusion about the Quality Payment Program has resulted in doctors viewing it as a checklist of must-dos rather than motivation to improve the quality of care patients are receiving, according to Dan Golder, a principal at Impact Advisors, a healthcare IT consultancy in Naperville, Ill.

"The whole point of the program isn't to score well, it's to have better care at lower costs," Golder said. "So you need to understand what the government views as better care, how it is being measured, and is it something I can actually influence in my day-to-day practice."