EDITOR’S NOTE: Last Wednesday, CMS Acting Administrator Andy Slavitt told members of the U.S. Senate Finance Committee that his agency might delay the implementation of MACRA scheduled to rollout January 1, 2017.

It is wheat harvest time in Rural America—a time when the amber waves of grain come full circle, when one hopes that the last several months of careful planting and growth during unpredictable weather patterns and season changes to maturation now translate to the best yields and market prices.

Like the wheat harvest, one hopes that with the release of the MACRA proposed rulings for “open comment,” in the end, rural will harvest a high yield return for sustainability. And this is where “sowing and reaping” get complicated. 

Back on April 27, 2016, the Centers for Medicare & Medicaid Services (CMS) released a notice of proposed rules for the Medicare Access and CHIP Re-Authorization Act (MACRA). To recap: MACRA focuses on three areas that create the Quality Payment Program (QPP) which, in essence: 

  • Ends the Sustainable Growth Rate (SGR) formula for determining Medicare payments for health care providers’ services.
  • Creates a new framework for rewarding health care providers for giving better care, not just more care.
  • Combines existing quality reporting programs into one new system.

While CMS accepted comments until June 27, 2016, it remains to be seen if any “rural comments” will show impact for consideration and ultimately be adapted or included as new and final changes for the proposed rule. The proposed changes are to focus on replacing the fragmented Medicare quality reporting programs with a system that allows to pathways linking quality to payments: The MIPS Merit-Based Incentive Payment System and the Advanced Alternative Payment Models (APMS). Rural Health Clinics (RHC) and Federally Qualified Health Centers (FQHC) are exempted from both offerings.

In taking a rapid pulse to see if many rural entities submitted response(s), it seems that many found the MACRA proposed ruling highly complex and enormously difficult to break down and respond.

While CMS reads every letter, if facilities did not understand how, why, or if the regulations would impact their respective facilities, they most likely didn’t respond, sending mixed signals to CMS and any possible next steps. If rural didn’t respond, it might be due to the following:

  1. The multiple pieces of the proposed rules were just too dense to even know where to begin in developing a response;

  2. There were so many moving pieces and more questions than answers that it was difficult to readily understand the potential impact, causing more confusion and angst;

  3. They are waiting for better clarity and that after the deadline for public comment, CMS would incrementally break information down the information into an easier-read version of next steps.

Let’s take a closer look at some of the complex moving pieces. 

Rural PC/Small Practices Penalized, Creating More Vulnerability:

Let’s begin with the Medicare Program, Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models. This proposed rule and structure of the Merit Based Incentive Payment System Resource Utilization domain causes great angst in several key areas:

  • It jeopardizes rural and safety net providers who as small medical practices have “data challenges” and reduced capabilities including numbers and experience with data collection, analytics, and quality reporting.
  • Due to the aforementioned definition or classification, smaller practices have unavoidable higher cost structures; fewer resources and support mechanisms; smaller patient panel sizes; and fewer options for infrastructure improvements.
  • Programmatically, many smaller practices don’t have the capacity building/bandwidth, and/or the access or implementation capabilities of many basic “population health”-based programs focusing on wellness and prevention, let alone unique individual models of care or even care coordination, patient health management, and/or electronic health records like the larger practices, so they are already at great disadvantages in this program.
  • There is a total lack of performance comparisons of “apples to apples,” or rather “peer to peer” in practice sizes, so the program widens the gap of attaining true results. Actuarial estimates predict that MIPS will penalize 69.9 percent of practices with 2 to 9 eligible clinicians, 59.4 percent of practices with 10 to 24 eligible clinicians, and 87 percent of solo practitioners (Table 64/P-28376).
  • The combination of Programs, Volume, Data and Scoring work against rural as larger physician practices who participate in Medicare Advantage Programs have larger pools of Medicare beneficiaries and can focus on comprehensive diagnosis coding, wellness visits, and care coordination plans to diagnosis and treat individual patient chronic disease management.

Top 10: Opportunities and improvements for “rural equity” that CMS can champion:

  1. If CMS can dedicate even more focus and initiatives to closing the gap between rural and urban physicians via support programs and technical support, that would add greater ability for rural providers to participate in programs.

  2. If CMS can develop a realistic peer-to-peer group size where rural physicians can be compared with statistical analysis and criteria, they would be able to perform more equally under MIPS. Development would create a more equitable playing field where small practices could avoid penalties based on small practice size and incentivize peer-to-peer appropriate group sizes to keep improving their practices and performance while still identifying those who are not advancing in their practices.

  3. CMS needs to take into consideration that there are multiple challenges within the rural healthcare delivery model, ranging from budgets to limited staff and staff resources including time, training, management, and areas of quality improvement activities/metrics and EHR navigation. Hence, the development of rural-relevant measuresappropriate for low volume and rural physicians addressing the rural reality of low patient volume challenges and high-risk patients while being in alignment with other programs that support creating more accessible/affordable care and healthier individuals/communities would advantageous to participation and program outcomes. Overall priority needs for success and sustainability include:
    1. The need to create a group of core measures specific to these primary care practices
    2. Allowing more sufficient time for rural data collection to be collected.

  4. More focus around “virtual delivery” inclusion that might help offset physicians experiencing low volumes.

  5. If CMS could close the current two-year gap of sharing performance result data and performance scores for quality improvement with physicians in a more expeditious manner, physicians could respond and provide better improvements in care and create a win-win throughout the entire system.

