MACRA: How to prepare for a moving target

In June, CMS released the 2018 proposed rule for the Medicare Access and CHIP Reauthorization Act's Quality Payment Program, which presents a handful of key modifications to the physician payment program. These modifications — which slow implementation and ease requirements, in some cases relieving physicians from participation entirely — could be interpreted as a change of course by CMS, or as inconsistent with the original intention to accelerate the shift to value-based care.

This content is sponsored by Optum.

These inconsistencies may leave some physicians, particularly those required to report for the Merit-based Incentive Payment System, feeling hesitant to funnel more time and money into preparation efforts that could be rendered unnecessary. For example, if the proposed rule is finalized, more physician practices would be exempt from reporting — it raises the MIPS low-volume threshold of annual Medicare charges to $90,000 and beneficiaries treated per year to 200. And even those who are still required by volume to participate will not be held accountable for cost for another year — the proposed rule would delay weighting the resource use measure in the MIPS composite scores until 2019, when it would jump up from 0 to 30 percent. Under the proposed rule, the advanced Alternative Payment Model track would also pull more physicians out of MIPS by extending the nominal revenue-based standard of 8 percent to the 2020 performance year, effectively allowing more APMs, and thus providers, to qualify as advanced APMs.

It's never too early to prepare

Despite these changes, experts from Optum believe physicians should stay the course. MACRA is still coming down the pipeline, albeit at a more leisurely pace. "CMS is slowing down a bit, rather than actually reversing course," says Erik Johnson, vice president of Optum's value-based care practice. "We saw the same thing with meaningful use for EHRs. When that came out there was a lot of tinkering to make sure that CMS was not getting too far ahead of the market."

The move is intended to meet physicians in the middle, many of whom are still unaware of the law, lack an understanding of it or are simply unprepared, according to Mr. Johnson. "CMS doesn't want to put themselves in any more of an antagonistic relationship with the provider community than they might otherwise be in," he said. "They are trying to be careful and make sure the calibration of the pace is correct."

Despite any pacing adjustments, the general parameters of MACRA today most likely represent what the law will look like in the future, according to Mr. Johnson. This means reporting on cost and quality measures and the push to enlist in advanced APMs will continue for the foreseeable future. "[Physicians] may prepare now and not have to put those preparations into practice for a few years," Mr. Johnson said. "There's certainly a time dimension to all of this, but I don't think it behooves anybody to wait and see because I don't think MACRA is going to fundamentally change what it's going to ask physicians to do."

The same advice holds for payers, according to Jim Dolstad, Optum's senior director of actuarial consulting. MACRA is on track to change the game and that will trickle down into the commercial plans, regardless of the pace of implementation. "When you look at MACRA, it's designed for providers in the Medicare fee-for-service arena, but the reality is it's just like [Medicare Advantage] Stars, just like risk adjustment, just like DRGs and every other thing CMS has done over the years," Mr. Dolstad said. "It will cascade into other lines of business."

Implications on payers and providers

Regardless of changes that may occur between the final and proposed rules, payers and providers can count on the following four major changes as a result of MACRA within the next year.

1. Physician MIPS scores will be public. This is a first for providers — there is not an all-inclusive view of provider performance right now, according to Julie Witt, director of actuarial consulting at OptumInsight. For the first time, the public will be able to compare physician performance with a simple, standardized measure when MIPS composite scores are published next year. For physicians who perform poorly, this poses a threat to patient volume and revenue. "It will spur them into action," Ms. Witt said.

2. Score misalignment. These scores also open the door for misalignment with commercial payer's proprietary rankings, which will call the validity of narrow networks into question if providers do not earn similar scores from CMS. "When CMS comes out with a ranking, it will be hard for the public to differentiate that that's a Medicare ranking and it doesn't carry over into the commercial rankings," said Mr. Dolstad. "You may have some misalignment as to what [plans] consider quality providers and not quality providers."

3. Providers will shift their payer strategy. Payers should brace for changes to MA enrollment numbers and value-based care contracts, according to Mr. Dolstad. Physicians hoping to minimize their MACRA impact may shift portions of business to MA, he said. "We are aware of a few plans already where they are expecting higher than average growth," he said. To lessen overall risk and administrative burden, physicians may also lean more heavily on commercial business to make up for potential lost revenue in Medicare, and they may pull out of commercial value-based contracts. "MACRA is going to take a lot of effort for providers to go through, and the effort may be better spent on CMS than on some initiatives payers have put out there through value-based contracting and population health," Mr. Dolstad said.

4. An even greater premium will be placed on collaboration. MACRA requires long-term patient attribution, which requires payers and providers to work together, exchange data and track patients throughout the continuum of care. Physicians and hospitals will also need to work closely with each other and draw other organizations in, including post-acute providers, pharmacies and community-based clinics, according to Mr. Johnson. "That more than anything is the existential lesson MACRA is trying to teach to the healthcare provider community," Mr. Johnson said. "You need to collaborate to truly mange care across 365 days, not just an episode and not just a visit, but across a year in a life."

Steps for success

The best way to start preparing for the QPP is to analyze the available historical data. MIPS builds on legacy programs like the Physician Quality Reporting System, meaningful use and the Value-based Payment Modifier. Physicians should dig into past performance in those programs to select MIPS measures they feel they can excel in, and excel in compared to their peers, because the program is graded on a curve, Ms. Witt notes. Payers, on the other hand, should analyze the potential impacts MACRA will have beyond Medicare and what the magnitude of those impacts will be, according to Mr. Dolstad.

Once payers and providers have a solid understanding of the program, its potential impacts and what their strategy will be, they should look to partner up. "You need really good partners. That's going to be critical," Mr. Johson said. Providers may even find their best partners are commercial payers. Beyond techonology and data, payers have valuable experience to share. "Payers have gone through this on the reporting side with [Healthcare Effectiveness Data and Information Set] before, and now Stars," Mr. Dolstad said. "They understand how to go through the reporting process with CMS and with HEDIS to improve scores as rapidly as they can, and they understand what changes are needed to score well."

Payers and providers can work together to best understand their local markets, coordinate care within that market and integrate risk and quality programs to streamline reporting requirements and processes. Teaming up will position both entities for success under MACRA.

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