The Fine Print of MACRA’s Final Rule: Good for Patients?

The Centers for Medicare & Medicaid Services (CMS) just released the final regulations for the most ambitious attempt in U.S. history to transform how medical care is delivered and paid for. But is it good for patients?

The impact of the Medicare Access and CHIP Reauthorization Act (MACRA) Quality Payment Program created a colossal chorus of kibitzers after the draft rule came out last spring: CMS received over 4,000 written comments. The gargantuan, 2,204-page final rule both sets out regulations and responds to commenters’ suggestions.

The rule is meant “to create a more modern patient-centered Medicare program by promoting quality patient care while controlling escalating costs,” says Andy Slavitt, CMS acting administrator, in a letter to clinicians posted online. The rule itself proclaims “high-quality, patient-centered care” as “the bedrock of the Quality Payment Program.”

Similarly, “improving outcomes by engaging patients through patient-centered payment policies” is listed as one of the “strategic objectives.” The program promises to support and reward clinicians “as they find new ways to engage patients, families and caregivers.”

OK, bestow an “A” for buzzwords. How about the substance?

Here, some context helps. Detailed quality measures in the rule are part of the Merit-based Incentive Payment Program (MIPS). Clinicians who treat enough Medicare patients to be subject to MACRA can choose from a menu of MIPS measures. Or, to avoid MIPS, they can practice as part of an Advanced Alternative Payment Model (APM) that has comparable quality requirements. Because there are menus, certain requirements may be optional, albeit sometimes “weighted” to encourage their selection.

Some critics believe that individual requirements don’t matter much because MACRA is so complex it will self-destruct. MACRA, they argue, is pay-for-performance run amok. They may be right, but for now we’ll assume that when money talks – the Department of Health and Human Services spends more than $1 trillion every year on health care – clinicians will try very hard to listen.

Having said that, I’d like to distinguish between what the program is trying to have clinicians do for patients and what it wants them to do with patients. In simplest terms, the kind of regulations that, say, require hospitals to have fire doors and use licensed doctors and nurses are “patient-centered” in that they help patients avoid being treated by incompetents working in a firetrap. However, those types of rules don’t address the issue of engaging with patients as individuals.

MIPS includes measures both “for” and “with” patients. For instance, one measure pushes integration of care plans for behavioral health and medical treatment. That’s something doctors should do for patients with chronic ills, such as diabetes, that are often accompanied by mental-health issues such as depression. Meanwhile, the MIPS requirement for use of a patient-reported score on a depression screening tool is something clinicians must do with patients.

Similarly, the total knee replacement measure says doctors should evaluate patients before surgery for their risk of a heart attack, stroke or deep vein thrombosis. A companion measure sets out a shared decision-making (SDM) process for first trying non-surgical options such as weight loss or anti-inflammatory drugs. Hepatitis C treatment is singled out with a requirement for better screening that is coupled with a measure that calls for reviewing “treatment choices appropriate to genotype, risks and benefits, evidence of effectiveness and patient preferences towards treatment.”

Some commenters wanted to eliminate patient satisfaction scores, but CMS rejected their erroneous contention that the surveys “may even conflict with clinically indicated treatments.” Instead, the Consumer Assessment of Healthcare Providers and System (CAHPS) survey for MIPS will include items related to “shared decision-making, access to specialist care and health promotion and education.”

On the other hand, CMS also declined to increase the number of patient-reported outcomes (PROs), but told commenters that the agency will “expand their portfolio” in the future.

Speaking of shared decisions, the American College of Surgeons (ACS) is named “steward” of a measure that requires surgeons to give patients “their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon.”

In other words, the professional society of surgeons, a membership organization, is in charge of a measure that uses shared decision-making to reduce unnecessary surgery. Performance on that measure, in turn, is linked to Medicare payment and potentially will have medical liability effects

When I spotted this potentially glaring conflict of interest in the draft MACRA rule, I called the college for comment. They told me they were too busy responding to MACRA themselves to talk. A couple of patient groups I spoke to didn’t know much. On page 2,172 of the final MACRA rule it says, “CMS did not receive specific comments regarding this measure.” Does that mean consumer groups didn’t notice, don’t care or didn’t know what to say?

The involvement of physician professional societies as stewards of many MIPS measures sends a larger message. MACRA passed with bipartisan support in large part because it represented a deal between the profession and the politicians: Get rid of the Medicare Sustainable Growth Rate (SGR) adjustment that sends doctors into a yearly panic over mandated automatic pay cuts that only Congress can override. In return, we’ll work with you on developing a new value-based reimbursement system.

But changing the rules so Medicare “pays for what works,” as Slavitt’s letter put it, only works itself with the active collaboration of the medical community. So, for instance, shortly before the final rule’s release, the American Medical Association unveiled a set of MACRA tools for physicians. CMS is acutely aware that pushing too far too fast could set back practice transformation a generation.

That’s why the fine print sometimes finesses the professed “commitment to patient engagement.” In an April 2016 blog post on the draft rule, I criticized the requirements on coordination of care through patient engagement via certified electronic health record technology (CEHRT). They “are startling in their laxity,” I wrote, requiring patient-generated data from just one unique patient a year to be incorporated into the electronic record or just one unique patient a year to actively engage with the EHR.

I submitted more detailed comments and a suggested fix to CMS. Nothing changed, most likely because more numerous complaints in the opposite direction were pouring in from those who were worried clinicians would “struggle” with the objectives and were being held “responsible for the actions of patients.” Some commenters called for the Patient-Specific Education and Provide Patient Access measures to be “retired,” arguing the results were already about as good as they could get. CMS disagreed, calling those measures “a critical step to improving health, increasing transparency and engaging patients in their care.”

Moreover, buried deep in the final rule is an Improvement Activities Inventory where clinicians can choose measures such as “access to an enhanced patient portal [that allows]… patients to enter health information and/or enables bidirectional communication.” Or a measure “that promotes use of patient engagement tools. Or “using evidence-based decision aids to support shared decision-making.”

The fine print giveth, and the fine print taketh away. If the Quality Payment Program works as hoped for, it will save patient lives, prevent avoidable complications of illness and even save money. Patients will also be on the path to becoming routine partners in chronic and acute care.

Yes, the path could have been widened and the progress along it hastened. But Medicare faces formidable political and practical constraints. Fortunately, many employers and private insurers are pushing providers along that same path, as are many professional organizations (even, sometimes, the American College of Surgeons!).

MACRA’s payments to clinicians are supposed to encourage “quality patient care,” including some specific patient-centered activities. The potential is extraordinary; the effect when the new rules are actually implemented remains to be seen.

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