SGR Out, MACRA In: Medicare's Move Toward Merit-Based Pay

Abstract

Practicing physicians and cost-cutting federal officials are seldom in agreement; current congressional Republicans and Democrats, hardly ever. Yet the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act of 2015 (MACRA) represents one of those increasingly rare points of convergence. Passed with strong bipartisan support and signed into law by President Obama on April 16, MACRA replaces the Sustainable Growth Rate (SGR) payment formula, a source of widespread complaints and annual last-minute legislative Band-Aids, with a system designed to steer Medicare compensation from volume-based fee-for-service to merit-based incentives. By changing the relation between payments and performance metrics, the act may help encourage cost-effective and better-coordinated practice. It will also raise critical questions about how those metrics are developed, how accurately they reflect clinical realities within different specialties, and how effectively any reform can control costs within the existing US medical-economic framework. MACRA holds out a promise of modernizing and rationalizing Medicare's payment system, removing the SGR's recurrent threat of drastic cuts to health care providers' income in favor of a stable 0.5% annual update during the transitional period from 2015 through 2019. It also brings down the curtain on the Physician Quality Reporting System, the Value-Based Payment Modifier program, and the electronic health records (EHRs) Meaningful Use Program, replacing those programs with 4 performance categories under the Merit-based Incentive Payment System (MIPS): quality, resource use, clinical practice improvement activities, and meaningful use of certified EHR technology. (These are weighted, respectively, 30%, 30%, 15%, and 25% as components of the MIPS score of 0 to 100.) MACRA offers 2 paths that providers can follow to increase Medicare payments. They can either qualify as a non–fee-for-service alternative payment model (APM), such as an accountable care organization (ACO), bundled-payment model, patient-centered medical home, or comparable entity, which will be eligible for up to 5% increased incentive payments, or have their payments adjusted up or down according to MIPS. Qualifying APM participants, whose providers do not have to participate in MIPS, must keep quality stable while cutting costs or improve quality while stabilizing costs, meet EHR use criteria, and carry more than a nominal risk for the total costs of patient care (a category defined as an eligible APM). APMs have no direct downside risks to individual physicians. MIPS can either bring a percentage increase in payments or penalize poor performance by cuts of up to 4% beginning in 2019, increasing to 9% by 2022. (MIPS maximum positive incentives also begin at 4% and increase to 9% but are multiplied by a scaling factor required to maintain budget neutrality.) Outside Beltway health policy and administrative circles in which the alphabet soup of Centers for Medicare & Medicaid Services (CMS) programs is common parlance, the transition from SGR to MACRA may strike many physicians as a form of inside baseball that is relatively remote from their daily concerns. Some commentators in and around CMS, however, recommend more extensive professional attention while the nuts and bolts of implementation are still being configured. MACRA also includes language on various 2- or 3-year “Medicare extenders,” including Children’s Health Insurance Program, the Medicare Advantage special-needs plans, the Geographic Practice Cost Index floor, abstinence-based education mandates, and the federal Personal Responsibility Education Program for unplanned-pregnancy prevention. But its central and most consequential provisions for most physicians are those pertaining to MIPS and APMs, particularly because cuts from lower-performing providers will pay for incentive payments to their higher-performing colleagues under MIPS (as described by one proprietor of a pay-for-performance automation service for providers, “[T]he winners take from the losers”).1Lee TS. Ten FAQs about the Merit-based Incentive Payment System. SA Ignite. Available at: http://www.saignite.com/resources/faq-about-merit-based-incentive-payment-mips. Accessed October 27, 2015.Google Scholar CMS has been soliciting public comments from professionals concerned with the specifics of the rulemaking process. A Request for Information was posted October 1,2Centers for Medicare & Medicaid ServicesRequest for information regarding implementation of the Merit-Based Incentive Payment System, promotion of alternative payment models, and incentive payments for participation in eligible alternative payment models.Federal Register. October 1, 2015; (Available at:) (Accessed October 28, 2015)https://federalregister.gov/a/2015-24906Google Scholar with its initial November 2 deadline extended until