How Stakeholder Input on Quality Payment Program Differs

October 17, 2016 - At the end of last week, the Department of Health & Human Services (HHS) released a final rule on the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and its policies on the new Quality Payment Program. HHS reiterated in a press release their intent to reimburse providers for quality care, prevention, and care coordination between facilities.

After the final rule on the Quality Payment Program was released, many medical organizations and healthcare experts expressed their opinion on the benefits and certain pitfalls of the MACRA regulations.

For instance, Premier, an alliance of about 3,750 hospitals and 130,000 medical providers, expressed in a public statement their support of the Quality Payment Program to bring more focus toward value-based care and change the incentives in the more traditional fee-for-service Medicare reimbursement system.

The organization found it beneficial that CMS allows “a gradual transition to this pay for performance reality” but recognized the nominal risk standard for Advanced Alternative Payment Models as too extreme.

“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,” according to the Premier public statement on MACRA legislation.

“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. CMS has chosen to ignore these realities. We call on CMS to rethink this risk standard in future rules to incent greater participation. We also call on CMS to accelerate recognition of ‘virtual’ physician groups that would allow small practices to band together using technology to meet the minimum thresholds and comply with reporting requirements.”

The healthcare reform that the Obama administration’s Patient Protection and Affordable Care Act stimulated led to further investments in improving Medicare reimbursement and creating the Quality Payment Program. Dr. Farzad Mostashari, former National Coordinator for Health IT and CEO and co-founder of Aledade, also offered his opinion on the Quality Payment Program and the healthcare industry’s shift to value-based care reimbursement.

“The Obama Administration set out to transform health care, and with today’s final rule, they put the country on a path to do just that. The rule will move the country to where doctors are reimbursed for quality and value not volume,” Mostashari said.

“In creating a clear path for small, independent physicians to embrace the transition to value, CMS makes it possible for leading independent practices to reduce costs, boost outcomes, and thrive. The creation of viable pathways for these practices is critical to maintaining competition and personalized care in our communities. There is still work to be done to help these practices come together in virtual groups, and to stand on equal footing with larger, more integrated groups. We hope the next Congress and Administration takes up and quickly acts on this issue in the new year.”

The final ruling for the Quality Payment Program alleviated some prior concerns from small medical practices regarding the proposed rule. The Centers for Medicare & Medicaid Services (CMS) went forward with making new adjustments as well as providing more flexibility and opportunities for providers to successfully participate  in the Quality Payment Program.

According to a press release, the American Medical Association (AMA) was pleased with the latest MACRA ruling that provides more flexibility and options to healthcare providers. In particular, the AMA is happy that the flawed Sustainable Growth Rate (SGR) formula has been completely eliminated and won’t bring any more risk of significant cuts to Medicare reimbursement.

“The AMA acknowledges the commitment by Acting Administrator Andrew Slavitt and his senior team at CMS for listening to physician concerns and taking several concrete steps to help them adjust to this new Medicare payment framework,” AMA President Andrew W. Gurman, MD, said in a public statement.

“By announcing the ‘Pick Your Pace’ approach to give physicians greater flexibility and increased options for participating in MACRA in 2017, HHS Secretary Burwell and Acting Administrator Slavitt took a significant step last month to address AMA concerns about the original proposal. The final rule includes additional steps to help small and rural practices by raising the low volume threshold exemption, and practices of all sizes will benefit from reduced MIPS reporting requirements.”

“Our initial review indicates that CMS has been responsive to many of the concerns raised by the AMA, and 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 continued. “With the flawed Sustainable Growth Rate (SGR) formula – and its annual threat of steep payment cuts – permanently eliminated, the new law gives many physicians the opportunity to be rewarded for the improvements they make to their practices and for delivering high-quality, high-value care to Medicare patients.”

While it seems that most favor the move toward providing smaller medical practices and clinics with more flexibility and opportunity to participate in the Quality Payment Program without severe penalties, the trade association AMGA feels differently. In a public statement, AMGA President and Chief Executive Officer, Donald W. Fisher, Ph.D., CAE said that the current ruling for MACRA legislation does not address providers who have made more investment in boosting quality while cutting on spending and that providers who improve quality should be rewarded instead of relying on the size of a medical practice.

“Ultimately, MACRA is about moving the healthcare system toward one that is based on quality and value, a goal that AMGA shares with the Department of Health and Human Services as well as the Congress,” Fisher said in a public statement. “We remain concerned, however, that in its understandable desire to provide flexibility, particularly as the program begins, CMS does not adequately recognize or reward the providers and systems who have made the investments to improve quality and decrease costs. We believe rewarding performance should be based on the value provided, not on size of the practice.”

Whether or not one supports the extra leeway and flexibility offered to smaller medical practices, this is the finalized rule for the Quality Payment Program and healthcare providers will need to be aware of several things.

Only providers who do not participate in the program in any way, shape, or form will be subject to a 4 percent negative Medicare payment adjustment. Additionally, practices and hospitals that only test out one quality measure under the MIPS regulations in 2017 will not have a positive or negative payment adjustment tied to their Medicare reimbursement. However, those who report a full year of quality data improvement efforts may receive as much as a 4 percent increase in their Medicare payment in 2019.

One thing is certain with regard to the Quality Payment Program. The traditional fee-for-service payment system has been left behind as providers and payers have aimed their sights on value-based care.

Dig Deeper:

How Medicare, Medicaid, and CHIP Guide the Health Payer Industry

How Payers Should Prepare for Value-Based Reimbursement