MACRA Compliance Overview: Why Participate?

If, like us, you’ve been in the business of MACRA compliance for the last seven or eight years, you know that it used to be called “PQRS.” You may also frequently hear repeated negative feedback and perspective, which deserves some comment on our side.

We see both sides of it.

Look, we’re on monthly phone calls with CMS, and we recognize the difficulty that they have. But we also sell a product that helps make this often murky and cumbersome process easier for our customers. So we live in the middle of these two different worlds, and we hear a lot of negative feedback primarily from practicing anesthesia providers. I feel like that makes for a good opportunity to just spend four or five minutes and talk about what the MACRA program is — not the technicalities of it, but perhaps a better way of framing it.

When people are negative toward the whole MACRA process, we hear things like,

  • “This is a government conspiracy,”
  • “The bureaucrats don’t know anything”
  • “Nobody understands how good I am or the job that I actually do.”
  • “This is all a ploy just to reduce our payments and limit the budget.”

Let me just slide in that the last bullet there couldn’t be further from the truth, because it’s a budget-neutral program. It’s just a redistribution of the income from the poor performers to the high performers. And, in fact, CMS is throwing in an extra 500 million per year. So if anything, it’s a bonus. It’s extra money that CMS is putting on the table to do this.

I want to try to offer some alternative frameworks to look at it so that it’s not such a negative, visceral response when you hear the word MACRA. The truth is, most can just opt out of it and say, “No, I’m not gonna qualify and I don’t wanna participate.” But I would tell you: that’s the wrong approach. Perhaps the following alternative approaches will frame it in a more helpful, proactive light.

First, I’d say this: the public wants quality. And the problem is they don’t know what that looks like, so they turn to the government and they say, “Well, we’re only gonna pay for quality healthcare, and we want to know — of all of these healthcare providers, who’s provides a higher quality of care than the others?” It creates a really interesting issue, because you can’t say that quality doesn’t matter.

You also can’t say that everybody is “high quality,” or you immediately lose any meaning behind excellence. If we’re all the same, then you just destroyed what the word excellent even means. Instead, now everyone’s average, which is not necessarily bad, except that people are demanding quality. Once you accept that that’s what the public wants, then you recognize that whatever “quality” is, it needs to have certain qualifiers. It has to be measurable. It has to be objective. You can’t just have an opinion survey of, “How well did you think you did today?” That wouldn’t go anywhere. And perhaps the most confusing part of the whole MACRA program is that it has to be different among providers.

It gets back to this definition of excellence. If you just say, “Well, I want to measure on-time antibiotics,” or, “I want to measure just the patients’ temperatures in the recovery room,” or, “I want to measure how often you did handoff protocol use,” that’s fine. The problem with that is everyone’s doing it. So if you’re trying to define quality and there’s this essence of who’s exceptional or who’s excellent, or how does a given measure’s outcome distribute across a group of providers, then you recognize it can’t be easy for everybody. It has to be something that will distribute, and not everyone can be perfect.

Every year, the CMS reaches out to special society groups like the ASA, and they also reach out to individual providers, so it’s open to anyone who wants to recommend a new measure. And every year (the bane of our existence), these rules get re-certified. New measures come up and then old measures that everyone did super well on get retired. MACRA then becomes a constantly evolving process, and I will tell you that it is very difficult to define good measures.

Once you’ve accepted that you need a quality program — either because the public wants it or the hospital certification bodies (e.g. the Joint Commission) want it, or maybe just your hospital wants it — then the next essential step is to recognize that you want your quality program to be meaningful. And why not use this program where the CMS is going to subsidize your costs? It’s going to cost money to develop and establish your quality program. You’ll need to collect more data, you’re going to have to analyze that data, you’ll have to report on those analyses, and that’s all going to take time. Furthermore, if you don’t want to use software and you just want to use an Excel spreadsheet or a sheet of paper, then it’s going to take a ton of someone’s time. Otherwise, if you want to adopt an electronic solution, that’s going to come at its own cost, too.

Thankfully, CMS is giving bonuses for folks that are exceptional performers. And in the world of anesthesia, it turns out that we all can become exceptional performers. We see it year in, year out — people do exceptionally well on their composite performance scores, and those bonuses go up every year. This year it’s somewhere around 5%-6%, which represents the realistic bonus that we should see. That should more than offset the costs of any data collection for a quality program.

So number one: the public wants quality. Number two: once I recognize I need a quality program, I might as well turn to CMS and let them pay for it. Maybe I can make some extra money on it as an extra ROI. But you should very easily break even for it, so why go off the reservation and develop your own unique quality program rather than not jump in line and follow the MACRA program?

Probably the biggest reason people actively seek out our solutions is because they’ve recognized that their competition is already doing it. So even if you want to disregard the public demand for quality and the fact that the CMS is gonna help pay for it, there still remains a competitive need.

Certainly the large national anesthesia groups are all collecting quality data. They all have infrastructure in place for regular, comparative reporting each month or each quarter across all of the members of their group. And the hospitals respond to that in a positive way. When they see that your culture is actually one of safety and that’s backed up by infrastructure, policies and processes in place to measure these things, it’s a head-turner, which we’ve seen time and time again. If you wanna protect and grow your existing market share, you need to be able to lead with, “This is how we handle quality. This is how we can help report and add transparency to you all at the hospital level.” That is a differentiator. Your value cannot be exhibited in simply, “We wake up all of our patients and everybody likes our service and our surgeons like us.” No doubt, all of that helps. But this is such an easy, realistic way to differentiate you from your competition in the marketplace.

In conclusion, MACRA is here to stay. It’s time to move on from the, “The government is ridiculous,” and all these political perspectives or framings of the issue, simply, aren’t constructive and are going to leave you stagnant at a time when everyone else in the marketplace is moving in a forward direction. Soon, you will be isolated and on your own and simply not have the infrastructure in place to report on very simple things like these different MACRA quality measures. Instead, you should take this opportunity to meet the public demand for quality, let CMS fund your entire quality program, and begin to stand out from your competition by delivering well-recognized quality metrics and reports.