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MACRA final rule could hit healthcare industry hard


MACRA, which will further the shift to value-based reimbursement, has industry insiders grappling with the complexities, particularly those related to reporting guidelines for providers.

As CMS released the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) implementation proposed final rule to align and modernize how Medicare payments are tied to the cost and quality of patient care for physicians, industry watchers weighed in.

Related: MACRA will drive value-based reimbursement momentum


“Since the Affordable Care Act, there has been a marked increase in private payers also pursuing bundled and other alternative payment models,” says Nilesh Chandra, a healthcare expert at PA Consulting Group. “Similarly, we expect other health plans to adopt some of the quality measures and increase the emphasis on quality in their reimbursement and incentive programs.”

Medicare beneficiaries should be very concerned, according to David A. Reid, Founder and CEO, EaseCentral.

“The MACRA options allow a provider to choose how they will be paid and the results will differ based on practices. Providers will choose between different reimbursement methods that will clearly effect how networks broadly treat Medicare patients,” he says.

Merit-Based Incentive Payment System (MIPS) versus the Alternative Payment Model (APM) are reimbursement mechanisms that will produce a different payment result to provider groups based on their practice patterns, according to Reid.


“The care received by a patient will likely be different based on the method adopted by the provider,” Reid says. “How is that best for the consumer? Once a provider chooses the reimbursement model, practice patterns will likely follow to maximize results."

With the goal of improving cost control by linking reimbursement more closely to outcomes, MACRA leaves all reporting in the hands of the provider, according to Reid.

“When identifying issues such as ‘efficient resource use’ relative to ‘patient outcome’ as a driver for financial reimbursement, providers are going to be under financial pressures when making daily decisions about what is best for their patients,” he explains.

“We have to address cost as a society, we all realize this,” Reid says. “However, it’s hard enough to select a quality provider. Now, the patient is going to have to be aware of how their condition fits into a reimbursement model selected by their provider, to determine which source will provide the best care.”  

Next: Grappling with the complexities


Even industry insiders are grappling with the complexities, he says. “There will be ample room for large practice groups to manipulate reimbursement levels based on self-reported actions and outcomes that are so complex it will be difficult to determine, if not impossible, that patient outcomes were the top concern,” he says.

Chandra offers some positive insights to the proposed final rule:

It is simpler. “This new model offers a simplified reporting structure by consolidating-sun-setting a multitude of incentive programs and reporting options into just two,” Chandra says. “In the past, a common challenge for providers was that the entire reporting framework was very confusing, it seems this will be alleviated to an extent.

It is outcomes focused. The incentives and measures are now oriented toward outcomes rather than just having technology-the Meaningful Use incentives for having an electronic health record, or having computerized physician order entry functionality.

It is flexible: Individual providers also have greater flexibility in choosing the set of measures they report against, based on their specialization and the unique circumstances in which they practice, according to Chandra. “Thus the model is more flexible, rather than adopting a ‘one-size-fits all’ approach in the past,” he says.

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