MAY 22, 2019

Welcome to the MACRA MIPS/APM Update eNewsletter
Editor: Philip L. Ronning
This issue sponsored by the National MACRA Summit, National ACO Summit,
and the National Bundled Payment Summit.

Senators Seek Feedback on Medicare's Pay Models Under MACRA
Members of a powerful Senate committee said during a Wednesday hearing that they are keeping tabs on the administrative burdens of Medicare programs meant to tie physicians' pay to judgments about the quality of care they provide. The Senate Finance Committee does not appear to have any immediate plans for making major changes to the programs created by the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. But during the hearing, members of the Finance Committee showed clear sympathy with physicians' complaints about the Merit-based Incentive Payment System (MIPS). "When it comes to assessing quality, the goal of implementing this new system is not to have doctors checking boxes all day long," Sen. Ron Wyden of Oregon, the ranking Democrat on the committee, told the witnesses at the hearing. Medicare's MIPS system is part of a broad move among insurers to try to tie physicians' payment to judgments about their performance. So far, this effort has forced physicians to spend many hours a day entering data, some of which have little immediate relevance to their role in patient care. Medicare has "retrofit a tired fee-for-service payment model with sporadic measures, which do not make sense to the surgical community," Frank Opelka, MD, medical director for quality and health policy of the American College of Surgeons, told the Senate Finance Committee. (MedPage Today, May 9, 2019)

Using Quality to Shine a Light on Homebound Care
Almost 2 million older adults are completely or mostly homebound, and another 5.5 million are dependent on others or have difficulty leaving their homes. Persons who are limited to the home tend to have multiple chronic conditions, functional challenges, and a high prevalence of cognitive impairment. These individuals constitute a high-risk, high-cost population who can be better cared for in the home. As home-based medical care physicians, we came to appreciate the issues faced by these patients in their everyday lives. Unfortunately, home-based medical care providers were not available for many of these patients, and incentives for providers to enter the field were limited. While the Veterans Health Administration has led the way in the development of comprehensive home-based medical practices for homebound adults within that system, homebound adults in the fee-for-service world are less likely to find a home-based medical care provider. Increasing recognition of the potential value of home-based primary care at the national level began in 2012, when the Centers for Medicare and Medicaid (CMS) Independence at Home Demonstration was signed into law as part of the Affordable Care Act. The purpose of the Independence at Home Demonstration was to determine whether a shared-savings payment mechanism predicated on the provision of comprehensive medical care in the home could (1) confirm the positive clinical and economic outcomes seen in previous studies and systematic reviews of home-based medical care and (2) provide a sustainable economic model for providers. In 2015, the Department of Health and Human Services (HHS) made clear its intention to move Medicare toward a value-based care framework. Furthermore, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) instituted a new Merit-Based Incentive Payment System (MIPS), which evaluated health care providers on the basis of quality, resource use, and clinical practice improvement activities. As HHS imperatives accelerated the shift to value-based care, the need to make our quality measures more available to home-based medical practices became more urgent. The best tactic to increase the availability of these measures, however, was not clear. An alternative approach to the traditional approach to develop and disseminate quality measures through the National Quality Forum endorsement process that seemed particularly attractive with the passage of MACRA was to make home-based medical care measures available through a qualified clinical data registry (QCDR). QCDRs are CMS-approved entities that collect clinical data to foster improvement in the quality of care provided to patients. Novel measures that are not National Quality Forum--endorsed may be included in a QCDR with CMS approval. Thus, providers are not constrained by the quality measures currently available in the CMS Physician Quality Reporting System (PQRS) library, most of which are not appropriate or relevant to home-based medical care. Practices participating in QCDRs have the opportunity both to engage in quality improvement and to avoid negative payment adjustments that are part of MACRA. The development of a QCDR was particularly attractive because it offered an infrastructure for reporting, benchmarking, quality improvement, research, and the use and testing of multiple measures. (New England Journal of Medicine Catalyst, May 14, 2019)

Medicare Physician Payment Reform After Two Years: Examining MACRA Implementation and The Road Ahead
Editor's Note:
The following is a testimony delivered by Matthew Fiedler to the Senate Committee on Finance on May 8, 2019. More information about the hearing and full video of the testimony can be found here.

