CMS Wavers on Commitment to MACRA Reforms

Andy Slavitt

The Centers for Medicare & Medicaid Services (CMS) is wavering on its commitment to the Medicare reform package passed in 2015, based on widespread concerns that the changes may be unwieldy and could increase the pace at which smaller physician practices are being forced into mergers.

In testimony before the Senate Finance Committee today, CMS Acting Administrator Andy Slavitt told lawmakers that CMS is considering modifying or delaying elements of the Medicare Access and CHIP Reauthorization Act, which includes changes in physician payment and new healthcare delivery models, including episode-based payment, designed to improve the efficiency and quality of healthcare.

“Some of the things we’re considering include alternative start dates, looking at whether shorter periods could be used, and finding other ways for physicians to get experience with the program before the impact of it really hits them,” Slavitt told legislators.

Slavitt’s remarks drew an immediate chorus of approval from leaders in the oncology community, which has long expressed reservations about the dramatic changes that would be imposed on the physician community by MACRA.

“We are very encouraged by the acknowledgement by CMS Acting Administrator Andy Slavitt that the concerns expressed by physician organizations may require adjustments in the phase-in of MACRA,” said ASCO chief executive officer Clifford A. Hudis, MD, FASCO. “ASCO supports the delivery of value-based care, but is concerned that an overly ambitious schedule may prove burdensome for some, especially rural and smaller, oncology practices. We appreciate Acting Administrator Slavitt’s statement that he will take timing into consideration as CMS moves forward on MACRA implementation.”

The Community Oncology Alliance (COA), which represents many independent practices struggling to maintain a competitive foothold while trying to transition to CMS reforms, has long been concerned that MACRA’s emphasis on one alternative payment model, in particular the Oncology Care Model, has the potential to force practices to compete against themselves owing to the type of performance reporting standards required. COA has promoted its own alternative payment model (APM) that it believes would be a better fit for oncologists. COA executive director Ted Okon expressed relief that CMS is taking a more conservative tack on its reforms.

“It is great to see that CMS is listening to the community,” Okon said. “This is an excellent suggestion from Acting Administrator Slavitt and one which COA asked for in its comment letter. MACRA is simply too big of a deal to rush through and it appears they are recognizing that,” he continued. “We hope that CMS will consider the other requests from community oncology, such as the Oncology Medical Home. It is very important that practices be recognized for all the hard work they are already doing to improve quality and value.”

In his testimony, Slavitt said that CMS has come to accept that many physician practices are not ready for the reporting requirements being imposed on them under MACRA, which many large medical association groups have urged CMS to delay. “The focus on small independent practices and their ability to continue practicing independently is a very important priority for us,” Slavitt said.

Under MACRA, CMS was instituting the controversial Merit-Based Payment System (MIPS) of performance payment incentives, which held the potential for payment cuts as deep as 9% for practices that failed to meet standards for quality and cost efficiency. The program also includes a series of payment increases to keep up with medical inflation as well as the potential for bonuses for meeting certain targets. When MACRA was signed into law in 2015, replacing the former Sustainable Growth Rate (SGR) formula for physician payment, it was viewed as a challenging system of reforms that would raise the stakes for the medical community. It was also considered a better way of balancing the budget for medical spending, as the SGR had consistently required yearly congressional acts to patch up funding shortfalls.

Earlier this month CMS officially launched the Oncology Care Model (OCM), which had 196 oncology practices participating. It was a “soft” launch with little fanfare by CMS. Oncology practice administrators described their preparation for participation in the OCM as a frustrating process that was short on time and critical information needed for them to fully anticipate how the OCM would affect their revenues and operations. They said CMS did not appear to have all aspects of the program worked out by the date of the launch.

COA has assumed the role of a liaison between CMS and participating practices by forming a committee that will attempt to resolve OCM information gaps and serve in an advisory role to practices that are struggling to correctly interpret OCM requirements. Under the OCM, participating practices will eventually face the potential for downside payment risk as part of the CMS improvement incentive play.

Practices not in approved APMs face the specter of MIPS based incentives, which were slated to begin in 2015, with 0.5% annual increases continuing through 2019. Those would cease in 2020, when potential payment changes from -5% to +15% would apply. From 2022 onward, -9% to +27% payment changes could apply, based on performance.