What impact will MACRA have on your organization? We asked experts to tell us.
The Medicare Access and CHIP Reauthorization Act, known as MACRA, is one of the most significant payment changes since Medicare’s inception in 1965.
"Physicians and other clinicians payments will be at risk, beginning with a plus or minus swing of 4% in 2019, that increases to plus or minus 9% by 2023," says Chester A. Speed, JD, LLM, vice president, public policy, AMGA.
To be successful under MACRA, providers will have to consider the clinical, financial and cultural changes they need to make to do well under risk, according to Speed.
"And while providers can rightfully say they’ve seen this before in the 1990s, risk, or value-based payments are now written into law and they are here to stay," he says.
What impact will MACRA have on your organization? We asked experts to tell us.
1. MACRA will require physician groups to understand and implement an incredibly complex payment system. According to CMS, the intent of MACRA is to merge existing value-based payment methodologies into a new, “two-track system for physician payments based more on value and less on volume.”
"However, due to the many variables involved, meeting MACRA requirements is going to be difficult for many physicians," says Bing Pao, MD, director of provider relations for CEP America. He currently serves on the California Medical Association MACRA Task Force and the American College of Emergency Physicians (ACEP) APM Task Force and was the past chair of the Reimbursement Committee for the California Chapter of ACEP.
For example, Pao says, with the new Merit-Based Incentive Payment System (MIPS) there is a composite score based on specific reporting parameters and performance. In addition there are multiple categories and performance valuation weights, with changes over time.
"Initially, it will be confusing, to say the least," Pao says. “All this requires providers to: 1) fully understand the incredibly complex new rules; 2) successfully employ all measures outlined; and 3) perform, track and report based on MACRA measures."
Next: Education is essential
2. MACRA will require physician groups to spend a tremendous amount of resources to educate providers, gather/analyze data, and report measures.
"The proposed MACRA rules are more than 960 pages of incredibly complex and dense details, formulas and explanations. It will take a cadre of experts to simply explain the basics to most of us in healthcare today," Pao says. "There are also many unknowns. For example, our organization, [CEP America], partners with physicians to provide acute care in hospital, ER, urgent care and other practice settings. It has not yet been finalized how some of the MACRA rules will apply to hospital-based physicians, leading to additional uncertainties."
3. MACRA does offer the opportunity for physicians to design alternative payment models (APMs), but the requirements for qualifying for advanced APMs are challenging.
"One of the more rigorous requirements to qualify as an advanced APM is that a provider or group must meet certain revenue thresholds," Pao explains. "Eventually, providers must receive at least 75% of Medicare Part B payments through an advanced alternative payment model in order to qualify for bonus payments. When combined with a risk-sharing mandate, meeting the requirements for an advanced alternative payment model will be difficult for smaller provider groups and certain specialties. Larger physician groups will have more resources to work under MACRA, but even so, adapting is going to take considerable time, resources and brain trusts."
4. Providers are going to be under financial pressures when making daily decisions about what is best for their patients.
"MACRA leaves all reporting in the hands of the provider with the goal of improving cost control by linking reimbursement to outcomes," says David Reid, employee insurance veteran and founder and CEO, EaseCentral. "Medicare beneficiaries should be very concerned."
5. The MACRA options allow a provider to choose how they will be paid and the results will differ based on practices. "Care received by a patient will likely be different based on the method adopted by the provider. Once a provider chooses a reimbursement model, price patterns will follow to maximize results. How is that best for the consumer?," Reid asks.
6. It will be easier for large practice groups to manipulate reimbursement levels based on self-reported actions and outcomes so complex it will be difficult to determine if patient outcomes were top concern, according to Reid.
7. MACRA will try to improve the relevancy of Medicare’s value and allow clinician flexibility to choose measures and activities appropriate to the type of care they provide, according to Ann Kuenker, DO, who has a wellness and prevention practice in Traverse City, Michigan, and serves on the Ideal Protein Inaugural Medical Advisory Board.
Next: MACRA clinical measures
"Pending your type of practice and your personal passion in medicine for helping patients improve their lives, MACRA will allow you to choose from a number of clinical measures to satisfy these measures-i.e., weight loss," says Kuenker.
8. MACRA will allow clinicians to be paid for providing high-quality care through measured success in performance categories.
"Measuring success in the performance category of weight-BMI-is fairly concrete and easily measured; hopefully making a less cumbersome reporting measure for the physician," Kuenker says.
