AACU on MACRA: Delay rollout, adjust low-volume threshold

Based on a partnership with Urology Times, articles from the American Association of Clinical Urologists (AACU) provide updates on legislative processes and issues affecting urologists. We welcome your comments and suggestions. Contact the AACU government affairs office at 847-517-1050 or info@aacuweb.org for more information.

The American Association of Clinical Urologists (AACU) submitted comments on the post-SGR Medicare reimbursement program, MACRA, on June 27, 2016. In its comments to the Centers for Medicare & Medicaid Services (CMS), the AACU expressed concern over a number of provisions that stand to negatively affect urologists in their practice of medicine and increase the cost of medical care.

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The AACU strongly opposed the program's aggressive implementation schedule. As currently envisioned, CMS will measure providers' performance beginning Jan. 1, 2017. This timeline does not allow ample time for physicians and other stakeholders to adequately prepare for the changes brought on by these new policies. While the flexibility of choice between alternative payment models (APM) and the Merit-Based Incentive Payment System (MIPS) is a positive change, this choice is fraught with complexity.

The administrative burden associated with the new requirements is prohibitive on many levels, including financial and human resource costs. The hurried pace will no doubt lead to unintentional mistakes, as well as expensive and onerous appeals.

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To add further burden to MACRA implementation, both the APM and MIPS programs require the use of electronic health record (EHR) technology by all providers beginning in 2018. While the intent of this requirement may be to enhance health care delivery, the AACU envisions the opposite effect. Under current, less stringent requirements, many providers and hospitals struggle with EHR adoption. Many physicians view EHRs as a barrier to treating patients and an ever-increasing overhead cost.

Next: "The complex issue of EHR liability is also left unaddressed in the proposed rule"

The complex issue of EHR liability is also left unaddressed in the proposed rule, and when directly questioned on this subject at the American Medical Association annual meeting in June, Acting Administrator Andy Slavitt had no answer to a number of serious questions. For example, who is responsible for compliance issues arising out of EHR system malfunctions-the vendor or the physician? Who is responsible for data breaches-the vendor or the physician? The fact that this issue has not been considered is no doubt worrying.

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Of similar great concern is the proposed rule's administrative compliance burden, particularly for small and rural practices. Although the proposal attempts to mitigate the negative effect on this subset by including a "low-volume" exemption, the threshold is insufficient and many practices or groups will be forced out of business. In addition, the low-volume threshold is based on the level of Medicare billings from providers, not the actual size of the practice.

Despite Slavitt’s statements that the goal for CMS in implementing MACRA is to “simplify wherever, whenever,” there is a logical contradiction when considering the proposed rule is 962 pages. For perspective, the original Title 18 amendment to the Social Security Act establishing Medicare was 18 pages. The AACU's comments include a pointed reference to the original law's promise not to interfere in the practice of medicine:

"Nothing in this title shall be construed to authorize any federal officer or employee to exercise any supervision or control over the practice of medicine, or the manner in which medical services are provided, or over the selection, tenure, or compensation of any officer, or employee, or any institution, agency or person providing health care services...."

The proposed rule's imposition of “practice guidelines” and “value standards” on medical providers stands in direct contradiction to this promise. Both MIPS and APMs strongly influence the care that providers give to their patients by introducing enumerable bureaucratic and financial obligations.

Next: AACU recommendations to improve MACRA

AACU recommendations to improve MACRA

• Postpone the performance period for at least one year, enabling physicians and their staff to gain an understanding of the many complexities involved in this new system.

• Provide incentives to encourage transition to EHR technology, as opposed to penalties for those who are unwilling or unable to make the transition. In addition, strengthen protections for physicians with regard to liability issues that will arise from EHR use.

• Raise the low-volume threshold for Medicare billing, or associate the threshold with actual practice size so that exemptions are appropriately applied and small/rural offices and hospitals are not burdened to the point of closure over this new policy.

• Reinstate the opt-out option for providers who would rather pay a penalty than assume the financial and human resource burden associated with the volume of reporting requirements.

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