WASHINGTON -- As the window for feedback on physician payment reform closes, physician and specialty groups warn that implementation of an "overly complex system" should not be rushed. In addition, one nurses' organization is protesting being virtually left out of process.
The Medicare Access and CHIP [Children's Health Insurance Program] Reauthorization Act aims to shift reimbursement away from the traditional fee-for-service arrangement toward paying for value. MACRA replaces the Sustainable Growth Rate (SGR) formula, which was repealed in April 2015, with two channels for statutory payment updates.
While the legislation aims to draw more providers into advanced alternative payment models, many provider groups are concerned the proposed rule implicitly creates barriers to achieving such a goal.
"The implementation of MACRA will impact our health care system for years to come, and it must be done thoughtfully, carefully and as simply as possible -- and this proposed rule at present falls short of these goals," said Robert Wergin, MD, chair of the American Academy of Family Physicians (AAFP) board of directors in a letter.
Under one payment system called advanced alternative payment models (APMs), clinicians meeting specific requirements would gain incentive payments of approximately 5% for 5 years. Those ineligible for the advanced APMs would be assigned to a default framework, the Merit-Based Incentive Payment System (MIPS).
In a letter to CMS, Wergin described the rule as "overly complex and burdensome to our members."
However, not everyone is entirely down on MACRA. "We're still optimistic that this new system will be better than the SGR was," said Lauren Wooster, MPH, of the American Osteopathic Association.
But the AOA is concerned that the narrow definition of an APM -- in particular the exclusion of patient-centered medical homes (PCMHs) -- will leave many providers at a disadvantage.
"It feels like this new system is trapping everybody in MIPS, " she said, which means they won't be able to gain that extra 5%.
The new Comprehensive Primary Care Plus (CPC) model would qualify as an advanced APM and incorporates many of the same values of the PCMHs, but that model is limited to 5,000 practices in specific geographic areas.
"You could be an advanced medical home doing everything right; doing everything exactly how it should be under MACRA, but if you're particular geography doesn't get picked for CPC ... plus, you still won't be able to get the 5%," Wooster noted.
The AOA is also worried that the proposed rule could force more small providers to consolidate.
Initially, Congress proposed the idea of establishing "virtual groups," which would allow small practices to band together, capture a larger patient population, and have quality measures tracked across the broader group, Wooster said.
In that way, if one practice is unlucky enough to have a handful of very sick patients, those poorer metrics will be diluted by the larger patient sample. A virtual group could also pool resources, such as investing in a shared electronic health record system, Wooster explained.
But CMS wasn't able to iron out the details of the "virtual group" concept before the proposed rule was issued. The AOA hopes that such a concept will ultimately be included in the final rule.
The AAFP, the AOA, and several other groups are calling to delay tracking of quality measures. Under the current proposed rule, quality measures will be tracked beginning in January 2017, just 2 months after the final rule is published.
Regarding the complexity of the new rules, Peter McMenamin, PhD, of the American Nurses Association (ANA), stated that "there are wrinkles on the wrinkles in terms of how it's supposed to work." He noted that CMS has taken a "Rube Goldberg approach" to payment reform, referring to the cartoon series that showed simple takes being performed by complicated gadgets.
The ANA's main gripe with the new rule is that the reforms exclude advanced practice registered nurses (APRNs).
While APRNs are technically eligible to participate in MIPS, "there's a substantial roadblock with the size limit," he said, noting that providers must have at least 100 Medicare Part B patients and at least $10,000 in Medicare charges.
By such measures, more than half of APRNs currently in Part B would be excluded, he said.
"The average size of the [APRN] patient load is a lot smaller than the physicians' patient load," he noted. "So it's that lack of an even playing field that worries me."
With regard to the advanced APMs, McMenamin noted that these are dominated by physicians who aren't motivated to include APRNs. Nurses also face the challenge of having their services properly attributed, he added.
Lisa Summers, CNM, DrPH, also of the ANA, pointed out that under MACRA, "on the one hand, we're saying 'We don't need to identify the quarterback when it comes to healthcare teams. We need to seek ways to enhance collaboration.' But on the other, we have these quality measures that are linked to an individual provider."
The ANA is lobbying to increase credentialing and direct billing of APRNS or to add a simple modifier in cases where APRNs are billed "incident to" -- under the physician's billing code.
Summers said there are plenty of nurses working in models that will qualify as advanced APMs. "The question is, are they findable? Are they recognizable? Can we attribute the care?"