MACRA Final Rule: Predictions for 2018 from MGMA’s Anders Gilberg

What's ahead in 2018 during the second year of MACRA? We asked Anders Gilberg about his impressions of the upcoming MACRA final rule.
Clinical Value-Based care

The clock is ticking as the healthcare industry awaits word from CMS on the 2018 Quality Payment Program (QPP) Final Rule, due no later than November 1. The regulation will outline the second year of the Medicare Access and CHIP Reauthorization Act (MACRA) and is likely to have major implications for medical groups and clinicians into the next decade.

While the nuances and complexities of the law might seem overwhelming, taking time to understand the key measures of the law can help clinicians and medical practices prepare for the new payment system.

Anders Gilberg MACRA Final Rule
Anders Gilberg, Senior Vice President, Government Affairs for MGMA

I asked Anders Gilberg, Senior Vice President, Government Affairs for the Medical Group Management Association (MGMA) for his take on the upcoming announcement and what to expect in the final rule.

Amy: We’re almost to the end of 2017 and the first year of MACRA’s QPP.  What has been your overall impression of how it has gone?

Anders: Well, for medical practices participating in MIPS [the Merit-Based Incentive Payment System] that are only trying to avoid penalties, I think there’s a relatively low bar. They could choose to report only one measure on one patient to avoid a financial penalty. However, based on feedback from our membership, we’ve found that many group practices are trying to do more than the bare minimum even though they’ve reported that the program is not very relevant to their clinical practice, and that there’s a lack of support in helping them adapt to it.

MGMA conducted a survey of 750 practice members last August, in which the QPP was cited as the most burdensome regulatory issue facing group practices in 2017. The majority are participating in MIPS, and more than 70% of respondents said they were very or extremely concerned about the lack of clinical relevance to patient care.

While medical groups and clinicians won’t be measured on cost for awhile, they are being measured on quality and that feedback won’t be delivered until the following year. This is a problem because for our members who are in value-based arrangements with private payers, the exchange of data is almost real-time.

Medical practices need timely feedback on their quality data in order to improve. There’s no feedback loop, so many practices view this as just a quality reporting program and don’t see the link to actual quality. On top of deficient and untimely feedback, another point of major concern is that the scoring methodology is very complex and hard to understand.

Amy: CMS is expected to publish the final MACRA rule for 2018 within the next two weeks, and there’s been a lot of industry conversation about what kinds of changes will be made to the new payment system. What was your impression of the proposed rule that came out at the end of the summer?

Anders: One of the things that CMS proposed was lengthening the collection period for quality data from the current 90 days to a full 12 months in 2018. We pushed back on that proposal and received a lot of strong comments that CMS shouldn’t move forward and should instead establish a permanent 90-day reporting period for all MIPS categories, with the option to report for longer periods at the discretion of the practice. Full-year reporting was only proposed for the quality category, but that’s the highest-weighted component of MIPS. If I had to pick one thing, that was our largest concern.

Amy: Do you think the final rule will mirror what was in the proposed rule?

Anders: Well, in terms of EHR usage and certification, the proposed rule extended the opportunity for practices to use current certification standards through 2018. MGMA supports that measure, and I do think that it will be finalized. In terms of the 90-day vs. full-year reporting period, I don’t know for sure.

The proposal also suggested expanding the low-volume threshold, which would exempt a large number (approximately 60%) of smaller practices and clinicians from MIPS. If this provision is finalized, it won’t be because these smaller providers can’t provide the same quality of care, but rather because they don’t have the same fixed resources in place to play the same game as larger practices. I think that’s unfortunate, and it’s consistent with [MGMA]’s main concern that, rather than addressing the complexities of the program so that everyone has the opportunity to succeed, we’ll just see more groups excluded from MIPS.

Amy: On that note, earlier this month the Medicare Payment Advisory Commission (MedPAC) issued a recommendation to “sunset” MIPS, saying the program was too complex and should be replaced with a voluntary value program that eliminates clinician-reporting requirements. Do you think there’s a chance we’ll see that take effect?

Anders: No, I don’t see any major fixes happening to MACRA anytime soon. MedPAC’s recommendations would require Congress to pass legislation since certain components of MIPS are fixed in statute, and I don’t think that will happen right now.

The recommendations resulted from issues similar to the underlying theme we found in our survey about MIPS: a lack of relevance of reporting measures to clinical care, and not enough of an emphasis on steps practices can take to actually improve quality.

Another concern with the recommendation has to do with Alternative Payment Models (APMs). When the QPP was originally structured, there was an idea that MIPS would act as more of a transitional program for medical groups before they moved to an Alternative Payment Model. The problem is that right now there are only seven available APMs, and that’s far too few. MedPAC has indicated they want programs that are more outcome-based, more relevant and that involve more risk, but to do that, we have to expand these Alternative Payment Models to allow for greater participation, and implement more models that qualify.   

Amy: Overall, does it seem like it’s going to be an easier year for practices when it comes to the administrative burden? Do you think it will be easier to comply in 2018?  

Anders: No. I think it will be significantly harder, especially if CMS requires a full year of quality reporting. I think people will be surprised by how much data they will have to report to the government.

Additionally, efforts to comply with this program are hamstrung by CMS’ delay in providing necessary information to clinicians, such as whether they are excluded from the program. In 2017, even with a low-volume threshold in place, CMS didn’t notify practices whether they were excluded until late in the spring. They will need to make that information available much sooner, especially if the quality reporting period is expanded to a full year.

Even if the low-volume threshold is expanded and more people are excluded from the program, that’s not going to help clinical groups on the edges that will be left with a more complex payment program.

Amy: What are one or two key things practices can do to ensure they’re ready for MACRA changes in 2018?

Anders: While we won’t really know until we see the Final Rule, one of the most important things they can do is to ensure open communication with third-party vendors. Practices need to ask, “Will you have upgrades available to be consistent with the government’s timeline?”

We’ve heard of several EHR and practice management systems that did not have their upgrades until late in the year, so if you don’t have those conversations early, you’re not going to have the means to comply with reporting requirements.

Practices should also look seriously at what APMs are available, because staying in MIPS is probably going to be the least preferable option going forward. Whether it’s one of the new ACO (accountable care organization) models or the medical home model, practices should learn about what alternatives can work for their practice.