Hospital Impact: MACRA final rule complicates journey to value-based pay

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headshot of Kent Bottles

The MACRA final rule, which the Centers for Medicare & Medicaid Services revealed Oct. 14, is actually not final, and its future is certainly murky. Since I had to present a previously scheduled MACRA keynote on Oct. 17, I had to scramble to read and digest the 2,400-page edict. It is worth noting at the outset that there are still 60 days for comment on the final rule that could introduce more changes.

Industry reaction to the MACRA final rule has been mixed. Many have appreciated CMS adjusting the proposed rule to partially take into account provider concerns and being transparent with blogs and even tweets to explain the agency’s thinking. Others remain skeptical because of the law’s mind-numbing complexity and the lack of scientific evidence that the underlying concepts will actually work in the real world. 

Groups expressing a somewhat positive reaction include:

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  • The American Medical Informatics Association commented: ”CMS has crafted a set of policies that are strategic, flexible and reflective of feedback from the informatics community.”  
  • The Medical Group Management Association stated, according to RevCycle Intelligence: “MGMA is pleased with the significant burden reduction for physician practices in the first year of the MIPS program and new alternative payment model options outlined in the final rule. It’s disappointing that flexibility provided for quality reporting in 2017 largely disappears in 2018 and beyond.”
  • The American Hospital Association wrote: “While we are disappointed that CMS continues to narrowly define Advanced Alternative Payment Models, which means that less than 10 percent of clinicians will be rewarded for their care transformation efforts, we are encouraged that CMS is exploring a new option that would expand the available advanced APMs that quality for incentives.”
  • Premier stated on its website: “Although CMS eased the policy defining the Advanced APM to allow additional programs to qualify and has signaled it will increase the number of available models, the nominal risk standard remains way too high.”

Niam Yaraghi, of the Brookings Institution, summarizes his concerns about MACRA by writing:

“In an age of evidence-based policy making, data and facts should trump opinions and gut feelings. It is appalling that an agency such as CMS, which should be spearheading evidence-based rule making, is insisting on pushing either failed policies or untested ones that are destined to fail.”

Yaraghi’s reservations include the failure of APM models in the Pioneer accountable care organization (ACO) program to improve value and problems with the design of the MIPS program. According to Yaraghi, the MIPS program design fails to allow valid comparisons between providers who choose different quality metrics, relies on self-reported measures that are subject to fraud, and rely on too few measures to adequately judge medical quality. 

In a post on The Health Care Blog, Niran Al-Agba, M.D., echoes Yaraghi’s call for evidence-based policy making and also highlights the tension between experts who create policy and small-town practicing primary care physicians.  

Simiarily, Kip Sullivan, J.D., wrote in a scathing post in The Health Care Blog that “the most fundamental problem with the rule is its insane complexity,” which he blames on Congress asking CMS to do the impossible. He also criticizes the “vaguely defined and unproven entities” like ACOs and medical homes that issue penalties and rewards “based on inaccurate data.”  

Few question the good intentions of CMS in trying to deal with the federal budget deficit by transitioning healthcare provider payments away from fee-for-service to value-based payment programs. Thoughtful criticism of the MACRA final rule says to me that we are in for a long and convoluted journey as we walk down this inevitable path without an accurate map to guide us.

Kent Bottles, M.D., is a lecturer at the Thomas Jefferson University School of Population Health and chief medical officer of PYA Analytics.

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