Provider Groups Express Concerns With MACRA Transition

An Interview with Jacqueline W Fincher, MD, MACP, Chairman of the Medical Practice & Quality Committee at the American College of Physicians (ACP).

In your experience, are providers ready for the transition to MACRA?

It truly depends on where you are, and what type of practice setting you are in.

Physicians and other providers who are part of large health systems or academic centers are really depending on the Chief Medical Officers, Chief Information Officers, and Quality Improvement Professionals to provide them with the information and workflows needed for implementation, along with putting the requirements, regulations, and data submissions into place for them. Private practices have much more skin in the game.  These physicians and providers generally know much more about the Quality Payment Program (QPP), but are concerned they don’t know enough to be successful in the transition. Most of these providers have already been participating in the Medicare Physician Quality Reporting System (PQRS) for several years, along with the Meaningful Use (MU) program. In addition, they have automatically been part of the Value Added Modifier program. So, in a sense they have already been doing what they will be asked to do for QPP. It will all just be combined into one program with a new scoring method. It is the scoring method and how that extrapolates into payment that is the most worrisome to providers. Physicians want to understand the scoring method so they know where to concentrate their energies, change their workflows, and have a pretty good idea of how they are doing long before they have submit data for an official score which will translate into their payment.

ACP recommendations are aimed at simplifying the QPP, can you discuss some concrete ways the QPP can be improved and simplified?

1. The scoring method that CMS has proposed is ridiculously complicated, making it very difficult for practices to keep their own running scorecard. There are four weighted performance categories areas that make up the composite performance score, and it is an equation that will change over time.  To start with in 2019 the equation is:

Quality 60% + Advancing Clinical Information 25%+ Clinical Improvement Activities 15% + Cost 0% = MIPS Composite Performance Score.

The problem is within each category CMS has a very complicated methodology for the weight of points that does not fully align with the value of the category.  It is this complexity that makes it very difficult for physicians to understand and follow their own performance score internally in real time. Practices cannot afford to wait 2 years and a potential pay cut to know how they are doing. ACP has proposed a much simpler scoring system, where the percentages of the total score actually are the points in each category. The available points within each category would actually add up to the percent of each category, for example, in the quality category there would by a total of 60 available points, and thereby counting for 60% of the score. 

2. ACP has strongly recommended that the Quality performance category, along with the ACI and Clinical Improvement Activities be set at a 90-day reporting period, so that physicians can gradually prepare for full participation and learn from each reporting period and thereby gain competence and confidence in the new system.

3. ACP has strongly recommended that CMS prioritize moving the performance period MUCH closer to the payment adjustment year as soon as possible. It will give physicians much more timely feedback and facilitate meaningful improvement.

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4. ACP has strongly recommended CMS consider the detailed recommendations to reduce administrative burden tasks and requirements outlined in our recent policy paper “Putting Patients First by Reducing Excessive Administrative Task in Health Care.” This would be especially relevant in the Quality Performance category and the Clinical Improvement Activities that may well be duplicative in many cases. We have asked CMS to collaborate and coordinate with specialty societies, frontline clinicians, EHR vendors, and patients on quality measure development, testing and implementation.

5. The recent proposed rule has raised the low volume threshold to $90,000 in Medicare Part B charges OR require < 200 unique Medicare patients seen annually. While this change will provide relief to more physicians from the QPP program, the ACP recommends that those physicians should at least have the option to be a part of the MIPs program if they so desire. If they participate, it may actually help them more in the long run, as practices change, consolidate, and the payment system evolves. 

6. ACP recommends the option of also allowing several smaller groups that are part of a larger Tax Identification Number (TIN) to report in a “subdivided TIN-level”, where the larger entity divides into smaller groups for the purpose of performance assessment relevant to their scope of practice. For instance, a larger multispecialty group with one TIN being able to “subdivide” into their own specialty areas for reporting, or a number of primary care groups reporting together under an IPA TIN number, but being grouped by Internal Medicine, Pediatrics, and Family Medicine, etc.

MACRA has been criticized for potentially creating an administrative burden, and the ACP recommended steps to reduce this burden—can you discuss why this is important?

It is critical to physician lives and practice survival to decrease administrative burdens by government, insurers, pharmacy benefit managers, etc. Physicians are at a breaking point everywhere with tremendous time constraints, productivity demands by employers, and increasing overhead costs. QPP cannot be the straw that breaks the camel’s back. QPP must actually streamline quality and accountability, improve care for patients, and truly HELP physicians take better care of patients, not just create more work for them that does not directly impact patient care. CMS has to work with the ONC-HIT to create standards and guidelines to dramatically improve EHR usability, so physicians can get back to spending time with patients, instead of spending most of their time as data entry clerks.

What can be done to encourage participation in patient centered medical home models under MACRA?

ACP has recommended that any practice already “certified” or “recognized” as Patient Centered Medical Homes,” should be able to participate in either the MIPs or APM program with NOMINAL or NO financial risk, and get full credit for clinical improvement activities, and not be penalized if all the practices within one TIN are not PCMHs. ACP has also recommended that CMS take several specific steps to provide multiple pathways for PCMHs to be included in the advanced APM pathway and starting in 2018.  Extensive details on these and other PCMH recommendations are included in the letter.

Is there anything else you would like to add about the ACP’s recommendations to the CMS?

The ACP has received tremendous input from frontline physicians in all kinds of practices and practice settings on changing the old payment system based on the very flawed SGR (sustainable growth rate) formula to a new system.  As you recall, the flawed SGR formula was causing physicians to face potential double digit payment cuts every year for the previous 12 years, creating a ridiculous circus every year with us begging Congress to prevent the cut, and then them giving us a measly 0-1% pay increase.  The MACRA law has at least brought that craziness to an end.  We are now focused on value of care, not just volume of services.  With major physician input and tremendous staff time and expertise, ACP has provided an extensive 90 page letter with detailed comments to CMS on the MACRA/QPP new proposed rules.  We are counting on CMS to be just as diligent in getting this right and to continually improve the payment system as we go along.

Change is stressful, even if it is a good change and leads to something better.  I want to really send a word of encouragement to my fellow physician colleagues; the ACP is listening closely to the concerns of physicians, and our fantastic staff is working on our behalf every day to make the new Quality Payment Program work for us and our patients.