In the effort to design the new Medicare payment system, Andy Slavitt, acting administrator of the Centers for Medicare & Medicaid Services (CMS), said that the driving factor behind many of the changes was physician input—and the proposed rule attempts to reflect that. But the physician’s role does not stop there.
“You represent one of America’s most potent and proudest forces of talent and ability,” Andy Slavitt, acting administrator of the Centers for Medicare & Medicaid Services (CMS), told physicians Monday at the 2016 AMA Annual Meeting in Chicago. There is an historic opportunity before us, he said, “to change how Medicare pays for care.”
“I’m also here to talk about something bigger: Reversing a pattern of regulations and frustration and ultimately unleashing a new wave of collaboration between the people who spend their lives taking care of us and those of us whose job it is to support that cause,” Slavitt said.
With little time left in his tenure, Slavitt called upon physicians to not only work with him until that time is up but also continue to work with CMS in the same manner after he departs from Washington.
“We don’t profess to have all the answers,” he said. “We continue to look for comments … on how to simplify further, how to align the performance categories, how to make sure we’re not encouraging compliance but rather rewarding care.”
CMS has collected comments, visited practices and held listening sessions with physicians and other health care professionals to learn from their expertise and experience as the new route in which health care system is headed is finalized, Slavitt said.
The proposed rule is open for comment through June 27, giving physicians and medical associations and societies an opportunity to provide their input to collaborate in the design of the new payment and care system. Physicians can submit comments through BreakTheRedTape.org, the AMA’s grassroots campaign.
The AMA will submit comments to CMS by that date to ensure physicians in all specialties and all practice sizes are properly represented so the system works in a way that allows them to determine the best ways to provide care for their patients.
As the health care system transitions to a new care and payment delivery system under the Medicare Access and CHIP Reauthorization Act (MACRA), physicians have a number of questions about how this process is going to work.
Slavitt provided some clarity on the details currently known about implementation, quality reporting, the Merit-Based Incentive Payment System (MIPS) and participation in alternative payment models (APM).
“The new program wraps around changes intended to promote coordinated care at reasonable costs through a uniform merit-based system,” he said. “This system is defined in the statute to focus on quality, cost, technology and practice improvement.”
The system also allows for physicians to design and participate in new models of payment, such as medical homes, specialty models, team-based models and other APMs. It also is intended to “reward physicians in those models with additional bonuses,” he said. But, “the first question, of course, for many physicians is: What do you really need to know about the program?”
“The goal of the program,” Slavitt said, “is to return the focus to patient care, not spend time learning a new program.”
Through CMS’ listening sessions with physicians, four cross-cutting themes have emerged:
Keeping patients at the center of care
“In all my years, I have never met—nor do I hope to meet—a physician who makes her decision on how to treat a patient based on how she gets paid,” Slavitt said. “She does what she thinks is right for the patient and hopes that the system will support her.”
“Over the last couple of years, we’ve been rapidly advancing models that put patients at the center. This includes over nine million Medicare beneficiaries today in accountable care organizations,” he said. Newer specialty models are already being used across the country, and the new system will support those models and reward physicians for their participation.
“MIPS is intended to move the focus to patients as well,” he said. “There are more than 90 clinical practice improvement activities for physicians to choose from which support patient-friendly steps.”
“If participating in an APM, no other reporting is required,” he said. “Either way, we need these first steps to help us move away from a compliance program to something truly patient-centered.”
Allow practices the flexibility to drive how they use the program
Many physicians have told CMS that a one-size-fits-all program won’t work, Slavitt said. “We have to aim for the sweet spot in building a program that is as flexible as possible so physicians can focus on what’s right for their patients and makes sense in their local communities and choose from a number of ways to participate in the quality payment program.”
“That means more options on choosing appropriate measures… on whether to participate in models like accountable care organizations and medical homes,” he said, “and the flexibility to move between them without having to report multiple times.”
“It also means using quality measures selected directly from work with specialty societies,” he said. “For specialists, there are many different avenues to success within the quality payment program. Already nationally, 70 percent of practices participate in accountable care organizations … and we are working on the development of more specialty-focused models.”
Focus on policies based on the needs of small practices
“We must make sure that our policies fit with the realities of the local markets where you operate,” Slavitt said. “We all need to acknowledge and work against the reality that many changes in health care today make it more difficult for solo and small practices to stay independent.”
“To level the playing field against these things—more complexity, the fast pace of change, the call for collaboration—we need to focus hard on the areas which increase the costs of operating a practice and look for other things we can do to offset these challenges,” he said.
The proposed rule calls direct attention to this with a schedule that demonstrates the negative impact on solo and small practices when they don’t report. “Under the quality payment program, we know that physicians in small practices who report performance can do equivalently well as mid-sized practices,” he said. “We’re committed to significantly reducing the financial cost and the burden of reporting.”
Simplify wherever and whenever possible
“One of the major opportunities is to use the rulemaking process to connect these programs together,” he said. “The good news is that the combined magnitude and reporting effort are far less than they are currently.”
“One reason we think we’re hearing some concern from physicians is that it’s the first time the entirety of these programs can be seen end-to-end in one place,” Slavitt said. He called attention to three simplifications in the proposed rule.
“We’ve reduced by one-third the number of quality metrics that need to be reported,” he said. “We simplified the process … [and] we made it so the programs talked to each other.”
Immediately following his address to physician delegates, Slavitt sat down with Matt Burnholz, MD, of ReachMD for a podcast to discuss why it is important for CMS to take an “outside-in” approach of listening to physicians as they finalize and implement MACRA.
“What the physician community has experienced is a reality on the ground that feels very different from all the big strategic policy talk,” he said. “I don’t say this to cheapen the policy process, but … it needs to be grounded in the realities of the world.”
The AMA offers a number of resources to help physicians prepare for the coming payment policies, including:
- A summary of the proposed regulations
- 4 steps to prepare for Medicare’s new payment systems
- A guide to physician-focused payment models
- Key points of the Merit-based Incentive Payment System
- What you can do now to prepare
- The AMA’s STEPS Forward™ collection of practice improvement strategies, which includes modules on advancing team-based care, implementing electronic health records, improving care and practicing value-based care