  6. Streamlining the ebb and flow burden of data collection to be more standardized so that it can be better utilized would also create better participation. And while nos. 5 and 6 respectively are tall orders for CMS, combined they would greatly reduce overall cost of patient care to Medicare while improving the care coordination for patients as well as quality and performance efficiencies. Now imagine what success would look like for rural healthcare or healthcare delivery across the board if this could be achieved. 

  7. To avoid unintended consequences that would perpetuate and advance destabilization of the rural delivery system and threaten access to care, CMS should apply normalization/calculations of rural costs to PPS rates/adjust costs for swing-bed and RCH visits. If it does not, it will penalize low-volume physicians, driving patients away from their respective PC physicians, forcing patients to seek care away from home and recover in a facility and/or receive additional services miles away from home or reach by family and friend support mechanisms. This threatens to decimate rural care opportunities for local care. Research continues to prove that once a patient leaves town for care, they generally never return to care in their backyard. 

  8. CMS needs more rural interfacing to understand that the life and lifestyle of rural living often creates a higher cost of providing necessary care even though this care is still classified as low-volume services. Hence, rural physicians should be rewarded and incentivized for providing the best value of care, not penalized for the continual amount of care. 

  9. In an example of more burden than the ROI, it would be advantageous for CMS to redefine “low-volume exemption” and criteria (where applicable) for FQHC and RHC. The way the proposed rule is currently written provides exception to MIPS for physicians that bill under the PFS for less than $10,000 and 100 patients over the course of a year, yet will not properly exclude providers working in the FQHC and RHC setting as was intended. This is where the time and effort necessary for FHCs and RHCs (in some settings) to obtain a good MIPS score would far outweigh the rewards of a positive MIPS adjustment based on the small portion of FQHC and RHC revenue.

  10. The elimination of confusion and program disparities within Method II of CAHs for MIPS reporting and how it relates to (Medicare Part A and Part B) billing, including how reimbursements and data are being applied as well as eligibility are assessed/counted (going back to how beneficiaries who are less acute and low cost to the Medicare program excluded in QPP attribution and those who are high-cost beneficiaries (those who needed inpatient and post-acute care settings)). Perhaps if CMS included all ambulatory physician services delivered in Method II CAHs in the PQRS attribution and applied an appropriate methodology to match outpatient claims with certain revenue codes utilizing applicable CPT codes, this would create better equity within the program? Again, this is where the areas of gray can be grey.

APM Model Creates Greater Pinch for Rural Safety Net:

As for the Advanced APM, CMS seems to have provided little clarity and very little wiggle room for participation as it relates to many rural physicians/practices, RHC, and CAHs. It currently appears that APM participation isn’t possible for rural physicians or RHC and CAH structures (including PCMHM) that operate with very thin margins, who don’t have the luxury or bare-minimum capability to absorb, operate, or endure even temporary payment reductions without there being a high risk in cutbacks or elimination of services or operational or staff cuts.

Rural Risks of Participation:

Because the aforementioned affects so many providers across Rural America, it would be helpful if CMS would reassess the costs (requiring down-side risks) associated with participating in the APM, including care coordination, training, new hires, and costs associated with additional IT, and eliminate the requirement for rural providers to take risk. Even the offering of a nominal risk of APM participation is out of reach for many rural providers where the requirements of nominal risk exceed the profit margins of the rural practice and jeopardize their very existence.

As it relates to ACOs, there is blurriness and lack of alignment of ACO and APM models to be more compatible in participation and criteria. High costs of participation jeopardize the opportunities for existence for both programs.

On a final note, rural providers that don’t bill under the Physician Fee Schedule (think RHC) need to have access to the 5 percent APM participation bonus, otherwise they won’t be able to offset the APM participation costs.

All in all, CMS needs to remember that there are a plethora of reasons rural is called “the safety-net,” and needs to cast a broad net of assistance and evaluation of metrics/assessments and qualifiers to preserve it. Without such measures there is too much cost burden for rural to absorb to participate or sustain itself.

In an example of “let us help you help us,” CMS should engage leadership stakeholders like the (NRHA) National Rural Health Association and (ORHP) Office of Rural Health Policy for direct recommendations for policy, payment, and delivery reforms, strategies, and initiatives to make sure rural is adequately represented and positioned for a healthy future. Rural has proven itself time and time again to be able to deliver high value and high quality of care, but the future has arrived and it is fragile.

The seeds have been planted for more than70 million rural residents.  Let’s hope a high yield is created in a complicated market.

After all, the amber waves of grain of rural communities and providers are depending on it.

About the Author

Janelle Ali-Dinar, PhD is a rural healthcare expert and advocate with more than 15 years of healthcare executive experience in many key areas addressing critical access hospitals (CAHs), rural health clinics (RHCs), physicians and patients. Dr. Ali-Dinar is a sought-after speaker on Capitol Hill. A former hospital CEO and regional rural strategy executive, Janelle is a past National Rural Health Association Rural Fellow, Rural Congress member Nebraska Rural Health Association President. She is currently the Nebraska DHHS Chair of The Office of Minority Health Statewide Council addressing needs of rural, public, minority, tribal and refugee health and is serves on the Regional Health Equity Region VII council as co-chair of Rural Health and Partnerships. Janelle holds a masters and doctorate in communications and recent graduate in public health leadership. Janelle is currently the vice president of rural health for MyGenetx.

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