Friday, April 29, 2016

MACRA Draft Rulemaking Released; "Reforms" Meaningful Use Mess; Attention for Socioeconomic Status

On April 28, 2016, CMS released 962 pages of rulemaking for MACRA, the physician payment reform passed by Congress last year.   MACRA began by turning off the SGR formula for physician payments ("the doc fix") but gave CMS wide ranging authority to change physician incentives under new schemes that offset much larger upside bonuses with much larger penalty risks.

  • The rulemaking is here (81 FR 28162, 5/9/2016)
  • A Health Affairs short summary overview is here.  Advisory Board provides "ten key takeaways," here.   For a blog on the patient engagement framework, here.  For a 7-point blog on the HIT framework, by John Halamka, here.  For an article and links see HiTech, here.  For a rundown at Dive Healthcare, here.
  • A CMS blog that discusses the need for, and approach to, EHR incentive reform, is here.  The term "meaningful use" is dead.  Long live the term, "Advancing Care Information" or ACI.
  • Even more CMS fact sheets and summaries are online at CMS, here.  And don't miss the CMS YouTube animated infomercial, here.
More after the break.

Critics have complained that the acronym festival of MACRA, MIPS, and APS system will be vague, onerous, not different enough, and confusing.  (For links to some of the critiques, here.)   

At its heart, MACRA rolls up existing PQRS, EHR, ePrescribing, and resource based (aka cost!) metrics into one summary metric.  
(Sounds like, instead of getting a hard to understand $50 penalty for speeding and a separate confusing $50 penalty for no-turn-single, you would now get a single unified and easier to understand $100 penalty for the speeding and turn signal combined program, the S-TS-CP). 
The system will kick off by measuring physician activity from the beginning to end of CY2017, assessing it mathematically as claims come in (during CY2018), and then doling out rewards and penalties in CY2019 based on the CY2017 claim files.   This means for the first round of budget payouts (occuring in 2019) CMS has little time to change the existing metrics and rules (by 1/1/2017).

However, the rulemaking, which everyone will be digesting for weeks, signals that over time, CMS wants to undertake more forward-thinking and more assertive reforms to the incentive systems that Congress creative one legislative hiccup at a time over ten years.  Comments are due by June 27.  

Socioeconomic Status

On a policy note, CMS noted that a physician's patients must be risk-profiled (just like commercial insurance patients) for the resource use parameter.  In the past, inner city hospitals and some policy experts have noted that a powerful flag of increased resource use is low socioeconomic status (SES), which CMS has always refused to use as a resource weighting factor.  HHS must continue to study this issue and must report to Congress in October 2016, as seen on page 12 of the rule:

[p 12] The U.S. Department of Health & Human Services’ (HHS) Office of the AssistantSecretary for Planning and Evaluation (ASPE) is conducting studies and making recommendations on the issue of risk adjustment for socioeconomic status on quality measures and resource use as required by section 2(d) of the Improving Medicare Post-Acute Care Transformation Act of 2014 (the IMPACT Act) and expects to issue a report to Congress by October 2016. We will closely examine the recommendations issued by ASPE and incorporate them, as feasible and appropriate, in future rulemaking. [Also p. 102, 132].
This topic dates at least to 1990 (here) and 1993 (here, open access).  There are hundreds of studies in this field, but for a couple open access new ones, see studies in 2014 (here open access), 2015 (here, open access).

MACRA Word Cloud (