Is the Optionality of MACRA Implementation Adding Complexity?

June 01, 2016 - When federal officials finally revealed their plans for MACRA implementation, they emphasized the importance of streamlining quality programs such as meaningful use and making reporting requirements less time-consuming for providers.

That was the case made by the head of the Centers for Medicare & Medicaid Services in late April for replacing meaningful use with the advancing care information performance category under the Merit-based Incentive Payment System (MIPS).

“Based on significant feedback, the program Advancing Care Information is designed to far simpler, less burdensome, and more flexible," Acting Administrator Andy Slavitt said at the time. "If this proposal’s finalized, this would replace the current meaningful use program for physician offices and be effective January 1, 2017 along with the other components of the MACRA implementation."

But is the federal agency's plan for MACRA implementation capable of achieving that simplicity and flexibility?

According to the Vice President of Congressional Affairs for the College of Healthcare Information Management Executives (CHIME), many healthcare leaders are voicing their doubts.

"The overall message relative to MACRA is that folks are still trying to digest the complexity," Leslie  Krigstein told EHRIntelligence.com. "Naturally, payment rules are long. We see that in IPPS and even the physician fee schedule in the past."

Contributing to these doubts is the number of pathways available to MIPS eligible clinicians.

"Just the level of optionality that was offered is often what is now being pointed to as complexity," Krigstein explained. "When you're trying to allow someone to charter their own path, you're going to have to right a rule which might appear complex, but to be able to enable such flexibility it's going to be long and it's going to be cumbersome."

Adding to those doubts is the reality that is likely to face many hospitals based on their relationships with physicians and ambulatory practices:

"Something that the CIOs have said even before the rule had come out was that many CIOs administer technology for ambulatory practices or have employed physicians, so how do we look to harmonize things — what's in MACRA and what's in existing meaningful use — because as we are all intimately aware the MACRA rules really don't impact hospitals," Krigstein maintained.

Changes affecting one and not the other program — that is, updates to the advancing care information performance category but none for meaningful use — would likely double the quality reporting requirements on hospitals.

"Efforts to map what has been proposed versus what's currently on the books did leave a lot of folks scratching their heads," Krigstein continued. "It is very complex and seems very counterintuitive to the administration's efforts to start to streamline."

More troubling still and fueling fears about not meeting the requirements of the propose MACRA rule is timing.

"More than that, it's just trying to predict what's going to be necessary and what's going to be possible beginning January 1. That's coming really quickly and there's a fundamental overhaul underway," said Krigstein.

Likewise, there remains the matter of reporting periods, the focus of many Congressional bills aimed at easing meaningful use requirements on eligible professionals and hospitals.

"Does the statute necessitate a full-year reporting that would need to start on January 1 or is there some wiggle room that it may be a quarter, two quarters, three quarters that would give extra lead time to prepare?" Krigstein wondered. "There is going to be some catchup that's going to need to take place. It's just a matter of does CMS under the current statutory authority have the ability to start to enable some of that extra flexibility along the way."

The feasibility of transitioning from meaningful use to MIPS is already raising concerns among members of Congress that small practices, especially solo practitioners, will struggle to keep up with their larger and more resourceful counterparts.

"The conversation is far from over," Krigstein observed. "There has been a recognition on Capitol Hill that health information technology — whether it be meaningful use or ACI — needs to be present in these conversations and technology is really what's going to facilitate the improved outcomes, but there's still a lot of dust settling."

An unintended consequence of the CMS approach to MACRA implementation could actually be a shifting rather than a reduction of burden.