Chairman Grassley, Ranking Member Wyden, members of the Finance Committee, thank you for the opportunity to testify today. My name is Matthew Fiedler, and I am a Fellow with the USC-Brookings Schaeffer Initiative for Health Policy, where my research focuses on a range of topics in health care economics and health care policy, including provider payment policy. Previously, I served as Chief Economist on the staff of the Council of Economic Advisers, where I provided economic advice on a range of health care policy issues. This testimony reflects my personal views and should not be attributed to the staff, officers, or trustees of the Brookings Institution. (Brookings, May 8, 2019)

Keep Bonuses Coming for New Medicare Models, Senators Told: Extending Them for Another 3 Years Isn't Enough
Extending the 5% payment bonus for participating in one of Medicare's new advanced alternative payment models (APMs) would help encourage their adoption, witnesses told the Senate Finance Committee Wednesday, although they had different ideas on how long it should be extended. "We urge Congress to extend the APM incentive for an additional 6 years," said Barbara McAneny, MD, president of the American Medical Association (AMA). "We recommend the bonuses be extended for an additional 3-5 years," said John Cullen, MD, president of the American Academy of Family Physicians (AAFP). "A good first step would be to make MACRA's advanced APM bonus permanent," said Matthew Fiedler, PhD, fellow at the USC-Brookings Schaeffer Initiative for Health Policy. Witnesses had plenty of other suggestions for lawmakers on ways to improve the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, which overhauled the way physicians were paid under the Medicare program. Under MACRA, physicians have two choices: one is to participate in MACRA's Merit-Based Incentive Payment System (MIPS) program, in which they must report a certain amount of quality data from 2017 in order to avoid a cut in their Medicare reimbursement. Their other options is to participate in an advanced APM, such as an accountable care organization (ACO). "The AMA is recommending that Congress replace the scheduled physician payment freeze beginning in 2020 with positive annual updates for physicians," said McAneny. "The recent Medicare Trustees report found scheduled physician payments are not expected to keep pace with physician practice costs. As a result, trustees say, access for Medicare patients will be a significant issue in the future. Positive payment updates are needed to provide physicians a margin to maintain their practice as well as transition to more efficient models of care delivery." "The AMA also urges Congress to continue to make technical changes to MACRA to simplify the program and make it more clinically significant," McAneny said. "The AMA continues to hear from physicians that the measures they're required to report are taking time away from patient care." (MedPage Today, May 8, 2019)

Senate Hearing Examines MACRA's Progress, Future
The Senate Finance Committee recently held a hearing on clinician payment reform under the Medicare Access and CHIP Reauthorization Act of 2015 and how it could be further improved, which featured witnesses from a number of physician organizations. MACRA's Quality Payment Program, now in its third performance year, includes two payment tracks: advanced alternative payment models and the Merit-based Incentive Payment System. In a statement submitted to the committee, AHA urged Congress to continue working with the Centers for Medicare & Medicaid Services to provide greater opportunity to participate in advanced APMs. "In addition, we urge Congress to consider changes to the fraud and abuse laws to allow hospitals and physicians to work together to achieve the important goals of the new payment models -- improving quality, outcomes and efficiency in the delivery of patient care," AHA said. "Finally, opportunities remain to improve fairness and reduce burden under the MIPS." (American Hospital Association, May 8, 2019)

As MACRA Implementation Turns 2, Industry Leaders Call for Change
For the past two years, MACRA has been shifting providers away from fee-for-service to value. But industry leaders still have reservations about MACRA implementation and the law's value-based reimbursement programs, including the Merit-Based Incentive Payment System (MIPS). In a recent Senate Committee on Finance hearing, leaders from the American Medical Association (AMA), American Academy of Family Physicians (AAFP), American College of Surgeons, American Medical Group Association (AMGA), and the Brookings Institution shared how providers are making the shift to value under MACRA. The industry leaders generally agreed that MACRA is a step in the right direction when it comes to eliminating fee-for-service and moving past the Sustainable Growth Rate (SGR) methodology of the recent past. However, MACRA is not perfect and Congress should update the law's value-based reimbursement programs to incent meaningful change across providers, the leaders added. For example, John Cullen, MD, FAAFP, president of AAFP, expressed concerns that MIPS is overly complex for providers, which takes away from patient care. "We are concerned that MIPS is created a burdensome and extremely complex program that has increased practice costs and contributed to physician burnout," he told policymakers. "Understanding the requirements and scoring for each MIPS performance category and reporting the required data to CMS is a complex task and detracts from the physician's ability to focus on patients." (RevCycle Intelligence, May 8, 2019)

Is MACRA Working?

You can get answers to that question on June 18.

MACRA -- the Medicare Access and CHIP Reauthorization Act -- was enacted 4 years ago this month in an unusual bipartisan effort, passing by almost unanimous margins in both Houses of Congress before being signed into law by President Obama. The law eliminated the problematic Sustainable Growth Rate (SGR) formula and created two alternative ways for physicians to be paid -- the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). Congress not only offered incentives for physicians to participate in APMs but encouraged physicians to develop APMs themselves by working through the newly-created Physician-Focused Payment Model Technical Advisory Committee (PTAC).

