CMS Headquarters-Windsor Mill, MD.
With Centers for Medicare and Medicaid Services Acting Administrator Andy Slavitt announcing to the Senate Finance Committee Wednesday that the implementation of MACRA may be delayed, physician groups are weighing in, generally agreeing that a delay would benefit smaller practices in particular.
MACRA, which was intended to simplify Medicare payment, quality improvement and performance measurement programs, has caused concern among many organizations that the timeline for practices to familiarize themselves with the new rules and make necessary adjustments is too narrow, and that the provisions currently in place unfairly benefit larger practices with deeper resources.
Wanda Filer, MD, MBA, president of the American Academy of Family Physicians, said holding off on MACRA until at least July 1, 2017, would be ideal for the group's member practices, and give them the necessary time to prepare.
"We're going to have a lot of work to do with our members," said Filer. "It's going to take them quite a bit of time to get them to succeed in MACRA. A delay would be quite preferable."
In a letter sent to CMS dated June 20, the AAFP said it saw "a strong and definite need and opportunity for CMS to step back and reconsider the approach to this proposed rule, which we view as overly complex and burdensome to our members and indeed for all physicians."
As of now, MACRA is slated for implementation on January 1, 2017, with the final rules having been published around November 1 of this year -- meaning providers would only have two months from when the final rules are published until MACRA goes live and providers must be ready to go.
That timeline, according to AAFP, "does not provide adequate time for education and practice adjustments that will be required to ensure the successful implementation of the quality payment programs in a majority of family physician practices." Members would need more time, the group said, to develop a quality plan, ensure the functionality of electronic health records and make the necessary changes to its reporting mechanisms.
Additionally, AAFP contends that the period between data reporting and payment under MACRA is too great. The two-year period between data submission and payment that's included in the proposed regulation "neither meets Congressional intent nor achieves the goals established by the legislation," according to the organization.
Drawing particular ire among various groups are the processes for reporting for quality measures under MACRA, embodied by the proposed rule on the Merit-Based Incentive Payment System and the Alternative Payment Model Incentive.
In his testimony, Slavitt conceded that small, rural and independent practices will struggle with the new rules; a central theme emerging from the public comment period was the need to design a program with special consideration for these groups.
Slavitt said CMS is "open to multiple approaches," including alternative start dates, shorter reporting periods, and other ways for physicians and clinicians to get experience with the program before "the impact really hits them."
That came as welcome news to the American Medical Association. In a statement, President Andrew Gurman said the AMA agrees that "CMS' regulatory framework must focus on patients, increase flexibility, reduce administrative burdens, and concentrate on aspects of health information technology that are critical for delivery system reform and improving patient outcomes."
He added the AMA was "heartened" by talk of a possible alternate start date, shorter reporting periods and efforts to get physicians up to speed with the program during its early stages.
"Successful implementation will require flexibility, and indications are that CMS intends to work toward the goal of giving physicians are fair shot in adjusting to this new policy framework."
The Medical Group Management Association, in a June letter to Slavitt, argued that the MIPS and APMs proposed rule strays from the terms and themes laid out in MACRA, and that "the framework of these programs would not achieve CMS' overarching goal of promoting high-value healthcare through patient-centric, flexible and streamlined payment incentives."
During a recent MGMA webinar about the proposed MIPS program, 65 percent of the nearly 500 participants said the proposed rule would detract from clinicians' ability to deliver high-value care.
"MGMA and our members recognize proposed MIPS criteria are so onerous that, when coupled with an almost nonexistent Advanced APM pathway, they would consume clinicians' time and resources in collecting and reporting what are essentially government-mandated data points rather than spending time with patients."
Echoing that sentiment in its own letter, the AAFP said it's highly probable that physicians practicing alone or in small groups would be at a significant disadvantage under the MIPS program.
"CMS' own actuaries noted this in their evaluation of the proposed rule -- projecting that 87 percent of solo practitioners and nearly 70 percent of those in practices of 2-9 physicians will receive a negative adjustment in 2019," the group stated.
With respect to MIPS, Congress had established the ability of solo and small groups to aggregate their data in an effort to eliminate any biases in methodology through the "virtual groups" rule. But CMS has also said it would be unable to establish the virtual group option as mandated by MACRA, much to AAFP's consternation.
Slavitt said Wednesday at a Senate Finance Committee Hearing that the virtual group option has great potential, especially for small practices, but there is much work to be done on working out the details on it and it would likely be at least a year before that option was finalized and available.
The organization said the lack of virtual groups would prevent physicians from participating equitably in the MIPS program, effectively widening the gap between smaller and larger practices, and those affiliated with health systems.
Worried that this might affect care for beneficiaries, the AAFP has argued that practices with five or fewer physicians should be exempt from any negative payment updates until such time that virtual groups are readily available.