November 17. When the proposed MACRA rules are submitted in approximately March 2016, CMS will announce another public-comment period, seeking detailed feedback about the proposals developed up to that point. Few will miss the SGR, commentators agree. Written with a budget-neutrality requirement as part of the Balanced Budget Act of 1997, the SGR formula required cuts if Medicare payments exceeded a threshold. With general health care costs steadily increasing, they consistently did. Seventeen times since 2003, to allay the fear that cuts of some 20% in Medicare payments might induce many physicians to cease treating Medicare patients altogether, Congress, responding to American Medical Association and specialty-society lobbying, has passed short-term patches to keep payments equal (although not increasing with inflation). “Every year there'd be this song and dance where the SGR was about to kick in,” said Laura Medford-Davis, MD, an emergency physician at the University of Pennsylvania and a Robert Wood Johnson Foundation Clinical Scholar who has worked at the Center for Medicare and Medicaid Innovation but is currently speaking on her own behalf, not the center's. Congressional Budget Office deficit calculations, she added, proceed “as though the cuts are really going to happen next year, so each year it appeared more expensive on paper to trash the law.” Along with this political fiction, Dr. Medford-Davis said, the SGR system “was trying to make the cuts to physicians' payments across the board, without a careful thought about what were the drivers of those increasing payments...the other increasing costs in the system besides physician payments. If you look at the amount, the percentage of health care costs that are going to physician payment is not very high.” MACRA finally replaces SGR with the more nuanced incentives of the MIPS and APM tracks. It “has some new elements, but it also wraps up all the programs it's phasing out into it,” she said; some, like the EHR meaningful-use program, are essentially unchanged, whereas others are substantively novel and require scrutiny. “Initially people were extremely happy because they were happy to see the end of SGR. But people have yet to fully unpack the implications of what MACRA means.” One source of potential dismay is that the preferable track has not been designed with all specialties equally in mind. The APM, she noted, “at least currently, is going to be a little bit limited for emergency physicians, because...there are no models out there that directly include emergency physicians.... A lot of the current alternative payment model tracks are really more relevant to primary care physicians and internal medicine physicians,” she continued. “There [are] not a lot of specialty tracks available in APMs currently for specialists of any kind,” except for recently announced bundled-payment initiatives involving orthopedics, oncology, and nephrology. An 11-member Physician-Focused Payment Model Technical Advisory Committee, established by MACRA and appointed by the Comptroller General's Government Accountability Office last October,3US Government Accountability Office. GAO makes appointments to new HHS advisory committee on physician payment models. October 9, 2015. Available at: http://www.gao.gov/press/appointments_hhs_advisory_committee_physician_payment_methods.htm. Accessed October 29, 2015.Google Scholar includes 6 members of other specialties but no emergency physicians. “The goal is try to get more specialty models out there,” she said, “so ACEP [American College of Emergency Physicians] could consider, for instance, coming up with an alternative payment model for emergency physicians, and they could take it to the Technical Advisory Committee and apply and say, ‘Hey, we think this is a good model,' and see if the Technical Advisory Committee approves their model.” The expanded-practice-access criterion under Clinical Practice Improvement Activities, Dr. Medford-Davis observed, gives providers credit for same-day appointments and after-hours access, aspects of practice that are already standard in emergency departments (EDs). ACEP consequently recommends, in its letter to CMS on multiple 2016 regulatory issues, that “ED providers automatically earn at least a minimum score of 1/2 of the highest potential score for this performance category simply for providing this access on an ongoing basis.”4Gerardi MJ. Medicare payment policies under the physician fee schedule proposed rule for 2016. Letter to Andrew M. Slavitt, CMS acting administrator. September 4, 2015, pp. 5-6. Available at: http://www.acep.org/workarea/DownloadAsset.aspx?id=102926. Accessed October 29, 2015.Google Scholar Scoring metrics within the quality performance category can pose definitional questions. Quality can be defined on an outcome basis or as “process-based measures, like ‘Did you do the right thing at the right time, regardless of how things turned out?'” said Dr. Medford-Davis. “One thing for emergency physicians that has been a criticism, I think, [is] that a lot of measures focus on what you should do on a certain diagnosis, but when a patient comes to the emergency department, typically you don't have the diagnosis. Maybe there should be more quality measures that are based on the symptoms you're presented with.” “The [Request for Information] is the first step to writing some of these details...