Public Policy

MACRA Rule Offers Little Clarity for Hospitalists


Last year, Congress put an end to the Sustainable Growth Rate (SGR), which had become a yearly battle fought on behalf of and by physicians to prevent significant last-minute cuts to Medicare reimbursement. Many hoped its replacement would provide more stability and certainty.

However, that replacement, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), has been anything but clear. On April 27, 2016, the Centers for Medicare & Medicaid Services (CMS) issued a Notice of Proposed Rulemaking in what it called a “first step” in implementing MACRA. CMS accepted feedback and input on the proposed rule through June 27, 2016.

The Society of Hospital Medicine worked to provide comment on what it sees as the biggest concerns of hospitalists.

For example, it remains unclear what quality markers CMS will use to evaluate hospitalists under MACRA, says Rush University Medical Center’s Suparna Dutta, MD, MPH, a hospitalist, assistant professor of medicine, and member of the SHM Public Policy Committee (PPC). “The biggest piece is, what will be used universally for all hospitalists and attributed to the work that we do?”

MACRA represents “a milestone” in efforts to “advance a healthcare system that rewards better care, smarter spending, and healthier people,” U.S. Department of Health & Human Services Secretary Sylvia M. Burwell said in a statement issued the day the proposed rule was announced.

What it is designed to do, says Ron Greeno, MD, MHM, president-elect of SHM, PPC chair, and senior advisor for medical affairs at TeamHealth, is push physicians to move toward alternative payment models.

To achieve this, MACRA creates a framework called the Quality Payment Program, which offers physicians two paths for value-over-volume-based payments: MIPS, for Merit-Based Incentive Payment System, and APMs, for Advanced Alternative Payment Models. The benchmark period for both pathways begins Jan. 1, 2017, and MACRA reimbursement would begin Jan. 1, 2019.

Under MIPS, current quality measurement programs are streamlined into a single payment adjustment, including the Physician Value-Based Modifier, the Electronic Health Record (EHR) Incentive Program and the Physician Quality Reporting System (PQRS).

Physicians will not assume risk on the MIPS pathway, but payment adjustments will be based on their MIPS score, which grows each year through 2022 and ranges that year from +9% to -9%. It will be budget neutral: The top half of scorers will see increases in payments, while the bottom half will see cuts. Additional adjustments will be given to top performers through 2024.

However, as Dr. Dutta and fellow PPC member Lauren Doctoroff, MD, FHM, a hospitalist at Beth Israel Deaconess Medical Center and instructor at Harvard Medical School, wrote for The Hospitalist in March 2016, it is not yet clear how MIPS scores will be calculated for hospitalists.

“The problem is that there is not a typical hospitalist in terms of the work that we do,” Dr. Dutta says. “It depends on the hospital and the types of responsibilities the hospitalists have and the types of patients they care for.”

CMS says 50% of the MIPS score will come from six reported measures that reflect different specialties and practices; 25% will come from technology use, with a focus on interoperability and information exchange; 15% will come from clinical improvement practices, like care coordination; and 10% will be based on cost, chosen from among 40 episode-specific measures.

The new hospitalist billing code, which has not yet been implemented, should be a tremendous help under MACRA, Dr. Dutta says. “As CMS plans on using peer-comparison groups for quality and cost measures, it is really important that we now have a specialty billing code for hospitalists, which should ensure we have a fair and valid comparison pool for any metrics we are measured on for MIPS.”

The second path may be much harder for hospitalists to achieve since it requires that physicians share in risk and reward and participate in alternative payment models like Next Generation ACO or the Comprehensive Primary Care Plus model.

Most hospitalists will not be candidates for taking on risks under APM since physicians need to achieve a threshold for taking on more than nominal financial risk, Dr. Dutta says, noting SHM’s efforts to better understand the implications.

“It depends on the the percentage of patients you’re seeing in an APM, and you might hit your threshold if your market has a lot of Medicare ACOs or risk-sharing, but it’s not something hospitalists can consistently plan on,” Dr. Dutta says.

Most hospitalists have little control over whether their facility participates in an APM, Dr. Dutta says, but allowing the APM to which a patient belongs count toward the care provided by hospitalists—though a patient may align with several APMs—may help reach these thresholds.

Feedback from SHM to CMS also included asking to allow the Bundled Payments for Care Improvement Initiative (BPCI) to qualify for APM and seeking clarification into whether hospitalists can tap into cost and quality metrics hospitals are already reporting to CMS.

“Hospitals are collecting a certain amount of data because they have to for Medicare, and that might be a good indicator of what hospitalists are doing,” Dr. Dutta says. This includes services like DVT prophylaxis after surgery in hospitals where hospitalists provide a majority of post-operative care or safety measures like CLABSI (central line–associated bloodstream infection) rates.

To stay up to date with MACRA, visit SHM’s MACRA website and follow @SHMadvocacy on Twitter. TH

Corrected version July 13, 2016.

Kelly April Tyrrell is a freelance writer in Madison, Wis.

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