Pressing ahead: Update on Congress’s oversight of the implementation of MACRA

CMS takes next steps in implementation of new Medicare payment lawPosted by Anne Phelps, US Health Care Regulatory Leader, and Daniel Esquibel, Senior Manager, Deloitte & Touche LLP on March 18, 2016.

On March 17, 2016, Patrick Conway,  Deputy Administrator for Quality and Innovation and Chief Medical Officer at the Centers for Medicare and Medicaid Services (CMS), testified at the House Energy & Commerce Health Subcommittee’s hearing on implementation of the new Medicare payment law, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

Overview of MACRA

MACRA repeals the Sustainable Growth Rate (SGR) formula and establishes a path toward a new payment system that will more closely align reimbursement with quality and outcomes measures while steering health care providers to participate in risk-bearing coordinated care models and away from the fee-for-service reimbursement system.

The law specified payment updates under the Medicare physician fee schedule for all years in the future and creates two payment tracks for clinician’s paid under the physician fee schedule. Clinicians who receive a substantial percentage of revenue through certain Alternative Payment Models (APMs) will be eligible for bonus payments of 5% of estimated Medicare charges each year from 2019 through 2024. Clinicians who remain in the fee-for-service system will participate in the Merit-based Incentive Payment System (MIPS), a pay-for-performance program that ties individual clinician’s payment adjustments to their performance in four performance measures: Quality, Resource Use, Use of a Certified Electronic Health Record (EHR), and Clinical Improvement Activities. Existing reporting programs — Physician Quality Reporting System (PQRS), Value-based Modifier (VM), and Meaningful Use of EHRs for eligible health care providers (MU) — will be consolidated into MIPS and sunsetted after 2018.

Highlights of the Hearing

Overall, there was overwhelming bipartisan support of the law and the direction in which it is pushing Medicare and the US health care system. Both Republicans and Democrats are fully behind this law and committed to implementing it per the timetable in the statute. Notably, Congressman Michael Burgess (R-TX), a leader of the House Doctors Caucus who was very supportive of MACRA, said the timeline was included in the statute in part to avoid “bureaucratic inertia.” He also described MACRA as “disruptive by design” and key to the long-term sustainability of the Medicare program.

In addition, Conway heavily emphasized that MACRA facilitates alignment among payers, referencing CMS’ work with the Health Care Payment Learning & Action Network, which includes private payers, health care provider organizations, consumer groups and other stakeholders.

Conway said CMS is “working expeditiously” on the proposed rule on the MIPS and confirmed that it will be released this spring. Based on his comments throughout his testimony, CMS is hoping to get significant feedback to the proposals they will outline in the rule.

Some of the key takeaways from this session include:

  • CMS sees the MIPS and APM tracks as equally viable options for clinicians and fully expects some clinicians to remain in MIPS long-term.
  • The performance period for some measures under MIPS could begin as soon as 2017, based on current practice under existing CMS reporting programs. It is possible the same 2017 performance period could be used to determine eligibility for APMs – CMS will outline this more clearly in the proposed rule and seek comment.
  • CMS is hoping to take advantage of the flexibility provided in MACRA to rework some existing reporting requirements, especially related to Meaningful Use and quality reporting. Congress is very supportive of this.
    • CMS is very interested in reporting via qualified clinical data registries and EHRs, with an emphasis on EHR reporting that can be done as part of a clinician’s workflow. CMS sees this as a way of reducing the cost of compliance for clinicians.
    • Regarding quality measures, CMS is very focused on developing measures that are outcome-based, meaningful to patients, and appropriate to providers.
    • On Meaningful Use, interoperability will be key. Congress is very invested in this requirement, and CMS is working to build a process around EHRs facilitating the reporting under MIPS.
  • On the APM front, CMS is confident that:

1) There will be a “reasonable set” of options for clinicians to consider in order to qualify for the 2019 bonus payment; and

2) The set of APMs will grow over time. Conway emphasized that once the Physician-Focused Payment Model Technical Advisory Committee (PTAC) releases its criteria for assessing APMs, organizations can propose new models to be considered as APMs. This criteria is due by November 1, 2016.

  • The definition of “more than nominal risk for financial losses” as a criteria for APMs is a work in progress – CMS will offer a proposal in the proposed rule this spring and seek comment.

For more information regarding MACRA and how it may affect your organization, please contact:

US National Health Care Regulatory Team

Anne Phelps
Principal | Deloitte Advisory
US Health Care Regulatory Leader
Deloitte & Touche LLP
Latest conversations from Anne Phelps on Twitter

Daniel Esquibel
Senior Manager | Deloitte Advisory
Deloitte & Touche LLP

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