MACRA’s virtual groups unveiled

Discussed since the initial rollout of the Medicare Access and CHIP Reauthorization Act (MACRA), “virtual groups” were seen as a key mechanism for small practices to assist with the burden of reporting Medicare performance metrics.

The groups were established in the initial MACRA rule in the fall of 2016, but not further defined until just recently with the release of the proposed rule for participation in 2018.

But even as the Centers for Medicare & Medicaid Services (CMS) has provided clarity on how the groups will operate, their immediate future appears a bit murky. And healthcare experts are divided on their effectiveness.

Kelly Kenny, JD, chief executive officer for the nonprofit Physicians Advocacy Institute, told Medical Economics the concept of virtual groups has potential to provide greater flexibility and opportunities for solo and small practices, regardless of location and specialty.

Related: Top 8 things doctors need to know about 2018 MACRA proposed rule

“The virtual groups option allows solo physicians and small practices to participate in [the Quality Payment Program] while maintaining their independence, providing an opportunity to achieve meaningful cost savings and quality improvements, while also adding the potential for additional funding opportunities for these practices and physician,” Kenny said.

However, not everyone is as optimistic. David J. Zetter, PHR, SHRM-CP, founder and lead consultant for Zetter Healthcare Management Consultants in Mechanicsburg, Pennsylvania, said he simply does not see the benefits of practices essentially “getting into bed together” to determine how they are paid and rated.

“I have clients all over the country and have not had one client interested or mention forming a virtual group at this point,” he told Medical Economics.

Virtual groups: What are they?

To participate in one of MACRA’s two tracks-the Merit-based Incentive Payment System (MIPS)-solo physicians and those in small practices can report their metrics via virtual groups, to report across all performance categories: quality, clinical improvement activities, cost and advancing care information.

The goal is to give these physicians a means to partner to meet the burdens of reporting the required performance metrics by working with peers in a similar situation.

In the 2018 proposed rule for MACRA, CMS defines virtual groups as solo practitioners and groups of 10 or fewer MIPS-eligible physicians who join up with at least one other solo doctor or group to participate for one performance year.

In a fact sheet issued with the proposed rule, CMS noted its goal was to, “make it as easy as possible for virtual groups to form no matter where the group members are located or what their medical specialties are.” But it made clear that these groups would be required to meet the same measure and performance category requirements as non-virtual groups.

How do doctors report data?

Virtual groups: How do physicians report data?

CMS notes that virtual groups can submit their MIPS scores through their electronic health record (EHR) systems, through a registry or the agency’s web interface. The virtual groups report to CMS under one taxpayer identification number (TIN).

As Medical Economics noted earlier this year, however, the EHR route, has its own issue. Part of the reason solo practitioners may go the virtual group route is due to IT infrastructure issues. But, since all the virtual group members need to aggregate their data, unless they all have the same EHR system, a highly unlikely coincidence, there could be issues in getting data organized and submitted.

CMS notes it will provide technical assistance for virtual groups in terms infrastructure and in 2019, will provide an electronic process to form groups, “if technically feasible.”

Virtual groups: How do physicians join?

To participate in a virtual group, CMS defined an “election process” in the 2018 proposed rule (starting on page 73). While virtual groups can include physicians who aren’t MIPS-eligible due to several exemptions (like falling under the low-volume threshold), at least one member of the virtual group must be fully MIPS-eligible.

If physicians want to elect to be in a virtual group, they must do so via written notice to the federal agency by December 1 of the calendar year preceding the performance period. Simply put, physicians need to send their letter in by December 1, 2017, if they want to be in a virtual group for the 2018 performance period. Given that the final 2018 rule won’t be published by CMS until this fall, that doesn’t leave a lot of time for physicians to prepare for finding virtual group partners and joining a group.

CMS did note in its proposed rule that to address this, they will allow virtual groups the ability to make their elections known prior to the final rule’s publication.

To officially be a virtual group, participants must have a formal written agreement between each member prior to notifying CMS. The virtual group must also have a designated representative to submit the December 1 letter, identifying members and contact information for each participant. Furthermore, if anything changes in the virtual group, the representative must notify their designated CMS contact.

CMS further states that an individual MIPS-eligible physician or group can only be in one virtual group per performance period.

Zetter finds several flaws with this process, from locating and trusting physicians who may be across the country to feeling comfortable enough to then create a legal entity to determine compensation.

Next: Can virtual groups really work?

“I just do not see that many solo physicians, operating under a TIN, and small groups having the time to discuss this and getting to know each other to organize this and then choosing an individual to spearhead this for them,” he said.

Another uncertainty in the proposed rule is whether physicians are essentially stuck in their virtual group for an entire performance period. While that may be one of the “changes” in the group that requires CMS notification, the proposed rule isn’t clear on the ability or consequences of leaving a virtual group. The rule notes that fluctuations will occur in virtual groups (such as a practice closing) but appears to keep the physician in that group for reporting purposes for the entire reporting period.

“If you get in, and then six months in you want to get out, I don’t think you can get out. And that’s a concern,” said Cindy Dunn, RN, FACMPE, director of client services for healthcare software provider IntrinsiQ Specialty Solutions in Titusville, Florida. “No offense to physicians, but they like individual reporting because they don’t trust their colleagues. I think for a virtual group, I just think it’s going to be difficult. I understand the concept, but you have to be able to get out if you want to get out.”

Some of this may get ironed out following the public comment period, which ends August 18.

Virtual Groups: Can they work?

One week prior to releasing the 2018 MACRA proposed rule, CMS issued a report on virtual groups, assuming low participation next year, due to many of the factors noted above.

The agency estimates that only 16 virtual groups would participate, made up of 765 MIPS-eligible physicians across the nation. That’s 0.1% of all eligible Medicare physicians nationwide.

“We assume that virtual group participation will be relatively low in the first year because we have heard from stakeholders that they need at least three to six months to form groups and establish agreements before signing up,” the document noted. “We are not able to give them that much time in the first year, rather closer to 60 days or potentially less.”

CMS estimates that those 765 physicians would be ones who participated in MIPS this year, hence familiar enough with the structure and requirements to find potential partners.

The report also estimates the financial burden for virtual groups, at an annual total of $832 per group, including cost to prepare the formal written agreement and to undergo analysis of the group post-election to verify eligibility.

“Given that only solo practitioners and groups of 10 or fewer may combine with another group to form a virtual group, I am not sure why a few solo practitioners, that aren’t of the same specialty would want to form a virtual group,” Zetter said. “Even if they were the same specialty, why would they form a virtual group if they didn’t want to be part of the group in a legal way?