MACRA 'Pick Your Pace' plan brings needed flexibility, but worries persist

The truncated turnaround time between when the MACRA final rule comes out in early November and when providers would have to start reporting in January has left many providers anxious and doubting their ability to be ready in time.

"In order to embrace any sort of change it requires a lot of energy and input. This isn't happening in a vacuum," said Andrew Gurman, MD, an orthopedic surgeon and the president of the American Medical Association. "It's happening at a time when a lot of other end-of-year reporting, consolidating and planning issues occur. And a two-month window in order to accommodate any major change is a formidable challenge to both large systems and practices, and small and intermediate practices."

A wave comments from clinicians, physicians and advocacy groups like the AMA led Acting Centers for Medicare and Medicaid Services Administrator Andy Slavitt in July to tell both the Senate Finance Committee and the American Osteopathic Association that CMS was considering a number of options and suggestions, including delaying the start of MACRA implementation.

[Also: CMS offers flexibility on MACRA, gives doctors ways to avoid payment adjustments]

Then in an early September blog post, Slavitt introduced the "Pick Your Pace" plan for the timing of the first year of reporting under MACRA's Quality Payment Program. Though the post was short on detail, the plan described four path options by which providers could participate at various levels and for a to-be-determined reporting period in 2017, including the caveat that choosing one of the four options would eliminate the possibility of receiving a negative payment adjustment in 2019.

Braden Lang, senior consultant, research at Advisory Board, said that a delay in its purest form might not have been possible anyway, since there are certain places where the federal agency's hands are tied. The MACRA legislation requires CMS to be making payment adjustments in 2019 on the basis of quality reporting, and they can't change that without further congressional action. So while they have some rulemaking authority around performance periods and exactly what the reporting requirements are, there is a firm deadline to make those payment adjustments.

"What I see in this is the need to bridge the feedback they are getting about the need for flexibility with that hard stop," Lang said.

"This was a welcome announcement," said Jeff Coughlin, senior director of federal and state affairs at the Health Information Management Systems Society, or HIMSS, who said they too were doubtful that a delay as it was originally proposed would happen. He said the "Pick Your Pace" plan is actually a better option because it still gets providers going on some level of reporting.

"With the different options CMS has presented for the quality payment program, practices can breathe a slight sigh of relief. There are different opportunities under these options depending on what your practice is ready for," Coughlin said.

[Also: No small feat: Rural practices brace for MACRA]

But this new proposal also carries with it a considerable amount of uncertainty because providers won't know the official details and requirements until the final MACRA rule comes out. So while experts say the proposal is a step in a better direction, especially when it comes to the survival of small practices who need more time to prepare for full-scale reporting, cautious optimism is about all they are willing to concede with "Pick Your Pace" because there are still plenty of questions to be answered.

Coughlin  said it is still unclear what the diminished reporting periods are going to be under the plan. As it reads now, the plan stipulates in option one that providers must submit "some data" in order to avoid the negative payment adjustment. While this option would appear to be the most flexible and least onerous, catering especially to those who are truly unprepared for MACRA, how big a help it will be remains to be seen.

"It all depends on what 'some' means. Everything hinges on that," Coughlin said.

Lang pointed out an apparent contradiction between "Pick Your Pace" and one of the most prominent details of MACRA. Under the Quality Payment Program, bonuses paid to high-performing providers are balanced out by penalties those who don't do well pay. He said it's hard to look at options one, two, and three and see how this could still be a budget-neutral program in year one if providers who feel like they're likely to do poorly opt out, or at least opt out of the penalties. It would seem counterintuitive that CMS could pay out bonuses of comparable size to those who are performing above the performance threshold if there are little to no penalties levied against and paid by lower performers.

"They told us in the proposed rule that they would make a performance threshold available before Jan 1 2017. That's going to complicate things even further. I think there are huge questions about how they maintain budget neutrality, and until they tell us explicitly that they won't I think I am just left scratching my head as we are all left scratching our heads as to exactly how these three options are going to work out," Lang said.

In the meantime, especially with these new options on the table, there are things providers should do to prepare for MACRA.

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Lang said providers will want to take a look at their immediate past performance in the programs that are most comparable to the programs that are now part of the Quality Payment Program. That includes looking at performance in quality metrics, cost benchmark data and their competency in attesting to meaningful use of electronic health records. Knowing how a practice is doing with reporting and gauging the level it is prepared to report the data will be key to decision making, as well as deciding what quality metrics your practice may want to select for reporting, Lang said.

If even some of those questions aren't easily answered, option one under "Pick Your Pace" may be the best option.

"There's a little bit here for all different kinds of practices. I think this is the flexibility that the community needs to help get this program off the ground," Coughlin said.

Twitter: @BethJSanborn