[about] exactly how MIPS and APMs are going to be defined and how the programs are going to be administered,” she pointed out. Having participated in the drafting of this 43-page document at CMS, she acknowledged that much of it reads like legalese—it devotes considerable attention to administrative matters such as provider identifier numbers, which can be a complex issue in group practice but have little direct bearing on clinical performance—but described it as deserving of physicians' attention: “basically, all the questions that CMS feels like they're not sure about, or like they'd want more input from physicians and other stakeholders about, in terms of how we write this rule.” So far, Dr. Medford-Davis said, the MACRA implementation process has drawn more attention from ED directors and owners of ED groups than from nonmanagerial emergency physicians. “I think that we need to be engaged as emergency physicians in advocating what's best for our specialty, now during the [Request for Information] and then again in March during the Notice of Proposed Rulemaking,” she summarized. “If not, a rule's going to be made that we may not like.” “The hope for the agency,” said Lemeneh Tefera, MD, MSc, medical officer for value-based purchasing at the Division of Value Incentives and Quality Reporting in the Center for Clinical Standards and Quality, “is that this new scoring system will be more comprehensive, easier to use for providers, and also provide meaningful information for various stakeholders, whether they're our patients or others in the health care market.” As a CMS official and an emergency physician, Dr. Tefera described MACRA as an instrument “designed for a long view on transforming the existing payment structure, which is really stuck in fee-for-service and volume orientation, to a new footing that incentivizes coordination, cooperation, [and] communication between patients and providers, but also between providers, so that the system is talking to itself.” “As an emergency doctor,” he continued, “I'm hopeful that a lot of the frustrations about not being able to effectively communicate with a patient's primary care provider, or not having actionable information about a patient's prior medical history, or important data elements from previous evaluations or patients' particular emergency visits—all that will hopefully improve because of the benefits of MACRA and how it's designed to change operations of physicians, and hopefully hospitals as well.” The incentives MACRA fosters include meaningful use of EHR, already a priority of SGR and the Patient Protection and Affordable Care Act, but go further to encourage other forms of communication and coordination through the new performance category, Clinical Practice Improvement Activities, which include expanded practice access, population management, care coordination, and beneficiary engagement. “Examples of that could be timely sharing of results from a doctor's office with a patient, but also from a doctor's office to other doctors that the patient is seeing, [or] coordination of telehealth in the care of the patient,” Dr. Tefera continued. He envisions a number of common-sense measures arising through the October Request for Information, such as increased office hours or upgraded call support “where, when you call your after-hours office, you don't talk to someone that doesn't know anything about you, which is often the case now. You talk to someone that actually has access to your medical records [and] medication list and can give you thoughtful information about the patient's condition.... So, while many folks generally think of the EHR as the main policy tool to drive communication, we're hopeful that this new performance category will provide many novel ways to incent providers to communicate with one another and patients alike.” Within the APM track, Dr. Tefera said, the distinction between an APM and an eligible APM is consequential. To take advantage of the APM option's benefits, including a 5% annual lump incentive payment based on the previous year's Part B expenditure, “it is incumbent upon providers to know that the alternative payment model that they are interested in has met the requirements of CMS in detail [as] an eligible alternative payment model,” including bearing financial risk for losses, a feature that many Center for Medicare and Medicaid Innovation models to date do not include: “The types of APMs in the current CMS portfolio