House Ways and Means Committee Hearing on MACRA Implementation – Grave Concerns about Impact on Small Practices

The House Ways and Means Subcommittee on Health held a hearing on the implementation of the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA). The hearing examined proposed regulatory efforts by the Centers for Medicare and Medicaid Services (“CMS”).

Subcommittee Chairman Pat Tiberi applauded the bipartisan passage of MACRA last year in his opening statement. He stated that the purpose of the hearing was to “look closely at how these regulations match up with Congressional intent and what our Members and CMS are hearing from stakeholders as they digest the 950 plus pages of regulation.”

He stated that by hosting the hearing, he hoped to gain better clarity on how the regulation will affect small provider groups versus large provider groups, and how the timing of implementation will proceed under “potentially tight” deadlines.

Ranking Member Jim McDermott was also grateful for MACRA, stating, “Thanks to MACRA, we have set Medicare on a more sustainable course that will allow us to pay for value in health care, rather than volume.” He also alluded to the importance of public comment by stating, “I am confident that the administration will continue to be responsive to the needs of the public as it develops the final rule. This is an ongoing conversation. We still have more to learn as we work toward our shared goal of making the implementation of this landmark law a success.”

Slavitt Testimony

In his testimony, Mr. Slavitt testified to the three guiding principles of the proposal: (1) Patients are, and must remain, the key focus. Financial incentives should work in the background and support physician and clinician efforts to provide high quality services; (2) That success will come from adopting approaches that are practice-driven. Quality measurements should reflect the needs of a diverse range of patient populations and practice types, and give physicians and clinicians the opportunity to select the elements of the program that are right for their practice; and (3) To strive to make care delivery as simple as possible, with more support for collaboration and communication through delivery system reform.

Mr. Slavitt also reiterated numerous times throughout the hearing that CMS is open to public feedback on the proposal during this initial comment period. He also focused on CMS’ commitment to open and robust public discussion, mentioning that in the month of May alone, CMS has scheduled 35 listening sessions, webinars, and educational events.

Discussion

Impact on Small Practices

The impact of MACRA on small practices was one of the most talked about practices. Members like Chairman Tiberi and Representative Sam Johnson spoke about feedback from their districts, and wanted to know how smaller, solo, rural practitioners will be able to succeed under the new payment models. Mr. Slavitt stated that this is one of the areas in which CMS is seeking feedback, but mentioned some aspects of the current proposal that may help. He mentioned that the proposal allows for reporting to occur through registries that small providers may already be participating in, and that small and solo practices are permitted to report in groups. Mr. Slavitt mentioned that CMS intends to accommodate as many practices as possible.

Qualifying APMs

Another much-discussed topic was what would qualify as advanced alternative payment models (APMs) under MACRA. Chairman Tiberi noted that the thresholds for qualification are “high, and set in statute.” Representative Ron Kind and Representative Tom Price both mentioned instances in their districts where physicians participating in the first generation Accountable Care Organizations (ACOs) and the Bundled Payments for Care Improvement (BPCI) initiatives would would not qualify for the 5% bonus payments under MACRA. Representative Danny Davis mentioned a CMS statistic that estimates only 30,000 to 90,000 physicians will qualify for APMs under the regulations as they are currently designed.

Further Information

Even though the only testimony given at the hearing was by Andy Slavitt, the Acting Administrator for the CMS, any individual or organization may submit a written statement for consideration by the Committee, and for inclusion in the printed record of the hearing. Submissions must be submitted online, and must be submitted by the close of business on Wednesday, May 25, 2016.

CMS Tip Sheet

CMS has also issued a tip sheet, “Flexibilities and Support for Small Practices,” which is meant to be a CMS response and acknowledgement of the “unique challenges” that small practices with 15 or fewer clinicians face. The report followed Mr. Slavitt’s testimony at the W&M hearing, where as mentioned above, small practices were of much talk.

In the document, CMS cuts some slack for practices of nine and fewer clinicians by subjecting them to only two population health measures in the quality category, compared to the required three for larger groups. Clinicians will also be afforded the choice of which measurement and reporting systems work for them, with the perk of bonus points if they participate in an APM or submit additional reporting.

The document also mentioned MACRA’s budget of $100 million over the span of five years for technical assistance dedicated to practices with 15 or less clinicians, which will hopefully help those practices boost their MIPS scores and transition into advanced APMs, where financial risks and rewards can be greater.