Reporting is cumbersome, and clinical benefits and financial rewards are lacking, they say
The Centers for Medicare & Medicaid Services is pleased with the way its new payment policy for physicians – better known as MACRA – is working out. But some physician groups don’t share the government’s sunny assessment.
The Medicare Access and CHIP Reauthorization Act of 2015, or MACRA, was intended to reward high-value, high-quality Medicare clinicians with payment increases, while reducing payments to those who aren’t meeting performance standards, points out Mollie Gelburd, associate director of government affairs, Medical Group Management Association (MGMA). But there’s a lot of work to be done for it to truly pave the road to value-based payment, she says.
In November, CMS Administrator Seema Verma said she was “pleased to announce” that 93 percent of MIPS-eligible clinicians received a positive payment adjustment for their performance in 2017, and 95 percent overall avoided a negative payment adjustment. (“MIPS” refers to the Merit-based Incentive Payment System, a key provision of MACRA.)
CMS calculated that 1.06 million MIPS-eligible clinicians were on track to receive a MIPS payment adjustment — positive, neutral, or negative. Broken down, the numbers were:
- 71 percent earned a positive adjustment and an adjustment for exceptional performance.
- 22 percent earned a positive payment adjustment only.
- 2 percent received a neutral adjustment (no increase or decrease).
- 5 percent received a negative payment adjustment.
“Admittedly, the MIPS positive payment adjustments are modest,” said Verma. “It is important to remember that the funds available for positive payment adjustments are limited by the budget neutrality requirements in MIPS, as established by law under the Medicare Access and CHIP Reauthorization Act of 2015. Moreover, 2017 served as a transition year to help ease clinicians into the program and encourage robust participation.”
Physician practice perspective
“There is a lot of MIPS fatigue among MGMA members,” says Gelburd. “We’ve gotten plenty of feedback on the program, but the main takeaway is that MGMA members view MIPS as a reporting program without a clear link to actual quality improvement.”
An MGMA survey taken last year found that 88 percent of respondents felt MIPS was very or extremely burdensome with little clinical benefit.
CMS must reduce the reporting burden, says Gelburd. “Our concern is that rather than addressing fundamental issues with program complexity so that everyone has the opportunity to succeed, CMS is just excluding practices from MIPS.”
CMS should also take another look at the financial incentives associated with MACRA, she adds. Under statute, MIPS payment adjustments could have been as high as 22 percent, considering the annual adjustment plus two additional payment adjustment factors. “In actuality, the payouts for MIPS positive performance adjustments are very low, at less than 2 percent, even for those that earned a perfect score.
“The lack of clinical relevance and the reporting burden, coupled with the prospect of low positive performance payouts, are causing physician group practices to assess the return on investment for robust participation in the program.”
MGMA believes CMS should accommodate more voluntary alternative payment models, or APMs. (An APM is a payment approach that gives added incentive payments to provide high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population.)
“CMS should work toward recognizing innovative care delivery and payment reforms in the marketplace, and encourage physician-led, value-based transformation,” says Gelburd. “There are not enough models available right now to account for the diversity of group practices in varying specialties and geographic regions.
“The APM pathway veers further from fee-for-service toward value-based payment,” she says. “This is what the industry as a whole wants. Yet this track has not become the robust payment pathway that we had hoped for.”
MACRA basics
Clinicians choose one of two tracks in Medicare’s Quality Payment Program (created as part of MACRA), based on their practice size, specialty, location, or patient population:
- Merit-based Incentive Payment System (MIPS).
- Advanced Alternative Payment Models (APMs).
MIPS
The Merit-based Incentive Payment System consolidates components of three prior programs: the Physician Quality Reporting System (PQRS), the Physician Value-based Payment Modifier (VM), and the Medicare Electronic Health Record (EHR) Incentive Program for Eligible Professionals.
For MIPS, physicians earn a payment adjustment based on evidence that they provided high-quality, efficient care supported by technology. To do so, they must submit information in the following categories:
- Quality (50 percent of final score), which measures health care processes, outcomes, and patient care experiences.
- Promoting interoperability requirements (25 percent of final score), which promotes patient engagement and electronic exchange of information using certified electronic health record technology. (This category was formerly referred to as “Advancing care information,” which itself replaced the Medicare EHR incentive program, also called “Meaningful Use.”)
- Improvement activities (15 percent of final score), a category that gauges participation in activities that improve clinical practice, such as expanding practice access, improving care coordination and promoting patient safety.
- Cost (10 percent of final score). This category – new in 2018 – measures resources that clinicians use to care for patients, and the Medicare payments for care (items and services) given to a beneficiary during an episode of care.
APMs
Alternative Payment Models, or APMs, are payment approaches that provide added incentives to deliver high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population; and they allow the provider an opportunity to earn an incentive payment for participating in an innovative payment model. Advanced APMs are a subset of APMs, and let practices earn more for taking on some risk related to their patients’ outcomes.
In performance year 2018, the following models were considered Advanced APMs:
- Bundled Payments for Care Improvement Advanced Model.
- Comprehensive ESRD (end-stage renal disease) Care.
- Comprehensive Primary Care Plus.
- Medicare Accountable Care Organization (ACO).
- Next Generation ACO Model.
- Shared Savings Program.
- Oncology Care Model.
- Comprehensive Care for Joint Replacement (CCJR) Payment Model.
Top 5 regulatory burdens
Percentage of MGMA respondents who reported the issue as very or extremely burdensome
- 88 percent: Medicare Quality Payment Program (MIPS/APMs).
- 82 percent: Prior authorization.
- 80 percent: Lack of electronic health record (EHR) interoperability.
- 77 percent: Government EHR requirements.
- 68 percent: Audits and appeals.
Source: Medical Group Management survey of 426 medical practices, October 2018, https://www.mgma.com/getattachment/721b533a-bccd-4a83-a72a-1e077b3ef9f1/2018-Reg-Burden-Summary-of-Findings-Final.pdf.aspx?lang=en-US&ext=.pdf