that would potentially meet the eligible APM criteria are the accountable care organization initiatives with 2-sided risk. Previously, the pioneer accountable care organizations would be the types of alternative payment models that would involve sufficient risk sharing to be deemed eligible alternative payment models.” Several APMs, whether eligible APMs or not, are moving toward decreasing costs and improving quality through a long-term medical-home-style relationship with a group of providers and institutions, “working in a synchronized way so that they're not only improving the day-to-day care of the patient but [also] decreasing unnecessary duplication, improving the efficiency overall of their particular practices of the hospital that may be associating with that payment model.” “I think emergency medicine has a lot to gain from alternative payment models and their diffusion into our health system,” Dr. Tefera said, “because when a patient arrives who receives care in alternative payment model, as opposed to needing to seek out 3 different providers who may have cared for that patient under multiple conditions, they could have a single site to refer to for the medical history.... Emergency providers would have more confidence that outpatient plans would actually be followed through.” “I think emergency physicians in groups participating in alternative payment models may have really unique opportunities to contribute to the organization of the alternative payment model and be involved in an institutional organizational structure that historically was not an option for emergency departments that often were an afterthought in an organization,” Dr. Tefera summarized. “Often emergency departments are contracted out and not necessarily integrally tied to the rest of the institution. I think alternative payment models provide an opportunity really for a reset for how emergency departments and the institution writ large operate. And this could be a great opportunity to develop strong links between the emergency department and other departments throughout the hospital.” At least one important faction of the medical community, advocates of a single-payer system, remain unconvinced. “These short-term fixes have occurred something like 17 times since 2005, and all we've been doing is kicking the can down the road,” commented James C. Mitchiner, MD, MPH, an emergency physician at the St. Joseph Mercy Health System in Ann Arbor, a clinical assistant professor at the University of Michigan Medical School, a past president of the Michigan College of Emergency Physicians and chair of ACEP's State Legislative and Regulatory Committee, and a spokesperson for Physicians for a National Health Program. “It's only because Congress has had the unusual wisdom to see that SGR cuts carried out would impede access of Medicare beneficiaries to providers that they come up with these last-minute reprieves. So organized medicine was all excited about this, because this was an annual thing, and everybody said, ‘Hooray! The SGR's repealed.' But they didn't bother to look at the details of what it was going to be replaced with.” Dr. Mitchiner sees more hope than evidence that the aims of MACRA, laudable as they are, are achievable or even mutually compatible. MIPS “would look at things like quality, resource utilization, cost efficiency, patient satisfaction...and the fact is, none of these things have been proven, at least on a large scale, to reduce the cost of health care in the United States. In fact, there is some evidence that patient satisfaction is not tied in with quality. So everybody's sort of drinking the Kool-Aid on this.” Addressing the real sources of inefficiencies, he cautioned, would require systemic restructuring rather than the reformism of MACRA. “Everybody is missing the elephant in the room here. And the cause of high health care costs in the United States is not doctors' ordering 2 tests, or pharmaceutical companies that are charging too much money for drugs, or overuse of MRIs and technology. It's the insurance companies. It's the rapacious, greedy, fee-for-no-service, for-profit insurance companies.... The first thing they do when they get a premium dollar, they immediately lop off 15 to 20% for their administrative costs to pay their armies of actuaries, accountants, claims adjusters, lobbyists, lawyers, public-relations people, marketing people, stockholder dividends, and grossly inflated CEO salaries.... Out of that health care dollar, you have between 80 and 85 cents to pay for actual health care, whereas with a public program like Medicare, about 3% of the amount that we pay into Medicare is actually used for administrative costs.” Citing an Institute of Medicine estimate of $189 billion for private insurers' annual administrative costs—more than 3 times the estimate of $60 billion in Medicare fraud—he noted that “the average primary care physician's office now spends