MACRA Improvements Coming, CMS Official Says

The agency is looking into ways that quality data could be extracted from EHRs with little effort by clinicians.

March 13—A series of regulatory changes are coming to the Medicare physician payment system this year, including an effort to ease quality-data reporting by hospital-employed physicians.

Changes this year to implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) will include the alignment of quality measures between hospitals and physicians, the lack of which has hindered quality reporting during the first years of the law, said Kate Goodrich, MD, director of the Center for Clinical Standards and Quality and CMO for the Centers for Medicare & Medicaid Services (CMS).

“The measures are basically the same, but what people have to do—the rules of the road, if you will—on the scoring are very different between the two,” Goodrich said, referring to hospitals and physicians. “And that creates problems for health systems that use a single [electronic health record (EHR)] to report on behalf of clinicians and to report on behalf of hospitals.”

Implementation of facility-based scoring would aim to help physicians who want to use their hospital’s quality-measure performance for reporting under MACRA’s Merit-based Incentive Payment System (MIPS).

“This gets to an alignment of incentives between hospitals and the clinicians who work in those hospitals in terms of what they are focused on for improvement and ultimately for accountability,” Goodrich said March 13 at a meeting in Washington, D.C.

The approach, she said, is part of CMS’s effort this year to reduce the regulatory burden that requires providers to expend large amounts of time and money.

Many of the responses to recent CMS requests for information on MACRA came from providers.

Goodrich said CMS is looking at overhauling MACRA—including through simplification of the data submission process—as authorized by the Bipartisan Budget Act of 2018 (BBA). Her agency is looking at each quality measure that physicians are required to report under MACRA and will consider dropping any measure that is underperforming or “topped out.”

The administration also is working with EHR vendors and registries to search for ways to automatically extract required quality data from electronic records with little or no action required by physicians.

However, such efforts will not produce another delay in implementing requirements that providers adopt 2015-edition EHR technology as part of the EHR meaningful use program.

“We’ve delayed this a couple years, but last year we finalized that this would be required starting in 2019; we are not backing down on that, so we are not changing that and will reiterate that” in upcoming payment rules, Goodrich said.

APMs Coming

Goodrich said CMS plans to offer more alternative payment models (APMs) this year, with the agency “absolutely continuing to move on the train to value-based payments.”

Moving more physicians into advanced APMs as part of MACRA continues as a “top strategic goal” of CMS, she said.

The ongoing enrollment of providers in the new Bundled Payments for Care Improvement Advanced (BPCIA) program is CMS’s latest push on APMs. That new model built on the four component models of the initial BPCI program, which taught CMS what works and what doesn’t—“and what clinicians and providers really need up front to be successful in these models.”

BPCIA enrollees will qualify as advanced APMs under MACRA starting in 2019.

The BBA included significant provisions for MIPS, removing Medicare Part B drug costs as a factor in MIPS payment adjustments and in low-volume threshold determinations for required MIPS participation. CMS plans to update by the end of March which physicians will be required to report under MIPS. However, updating which physicians qualified as APM participants will come “just a little bit later.”

The agency also still plans to release a multi-payer APM under MACRA that will start in 2019.

Overall, the agency plans to ramp up MACRA more slowly after the BBA gave CMS an additional three years (through 2021) during which it can keep the scoring and weight of the MIPS cost category at a lower level, and three more years of flexibility in setting the performance thresholds that providers must meet to avoid payment reductions.

“We continue to hear that the program is still too complicated,” Goodrich said. “People are glad we’ve allowed for a lot of flexibilities, but what that does is makes things complicated. We’ve gotten some very specific ideas about ways we can further simplify the scoring in some of the policies.”

Keith Fernandez​, MD, national chief clinical officer, Privia Health, said he was disappointed with the longer MACRA implementation timeline.

“It was the first time somebody was actually going to throw a grenade in the way we practice medicine, which I thought was good,” Fernandez said about the needed pressure to move toward value-based contracts.

However, more APMs will make it easier for “people all over the United States at different capability” to participate in them, he said in an interview.

Data Initiatives

Another CMS initiative is “MyHealthEData,” which aims to increase patients’ access to their data. As part of that effort, CMS is considering working with commercial health plans to also share their clinical data in a similar way as the Medicare Blue Button initiative.

“The interest from commercial payers has been very, very strong,” Goodrich said. “We’ve had a lot of conversations more informally with a lot of payers, many of whom are taking action now to do that.”

Payers pushing the same interoperability standards are potentially “a pretty big deal,” said Asif Dhar, chief medical informatics officer for Deloitte.

“When payers create market incentives for interoperability you will have massive changes in the market,” Dhar said in an interview.

One idea that came out of White House interoperability roundtables was to incorporate interoperability and patient data sharing into measurements that factor into Medicare Advantage star ratings. The agency is looking into how to implement that, she said.

Another possible rule would require patient data sharing as a condition of participating in Medicare, Goodrich said.

Rich Daly is a senior writer/editor in HFMA’s Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare