The 2018 MACRA proposed rule published in June 2017 was supposed to clarify the concept of "virtual group" reporting, introduced in the initial legislation in 2015. But policy analysts and consultants say there are still too many unanswered questions and compressed timelines for many physicians to feel comfortable participating next year.
The original idea was that solo practitioners and groups of 10 or fewer eligible clinicians would come together "virtually" to participate in the Quality Payment Program's Merit-based Incentive Payment System (MIPS) pathway. Physicians in smaller practices who may not have enough patients to get statistically valid quality measurement results would join together to get statistically valid results on more measures.
Even though the final rule for next year's reporting will not be published until October at the earliest, participants in virtual groups would have to decide by Dec. 1, 2017. Perhaps that is why CMS estimated that nationwide only 16 virtual groups made up of 765 MIPS-eligible physicians would participate in 2018.
Amy Mullins, medical director for quality improvement for the American Academy of Family Physicians, said CMS sent physicians mixed signals with the proposed rule. "When you update the rule in one place, it affects things down the line," she said. For 2018, CMS is proposing to raise the low-volume threshold for MIPS participation from $30,000 in in allowable Medicare Part B charges or 100 unique beneficiaries to $90,000 or 200 beneficiaries. If you are below that number, you can't participate in a virtual group. "It seems counter-intuitive," Mullins said. "Virtual groups are supposed to help small practices participate in MIPS, but if you are too small, you can't participate in a virtual group."
She said AAFP has some members who are happy that the low-volume threshold is being increased, but others who want to participate because they see the potential for a positive payment adjustment. "If they are not participating in MIPS, they are getting a zero percent adjustment, and inflation is not staying at zero percent," Mullins said. "If they want to participate and they are small, they can't. It seems counter to what the legislative intent was, in my opinion."
Anders Gilberg, senior vice president of government affairs for the Medical Group Management Association, said its members are finding it difficult enough to grasp all the complexities in the MIPS reporting system within their formal medical groups without considering the potential risks of co-mingling their quality reporting with other providers. "Who would oversee it? A consultant you have to pay? It would require an aggregation effort," he said. "There are still a lot of questions, and the small and solo practices are the least educated about MIPS, so it doesn't surprise me that they predict only 16 will participate in 2018."
"The only potential interest I have heard is from clinically integrated networks made up of small groups that have a large health system sponsor who could do this work for them," Gilberg added. But he said it is an untested concept and the return on investment is unclear. "I haven't seen any practical examples or models."
Tina Colangelo, a medical practice consultant in New York City specializing in value-based reimbursement, said initially she thought virtual groups were a good idea, but now is skeptical. "To me it looks risky," she said. "MACRA is risky to begin with, and on top of that, who is going to coordinate the different EHR systems?"
She said CMS has not incentivized small practices enough to want to join with somebody else. Practices are judged and assessed together, so they would have to do a lot of research on the past Meaningful Use and Physician Quality Reporting System scores of potential partners, she said. "If somebody called me up tomorrow and asked if I would help them set up a virtual group, I don't think I would do it."
But not everyone is critical. "We think virtual groups are a very important provision of the law," said Paul Cotton, director of federal affairs for the National Committee for Quality Assurance (NCQA). "The proposed rule laid out a process for people to make decisions on forming these virtual groups, and we think that's a good thing. We were encouraged to see them moving forward on this."
NCQA has suggested in its comments to CMS that providers should get MIPS bonus points for participating in virtual groups. "There is some effort in coming together to do this," Cotton said, "and bonus points would provide further encouragement for physicians to do so."
Cotton sees the virtual groups as a first step in moving physicians from being independent practitioners on their own to being part of a well-organized system. "We know that the more well-organized systems are much more capable of improving quality and getting waste and inefficiency out of the system."