HIMSS16: Arien Malec warns MACRA preparation needs to begin now
Legislative language is confusing; that's no secret. Sometimes, legislative language is purposefully written in a convexing vernacular. If something is confusing, a natural reaction is to zone out.
While the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) is a bit confusing and details are yet to be determined (CMS Acting Administrator Andy Slavitt at HIMSS16 noted CMS is "months away" from a MACRA proposed rule), that does not mean preparation can't begin now.
At HIMSS16, Healthcare Dive sat down with Arien Malec, ONC Health IT Standards Committee Co-Chair and VP at RelayHealth, to discuss what providers should know about the new legislation and how they should start preparing.
What should providers know about MACRA?
Arien Malec: Every dollar for how you’re going to get paid by CMS is going to change and the measurement year is earlier than you think. If you were thinking about this and looking at where the world is going, you should be starting the upfront work to participate in an alternative payment program now.
A secondary takeaway is there’s been a lot of news of meaningful use changing or meaningful use is over. There’s some truth to it but meaningful use is indelibly part of MACRA for eligible providers and it’s still enshrined for eligible hospitals and critical access hospitals. So meaningful use is here to stay but the mechanics of how we measure attestation or meaningful use attainment is going to change.
Andy Slavitt had a nuanced message and the problem, if you will, with his statement is the first part of his message was such a compelling statement that everyone forgot the second part.
What industry environments caused the spurred legislation?
Malec: Awhile back, Congress was looking at the rate of increase in medical costs, panicked, and as a deficit reduction measure put in the sustainable growth rate (SGR). Since the cost of care was rising much faster than inflation, it felt to providers like a pay cut year in, year out.
Every year, dutifully, the major societies would all go to Congress and say “If you don’t fix this, doctors won’t provide care for Medicare patients and Medicare patients will be angry and they’ll blame you.” Every year, there was a “doc fix” and it usually got put into legislation at the last moment as part of an omnibus bill; it was like clockwork.
So the whole system didn’t work. One of the problems with the system is the CBO would score the budget every year according to the SGR even though everyone knew that every year Congress would undo it.
The problem with that is because we’ve enshrined pay-as-you-go mechanics in budget-making, Congress needed a way to figure out a way to fix the doc fix, replace the SGR and pay for it. The good news was a couple of years ago the House and Senate got together and came to [a bipartisan] agreement.
Last year, they passed MACRA which completely replaced every aspect to how doctors get paid.
What are those changes?
Malec: First thing it does is put in a .5% year-over-year increase into the fee-for-service payment structure until 2019. Then, from 2019 to 2025, it freezes that if you’re on the MIPS [Merit-Based Incentive Payment System] track. It amounts to a pay cut with the chance to earn some money back.
There are two tracks: MIPS and the APM [Alternative Payment Models] track.
On the MIPS track, Congress combined a bunch of programs — meaningful use, PQRS and the VBR program —and smushed them all together into one program called MIPS. MIPS puts in place a measurement according to a provider’s ability to attest to meaningful use, do quality reporting, and hit certain quality targets.
Effectively, what we’re doing is shifting how doctors get paid under regular Medicare to what looks kind of like a pay-for-performance system. If you look a lot of the commercial plans that put in pay-for-performance systems, usually they have a health IT component, a patient engagement component, and a quality reporting component.
MIPS looks very much like a traditional pay-for-performance program. But it’s really important to note everything is zero-based. What that means if I do really well and get paid more then that means someone else is doing poorly and getting paid less. From Congress’ perspective, the net is to provide stability and budgeting over those years.
But it kinds of sounds like a bit of a rat race. Some providers are going to do really well under MIPS but most are going to hit around the mean because that’s usually the way it works.
That’s where track 2 comes in, which is the alternative payment methodology track. This is the track that is “paved with gold.” Unlike in the MIPS track where the pay is frozen, you get a 5% annual bonus on your fee-for-service payments.The APM might be something like a two-sided risk ACO or a bundled payment program.
The key under CMS is the provider has to have a majority of their dollars under the program and, secondly, it's got to be a program that has some financial risk associated with that program.
My net of MACRA is it’s heavily skewed towards the APM track. I ask a lot of CIOs, CMIOs, etc. what they are doing to prepare for MACRA. Universally, I get a blank stare back because I don’t think people have calculated or thought about what’s required but I think 2019 keeps people thinking “I don’t have to think about this for a while.”
CMS traditionally — this is the way meaningful use works — measures a program two years before they do the payment adjustment so 2017 would be the measurement year for the 2019 payment year.
There’s this weird moment where every way a physician’s way of getting paid is changing. The details are kind of complicated and a lot of the details aren’t ironed out yet but there’s not a lot of time. It’s 2016; if the measurement year is 2017 then I got to be doing stuff now to prepare for that measure year. More to the point, if I’m going to participate in an alternative payment program that has two-sided risk, I need to start organizing now.
There are a lot of lead time activities such as forming the organization and physician engagement. Data acquisition is really hard so I need to be thinking about how I'm going to measure quality and how to manage quality and manage costs 2-3 years from now.
You need to start organizing now; you need to start opening interfaces now and be thinking about how to reconcile clinical and financial data. I really don’t think there’s a lot of time for folks to prepare.
Will this change provider/payer relationships?
Malec: One of the things CMS is trying to do is work across payers. MACRA changes Medicare but CMS is trying to align the clinical quality measures that they’re measuring with the commercial payers and CMS just recently did a revision based on some of that reconciliation work they’ve been doing. So they’re trying to get these programs directly lined up.
The expectation is commercial payers will have very similar programs. Many of them have an ACO program or a bundled payment program or a medical home program and I think we’re going to see a lot of work in the policy area trying to file the edges off those programs to make them a little more harmonized so I can tell a provider as CMS and as Aetna and as the Blues “Go do this set of things and you’ll be OK” because I think a lot of providers are confused.
Does this program have any implementation similarities to ICD-10 or meaningful use?
Malec: It’s a lot more like the meaningful use roll out. It is more akin to changing a lot about how the mechanics of the practice of medicine occur. The complaint people had for meaningful use was that we were measuring clicks and we were measuring stuff that didn’t tie back to clinical quality.
And one of the things to keep in mind with what Andy Slavitt and Karen DeSalvo have said is that they’re taking people at their word and [responding], “We agree. We’re going to start counting a lot fewer clicks and we’re going to start collecting and measuring end quality.”
What I don’t think providers realize about that is that’s a lot scarier than counting clicks in many ways, yet much more meaningful. What CMS has announced in terms of its direction is an intent to move towards outcome-oriented clinical measures that are less about counting clicks and more about counting the things that really drive patient quality of care.
It’s simpler in some ways than meaningful use because it’s more outcomes oriented at least by intent but it’s much more difficult because it actually requires real interoperability. It [also] requires a lot more process change than meaningful use did. Providers are going to find [MACRA] more of a challenging program but hopefully challenging and rewarding at the same time.
Any final thoughts?
Malec: We’re seeing the level of attention to health, health quality and interoperability be larger than it ever has been and that’s driven in many ways by provider pain.
[However,] I would not anticipate that Congress is going to change this. Rather than get angry as a provider, I would get organized to set out the good work of improving clinical quality.
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