Q+A: AMGA says MACRA proposed rule sends wrong message on value-based care

Groups representing physicians, hospitals, internists and health IT were quick to praise the proposed rule for the second year of the new payment tracks under the Medicare Access and CHIP Reauthorization Act (MACRA). The American Medical Group Association, however, has a decidedly different take.

The most striking change proposed was raising the low-volume threshold, allowing clinicians with under $90,000 in Medicare Part B charges or seeing fewer than 200 beneficiaries to be excluded from the Merit-based Incentive Payment System (MIPS) in the Quality Payment Program (QPP). To the AMGA, that provision would be a concession to smaller providers.

“Large systems in our membership are internally committed to getting to value because they feel it’s the right thing to do, so we’ll keep moving in that direction, but this isn’t the signal they really wanted to see,” said Chet Speed, LLM, AMGA’s vice president of public policy.

Speed and AMGA’s director of regulatory affairs, Darryl Drevna, spoke to HealthExec about the potential ramifications the rule could have on the transition to value-based care.

HealthExec: What’s your overall reaction to the proposed rule?

Chet Speed: It demonstrates the tension that we have in getting to value. On the one hand, MACRA represents the congressional agenda as far as moving Medicare from volume to value. To get to value, of course, you need to measure your performance, whether it’s quality or cost or what not, and that’s the rub. A lot of the small practices have said pretty vocally that being measured on cost and quality is just too burdensome for them.

So looking at CMS’s proposed rule, they basically excluded a fairly large chunk of providers from MIPS. AMGA members are at the opposite end of that spectrum. Our members include groups like Mayo Clinic, Cleveland Clinic, Intermountain, Geisinger, etc., and our members have made, in many cases, multimillion-dollar investments to take on value, to hire care coordinators and nurses who do actual care coordination activities. They’ve also invested in (electronic medical records) and analytics to look at the clinical data and target patient populations with better interventions.

When we look at the end result of the proposed rule, we have a real squeeze of awards for those who have done well, or think that they’ll do well. It’s not the best message for our members who are trying to get to value.

You mentioned how more clinicians would be excluded from MIPS under this rule, and 65 percent were already excluded in 2017. Does this undermine the goal of MACRA?

Chet Speed: That’s a good question. Let me answer that delicately. MACRA is the congressional value agenda—they clearly want to move Medicare from fee-for-service to value and risk, and yes, when you exclude 65 percent of all providers from that value mechanism, it’s hard to say you’re fulfilling the congressional goal.

When you look at our members who have invested in getting to value to risk, they don’t feel their investments, their time, their treasure, are being recognized at all. Our members are moving to this new model because, I sincerely believe, they think it’s better for the patient to take care of the patient at a better cost.

What other important provisions in the rule represent a change from the past CMS administration’s policies?

Darryl Drevna: Most of the rest of these are technical changes, like how quality reporting is going to change a little bit. The weights are staying the same, pretty much. However, if you want a program that’s going to account for cost, eventually you have to account for cost and they’re proposing to zero (the cost metric) out again.

Chet Speed: The way you move behavior is through economic incentives. Zeroing costs for the second year in a row, you’re not really going to move behavior until cost is part of the value equation. Another thing, and I don’t know if I’ve seen this covered, they once again excluded Medicare Advantage from counting to help providers get (advanced alternative payment model) status in 2019. CMS says the statute doesn’t allow them to take into account MA beneficiary count under APM eligibility.

What’s happening is you’re legislating healthcare in a piecemeal fashion. So MACRA is all providers. Medicare Advantage is sort of the payor space. If we’re really going to get to value, we need to start melding providers and payors at the same time. Both of those groups need to be incentivized to go to value simultaneously, not separately.

To clear up some confusion about the proposed rule, does it retain the first year’s “pick your pace” participation options?

Darryl Drevna: No, CMS is not offering a pick your pace option this year. So unless you’re otherwise excluded, you need to participate fully. For quality, for example, in this performance year you get to submit one quality measure and be held harmless and that’s not the case (for 2018). You can actually submit the full six measures for a 12-month performance period.

Chet Speed: The way they handled the small practice issue was, instead of doing pick your pace part two, they just excluded a vast swath of small practice providers.

Your reaction to the proposed rule seems to be largely negative. What parts of it do you like?

Chet Speed: That’s a good question. What pleases us is MACRA remains a value-based mechanism. Value will be incentivized, albeit slower than we like, but MACRA still remains the law of the land. At some point and time, we will need to move toward value, and MACRA is going to be that mechanism to do it.