Implementation of MACRA will impact not only physicians, but also the hospitals with whom they partner, the American Hospital Association told Andy Slavitt, acting administrator of CMS, and the U.S. House Ways and Means Subcommittee on Health on Wednesday.
Health Subcommittee members met with Slavitt Wednesday on the implementation of the Medicare Access and the CHIP Reauthorization Act of 2015.
MACRA's Quality Payment Program, released by CMS on April 27, consolidates a patchwork of programs into two paths for physicians receiving Medicare payments: the Merit-based Incentive Payment Systems (MIPS); and an Advanced Alternative Payment Model (APM).
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The AHA said it applauds MACRA's streamlining of the physician reporting burden, but still has concerns, especially for smaller practices, and is disappointed the federal government is providing no financial incentives for upfront investments in technology to meet the demands of implementation.
The estimated investment is $11.6 million for a small accountable care organization and $26.1 million for a medium ACO, the AHA said.
"Hospitals that employ physicians directly may bear the cost of implementation of an ongoing compliance with the new physician performance reporting requirements under the Merit-based Incentive Payment Systems, as well as be at risk for any payment adjustments," the AHA said in a statement. "Moreover, hospitals may be called upon to participate in alternative payment models so that the physicians with whom they partner can qualify for bonus payment and exemption from MIPS reporting requirements that accompanies the APM 'track.'"
House Ways and Means Subcommittee on Health Chairman Pat Tiberi, R-Ohio, asked Slavitt about concerns he's heard about the difficulty smaller practices may have coming into compliance, saying the rural provider, and one or two-person provider group "has a bunch of angst right now."
Slavitt said the data shows that smaller and solo practices can succeed as well as physicians in larger-size groups as long as they report. It's up to CMS to make the reporting burden as easy as possible, Slavitt said.
"Importantly we are looking for additional steps and ideas as people review the rules, but I will say that we are focusing on technical assistance, providing access to medical home models, opportunities to report in groups and using a reporting process that automatically feeds data, reduces the number of measures and overall lowers the burden for small practices," Slavitt said.
Small physicians can report in groups and other physicians may not have to report at all because they're under a minimum threshold for the number of Medicare patients they see, Slavitt said.
Slavitt said he's heard from physicians that they want to focus on care, not reporting.
Congress has provided funding for MACRA technical assistance to small practices, rural practices and others, he said.
MACRA replaces the sustainable growth rate and changes the way physicians and providers are paid, moving the healthcare system closer to CMS's goal of tying 50 percent of Medicare payments to alternative payment models by 2018.
CMS is taking comment on the MACRA proposal for 60 days.
"Success will come from adopting approaches that are practice-driven," Slavitt said. "It is our intent to align the MIPS and the Advanced APM components of the Quality Payment Program, allowing maximum flexibility for clinicians to switch between MIPS and participation in Advanced APMS based on what works best for them and their patients."
To spur motivation, MACRA established an 11-member independent advisory committee, the Physician-Focused Payment Model Technical Advisory Committee, PTAC, that will meet quarterly to review payment models.
The AHA has formed its own clinical advisory group to identify important policy and operational implications of MIPS and APMS for hospitals.
The AHA recommends hospital-based physicians be able to use their hospital's quality reporting and pay-for-performance program measure performance in MIPS; employ risk adjustment rigorously, including for sociodemographics to ensure providers do not perform poorly simply because they care for more complex patients; and align EHR Incentive Program changes for physicians with those of eligible hospitals.
The AHA applauded CMS's proposal to reduce the number of measures for quality reporting from nine to six, and also for its recent work with private insurers and physician groups to reach agreement on a common set of physician quality measures that can be used in both CMS and private payer pay-for-performance programs.
"Physicians and hospitals alike spend significant resources reporting on multiple versions of measures assessing the same aspect of care to meet the differing requirements of CMS and individual private payers," the AHA said.
The AHA is disappointed CMS has proposed a narrow definition of financial risk in advanced APMs for purposes of MACRA bonus payments, in not recognizing the upfront investment made by providers to implement alternative payment models.
The AHA also said fraud and abuse laws need to be modified for a "legal safe zone" where physicians and hospitals can share information without breaking the Stark law on referrals and payments.