Doctors look to Price for tweaks in Medicare rule

Doctors look to Price for tweaks in Medicare rule
© Keren Carrion

A version of this story previously appeared in The Hill Extra.

Doctors are hoping Health and Human Services Secretary Tom Price, a fellow physician, will address challenges for small practices in a proposed Medicare rule expected in coming weeks.

The White House is reviewing potential 2018 updates to Medicare’s new payment system commonly known as MACRAa shift in reimbursing physicians to reward them with bonuses for better patient care.


Doctors are hoping that Price, an orthopedic surgeon, will make it easier for small practices to participate, including easing the reporting burden and finding additional opportunities for doctors in advanced alternative payment models, which offer higher risk and higher financial reward.

The Centers for Medicare and Medicaid Services has only labeled 11 models as APMs, which leaves specialty doctors stranded in the lower payment track, the Merit-Based Incentive Payment System. That track, known as MIPS, requires more data reporting, but offers less risk for losing money.

“What’s going to be interesting to see is how this administration squares Dr. Price’s view of caution in moving toward those models with the law as directed, and goal of moving toward risk-bearing arrangements,” said Peter Fisea senior policy analyst with the Bipartisan Policy Center. “Some of that may operate outside of the actual rule itself, but in the past you’ve seen CMS fold major model announcements and policy changes into a rule like this.”

Only 10 percent of doctors are expected to take part in the higher payment track this year. To spur participation, the payment law created the Physician-Focused Payment Model Technical Advisory Committee to solicit and evaluate proposals from the industry. 

That panel apprehensively voted earlier this month to recommend its first two proposals to Price as limited demonstrations, but Fise said he would be surprised if they could move quickly enough to adapt and incorporate the models into the rule.

CMS could look elsewhere for alternative payment ideas, like privately-run Medicare Advantage plans, where there are a number of arrangements with a track record of success, according to John O’Shea, a surgeon and senior fellow with The Heritage Foundation. Incorporating some new options from MA would probably require legislative or regulatory changes to the payment law, but O’Shea said it’s a move that needs to happen.


“Providers are going to be pushed out of fee-for-service before they have anywhere else to go,” he said. “The prospects, unless something changes, are not good,” he added.

This is Price’s first chance to leave his mark on Medicare’s four-month old payment system, which replaced the deeply unpopular Sustainable Growth Rate formula. Doctors have complained that reporting requirements are keeping them from spending more time with patients, and they’re expecting Price to help fix the problem

Small practices will suffer the most under MIPS reporting requirements since they lack the technology and resources that larger hospitals have.

The payment law allows for doctors to band together in “virtual groups” to clear that hurdle, but CMS postponed the groups last year after failing to work out all the kinks. One issue was figuring out how to integrate doctors using different electronic health record systems.

The proposed rule will contain provisions for virtual groups, according to CMS Chief Medical Officer Kate Goodrich.

“We will make proposals around virtual groups, which is something that clinicians have very much wanted,” Goodrich said at a Health Affairs panel April 18. “We were disappointed that were weren't able to do that in the first year,” she added. 

Partly because of that, former CMS Administrator Andy Slavitt rolled back reporting requirements for 2017, allowing doctors to report a partial year’s worth of data to avoid a penalty. The likelihood of Price extending that flexibility is “a pretty sure bet,” according to O’Shea. 

“I don’t think most physician practices are going to be that much more ready for MIPS than they are this year,” he said, citing a recent Deloitte survey that found half of doctors had never even heard of the new payment law. 

“We make an enormous investment annually in just reporting on performance measures and basically none of the stakeholders involved think they help them in any way,” O’Shea said. 

But easing the rules could disadvantage larger providers like hospitals and integrated care systems, which already have reporting systems in place.

That’s because these bonuses will be doled out on a budget-neutral basis, meaning that fewer penalties for doctors who fail to report data will result in lower rewards for the doctors that do report. 

“We think it’s time to get MACRA fully implemented and reward those providers that have invested in doing well,” said Chet Speed, vice president of public policy for AMGA, which represents hospitals and other large provider groups.

But Speed acknowledged that Price’s background as a small practice doctor makes it unlikely that he would ramp up participation requirements.

One relaxed reporting measure experts anticipate Price to continue is known as “resource use,” which essentially gauges how efficient doctors are in delivering care.  The measure is supposed to account for 10 percent of doctors’ reporting scores in 2018, Fise said, although Price could change that. 

CMS zeroed out the weighting in resource use for this year as doctors familiarized themselves with the new system. Price could keep it at zero percent in 2018 as well.

“We need relief from the regulatory hassle and administrative burden of current regulations,” said John Meigs Jr., president of the American Academy of Family Physicians, in a statement. “This burden is interfering with patient care and is a major contributor to the rise in physician burnout and lack of resiliency.”

Kat Lucero contributed to this report. 

This story originally appeared on The Hill Extra. See more exclusive content on policy and regulatory news on our subscription-only service here.