Medicare Proposed Rule Clarifies, But Leaves Work To Be Done, Experts Say

Jeffrey Clough, Dr. Mark McClellan encourage physicians to take time to understand the key features

On April 27, the Centers for Medicare and Medicaid Services (CMS) proposed rules that will move physician payments away from fee-for-service and toward a model that aligns payments with better quality of care that avoids unnecessary costs.  

These changes, outlined in a 962-page document proposed for implementing the Medicare Access and CHIP Reauthorization Act (MACRA), are expected to affect payments throughout the entire U.S. health care system. 

In a Viewpoint commentary published Monday in the Journal of the American Medical Association, Dr. Jeffrey Clough, a member of the Duke Clinical Research Institute, and Dr. Mark McClellan, director of the Duke-Margolis Center for Health Policy, encourage physicians to take time to understand the key features of the rule and the opportunities it presents to shape the future of payment and medical practice. 

“Our aim in this commentary is to provide physicians with an overview of the options for participation in payment reform and quality improvement under MACRA. Their leadership is essential to the future of high-value health care,” Clough said.    

The proposed payment models aim to create greater accountability for efficiency and care improvement. CMS expects the vast majority of clinicians to initially participate in the new Merit-based Incentive Payment System (MIPS). Under this model, which begins in 2019, payment will be adjusted based on factors that include specific patient outcome measures, efficiency, use of information technology and clinical practice improvement activities. 

As outlined in the proposed rule, Alternative Payment Models (APMs) provide an option for physicians to be exempt from MIPS by taking on a higher level of accountability for quality and expenditure performance. Clough and McClellan say new APMs should be aggressively developed for a broad range of physician practices.

“We estimate that about 10 percent of physicians could qualify for extra payments associated with advanced Alternative Payment Models based on the Medicare payment options and pilots available now. These would mainly include certain primary care doctors and clinicians practicing within large integrated systems that take on significant financial risk,” McClellan said. 

Clough and McClellan note challenges with existing measures for pay-for-performance in reducing overall costs. They urge physicians to work through professional organizations to participate in improving the proposed rule and in developing better utilization and quality measures, as well as advanced APMs.  

“Physicians have a real opportunity to shape the future of clinical practice, by developing models that enable a broader range of physicians to qualify for advanced APMs. These include models affecting specialists involved in the care of patients with complex or advanced needs, and models with meaningful but manageable risk for physicians in small practices,” McClellan said.