9. MACRA will shift the accountability model so that there is increased counseling, follow-up, and patient care.
"Accountability for their own health is ultimately the patient's responsibility," Kuenker says. "However, since physician payment will be tied to the patient's success, the comprehensive nature of a medically-sound weight-loss program makes it well suited for a successful outcome for both the practitioner and the patient."
10. MACRA puts Medicare Part B payments at risk beginning in 2019.
Each of the four performance categories will be used to calculate a Composite Performance Score (CPS). The CPS will then be used to determine an eligible clinician or group’s payment under MIPS, explains Speed. "Scoring accommodations will be made for small and rural providers and non-patient-facing providers," he says.
Physicians, either independently or in a group, will have their CPS measured against the annually established performance threshold, according to Speed. Scores below the threshold receive a negative payment adjustment, and scores above receive a positive payment adjustment.
"These adjustments are limited and apply to Medicare Part B payments," he says. "For 2019, clinicians will receive a between a positive or negative 4% adjustment. This adjustment increases to 5% in 2020, 7% in 2021, and 9% in 2022 and beyond."
MACRA requires that the overall payment adjustments be budget neutral, Speed says. "This budget neutrality adjustment, also referred to as the scaling factor, may be up to three times the base payment adjustment. Effectively, if in 2019 there are three times as many minus 4% scores as there are plus 4% scores, those providers that score plus 4% could potentially earn a total of plus 12%. This would keep the program budget neutral."
The three times scaling factor applies to the subsequent years, resulting in possible updates of positive 15% in 2020, positive 21% in 2021, and positive 27% in 2022. "This scaling factor is only applicable to positive updates. MIPS offers up to $500 million annually-within a top gain limit-to providers demonstrating superior performance," Speed says.
Next: Past performance
11. Past performance under the Physician Quality Reporting System, Meaningful Use and the Value Modifier programs will give providers an indication of how they may do under MACRA in 2019.
In 2019, the MIPS payment formula will consolidate three current programs: the Physician Quality Reporting System (PQRS), the Value-based Modifier (VM) program, and the Meaningful Use program.
"These programs will be replaced by new MIPS performance categories on Quality, Resource Use, and Advancing Care Information. CMS is adding a fourth component, Clinical Practice Improvement Activities (CPIA), which will measure areas such as care coordination, shared decision-making, safety checklists, and expanding practice access," Speed says.
Each performance category will be weighted, and those weights will change over time. Initially, CMS is proposing to weigh Quality at 50%, Advancing Care Information at 25%, Clinical Practice Improvement Activities at 15%, and Resource Use at 10%. Clinicians will receive a score for each category.
For the Quality performance category, providers will select six measures to report, down from the nine required under PQRS. Of the six, one must be an outcome measure and one must be a cross-cutting measure, which are broadly applicable across multiple clinical settings and eligible professionals or group practices within a variety of specialties, Speed explains.
"Clinicians will have the option to report individual measures or a specialty measure set. The proposed rule includes a list of proposed measures. There are more than 200 measures available and many are designed for specialists," he says.
According to Speed, the Resource Use category, which CMS also refers to as the Cost category, does not include a reporting requirement, as the information will be obtained by CMS from Medicare claims. Resource Use replaces the VM program and it adds more than 40 episode-specific measures.
"It is expected that the measures that CMS will use for the Resource Use category will be drawn from the existing VM program," he says.
For Advancing Care Information, which replaces Meaningful Use, CMS is proposing to require clinicians to use certified electronic health record (EHR) technology and report on measures that address interoperability and information exchange, according to Speed.
"The Advancing Care Information score would be made up of a base score and a performance score. For the base score, providers would earn points for reporting on six proposed objectives: protecting patient health, electronic prescribing, patient electronic access, coordination of care through patient engagement, health information exchange, and public health and clinical data registry reporting," he says.
For the performance score, clinicians would select the measures that best fit their practice on three proposed objectives that CMS believes emphasizes patient care. These categories of these measures are patient electronic access, coordination of care through patient engagement, and health information exchange.
The last component, Clinical Practice Improvement Activities, is designed to encourage clinicians to engage in a number of activities that CMS contends will improve the patient experience, Speed says. CMS is proposing a list of more than 90 activities options that are based around the following categories: Expanded Practice Access, Care Coordination, Population Management, Beneficiary Engagement, Patient Safety and Practice Assessment, Achieving Health Equity, Emergency Preparedness and Response, and Integrated Behavioral and Mental Health.
"CMS is requiring that clinicians select one CPIA activity to report," he says. "Additional points in this category may be earned for reporting more activities. In addition, clinicians would receive credit toward scores in this category for participating in APMs and Patient-Centered Medical Homes."