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MACRA implementation emphasizes specialty collaboration


In this exclusive interview, Andy Slavitt, acting administrator for the Centers for Medicare & Medicaid Services, discusses alternative payment models, outlines what resources are available for practices, and provides an overview of the three options practices have for participation in the Quality Payment Program.


Many have argued that CMS is attempting to drive the consolidation of smaller hospitals and practices into larger, integrated, delivery systems with the thought that they can provide more cost-effective care. Do you believe this is the case?

No. In fact, we have been fairly outspoken about concerns regarding hospital-based physician acquisitions. Small practices are the backbone of American health care and CMS is actively working to support them. A major focus in our implementation of MACRA is on the impact to small and rural practices to make sure we have a level playing field. This has been an important part of many of our conversations as we traveled the country. We know from experience that small practices can be successful in earning quality bonuses if the bar to participating isn’t too administratively burdensome.


There is significant concern that MACRA puts small specialty practices at a disadvantage when compared with larger ones. What, if anything, is being done to level the playing field?

This is a valid concern, so we are working directly with physician user groups representing small specialty practices to listen to how we can design additional ways to make participating in the program easier, no matter if the small practice chooses to be in the Merit-Based Incentive Payment System (MIPS) or in an Advanced Alternative Payment Model (APM). We know smaller practices can provide the same high-quality care as larger ones and can be just as successful at MACRA.

Based on the feedback we received, we made a number of adjustments to the final policy to help level the playing field by:

  • reducing the time and cost to participate

  • raising the threshold to exclude more small practices (the new policy will exempt an estimated 380,000 clinicians)

  • increasing the number of Advanced APMs available to small practices, including the new ACO Track 1+ and CPC+, both of which will provide opportunities for small practices to join

  • allowing practices to begin participation at their own pace

  • conducting significant technical support and outreach to small practices using $20 million a year over the next 5 years.

Next: What is CMS doing to make APMs more accessible for urologists and specialists in general?


The MACRA incentive structure suggests that CMS is encouraging specialists to enter the APM track; however, it’s expected that most providers will opt for the MIPS track, at least initially. What is CMS doing to make APMs more accessible for urologists and specialists in general?

To take a step back on APMs, I think it’s helpful to define what we mean when we use that acronym. It’s an overarching term to describe payment models that are locally formed, clinically based, and physician led. They generally apply to either a specialty, a care episode, or a population.

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For specialties, we have models like the Comprehensive End Stage Renal Disease Care Model for nephrologists and the Oncology Care Model for oncologists. We have also developed a number of models for surgeons, and I could see this approach applying to urology. To create these additional specialty-focused models, the law established a physician-led board called the Physician-focused Payment Model Technical Advisory Committee that is accepting suggestions on the creation of new models. We expect to be continually adding payment models, especially those focused toward specialties. And we are designing on-ramps and off-ramps so physicians can join these new models as they become available.

In the final policy, we changed the qualification for participation in Advanced APMs to be practice-based instead of total cost-based, so that should help more specialists access Advanced APMs.


The current list of Clinical Practice Improvement Activities (CPIA) outlined in the proposed rule is tailored primarily to primary care physicians. What plans does CMS have to provide more CPIA options for urologists?

First, MIPS should support physicians in delivering high-quality patient care. This objective is achieved by connecting physicians to specialty-specific quality measures, which are typically developed and endorsed by specialty societies or associations. For example, the AUA engaged in the development of urology quality measures for MIPS that include measures relating to prostate cancer and urinary incontinence. As physicians use quality measures more, clinical communities will be able to establish and quantify a baseline of care, and then develop goals on how to improve care. MIPS will help that progress by providing useful feedback to physicians, creating a continuous cycle of improvement.

The practice-generated improvement activities, referred to in the law as Clinical Practice Improvement Activities, are not necessarily specialty specific, but rather are focused on how you’ve designed your practice to respond to your patients’ unique needs. For example, there are improvement activities for those practices who provide care to underserved, vulnerable, or at-risk populations or improvement activities for those practices that are available to their patients through expanded hours, telehealth, or home visits. These practice-specific activities will continue to be developed and we’re actively seeking input on other improvement activities we should include.


