It’s here: the final rule for CMS’ Quality Payment Program (QPP/MACRA) has been released! You dug through 900+ pages, added new acronyms to your vocabulary, submitted comments, and, at the end of a long campaign, have another 2400+ pages to wrap your head around this weekend. We here at the Center for Consumer Engagement in Health Innovation are no different.

Overall, we are excited about the move that CMS is making toward value-based payment. CMS has been working to move the health care system away from one that is based solely on fee-for-service and toward a system that focuses on better coordination and quality of care. We are supportive of these efforts because of their potential to improve care for consumers.

At the same time, we think it’s important that consumers be the North Star for the kind of reform that is envisioned by MACRA. Thus, when we entered this process, we had four burning items we were looking for on behalf of consumers. As we begin digging into the final rule, here is our preliminary judgment on how well the rule addressed these core concerns:

QUESTION:  Is enough being done to prepare consumers for system change?

VERDICT: NO

This rule will have sweeping and lasting changes on this nation’s health care system and will have significant impacts on the care consumers receive. Consumer outreach and engagement will be necessary for ensuring that the implementation of new models remains patient centered, educating consumers about what these changes mean for how their care is delivered and effectively empowering patients to engage in their own health care decisions. Unfortunately, the final rule does not seem to strengthen consumer engagement requirements beyond what was in the previous proposal. For example, all but one of the beneficiary-engagement improvement activities are given only medium weighting, and CMS is now requiring practices to complete even fewer improvement activities. Additionally, CMS bypassed opportunities that would have ensured robust patient engagement in advanced alternative payment models, such as strengthening requirements for medical homes.

QUESTION: Are there protections in place for consumers as providers take on financial risk for the cost of care?

VERDICT: INCONCLUSIVE

The Quality Payment Program incentivizes providers to take on greater financial risk for their patient populations. The hope is that this will lead to better care at lowers costs, but it also comes with the possibility that provider losses could lead to disruptions in care for patients. That’s why it’s so important that the final rule include provisions meant to protect consumers in these new payment models. As we continue to analyze the final rule we will be keeping an eye out for consumer protections such as the right to know what risk arrangements a provider is taking on, freedom for consumers to choose their provider, access to all covered services, easy-to-navigate appeals and grievances systems, and easy-to-read accessible program materials for beneficiaries including those with disabilities, speech and vision limitations, and limited English proficiency.

QUESTION: Will consumers get to define “quality” in this program?

VERDICT: NOT ENOUGH

A major goal of the QPP is to move toward a more integrated, person-centered system of care. To meet that goal, quality measures should reflect the experiences, goals, preferences and needs of consumers, in particular low-income older adults and other vulnerable Medicare enrollees. Unfortunately, of the 271 quality measurements to choose from, on our first look we only spotted about 15 that are patient reported. We are concerned about the lack of patient-reported measures because it sidelines one of the most important - if not the most important - voice in the room. If the quality of care within our health system is to improve, people must have a more important say in how quality is defined.

QUESTION: Will this new program improve or worsen health disparities in the United States?

VERDICT: TBD

The final rule represents a major opportunity to transform the health system in a way that better addresses the persistent health disparities that exist for marginalized and underserved populations. It’s not clear that CMS fully capitalized on this opportunity. For example, the list of clinical practice improvement activities was not expanded to promote cultural competency or implicit bias training. CMS does promise to release best practices for collecting data stratified by demographic characteristics and notes that in future rulemaking they will consider additional strategies for addressing health equity, for example finding ways to incentivize providers who reduce disparities and identifying appropriate measures of health equity. As CMS moves forward with implementing the QPP, we will need to advocate that health equity remains a priority and that payment methodologies do not unfairly penalize practices who are caring for socially and economically disadvantaged patients.

We appreciate that CMS has made changes to make it easier for providers to participate. However, the final rule illustrates the ever-present need for state and federal consumer advocates to continue to elevate the importance of consumer engagement in order to drive reform that will be truly transformative for consumers.