The proposed MACRA implementation rule was released earlier this month,. As stakeholders have begun to exit their libraries -- glazed over from taking in parts or all of the 962-page tome -- opinions over the measure and its implications are surfacing. 

While the law is a huge legislative step from volume to value, it's still a proposed rule and can be changed. Whether it is a perception of undue burden on small practices or the implementation timeline is too aggressive, submit comments and make your voice heard to CMS to suggest changes. The agency will take public comments on the MACRA implementation proposed rule until June 27.

The skinny on MACRA

The implementation rule is sweeping but at a bare-bones level, MACRA will eliminate the sustainable growth formula and replace it with a .5% annual rate increase through 2019, after which physicians are encouraged to shift to one of two Quality Payment Programs: 1) Merit-Based Incentive Payment System (MIPS) or 2): Alternative Payment Model (APM).  

Of particular note, the measure will phase out Meaningful Use -- as hinted at in January -- with the new Advancing Care Information (ACI). Providers can choose customizable measures to report how they use technology in their day-to-day practice, with a particular emphasis on interoperability and information exchange. 

The implementation timeline (image below courtesy of Health Affairs) can be construed as a bit bold. As currently written in the NPRM, 2017 will serve as the performance year for the 2019 payment year, a relatively mere eight months away for a highly technical program.

Quick takes

"If you look at what Congress actually wrote, I don't think -- with the exception for the definition of what an advanced APM looks like -- there's much in this rule that is surprising with respect to the use of certified EHR technology, being a meaningful user, and the check-box approach to various sub-constituent measures," Arien Malec, vice president, strategy and product marketing at Relay Health, told Healthcare Dive.

Malec stated many of the details in MIPS look similar to other pay-for-performance plans around the country, such as Integrated Healthcare Association's Value Based P4P, a program contains incentive payments and benchmarks as well as a public reporting component.

"There is still a lot of independent practice in California," Malec stated, adding that joining an independent practice association, which contracts with independent practices to work together when contracting with other payers and HMOs, provides some air cover for such initiatives.

In 2014, the California Health Care Foundation stated 21% of the 91.775 physicians in California were solo practices. "Primary care physicians in general are going to survive MIPS," Malec stated.

Some criticisms came with more heat. For example, Harvard Medical School CIO Dr. John Halamka's initial analysis of the rule regarding the surveillance provisions and ACI requirements had him conclude, "As a practicing clinician for 30 years, I can honestly say that it's time to leave the profession if we stay on the current trajectory." He later noted he encourages dialog about the rule. 

From Sen. Sheldon Whitehouse's (D-RI) perspective, MACRA is in danger of making some of the same mistakes that Meaningful Use made many years ago where "more than $30 billion got spent putting gear on desktops and a couple of hundred million spent on building the actual information exchange infrastructure that enables the value proposition of the desktop hardware," Whitehouse said, adding, "I think we ended up going about that kind of backwards." 

He stated the driving force behind Meaningful Use was to incentivize doctors and set technology standards to prime a bank shot into the tech community to come up with the tools for doctors. "In principle, that's not a bad idea," Whitehouse told Healthcare Dive. However, "there simply wasn't the information transfer infrastructure to do that nor was there any meaningful way of getting that information transfer infrastructure built unless you had monopolies that could reach across all the payers in the market," he said. 

He added, "The idea that Epic and other big data services providers were going to build out data exchanges and share data without looking to get a competitive advantage against each other was optimistic in the extreme." Because of this, Whitehouse believes the U.S. is behind where it should be on health IT considering the price tag.

For MACRA, Whitehouse said it worries him there seems to be money sprinkled as widely as possible rather than "robustly rewarding the trailblazers," adding, "We could end up with a situation where yet again we paid huge amounts of money because we haven't advanced the techniques of this as far as we should have."

Big trouble in little practices?

One of the largely debated topics of the MACRA implementation proposed rule is the impact it may have on small and independent practices. "As currently proposed, it would really massively disadvantage smaller practices compared to larger practices," Dr. Farzad Mostashari, CEO and founder of Aledade, told Healthcare Dive.

"To me, that is the policy concern that we should all be really worried about because consolidation in the healthcare marketplace is the single biggest threat to this movement from volume to value," Mostashari said.

Earlier this month, members of Committee on Ways and Means' Health Subcommittee voiced concerns over Table 64 (shown below) in the proposed rule. "If CMS is trying to win back the hearts and minds of physicians, this proposal falls short because it will continue to push physicians out of their small practices or solo practice," congressman Sam Johnson (R-TX) said during the hearing. 

