By STEVEN FINDLAY

With all the machinations over ACA repeal and replace, the new law that makes big changes in the way the federal government pays doctors—the Medicare Access and CHIP Reauthorization Act, or MACRA—hasn’t garnered much attention lately.

But doctors nationwide are sure thinking about it. That includes many of the regular commentators on THCB. I think it’s accurate to say that most of them have been highly critical of MACRA since the law was enacted in April 2015, and even after it was significantly amended late last year to address physician complaints. (See, for example, Kip Sullivan’s most recent post here.)

The law’s main provisions kicked in on Jan. 1, 2017, with 2017 being the first performance-reporting year, affecting payment in 2019.

In a policy brief on MACRA for Health Affairs published late last month, I raised a host of questions about MACRA.

As Kip and many others have noted, some parts of MACRA are weakly designed and both the law and regulations implementing it make some big assumptions. Excerpts from one section of the policy brief are below. The whole brief can be had at the link above. If you are well versed in MACRA, you can skip to the section titled “What’s the Debate?

Is the overall design coherent and workable?

Major special-interest groups, including those representing physicians, industry, and consumers and patients, supported MACRA’s intent and the general framework of the regulations through three comment periods.

However, almost all groups sought changes and raised questions. CMS’s final revisions were most responsive to physician groups, which were insistent on an easier path and more flexibility for doctors in the initial years of the program.

Dissenting voices raised questions that are not easy to dismiss, however. These could gain credence and traction if implementation proves difficult or falters. For example, does the assessment of individual physicians’ performance with existing quality measures yield meaningful results?

Some critics say there’s no clear evidence that current measures, or the scoring framework proposed by CMS, will provide anything close to a full and accurate picture of how well an individual doctor does in treating his or her Medicare patients. Thus, basing payment to individual doctors on the MIPS scoring sys- tem—or any scoring system—is flawed and irresponsible.

These critics would scrap MIPS and, over time, prod doctors to join APMs. But other critics take aim at the whole notion of changing or incentivizing physician behavior through performance measurement and financial incentives. They assert that this has not conclusively yielded improvements in care or in the health status of the US population.

Still other critics say there’s only weak evidence indicating that ACOs and APMs
(including bundled care payment) improve care and lower cost growth enough to justify the administrative costs they incur—which would extend to the administrative costs that physician groups, APMs, and the federal government will now incur as MACRA gets implemented.

CMS officials and other health policy experts don’t reject these critiques completely. But they do argue that some early evidence suggests that financial incentives, performance measurement, and ratings can and do propel individual clinicians and groups of physicians to improve care.

Moreover, they assert, the government has a moral duty to prevent unnecessary and wasteful care, and a powerful fiduciary duty to spend tax dollars wisely, in part by restraining excessive growth in health care spending, which makes up a substantial part of the federal budget as well as business and consumer spending.

Is the program good or bad for solo doctors and small or rural practices?

MACRA is designed to push doctors who practice on their own or in small groups into larger groups and into APMs. A vocal group of such doctors don’t want to do this. They prefer their current arrangement.

The government recognized this dilemma and increased the number of physicians who would be exempt. It also gave clinicians more flexibility, primarily to accommodate those in small practices who had not to date been participating in any pay-for-reporting or pay- for-performance programs.

CMS officials and other experts acknowledge that the evidence is not strong that solo or small practices deliver poorer-quality care than larger practices. Even so, debate continues about the pros and cons of larger versus small physician groups or solo doctors.

That debate will continue and is likely to trigger changes to MACRA rules in the years ahead as evidence mounts one way or the other.

In comments accompanying its final rules, CMS said: “Although small and solo practices have historically been less likely to engage in [the existing physician quality reporting system] and quality reporting, we believe that small and solo practices will respond to MIPS by participating at a rate close to that of other practice sizes.” The agency also estimates that “at least 80 percent of clinicians in practices with 1–9 clinicians will receive a positive or neutral MIPS payment adjustment [in 2017 and 2018].”

Does MACRA constitute government intrusion in the practice of medicine?

Federal law dating back to the 1930s discourages, and in some cases prohibits, the government from dictating how doctors practice medicine, collectively or individually. Some, mostly conservative, commentators and physician organizations say that recent history has eroded that principle.

In keeping with that emerging debate, doctors and groups allied with conservative and libertarian interests believe that MACRA is intrusive and that, by definition, it pushes doctors to practice in certain ways that could be inimical to good patient care. The same argument was brought to bear against managed care, as wielded by both government and private insurers, in the 1990s and early 2000s.

Mainstream medical groups disagree that MACRA dictates to doctors how to treat individual patients. However, recent surveys indicate that a majority of physicians have low morale and are concerned about excessive paperwork, the time they have with patients, and the future of medicine. In one large-scale 2016 survey that garnered responses from 17,236 physicians, only 14 percent said they had the time they needed to provide the highest standards of care.

“Volume to value”—slogan or sound policy?

