Delay MACRA, Organized Medicine Tells CMS

June 28, 2016

Medical societies are asking the federal government to delay the kickoff of its new Medicare payment system by 6 months to a year to give physicians more time to master the rules of the game.

And the American Medical Association (AMA), for one, wants to slow down the process of writing the rules for the new reimbursement game, created by the Medicare Access and CHIP Reauthorization ACT (MACRA) of 2015.

The new system goes by the bland name of the Quality Payment Program (QPP). The QPP is supposed to begin rewarding or penalizing most Medicare physicians in 2019 — those in its Merit-Based Incentive Payment System (MIPS) track — on how they perform on various quality and cost measures. In proposed regulations fleshing out MACRA, the Centers for Medicare & Medicaid Services (CMS) will base 2019 compensation on physician performance in 2017, starting on January 1.

That's too early, say the AMA, the American Academy of Family Physicians (AAFP), the Medical Group Management Association (MGMA), and other medical societies in comments on the proposed regulations. They noted that the CMS won't issue its final regulations implementing MACRA until October or November, giving physicians only a few months to get ready for their first performance year.

"Our members need more than 3 months to develop a quality plan, ensure EHR [electronic health record] functionality, identify and select relevant clinical practice improvement activities, and make necessary changes to reporting mechanisms," the AAFP said in a letter to the CMS. The deadline for public comments on the draft regulations was today.

The AAFP, the AMA, the American College of Physicians, and others urged the CMS to begin measuring physician performance under MIPS no sooner than July 1, 2017. The MGMA asked for a start date of January 1, 2018.

Besides allowing for more prep time, a later start date would narrow the time gap between physician performance and physician payment, which had been a priority for the drafters of MACRA, according to various medical societies. A 2-year lag time is too long, they said.

Proposed Regs Receive Mixed Reviews

Organized medicine lobbied hard for MACRA as a replacement for Medicare's detested sustainable growth rate formula for physician compensation. MACRA aims to shift reimbursement from fee-for- service to pay-for-performance, and its MIPS track aims to simplify and align Medicare's existing incentive programs for improving quality and lowering costs, including how physicians report their performance.

In their comments, medical societies gave the proposed CMS regulations mixed reviews as to whether they measure up to the law's intent. "Overall, we applaud CMS for identifying and adhering to the fundamental provisions of the law," the AAFP wrote. In particular, it said, the CMS had simplified quality reporting for physicians. Still, the AAFP called the proposed regulations "overly complex and burdensome."

Other medical societies rendered harsher opinions. "Unfortunately, as we review the draft implementing rules for MIPS, it appears that the net result is neither simplified nor improved," wrote the Texas Medical Association. "Compliance costs exceed any likely financial return on investment through incentives and avoided penalties." Likewise, the MGMA said the proposed regulations "strayed significantly from the terms and themes of MACRA." The CMS plan for MIPS, the association said, would "consume clinicians' time and resources in collecting and reporting what are essentially government-mandated data points rather than spending time with patients."

MACRA established another payment track for physicians besides MIPS called Advanced Alternative Payment Models (APMs), designed for physicians willing to assume more downside financial risk in the pursuit of bigger performance bonuses. Such Advanced APMs will receive lump-sum bonuses of 5% per year in addition to what they might ordinarily earn (or lose).

Here, too, medical societies registered complaints, saying that the CMS makes it too hard for existing APMs in Medicare to qualify as Advanced APMs. They want the bar lowered to admit such entities as medical homes and so-called Track 1 accountable care organizations (ACOs) in the Medicare Shared Savings Program, which represent the majority of ACOs out there.

The responses to the proposed regulations from individual medical societies ran upwards of 100 pages, giving CMS officials plenty to chew on. Normally, the agency would issue its final regulations after reviewing the comments, but the AMA proposed extending the dialogue. It asked the CMS to issue "interim final regulations" that could be further improved and fine-tuned through public comment.

Follow Robert Lowes on Twitter @LowesRobert


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