MACRAnomics: a guide for physicians

On April 27^,the Centers for Medicare & Medicaid Services (CMS) released 962 pages of proposed rules for the Medicare Access and CHIP Reauthorization Act of 2015, or MACRA. This is the payment plan Congress passed last year to replace the controversial sustainable growth rate formula (SGR).

Awareness of, and preparation for, coming changes should begin now, according to Robert Doherty, senior vice president for governmental affairs and public policy with the American College of Physicians. While the legislation won’t become effective until 2019, it relies on 2017 metrics for payment baselines.

“MACRA was created to bring greater value to Medicare,” says Doherty. “But it depends on what you mean by value, and to whom.”

Under MACRA, CMS combines the Value-based Payment Modifier (VM), Physician Quality Report System (PQRS) and Meaningful Use (MU) into a new Merit-Based Incentive Payment System (MIPS). Physicians are scored on quality, advancing care information (health IT), clinical practice improvement activities and cost.

Physicians with high scores have an opportunity to receive upward adjustments in their Medicare reimbursements-up to 4% the first year, and as much as 9% in 2022. Those who score lower will see their reimbursements adjusted downward. Since MIPS is budget-neutral, higher reimbursements for top-scoring physicians are offset by savings from paying low-scoring practices less.

The other payment option under MACRA is Alternative Payment Models (APM). These advanced payment systems reward some participating healthcare providers with a lump-sum incentive payment for quality improvement and cost-savings. Physicians choosing this option are exempt from MIPS reporting requirements.

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Under MACRA, payment based on performance must be at least 25% of Medicare revenue in 2019; that increases to 75% of Medicare revenue in 2022. Only certain care models, such as the Comprehensive Primary Care Plus (CPC+) initiativeand some patient-centered medical homes currently qualify as APMs. Other models, including some accountable care organizations, may be added later.

“The real goal of the legislation is to encourage as many physicians and physician groups and specialty physicians to move out of traditional fee-for-service and move into an alternative payment model of some type,” says Eugene Rich, MD, senior fellow and director for Mathematica Policy Research’s Center on Health Care Effectiveness in Princeton, New Jersey.

Further reading: 7 things physicians need to know about MACRA proposed rule

Concerns about forced practice consolidation are understandable, but provisions in the legislation recognize a need to support smaller practices and not necessarily to drive everyone into large, consolidated systems, he says.

MACRA identifies five quality domains (clinical care, safety, care coordination, patient and caregiver experience, population health and prevention) for measures developed under the Quality Measure Development Plan (MDP). This is the strategic framework for future clinician quality measure development under MACRA. The proposed rules also incorporate efficiency and cost reduction as a domain. MACRA further establishes priorities for the types of measures developed, which include outcomes, patient experience, care coordination and appropriate use of services, such as testing.

Not everyone thinks MACRA is the best solution to improving care and reducing costs. While there are many measures that can be quantified, important components of primary care, the “cognitive” skills, aren’t as easily calculated. “While preventive screenings are important, that’s by no means the most important aspect of primary care,” says Robert Berenson, MD, policy fellow at the Urban Institute and former vice chairman of the Medicare Payment Advisory Commission (MEDPAC).

Berenson is dissatisfied with the lack of measures for physician-patient communication and for making timely and accurate diagnoses, a core expectation of primary care. He says MACRA’s metrics “barely touch” the wide range of activities that primary care physicians perform. The average primary physician sees approximately 400 different conditions a year; about 70 of those represent 80% of care provided.

He calls it “absurd” that MACRA picks a handful of measures, mostly around screening tests, and that physicians accept this as a measure of quality. “It’s not even close to something reasonable. The worst part is that it’s not going to get any better,” he says.