The challenges and opportunities of MACRA's virtual groups

Doctors are about to hear a lot more about the MACRA "virtual groups" provision, which gives solo practitioners and small-group practices a way to participate in quality reporting. FierceHealthcare talked to five industry experts to weigh the pros and cons and explain the challenges and opportunities under the program.  

Next year, as part of the proposed rule for participation in the Medicare Access and CHIP Reauthorization Act program, the Centers for Medicare & Medicaid Services will launch virtual groups, an idea put forth as a way for smaller practices to join together to report Medicare performance measures.

The program was included in a proposed rule released last week that would allow virtual groups, composed of solo practitioners and groups of 10 or fewer eligible clinicians who come together virtually with at least one other solo practitioner or group to participate in the Merit-based Incentive Payment System (MIPS) track under MACRA for one year.

RELATED: CMS releases updated proposed rule for MACRA, eases burden on small and rural practices

‘An untested concept’

The proposal is being welcomed by some, but the jury’s still out as to how successful the program will be.

Anders Gilberg
Anders Gilberg

The Medical Group Management Association is taking a conservative view, said Anders Gilberg, senior vice president for government affairs, in an email to FierceHealthcare.

"MGMA is examining this aspect of the rule but its feasibility and potential popularity is not clear,” Gilberg said. “Overall it's an interesting concept, but an untested concept.” 

The program is likely to get off to a small start. (The proposed rule is open for comment until August 21 and won't become official until CMS issues a final rule, expected in the fall.) CMS predicts that just 16 virtual groups will form for 2018. 

“This is likely a result of major barriers, such as identifying reliable partner practices, sharing and aggregating data, and coordinating workflows across multiple physicians and/or different small groups,” Gilberg said.

The National Committee for Quality Assurance (NCQA) accrediting body is more optimistic. “We strongly support the idea,” said Paul Cotton, director of federal affairs, public policy and communications for the group.

RELATED: Doctor groups upbeat about proposed 2018 MACRA changes

Virtual groups is an entirely voluntary program. For small practices, it's difficult to get significant statistics on many of the performance measures under MIPS. Those who join a virtual group are likely to get much more reliable results, Cotton said in an interview.

The NCQA supports the concept as a way for practices to have a better ability to coordinate care and improve quality, he said: “Care coordination is the cornerstone of higher quality of care.”

The NCQA, which plans to submit comments on the proposed rule, will encourage CMS to provide bonus points to those who join virtual groups to provide more incentive for clinicians to join, Cotton said.

It's an interesting idea, said Rebecca Altman, a healthcare consultant with the management consulting firm Berkeley Research Group.

“I like that virtual groups were included in the rule. I think it’s ingenious to allow physicians who may be in small rural areas to connect with each other in virtual communities. It’s a clever way for more of the rural physicians to leverage each other’s talents and expertise to help patients,” she said. “I could see the virtual groups being a first step towards physicians creating more formal partnerships.”

Some barriers to participation

One challenge: Identifying reliable clinicians or group practices to partner with.

“We think clinicians should choose their partners with care if they are looking to do this,” Cotton said. However, practices that are now patient-centered specialty practices or patient-centered medical homes might be ideal partners if they are focused on quality care.

Additionally, physicians and small groups would be locked into a virtual group for the full performance year, so they could not kick out an unreliable partner or exit to report their own MIPS data, said Gilberg.

“The challenges I see for virtual groups are getting engaged physicians to step up and lead the virtual group,” said Altman. “I also foresee that there may be administrative and operational challenges.”

Interest from clinicians

While CMS is predicting low participation in the first year for virtual groups, there were a number of questions from participants in a webinar Monday put on by the government agency to provide an overview of the proposed rule.

One participant wondered if a virtual group could be a combination of solo practitioners and groups of 10 or fewer clinicians. That is the case, said Lisa Marie Gomez, a health insurance specialist at CMS. “It’s basically a combination of TINs [taxpayer identification numbers],” she said.

RELATED: More than 500K clinicians will be hit with 2% Medicare quality reporting penalty this year

Molly MacHarris
Molly MacHarris

Participants in virtual groups must pull the trigger by December 1, 2017, said Molly MacHarris, CMS' program lead for MIPS. They cannot change status once the performance period begins.

There is a lot of flexibility as to how virtual groups form, with no restrictions based on location or specialty, she said. Initially, there is also no restriction on the size of virtual groups.

In a report CMS released on virtual groups, the agency said it expects low participation next year. It estimates that only 16 virtual groups will participate made up of 765 MIPS-eligible physicians nationwide.

“We assume that virtual group participation will be relatively low in the first year because we have heard from stakeholders that they need at least three to six months to form groups and establish agreements before signing up,” the report stated. “We are not able to give them that much time in the first year, rather closer to 60 days or potentially less.”

CMS assumes those 765 clinicians will be ones who participated in MIPS this year because of the limited time to create processes. The virtual groups could range in size from a few clinicians to hundreds, the report said.