MACRA: A Promising Step Toward Improving Health Care Quality and Value
Update: On October 14, 2016, CMS released the final version of the rule.
On Monday, Families USA submitted comments on a proposed rule released by the Centers for Medicare & Medicaid Services (CMS) on how the Medicare Access and CHIP Reauthorization Act (MACRA) will be implemented.
Passed with bipartisan support in 2015, MACRA is the biggest change to how Medicare pays for services in decades. It will accelerate the movement towards value-based payments—where what health care providers get paid depends, at least partially, on the quality of care they provide, not just the volume of services.
Overall, Families USA believes that the proposed rule is a significant step in the right direction for improving care quality and value, as well as improving health outcomes for patients and ensuring the long-term sustainability of the health care system.
But we do see clear opportunities to build on the proposed rule, particularly in order to ensure that incentives for providers are structured in a way that will promote greater participation in alternative payment models (APMs), which seek to improve the quality of care and reduce costs through improved care coordination and through agreements among providers to share financial risk for the cost of care.
Below we discuss key provisions of the proposed rule and areas where we focused our comments.
MACRA accelerates the movement to “Alternative Payment Models” (APMs)
In order to participate in the alternative payment model (APM) pathway, providers must participate in what CMS is calling advanced APMs. CMS proposes that advanced APMs must:
- Be part of an APM initiative with CMS
- Use certified electronic health record (EHR) technology (CEHRT)
- Accept a minimum of financial risk
- Tie payment to quality of care
Providers are encouraged to participate in advanced APMs through the use of a 5 percent bonus payment through 2024 and then higher fee updates in subsequent years than providers who are not in advanced APMs.
We are very supportive of CMS’s commitment to new payment models that reward value instead of the volume of care and that move toward more coordinated care. If done right, these models can improve quality and health outcomes, while driving down health care costs. But they can only be successful if they truly improve how care is delivered. Advanced APMs under MACRA will only be as successful as the underlying models that qualify. Therefore, we urged CMS to increase transparency and opportunities for public input throughout the design and implementation of these models.
We also called for stronger requirements related to the quality and delivery of care. This will be especially important in future years, as providers can use their participation in commercial APMs to qualify for the MACRA Advanced APM bonus payment. In the proposed rule, advanced APMs only need to have payment tied to one quality or performance metric. We believe this is far from sufficient, and it is considerably less than the number of measures used by the APMs that CMS has already certified as advanced APMs.
Finally, we are recommending CMS require all future advanced APMs to meet the care delivery standards of medical homes. These include:
- Planned coordination of chronic and preventive care
- Patient access and continuity of care
- Risk-stratified care management
- Coordination of care across the medical neighborhood
- Patient and caregiver engagement
- Shared decision-making
All of these elements are central to providing high-quality, patient-centered care, and should be included in our health care system as we move more towards value-based payments through APMs.
Most providers will be in the new Merit-Based Incentive Payment System
At least at first, CMS estimates that almost all Medicare providers will not be a part of an advanced APM and will instead be in the new Merit-Based Incentive Payment System (MIPS). Beginning in 2017, each provider or group of providers will be evaluated across the four categories below.
In each category, providers can earn a certain number of points, and those providers who earn above the average number of points, will receive a percent increase to their regular fee-for-service payments. Those who earn below the average number of points will receive a percent decrease to their regular fee-for-service payments. In 2019, the year providers receive the payment adjustments, based on 2017’s performance, the adjustments will be up to +/- 4 percent, which increases to an adjustment of up to +/- 9 percent in 2022.
The four performance categories that make up MIPS are:
Quality: CMS proposes that most providers will have to choose 6 quality measures to report and be evaluated on, including at least one outcome measure. There are incentives for providers to report on additional outcome or other high priority measures, which are measures related to safety, care coordination, patient experience, appropriate use, and efficiency.
We are glad that CMS is putting an emphasis on outcome measures and the other high priority measures, and we support raising the number of these high priority measures that providers have to report over time. Better measures are also needed so we can be sure that we are measuring the things that matter most to patients and their families. New measures in the areas of care coordination, patient experience, and patient-reported outcome measures are especially needed.
In our comments, we encouraged CMS to require that quality measures be disaggregated by race, ethnicity, gender, gender identity, sexual orientation, disability status, and primary language, as much as possible. Doing so is necessary for identifying and ultimately addressing health disparities. In future years, we also encouraged CMS to consider incorporating reducing health disparities into a provider’s score in this category.
Resource Use: In this category, providers are evaluated using Medicare claims data to measure total cost of care and costs for specific episodes of care. Measuring resource use is important because it can help ensure clinicians are providing high-value services and preventive care, and that they are coordinating with all of an individual’s health care providers.
Broadly, we encourage CMS to consider resource use performance as measurement of appropriate care delivery, rather than solely focusing on high-cost “episodes” of care and the potential for overuse of certain health care services or procedures. We also strongly urged CMS to include four total cost of care measures for specific health conditions. By only including measures of care “episodes” and not including these total cost of care measures, we miss a critical opportunity to capture the full breadth of resource use for chronic diseases that are very common in Medicare. Importantly measuring total cost of care for chronic conditions is a necessary step to help providers prepare to be accountable for the total cost of care, as they are in many APMs.
Advancing Care Information: In this category, providers have to report on the available functions of their electronic health records (EHRs) and how well they are using their EHRs to improve quality and to deliver patient-centered care. As proposed, this score is made up of two parts: the base score and the performance score. The base score encourages providers to use EHRs by essentially giving providers points for using different EHR functions with at least one patient. The performance score measures how well they use certain EHR functions, such as how many patients view and download their health information or securely email with their physician.
Using EHRs and other health technology can be great tools for improving care by engaging patients and their caregivers, helping to coordinate care, and increasing access to providers, such as through secure email. But these tools are only beneficial if they are used in a meaningful way, which is why we encouraged CMS to put a greater emphasis on the provider’s performance score. As currently proposed, 50 percent of a clinician’s score in this category can come from the base score—where they only have to show that they engaged one patient for each of the functions. CMS should decrease the weight of the base score in future years, as more providers and patients become familiar with this technology.
Clinical Practice Improvement Activities: CMS proposed an inventory of over 90 clinical practice improvement activities, and most clinicians must perform between three and six activities, depending on how highly weighted each activity is. By law, these activities must be organized into the following subcategories: expanded practice access, population management, care coordination, beneficiary engagement, participation in an APM, and patient safety and assessment.
In the proposed rule, CMS proposed the addition of the additional subcategories of emergency response and preparedness, integrated behavioral and mental health, and achieving health equity. We support the addition of all of these subcategories, especially achieving health equity. However, in our comments, we encouraged CMS to consider health equity as an integral part of all of the activities in this category, and not just a limited number of specific activities. We also recommended that CMS include the additional subcategory of social and community involvement. Given that many other factors besides clinical care influence the health of individuals and communities, including housing, transportation, access to healthy food, we believe encouraging and rewarding providers who are coordinating with social and community-based services can help to improve health and reduce disparities.
We also believe that in order for the clinical practice improvement activities to meaningfully improve the delivery and experience of care, the structure and reporting requirements for these activities needs to be greatly improved.
As proposed in the rule, most activities are very broadly defined, lack a minimum number or percent of patients who need to be reached by the activity, and only need to be performed for 90 days during the entire performance year.
Providers also only need to attest that they are doing these activities, without having to provide supporting documentation that they did so or that the activities actually improved care. Addressing these concerns will help ensure the activities are not just a “check the box” requirement, but instead that they promote continuous quality improvement.