Another subcommittee member noted the table states solo practitioners could see a negative adjustment of 87%.

"It's a problem if 87% of solo practices are losers and 87% of large practices are winners and that net transfer will make it harder for practices to stay independent," Mostashari told Healthcare Dive.

It may be that smaller practices have poorer quality scores but they don't actually have higher costs or worst patient outcomes or readmissions. "They just have fewer capacity to have compliance officers running around checking boxes," he said.

CMS acting Administrator Andy Slavitt during the subcommittee hearing noted Table 64 used 2014 data, a year most physicians did not report on their quality measures. In subsequent years, physicians reporting increased because of an expansion in ease of data reporting, Slavitt noted.

CMS will continue to ensure small practices will prosper just as much as larger practices, Slavitt said at the hearing. "Our data shows that physicians that are in small or solo practices can do and do do just as well as physicians in larger practices," he said.

A key fix, Mostashari told Healthcare Dive, in the advanced APM portion of the rule is for CMS to create a pathway so independent primary care practices can take on two-sided risk contracts that won't put them out of business.

The rule as it's currently structured makes the transition from volume to value hard because there are relatively few existing successful APM models that providers can join,  Malec stated. 

"I was hoping for what I've called the Goldilocks APM that may not be the one-sided, only upside MSSP but something that has a sufficient amount of revenue risk and downside risk but not the difference between being successful and completely going out of business," Malec said. "That's the risk model that you face in the current set of two-sided ACOs, for example."

Over the weekend, Slavitt took to Twitter to discuss reactions and takeaways surrounding MACRA. While the entire tweet storm is worth the read he did acknowledge the small practice impact:

2. A 2nd area is how small practices will fare relative to larger sized practices under #MACRA. We put this out: https://t.co/QQuG3y3Fye

— Andy Slavitt (@ASlavitt) May 22, 2016

Certified surveillance programs

The surveillance provisions of the proposed rule seem to be welcomed with caution. The proposed rule would require eligible professionals, eligible hospitals, and critical access hospitals to attest they have cooperated with EHR technology surveillance conducted under the ONC Health IT Certification Program.

The proposed rule for the oversight program is set to provide ONC with the authority to review certified healthcare IT products and take actions to correct non-conformities. Public comments for this rule are no longer being taken. 

However, the proposed rule has raised some concerns among healthcare associations, such as HIMSS, CHIME, AHA, and AMIA, that ONC could suspend or terminate a vendor's Meaningful Use for a product or a quality measure within a product until an issue is fixed. 

"To me, cooperating with surveillance is not a check box; that actually is important," Mostashari said. "If you're going to have certification you need to have enforcement in the field and surveillance is part of that. I don't see that as being as issue considering the likely scope."

He added, "In Aledade's experience, only 38% of the EHRs we work with in the field can actually demonstrate in the field what they successfully passed the tests in the lab around interoperability. That's a big problem and rather than pile on more and new certification requirements, we have to make sure that the ones we already have that supposedly people have been doing for four years actually work for the physicians in the field."

2017 isn’t that far away

Change is hard. Just ask Theranos. To achieve an alternative payment methodology, that requires a lot of time and organizational change related to technology rollout, data acquisitions, and how processes work. The proposed 2017 start date for MACRA's first measurement year affecting payment in 2019 could cause "a lot of mess and chaos," Malec stated.

"I worry the MIPS program requires a whole set of process and technology changes that are very different from what providers are used to in the meaningful use program," he said, adding CMS does not have a list for what alternate payment methodology programs are qualified as advanced APMS under the rule.

Under the proposed rule, "you're going to have to decide what you do before the rule is finalized in November," Mostashari said.

"I would love to see a more thoughtful phase-in model," Malec said.

Policy writing is hard, comments are needed

Mostashari and Malec told Healthcare Dive while it can be hard to write policy in general, it’s particularly hard when policy is supposed to touch all the different kinds of doctors from radiologists to pathologists to dentists. It's also hard to think about unintended consequences of policy but the solution is evolving and listening.

Meaningful Use had largely been accused of focusing too much on primary care physicians and MACRA's implementation is an attempt to bring all physicians to focus on value-based care. “I think CMS really did listen,” Mostashari said.

The agency tried to simplify and remove burdensome requirements as well as harmonize the regulation across a variety of practices and programs, which is no easy task. "I do think there are some fixable, and I want to underscore fixable, changes," Mostashari said. "This is a proposed rule; they want to hear comments." 

Healthcare Dive's Ana Mulero contributed to the reporting of this article.