​Whether providers were ready for it or not, the long-awaited Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) implementation final rule dropped last Friday. Some of the top healthcare experts and organizations were quick to share their reactions.

MACRA replaced the sustainable growth rate (SGR) formula. Qualifying physicians will be required to choose one of two quality payment paths - the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs) - when the law takes effect in January 2017.

Dr. Farzad Mostashari, Aledade CEO and co-founder, is among those who have expressed support for MACRA's main goal, which is to improve the quality of care provided to patients through payment reform, and its finalized version. “The rule will move the country to where doctors are reimbursed for quality and value not volume.”

CMS made several significant changes to the April proposed rule. Some changes, such as reduction of the health IT quality measures physicians would be required to report, pleased several healthcare groups. However, some of its final provisions, such as the reduced flexibility for reporting requirements in 2018, or lack thereof caused some disappointments. 

Where the proposed rule benefited from feedback

One of the main concerns about MACRA that members of Congress and the provider community had was that it required too much too fast from physicians, particularly those in small and solo practices. The new “pick your pace” approach offers four different participation options to help physicians ease into the new requirements during MACRA’s first year.

Boyd Buser, president of the American Osteopathic Association (AOA), said its members – 50% of which will be impacted by MACRA – “greatly appreciate the 'pick your pace' options offered for the first year, giving them time to adjust to the new system.”

Mostashari said CMS took steps to help smaller providers and they heard and shared their concerns. “They made several important changes that, in my view, tilted the equation,” he said. The most significant change to the final rule, according to Mostashari, was creating the Track 1+  model for small and rural providers. The concept is a qualifying APM with a more-than-nominal financial risk that is capped based on Medicare revenue. “It will absolutely help many, many more independent practices into being capable of taking a leadership in pushing the new payment models,” Mostashari said.

The AMA, which recently launched several tools to help physicians prepare for the new regulations, showed its appreciation for the amount of reporting requirements being reduced in MIPS. President Andrew W. Gurman said, “Practices of all sizes will benefit from reduced MIPS reporting requirements.”

Healthcare improvement company Premier, with an alliance of 3,750 U.S. hospitals and 130,000 other providers, was pleased with the increase in the projection of the number of physicians that can now qualify for the APM path, and the accelerated timeline for determining if physicians meet the standards for these payment models. “This mitigates the uncertainty and added administrative work for ACOs and other organizations who otherwise would have reported through MIPS in the absence of certainty about whether they met the Advanced APM thresholds,” Premier SVP of Public Affairs Blair Childs told Healthcare Dive.

Where the final rule could still use some work

MACRA is not a $100 bill, so it was unlikely all of its provisions were going to make everybody happy. The implementation rule has yet to provide “the right policy for how smaller practices can choose to come together in virtual groups, and that was something that Congress thought was a good idea to help the practices not be atomic anymore, be part of a group that they self-formed, and to take advantage of group reporting and minimize the burden,” Mostashari said.

CMS may be in need of help for defining how these virtual groups should be shaped and supported, according to Mostashari, adding they would allow for a sample size of quality measures to be meaningful across the number of groups. The healthcare industry has already been seeing how policy changes has caused some physicians in small and independent practices to join larger practices. Mostashari argues smaller practices are important for maintaining competition and personalized care.

Not providing smaller providers the ability to form virtual groups to "better position themselves to achieve MIPS bonuses" may have been a missed opportunity, according to Buser. “That kind of collaboration could have a ripple effect, where the virtual groups then begin to leverage their numbers and create economies of scale that could help mitigate the costs of information systems and other capital expenditures.”

Having regulation in the MACRA final rule that would have allowed for virtual group formations also received backing from the AOA and Premier.

Buser was disappointed that many physicians in patient-centered medical homes will still not qualify for APMs “and opportunities to enter other such value-based models remain limited.”

While MGMA SVP for Government Affairs Anders Gilberg was pleased the final rule mitigated some of the reporting burden for physicians in the MIPS program in 2017, he argued there is an inherent disappointment in the approach CMS is perpetuating. MGMA had asked for CMS to move the measurement year closer to the performance year and provide feedback to physicians every quarter to tell them how they are doing based on data from physicians or claims data, Gilberg said.

Another aspect of the final rule that let some down is that the flexibility CMS is offering for reporting requirements in 2017 will fade out, as Gilberg told Healthcare Dive.

The nominal risk standard remains “way too high,” Childs maintained. “As we have learned from members in our Bundled Payment and Population Health Management Collaboratives, these models require significant investment in redesigning care through new technologies, data analytics and additional staff," Childs said. "CMS has chosen to ignore these realities.”

It's not over yet

As physicians prepare to comply with the new regulations, MACRA will probably continue to change with the years to come. The MGMA will be collaborating with the new administration and members of Congress and their oversight capacity next year because as Gilberg strongly believes, MACRA refinements will continue. 

MGMA isn’t the only association hoping to continue its work on the rule. “In the days ahead, the AMA will conduct a comprehensive review of the final rule to ensure that it promotes flexibility and innovation in the delivery of care to help meet the unique needs of all patients,” Gurman said.

Some healthcare groups were satisfied with how responsive CMS was to the concerns they raised after the proposed rule. CMS' acting Administrator Andy Slavitt said during a press call at the release of the rule that the agency knows the final rule is going to have to evolve as medicine and technology evolves. For example, members of the administration are getting the word out it's open to suggestions:

Don't see the APM you want? You can make your own! Submit model ideas to the independent advisory committee. https://t.co/oRkrqu1Ol0

— Aisling McDonough (@AislingMcDL) October 16, 2016

Financial incentives for quality care have the potential of leading to substantial health benefits for the entire U.S. healthcare system. MACRA may have just been the first major step in the system's journey toward quality improvement. The final rule (set to be published on October 19) will take public comments for 60 days as the agency works to implement the law on an iterative basis.