Ready, Set, Go: Helping Physicians Move to Value as MACRA Begins

Abstract

Passed with the broad bipartisan support of Congress in 2015, the Medicare Access and CHIP Reauthorization Act (MACRA) will bring about comprehensive changes to how Medicare pays for physician services. MACRA aims to accelerate the transformation from fee-for-service payment to alternative payment models that require physicians to assume risk for the cost and quality of care. Civen the nation's unsustainable healthcare costs, MACRA is expected to survive regardless of the outcome of the November presidential and congressional elections.MACRA is critically important legislation for all providers, not just physicians. This column addresses implications and challenges for hospitals and health systems and complements an earlier column by Bosko and Hawkins (2016) that examined implications for physicians and physician groups.A CATALYST FOR MOVING PHYSICIANS TO VALUEReplacing the long-contentious Sustainable Growth Rate formula, MACRA rewards physicians for providing value-based care through a two-track framework: The advanced alternative payment model (ARM) track incentivizes providers who are taking risk on the basis of the quality and cost of care for particular episodes or defined patient populations and requires use of certified electronic health record (EUR) technology. The Merit-Based Incentive Payment System (MIPS) track is based on the fee-for-service model but is directly and rigorously tied to performance in four areas: quality, resource use, advancing care information (use of EHRs), and clinical practice improvement.For most physicians participating in the Medicare program, inclusion in one of the two tracks is mandatory; those who do not select the advanced APMs track will be default participants in MIPS. Implications for both tracks begin imminently; performance reporting by physicians starts lanuary 1, 2017, for payment 2 years later, in 2019. Based on feedback received and to allow physicians time to obtain help and experience before the program affects them, the Centers for Medicare & Medicaid Services (CMS) may consider postponing implementation of portions of MACRA or shortening the reporting periods; but even with these possible changes, the time for physician and hospital and health system leadership teams to prepare is now.The MIPS track is revenue neutral, so there will be winners and losers. MIPS payment adjustment of up to 9%, plus or minus, is making small practices feel vulnerable, as indeed CMS projects to be the case: Buried in a table on page 215 of the 426-page proposed rule as published in the Federal Register (CMS, 2016), CMS's estimation is that 87% of eligible clinicians currently in solo practices and nearly 70% in practices with two to nine clinicians will experience a negative adjustment in payment beginning in 2019. In contrast, 81% of clinicians in practices with than 100 clinicians are expected to experience a positive adjustment in payment (Table 1 ).The stakes are high for those who participate in the APM track, which offers physicians and physician groups a 5% incentive payment through 2024. To qualify as an advanced APM, physicians and physician groups must meet financial standards for bearing risk for monetary losses, as well as eligibility thresholds based on Medicare volume or payment standards. The requirements as outlined by CMS are complex (CMS, n.d.), but the aim is clear: to ensure that qualifying APMs assume more than a nominal amount of risk-i.e., significant downside risk-for monetary losses under value-based payment contracts.CMS anticipates that these six models will qualify as advanced APMs in 2017 (Quality Payment Program, n.d.): Comprehensive ESRD Care (CEC)-two-sided risk; Comprehensive Primary Care Plus (CPC+); Next Generation ACO Model; Shared Savings Program-Track 2; Shared Savings Program-Track 3; and Oncology Care Model-two-sided risk. Additional models, such as a new voluntary bundled payment program, a new Medicare ACO+ track, and an amended Comprehensive Care for Joint Replacement (CJR) model, are being evaluated for possible inclusion in 2018 or later years. …