Although both MIPS and APMs were expected to accelerate progress toward higher quality care for patients and lower healthcare spending, CMS has struggled to implement the programs in ways that achieve these goals:

  • MIPS has been widely criticized for increasing administrative burdens on physicians while failing to achieve meaningful improvements in value, and for penalizing small physician practices and physicians that treat more complex patients. The Medicare Payment Advisory Commission (MedPAC) has called for abolishing the MIPS program.
  • Most physicians have not even had an opportunity to participate in an APM because of the small number and narrow focus of the APMs that have been implemented by CMS. Moreover, the APMs that do exist have failed to achieve significant savings. Although PTAC has received and reviewed more than 30 proposals for new types of physician-focused APMs and it has recommended that HHS implement or test more than a dozen of the proposals, none of PTAC's recommendations have been implemented by CMS.

Major changes are underway in 2019 to try and address these problems. HHS Secretary Alex Azar has made value-based transformation of the healthcare system one of his four priorities. This week, he announced several new primary care APMs that are partly based on recommendations from physicians and PTAC. HHS is expected to announce additional new APMs in the near future. Earlier this year, CMS made radical changes in the Medicare Shared Savings Program in an effort to get physicians and hospitals to take on more financial risk for Medicare spending. Significant changes in the MIPS program may be included in the proposed regulations for 2019 that CMS will be releasing soon.

Will these new initiatives achieve MACRA's goal of creating a truly "value-based" healthcare system? If not, what would be better? You can hear the most current and comprehensive answers to those questions at the National MACRA MIPS/APM Summit on June 18 in Washington, DC. I'm serving as one of the Co-Chairs, and the speakers we've recruited include both supporters and critics of current approaches and innovators who will describe specific ways to improve current approaches.

Examples of the topics at the Summit include:

  • Are APMs better than fee-for-service? In my Keynote Address, I'll show why most current CMS APMs don't actually fix the problems with current fee-for-service payment and how they can actually harm patients. I'll explain what's needed to create APMs that truly improve value. In separate sessions, my Co-Chairs (John O'Shea, Kavita Patel, and Grace Terrell) and I will provide our assessment of the new APMs coming from CMS and our thoughts on other value-based care topics.
  • How do you really measure and reward quality in healthcare? It doesn't matter how few or many quality measures you use in MIPS or APMs if the measures aren't any good. I'll be moderating a panel with Catherine MacLean, Frank Opelka, and John Wasson to discuss how to create a really meaningful quality measurement program.
  • How do you risk adjust payments and performance measures? The standard approach CMS uses doesn't work well and has the potential to reduce access to care for complex and high-risk patients. I'll be moderating a second panel with Richard Fuller, Eric Roberts, and John Wasson describing both the problems with the current approach and different methods of risk adjustment that could be much more effective.
  • How do you design APMs for specialists? CMS APMs are focused on primary care and hospitalized patients, and there are no APMs at all for most types of outpatient specialty care. Several specialists who have developed APMs, including two of the APMs recommended by PTAC, will be describing how patients and Medicare could benefit if CMS implemented APMs that are specifically designed for specialists and their patients.
  • What about rural areas? Most current APMs are designed for large providers in urban areas, not the small physician practices and hospitals that provide care in most parts of the country. Bill Finerfrock, Tim McBride, and Grace Terrell will discuss how to design and implement APMs that will work for rural providers.
  • What's coming next from the CMS Innovation Center? Adam Boehler, the Director of the Innovation Center and the Senior Advisor to Secretary Azar, will describe the new APMs the Innovation Center has developed and what's on the horizon.

You can see the full agenda here: https://macrasummit.com/agenda-day-2/

There are over 50 different sessions and nearly 100 different speakers in total because the National MACRA MIPS/APM Summit is being held at the same time and place as the National Bundled Payment Summit and the National ACO Summit. The same registration fee provides access to all three conferences. If you can't attend in person, you can see and hear all of the presentations by registering for live-streamed internet access.

Here is the link to register: https://macrasummit.com/registration/

Harold Miller

MACRA MIPS/APM Update e-Newsletter is one of a family of free e-Newsletters providing a complimentary video presentation and regularly updated news and key resources on major health care issues such as ACOs, patient safety, pay for performance, bundled payment, readmissions, and Medicaid. To view and subscribe to other e-Newsletters go to healthcareeNewsletters.com.

Panel II: Making the Business Case for Value-Based Care: Real-World Provider Case Studies Show Evidence that Focusing on Value is a Better Business Model than Maximizing Volume

Karen Conway
Vice President, Healthcare Value, Global Healthcare Exchange

David B. Muhlestein
Chief Research Officer, Leavitt Partners, LLC

Sanjay Doddamani
Senior Director in Population Health, Geisinger Health System

David Nace
Chief Medical Officer, MarkLogic