The open comment period is over for the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) proposed final rule. MACRA is the proposal from the Centers for Medicaid and Medicare Services (CMS) that makes sweeping changes to the way physicians will be paid for their Medicare populations. For the two months since the release of the proposed final rule, stakeholders have combed through the 962-page document, attempting to understand how it will impact them, their practices and those within the organizations they represent.
Everyone had a lot to say. The vast majority of comments expressed appreciation for the immense challenge facing CMS while providing constructive suggestions and valid concerns. More than one hundred medical associations, along with countless individuals submitted more than 3,800 comments, many of which exceeded 50 pages. Throughout the comments, significant trends emerged.
Concern for the impact to small-practice and solo practitioners, who, lacking technology and resources face tough decisions about their future in medicine. Without technology, capital and adequate administrative support, 67 percent of doctors with a high percentage of Medicare patients believe the end of their independence is near. According to a recent Black Book Report, “two-thirds of independent practices are now deliberately selling out to hospital systems and larger groups or closing down by 2019 as the resource-intensive requirements of MIPS, administrative burdens, and under-optimized technology may make the transition to value-based care too discouraging.”
Dr. Douglas Johnson of Michigan submits, “I am a rural surgeon who will be forced into early retirement in a community that can ill-afford the loss but I cannot handle the enormity of the administrative task you hand me daily.”
This is a dire prediction and predicament for the entire healthcare industry. When independent physician practices merge, prices tend to increase for payers and consumers, while physician satisfaction and productivity declines. Small practices and solo practitioners still provide the majority of primary care services. A recent study by AMA shows 60.7 percent of physicians work in practices of 10 or fewer. Many independent physicians want to stay independent, knowing that absorption into a larger system is not the path to their continued joy of medicine, but many fear MACRA threatens their ability to do so. While MACRA provides financial assistance for technology investment, it is unlikely these funds will be released and distributed in time. Stakeholders throughout the industry that have a vested interest in keeping costs down while delivering quality care must take action now to help physician practices remain independent.
Concern over imminent start. Comments revealed overwhelming agreement that CMS must give physicians more time to prepare. Many advocated pushing back the Jan. 1, 2017 start. A 70-page comment letter from the American Medical Association (AMA), states the start date is “inconsistent with the intent of Congress.” Instead, AMA recommends the last six months of 2017 become a “transitional period” that would “ensure the successful and appropriate implementation of the MACRA.” A joint letter from the Healthcare Information and Management Systems Society (HIMSS) and the Association of Medical Directors of Information Systems (AMDIS) echoed the sentiment. “[We] are very concerned the shortened timeline will not provide the necessary time to address possible technology changes and conduct testing of electronic health records (EHRs) and other health IT solutions before the program start date.” Individual doctors agree.
There is little health IT systems can do before CMS’s release of the official final rule. Specific details are needed to appropriately direct technology development. The final rule is not due until November 1, 2016. It is improbable that technology can be created or updated and implemented in time.
Concern over the lengthy reporting period. Comments rolled in expressing concern that the year-long reporting period does not provide eligible clinicians with the opportunity to receive and respond to feedback. The American Medical Group Association submits “AMGA remains concerned CMS does not provide performance feedback promptly. AMGA encourages CMS to evolve MIPS measurement such that reporting becomes a more iterative process where eligible clinicians and vendors provide performance data more routinely and CMS responds as frequently as monthly with composite score performance, particularly resource use performance since it is derived from claims data.” HIMSS and AMDIS urged CMS to move to a 90-day reporting period to facilitate ongoing clinician improvement.
The ability to capitalize on practice strengths and shore up weaknesses within a meaningful timeframe is critical to the ongoing success of all practices operating within the MACRA framework. With the recent proposed CMS hospital payment rule allowing a 90-day reporting period for Medicare providers to attest to meaningful use in 2016, we are hopeful this logic carries forward to MIPS reporting in MACRA.
Concern over complexity. Organizations and physicians alike commented favorably on reporting flexibility and the intention of CMS to create a system that facilitated maximum participation. However, few understand how to apply the complicated rules to their practices. HIMSS and AMDIS sum up the general consensus, “In creating this flexibility, CMS is proposing a level of complexity that increases the burden on eligible clinicians” and offered alternatives that would “reduce the overall complexity of the rule while achieving the flexibility the [eligible clinicians] will need to be successful in the program.”
The balance between flexibility and simplicity is difficult to achieve. Many comments expressed concern that the complexity and forced participation would overwhelm many small practitioners, driving them to drop their Medicare patients or move to a cash-only system.
It is now CMS’s turn to diligently mine comments for understanding and inspiration as they craft and refine the official and final MACRA rule.