Industry Orgs Concerned with 2018 MACRA Implementation Rule

Stakeholders argued that the 2018 MACRA implementation rule will slow the value-based care transition and does not promote quality over quantity.

Industry groups, including the American Medical Group Association (AMGA) and the Medical Group Management Association (MGMA), are questioning if the new 2018 MACRA implementation rule truly promotes value-based care.

In recent comments on the 1,653-page rule, AMGA President and CEO Jerry Penso, MD, MBA, stated that 2018 participation rules for MACRA’s Merit-Based Incentive Payment System (MIPS) will slow the value-based care transition.

CMS finalized greater participation thresholds that would exclude more Medicare providers from attesting to MIPS in 2018. In the first performance year, CMS excluded providers if they received $30,000 or less in Part B allowed charges or saw 100 or fewer Part B beneficiaries.

The 2018 MACRA implementation rule stated that providers are excluded from the second performance year if they received $90,000 or less in Part B allowed charges or saw 200 or less Part B beneficiaries.

“The transition to value is challenging and CMS understandably wants to ease providers into value,” wrote Penso. “But excluding providers isn’t the same as learning how to deliver care in a value-based world. Taking accountability for the quality and cost of care requires years of experience. Despite CMS’ intentions to ensure a smooth transition, AMGA is concerned that this rule actually hinders the prospects for value-based care.”

READ MORE: What We Know About Value-Based Care Under MACRA, MIPS, APMs

The National Committee for Quality Assurance (NCQA) also pointed out that increasing the number of excluded providers would impact virtual group implementation. Virtual groups allow small practices to join together to report to MIPS.

“Unfortunately, the rule prevents the smallest practices from joining virtual groups be defining ‘low-value’ practices as ineligible for MIPS,” the committee explained. “Low-volume practices…need virtual groups so they can have reliable measurement and reap rewards for improvement. CMS could remedy this by amending its low-volume definition to say these practices are ineligible for MIPS ‘unless they join a virtual group.’”

AMGA also voiced concerns with individual assessments under the Advanced Alternative Payment Model (APM) pathway.

Advanced APMs encourage care coordination along the care continuum. However, MACRA implementation policies that allow eligible clinicians to choose whether to be assessed at the individual level or at the APM entity level counter care coordination efforts.

“The models under the advanced APM pathway are designed to evaluate providers as a group and AMGA is concerned how this will be put into practice,” the group explained. “Differentiating by individual clinician undermines the care coordination efforts that are at the core of not only the group practice model but of APMs.”

READ MORE: Understanding the Quality Payment Program’s Advanced APM Track

Additionally, MGMA commented that increasing the quality reporting period in the second performance period for MIPS does not promote quality.

“MGMA is very disappointed that CMS quadrupled the length of the quality reporting period under MIPS from the current 90 days to 365 days in 2018,” Anders Gilberg, Senior Vice President of MGMA Government Affairs, wrote in an emailed statement. “This fourfold increase to the quality reporting requirements is in stark contrast the Agency’s statements today that the final rule reduces regulatory burdens. “

“CMS is in effect prioritizing quantity over quality and giving physicians less than 60 days to prepare for the 2018 MIPS requirements,” he added.

While quality reporting under MIPS increased, CMS did not change the reporting period for the other three MIPS performance categories. The period is still a minimum of 90 days for Advancing Care Information, Improvement Activities, and cost.

While some stakeholders criticized 2018 MACRA implementation rules, other industry groups commended CMS for considering Medicare Advantage plan inclusion in the Advanced APM pathway.

READ MORE: How MACRA Implementation Rules Affect Provider Profitability

Qualifying participants in the Advanced APM track can earn a 5 percent incentive payment based on their Medicare Physician Fee Schedule reimbursements. CMS planned to include Medicare Advantage arrangements as part of the pathway by 2021.

But the 2018 MACRA implementation rule stated that CMS intends to establish a Medicare Advantage alternative payment model demonstration that will test the effects of extending incentives to eligible clinicians in qualifying Medicare Advantage arrangements.

“We are also encouraged that CMS indicated its intention to develop a demonstration project to examine how clinicians participating in Medicare Advantage (MA) alternative payment models can qualify for bonus payments,” stated Premier’s Senior Vice President of Public Affairs Blair Childs. “Nearly one-third of Medicare beneficiaries are enrolled in an MA plan. Many MA plans have engaged providers in innovative value-based contracts that are benefiting patients. This policy would level the playing field for clinicians in areas with high MA penetration.

Including Medicare Advantage alternative payment models should also boost clinician participation in risk-based value-based care models, AMGA added.

“Improved access to the Advanced APM pathway would go a long way to giving providers a real choice,” Penso wrote. “One of the best ways to increase APM participation is to include clinicians’ contracts with Medicare Advantage plans that meet the risk and quality requirements. More and more beneficiaries choose to enroll in Medicare Advantage and factoring these plans into the APM thresholds now would increase the number of providers in risk-based models and help move Medicare away from fee-for-service.”

Industry group reactions to the final 2018 MACRA implementation rule represented a mixed bag. Stakeholders can continue to voice their opinions on the rule by submitting comments to CMS by Jan. 2, 2018.

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