Big news this week when on Wednesday CMS dropped the draft rules for MACRA, all 962 pages worth. These rules are the outcome of legislation that passed a couple of years back to replace the flawed SGR reimbursement model for physicians and hospitals. In its place, CMS is proposing two dominant reimbursement models:

• APM, short for alternative payment models, is primarily targeted at hospital systems.
• MIPS, short for merit-based incentive payment system, is primarily for ambulatory providers, otherwise known as eligible providers (EP) under Meaningful Use (MU).

In the conference call on Wednesday, acting head of CMS, Andy Slavitt, made it clear that the intent of MACRA is to move towards a model that provides flexibility for physicians to deliver quality care and enable the free flow of information across the sector in support of patient care and more broadly population health.

Plenty to talk about regarding both APM and MIPS, but for brevity’s sake, let’s focus on MIPS and we’ll do a follow-up post on APM in near future.

Five Things to Know About MIPS
Unpacking 962 pages of proposed rules in not for the feint of heart. No, we have not gone over every little nuance of the rules but in our cursory review we have identified five key points that really are the crux of the rules for EPs as it pertains to MIPS. These are the things that define the intent of MIPS and also where we are likely to see some push-back, after all, these rules are not quite set in stone – yet.

1) Quality and information exchange are top priorities. MIPS reimbursement will be based on a composite score of four key components: quality, resource use, clinical practice improvement activity, and advancing care information. Quality and advancing care information will be 75% of total weighting. Thus, it is quite clear where CMS wants physicians to focus in the near term – improving quality of care delivered and accelerating the use of IT to facilitate the flow of PHI in support of care quality.

2) Move from highly prescriptive to more flexible model. Under MIPS, MU is effectively dead for EPs under Medicare – the odd twist though is that MU is still in place for hospitals and Medicaid EPs, though CMS has expressed its intent to modify these areas as well in the future. CMS is giving quite a bit of flexibility to EPs in reporting out what measures are most important and relevant to their practice. Gone are the prescriptive, strictly defined measures that were part and parcel of MU, measures that often did not align with other CMS programs.

3) Be careful what you wish for – flexibility may breed complexity. While physicians now have a range of options as to what they will report out on as part of MIPS, this flexibility has a way of compounding itself in a nearly exponential way. Eligible physicians will need to wade through the many permutations of MACRA reporting requirements to settle upon what is best for their practice. This will create a lucrative opportunity for consultants serving this market. We also wonder how CMS will keep track of all of this as well – this is a non-trivial issue.

4) No time to waste – one year reporting period, begins January 1, 2017. Due to legislative requirements, CMS’s hands are tied as to when the switch to MACRA begins – but Jan. 1 2017 is only a short six months or so away from when rules will be finalized. What CMS does have flexibility on is the reporting period and they have chosen to go with one year, versus the more popular 90-day reporting period. CMS will get some heavy pushback here and likely acquiesce to 90-day. Would also not be at all surprised if the whole program gets push back a full year – just remember what happened to switch from ICD-9 to ICD-10.

5) Trust then verify is the mantra. Under MACRA’s new reporting requirements CMS recognizes that it will need to trust EPs to do the right thing. That being said, the proposed rules also have a significant amount of language pertaining to surveillance. How that surveillance will occur, how much will big brother be looking over a physician’s shoulder is up for interpretation,

While there are aspects to MACRA that have cause for concern, as outlined above, we are quite impressed with what CMS has put together. Clearly, a lot of hard work has gone into these proposed rules. CMS has reconciled many of the past ills – from the defunct SGR reimbursement model, to the oft-maligned MU program – with the desire to align the program to how physicians actually practice care that will lead to improvement in quality of care provided and value for the U.S. citizen. This is a Herculean task and for that CMS, Andy Slavitt, Karen DeSalvo, and countless others that have contributed to this effort deserve applause.

Some Additional Resources:
HHS Secretary Burwell’s take, with a pretty slick video giving high level overview of MACRA
The proposed rules, all 962 pages
Nice, digestable summary of MACRA
Similar to previous, but takes closer look at Advancing Care Information – the replacement to MU
Politico’s, Dan Diamond’s, interview/podcast with Andy Slavitt about MACRA