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Tuesday Nov 24, 2015

Maximizing MACRA for Family Medicine

"The pen is mightier than the sword." – English writer and politician Edward Bulwer-Lytton, 1839

In the past two weeks, the AAFP has submitted more than 60 pages of comments and recommendations on the delivery system and physician payment reforms outlined in the Medicare Access and CHIP Reauthorization Act (MACRA) (Public Law 114-10). Optimistic that the phrase made famous by Bulwer-Lytton 176 years ago still holds true, the Academy is exercising its "pen" to influence the implementation of MACRA in a manner that best benefits family physicians and their patients.  

On Nov. 9, the AAFP responded to CMS’ request for information(www.gpo.gov) regarding the Merit-Based Incentive Payment System, Promotion of Alternative Payment Models, and Incentive Payments for Participation in Eligible Alternative Payment Models. The AAFP’s 53-page response responds directly to the 126 questions in the RFI.

On Nov. 19, the AAFP responded to the Alternative Payment Model Framework Draft White Paper published by the Health Care Payment Learning and Action Network(publish.mitre.org) (HCPLAN), a group assembled by CMS to assist with MACRA implementation .

MACRA was signed into law April 16, bringing to a close the 13-year drama that was the sustainable growth rate (SGR). Repealing the SGR was a significant accomplishment that created an environment whereby we can begin the transition away from episodic and fragmented delivery and payment models towards those that promote continuity, coordination and connectivity. MACRA represents the future -- albeit a somewhat confusing future.  

The transition from legislation to regulation is one of the most important processes in government. It also is the arena where the AAFP must perform at the highest level on behalf of our members. We take the regulatory process very seriously. The emphasis we are placing on the implementation of MACRA is driven by our desire to realize the full potential of delivery and payment system reform and our understanding that MACRA refers decisions to the secretary of HHS more than 100 times.

The AAFP response to both documents advance the importance of increasing the overall investment in primary care and not building new delivery and payment models on the biased and inaccurate relative value data used in the fee-for-service system. Our letters strongly recommended that CMS and private payers do more to ensure that Medicare and all other public and private programs pay appropriately for primary care physician services. Appropriate, obviously, means more than current levels.

To achieve this goal, the AAFP urged CMS to use its authority and take administrative actions to increase the values of primary care services in the Medicare program.  Additionally, the AAFP outlined a comprehensive payment proposal that would move a larger percentage of payments from the traditional fee-for-service model toward alternative payment models. With respect to primary care, the AAFP proposes that payments for primary care services under this advanced primary care delivery model be made on a per-patient basis through the combination of a global payment for direct patient care services and a global care management fee.

Our letters also raised concerns about several barriers that may prohibit successful participation in the new payment models. The most significant barrier is the poorly designed meaningful use program and its lack of interoperability standards, which prohibit the sharing of patient information. Family physicians continue to face significant challenges with their EHRs and meeting meaningful use standards. Until this program is improved and the EHR issues are resolved, it is difficult to foresee a large percentage of physicians -- particularly physicians in small and independent practices -- being successful in MACRA programs.

We continued our advocacy aimed at encouraging CMS to use the Joint Principles of the Patient-Centered Medical Home and the key functions of the Comprehensive Primary Care (CPC) initiative as criteria for determining what constitutes a medical home. The Joint Principles, when aligned with the five key functions of the CPC initiative, capture the true definition of a PCMH and its performance thresholds. The AAFP clearly states in multiple places that we do not believe a physician should be required to pay a third party to secure the PCMH recognition necessary to participate in a Medicare program.

Finally, we strongly urged CMS to streamline, harmonize and reduce the complexity of quality reporting in the MIPS and APM programs. Out letters outline a vision for quality improvement programs that promote continuous quality improvement and measure patient experiences. The AAFP expresses opposition to any approach that requires physicians to report on a complex set of measures that do not impact or influence the quality of care provided to patients. Instead, we suggest that all measures used must be clinically relevant, harmonized among all public and private payers and be submitted in a manner that is minimally burdensome on physicians.

Our letter offers recommendations on numerous additional topics, but the above information captures the major themes. Clearly, the implementation of MACRA will be a major undertaking, and the AAFP is committed to influencing this process in a manner that benefits family physicians and their patients. This undertaking will not be easy, but our team is capable and ready. I encourage you to follow our work on your behalf on our MACRA resource webpage.

I anticipate that many of you are prepared to utilize your "pen" to communicate your views on MACRA and the choices family physicians face in the next few years. I look forward to your comments, thoughts, and suggestions. More importantly, I look forward to learning from you and your experiences so that we can better serve you and your practice.

Wonk Hard
The IMS Institute for Healthcare Informatics has released a new report, Global Medicines Use in 2020: Outlook and Implications(www.imshealth.com) that project global spending on pharmaceutical products will increase 30 percent by 2020, resulting in a global spend of $1.3 trillion. The report notes that the spending will be driven by expensive new drugs, price hikes for existing drugs, increased use of generic drugs in developing countries and an aging population. IMS projects that, by 2020, annual use of medicine will hit 4.5 trillion doses, up 24 percent from this year. Additionally, the report projects that more than half of the world’s population -- currently 7.6 billion -- will be taking more than one medicine dose per day.  Finally, IMS projects that roughly 90 percent of U.S. prescriptions dispensed in 2020 will be for generic products.

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Stephanie Quinn, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy.

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The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.