It all seems a bit like “alphabet soup.” What resources is CMS developing to assist urologists, and other specialists, in navigating the complex choices involved in MACRA participation?

That question makes me smile because health care invents things and shrouds them in acronyms at the same time. That is why our aim for implementing the law has to be to simplify wherever possible and to give urologists and other physicians the ability to tailor the program to fit their unique circumstances.

In order to help clinicians understand and get started with the program quickly, we’ve launched a new website and measures tool. The new website is QualityPaymentProgram.cms.gov.

Read: MedPAC talks cost cutting as IPAB looms

On the site, you can quickly learn the basics of program, and then dive into the specialty-specific measures we have available. In the “Explore Measures” section of the site, you can select “urology” and see the measures that have been approved by the AUA as being applicable to urologists. The site will continue to evolve to help clinicians understand and participate in the program successfully. This is in addition to webinars, fact sheets, and on-the-ground help, both from CMS and local specialty societies and associations.

Next: What can an individual urologist specifically do to optimize his or her reimbursement under MACRA?


In a nutshell, what can an individual urologist specifically do to optimize his or her reimbursement under MACRA?

The short answer is just to focus on providing high-quality patient care. The Medicare program will get better and better at supporting that goal. As a practical matter, the important thing about MACRA is that it was designed to phase in, so that it gives doctors, including urologists, time to learn the program. We’ve built on that by allowing physicians to pick their own pace of participation in the first year. The first year is about getting your feet wet and preparing for the future-as long as you submit a very minimal amount of information, then you will avoid a negative payment adjustment. This option helps physicians test their systems and prepare for broader participation in 2018 and 2019.

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However, some physicians are ready to go beyond the “test” option. This program streamlines and improves programs like the Physician Quality Reporting System (PQRS). MIPS uses the same quality measures, but reduces what you need to submit compared to PQRS. If you’ve used PQRS in the past, then you should be able to easily participate fully and receive a positive payment adjustment of upwards to 4%.

If you’re ready to be a part of an Advanced APM, like Medicare Shared Savings Track 2 or 3, then you could earn the highest bonus in the program-a 5% bump to your fee schedule payments, plus whatever shared savings you receive from the Advanced APM.


At a U.S. Senate hearing in early July, you suggested a postponement wasn’t out of the question. Can you please give us your best estimate for the timetable on MACRA rollout?

A: We knew that in order for MACRA and the Quality Payment Program to begin with a strong start, we needed to meet physicians where they were in terms of readiness. That is why we recently announced our intention to allow physicians to pick their pace in 2017, the first year of the program. We’ve announced three choices:

  • Test: We are designing the test option so that as long as physicians submit one quality measure or one improvement activity for 2017, then they would be able to avoid a negative payment adjustment. We expect that all physicians should be able to meet this minimal standard. We are designing this option to help physicians test their systems and prepare for broader participation in 2018 and 2019.

  • Partial: Physicians could choose to participate for part of the calendar year. This means they could begin as late as Oct. 2, 2017 and their practice could still qualify for a positive payment adjustment.

  • Full: Physicians in practices ready to go on Jan. 1, 2017 could choose to participate for the full calendar year and qualify for a positive payment adjustment. We’ve seen physician practices of all sizes successfully submit a full year’s quality data, and expect many will be ready to do so.

Of course, physicians can also choose to join an Advanced APM in 2017 and could qualify for a 5% incentive payment.

More from Urology Times:

Look for MOC changes in 2017, American Board of Urology says

Update: States limit the role of specialty certification

MOC: Members of the UT editorial board weigh in

Acknowledgements: Dr. Stork acknowledges the assistance of urologists J. Stuart Wolf, Jr., MD, and Brent K. Hollenbeck, MD, as well as Wendy Isett of the AUA in preparing the questions for this interview. He also thanks Aisling McDonough of CMS for coordinating the interview.

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