Critics allege that the volume-to-value movement is, for now, based more on faith than strong or conclusive evidence. For example, they cite the experience of countries in Europe that control spending primarily through regulated prices and fees in fee-for-service systems, instead of relying on performance measurement and payment incentives.

Critics also argue that “value” in medicine is an elusive concept and not one likely to be pinned down through a single composite score—especially for an individual physician. As yet, these critics further allege, value has not been clearly pegged or produced by ACOs, patient-centered medical homes, or integrated health care systems.

Such criticisms are countered by researchers who point to published studies as well as hundreds of initiatives and innovations in care delivery over the past twenty years that claim to have improved care delivery through enhanced accountability, quality measurement, and incentive payments.

The magnitude, depth, and significance of the improvements certainly can be disputed, and MACRA’s impact will almost certainly trigger continued debate on this issue.

MIPS versus alternative payment entities

It’s clear that in designing MACRA, Congress wanted the majority of physicians, over time, to join APMs. Larger potential bonuses (compared to MIPS) and fee increases are inducements to physicians to take the alternative model path. MIPS is designed as a bridge to that end, although it is unclear when and if MIPS would be terminated.

This approach is consistent with the Obama administration’s approach under the ACA and with other recent bipartisan laws, as well as marketplace dynamics, over the past fifteen years. All promote larger group practices, integrated systems, a shift away from fee-for-service, and enhancement of the Medicare Advantage program as an alternative to traditional Medicare.

How much financial risk should physicians take on in alternative payment models?

An APM will qualify as an advanced APM in performance years 2017 and 2018 if it is at risk of either losing 8 percent of its revenues when Medicare expenditures are higher than expected or repaying CMS up to 3 percent of total Medicare expenditures, whichever is lower.

However, it’s not yet clear how much financial risk will flow down to individual physicians in APMs. CMS uses the phrase “more than nominal risk” to define its approach, but physician interest groups want limited physician exposure to losses from taking on insurance or financial risk.

“Physicians will be much more willing to take on accountability for costs that they can affect through their own performance, such as the costs of preventable complications, than they are to take on risk for the total cost of care for a large patient population,” the AMA said in its initial comments on the MACRA proposed rules.

Measures that matter

A majority of the comments on the proposed regulations urged CMS to adopt a common core set of measures focused on population health, clinical outcomes, and assessments of patient experience for both MIPS and the alternative payment entities.

Most also urged CMS to eliminate overlapping, duplicative measures and “topped out” process measures that no longer provide meaningful barometers of quality of care or performance.

CMS in its final rule concurred on these points and said it was undertaking efforts to focus on “measures that matter.”

Notably, in February 2016 CMS and the insurance industry jointly released an initial set of core physician performance measures intended to replace existing overly complex measure sets.

In its initial MACRA comments, the AMA expressed concern about a too-rapid shift to claims-based cost and outcome measures. “We would view proposals to dictate the percentage of measures that must be based on outcomes rather than process as highly premature,” the group said.

For their part, employer and consumer groups want CMS to put more emphasis on the results of patient experience surveys such as those developed by the Agency for Healthcare Research and Quality’s Consumer Assessment of Healthcare Providers and Systems (CAHPS) program.

Employer and consumer groups also have urged CMS to aggressively explore the use of patient-reported outcomes—information and data that patients themselves document about their care. But physician interest groups such as the AMA are divided on the utility of CAHPS and patient-reported outcomes. The American College of Physicians, for example, requests that CAHPS surveys not be used at all under MIPS.

Other comments reflect near-universal agreement that CMS should make more use of the data contained in patient registries, as CMS proposes. But how such registries can be standardized is an open question.

Attribution

Physician groups urged CMS to concentrate on assessing performance and quality at the group-practice level and avoid grading individual physicians in MIPs and APMs.

Employer and consumer groups, in contrast, want CMS to push toward performance measures at the level of the individual physician, where appropriate, since, they argue, that is what consumers want.

Under the ACA and now MACRA, CMS is mandated to assess performance and quality at the individual physician level. But this intense debate is unlikely to go away anytime soon. It reflects a fundamental disagreement—as mentioned above—about whether current methods and tools allow accurate assessments of individual physician quality of care or outcomes.

Public reporting

MACRA mandates that performance results be made available to Medicare beneficiaries and consumers broadly, to aid their choice of individual physicians and physician groups.

CMS says it is finalizing how it will fulfill this public reporting requirement, of MIPS information, through the Physician Compare website. The agency says it remains committed to reporting performance results for both individual physicians and groups, in “an easily understandable format” for consumers.

Debate over the reliability of performance results for individual physicians, versus groups, could undermine this intent, however. Some observers say they expect the Trump administration to take a fresh and close look at what will be posted on Physician Compare, and when.

Electronic health records

CMS concurred with commenters that the previous EHR “meaningful-use” program was in need of reengineering under MACRA. To that end, there will be far less emphasis on data entry and “check the box” use of EHRs and more emphasis on the secure exchange of patient information; promoting patient engagement; and reporting to state and federal public health agencies and clinical data registries.

Steven Findlay is an independent journalist, health policy analyst, researcher and consumer advocate.