CMS is developing ways to informally partner with specialty societies and EHR vendors to increase its technical assistance to physicians in preparation for the coming quality measurement system.


May 23—Notifying all physicians treating Medicare patients of the new payment provisions that begin next year will be a “huge lift,” according to a senior Medicare official. And that is just one of the timing issues that worry policy makers and observers regarding the Medicare payment overhaul.

The Centers for Medicare & Medicaid Services (CMS) has proposed rules to implement the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which replaces Medicare’s current physician payment methodology. The new rules split Medicare physicians into two payment systems: one for those participating in qualified alternative payment models (APMs), the other a quality-measurement system called the Merit-based Incentive Payment System (MIPS).

Most physicians are expected to be paid in the initial years under MIPS, which begins tracking physician quality metrics at the start of 2017. Letting physicians know about that looming change is taking a lot of focus by CMS.

“That’s a huge lift and something we’re spending a lot of time on now at CMS,” Kate Goodrich, director of CMS’s Center for Clinical Standards and Quality, said May 20 during a MACRA discussion for congressional staff. “For the next several months and beyond that we need to spend a lot of effort educating, educating, educating and helping clinicians to know about the program and be able to participate—at least in MIPS—in 2017.”

The agency already has reached out to 30,000 clinicians, according to weekend tweets from CMS Acting Administrator Andy Slavitt, and it planned to hold 35 MACRA education events in May.

Goodrich noted that “a lot” of small and solo practitioners will not be subject to MACRA reporting requirements because their volume of Medicare patients is below a threshold proposed in the regulations. The proposed rule makes physicians exempt from the reporting requirements if they have $10,000 or less in Medicare billing charges and care for 100 or fewer Part B-enrolled Medicare beneficiaries.

Other Concerns

The challenge of issuing a final rule to implement MACRA—expected by Nov. 1—and then beginning measurement within two months also raised feasibility concerns among industry advocates. Public comments on the proposed rule are due by June 26, and sifting through the thousands of expected responses will take time.

“I’m worried about CMS and how they’re going to get ready,” Ashley Thompson, a senior vice president at the American Hospital Association, said at the event. Hospitals employ or contract with about 540,000 physicians.

The tight implementation time frame also raised concerns that $100 million in promised technical assistance to improve MACRA compliance by physicians—including small or rural practices and those in health professional shortage areas—may come late. Specifically, a contract required by the law for a third party to provide technical assistance to small practices is not expected to be issued until October or November.

“We need to see all of these things moving forward as quickly as possible,” Elizabeth Mitchell, president and CEO of the Network for Regional Healthcare Improvement, said about the assistance contract during the MACRA event.

Existing initiatives aimed at helping practices improve their quality measurement capacity include the Transforming Clinical Practice Initiative, under which regional healthcare networks and other organizations have aimed to help 140,000 clinicians in practices of different sizes. Quality improvement organizations also are expected to help some providers.

“There’s a lot happening, but it’s not going to cover everybody,” Goodrich said.

That is why CMS also is trying to figure out ways to informally partner with specialty societies, electronic health record (EHR) vendors, and registries, “to help them be able to help their clients in being able to be successful,” Goodrich said. “In terms of technical assistance, there’s a lot we are doing, but we need other surrogates out there to help practices.”

Measurement Lag

Another timing challenge that has drawn increasing provider concern is the two-year gap between the start of quality measurement in 2017 and the start of resulting payment changes in 2019.

The MACRA rules are “asking physicians to make investments in infrastructure and change behaviors two years before they know about whether they are getting a reward or punishment,” Timothy Ferris, MD, senior vice president, population health management, Partners HealthCare, said at the MACRA event. “That’s a problem.”

Goodrich of CMS agreed that the lag was “an interesting problem,” although she noted the physicians would be notified of their quality results by mid-2018. The challenge, from the perspective of CMS, is that the one-year performance period data needs to be submitted through third-party EHR vendors and others, with feedback reports then provided before payments can be changed.

“Once you look at that sort of full timeline,” Goodrich said, “you’ve got to think ‘OK, where do I squeeze?’”

Moving data measurements and payment changes closer together will require “shifts in behavior and also in process,” Goodrich said. The agency’s goal, according to Goodrich, is to move toward the type of physician quality measurement program used by Partners, which measures physicians in periods of three months and pays them within six months of a measurement period.

“That’s the kind of time cycle that works where I work,” Ferris said.

Until the 2017 quality measures are finalized, Goodrich said physicians can best prepare by participating in Medicare’s physician quality reporting system (PQRS) and the EHR meaningful-use incentive program, both of which will be replaced under MACRA.

“The difference between what you have to do in 2016 if you do participate in PQRS and meaningful use and what you have to do in 2017 [under MACRA] is not wildly different,” Goodrich said. “In terms of the types of measures that are available and what you have to do to submit, there is not a wholesale difference between the two.”


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

Publication Date: Monday, May 23, 2016