about $84,000 per year per doc just dealing with all the paperwork of all the different insurers,” including preauthorizations, formularies, and multiple inconsistent processes. Problems that MACRA leaves unresolved, Dr. Mitchiner said, include choice, portability, risk adjustment, and what he terms “the attribution issue.” As long as approximately 160 million Americans obtain their health coverage through their employers, “that means that their company is picking their insurance company for them. Sometimes, if they're lucky, they might get a choice of 2.... What good does it do for a consumer to be able to get on the Internet and access, for example, Hospital Compare or Physician Compare and find out which doctor or which hospital has the better quality if their insurance plan doesn't cover them? That's un-American. Americans like choice, and [that's] what the politicians are missing: they're all talking about the fact that Americans should have a choice of insurance companies. Well, baloney. I think they ought to have a choice of doctors and hospitals.” In contrast, Medicare's portability, universality, lower cost-shifting than in commercial plans, and lack of forbidding deductibles or complex networks make it broadly popular with patients, Dr. Mitchiner said, citing figures of 60% approval in the general population and approximately 80% among seniors. Private insurance puts many citizens in a condition Dr. Mitchiner identified as job lock, unable to improve their employment situation lest benefits vanish, or constrains options if they become ill while traveling. MACRA does nothing to address such shortcomings directly. Could its capacity for producing data on quality and efficiency, however, indirectly increase pressures toward better performance? “Yes, it will generate data,” Dr. Mitchiner said, but “will it be useful? If you get information that Doctor A is better than Doctor B, but your insurance plan won't pay for you to go to Doctor A, what have you accomplished?” “What we're finding out with the early data that's coming out of the Affordable Care Act,” he continued, “is that people are picking insurance plans primarily for the premium. So they're buying silver plans, they're buying bronze plans, because they like the idea of having a low premium, particularly if it's subsidized...but then they find out, when they have to use it, how much they have to pay out of pocket.” In addition, “there is no evidence that I'm aware of that the costs and the prices are necessarily tied in with quality.... The majority of people are picking their doctors based on what the recommendations are for their own doctor, or from their family or from friends.” Dr. Mitchiner agreed that the minutiae of metric development are critical. “If we do go to quality measures, it's very important that they be risk adjusted so you don't punish the doctors who voluntarily take on sick patients and don't have as good an outcome as those who do. And that's one of the things that we're worried about with MACRA: that we're going to have situations where doctors are ‘teaching to the test'” in various ways, such as excluding constantly sicker patients or Medicare patients from their practices. Attributing certain variables in outcome assessments to the appropriate source may also be too complex for the scoring system: for a hypothetical patient who consults multiple specialists, including a primary care physician, a cardiologist, and a gynecologist, he asked, “Who gets credit if the lady's blood pressure is under control?... If it turns out in any given year that the lady is seeing her gynecologist more often than she's seeing her primary care doctor or cardiologist, it could be the gynecologist that'll get credit for the blood pressure, which is silly.” ACOs may be “the wave of the future,” he finds, but have not resolved attribution problems: when “somebody goes outside the organization to get health care—for example, snowbirds in Michigan: their cardiologist's in Michigan, their urologist for their prostate is down in Boca Raton—how are they going to coordinate all this?” In cases of comorbidity, “are we in the ED going to be expected to contribute to the improved management of hypertension if somebody comes in for an unrelated problem?... It's very murky and unsettled what emergency medicine's role is in population health, and it most certainly is going to require cooperation with other specialties.” MACRA's EHR-use incentives can improve such coordination, Dr. Mitchiner observed, provided the interoperability and security challenges are resolved. Many patients he treats are assuming this is already the case: “A lot of patients sort of have this idea there's a big cloud in the sky now, and all these records are easily exchanged. Or they think we all have the same computer system. They don't recognize that there [are] different EHRs, and they don't talk to each other. So interoperability is absolutely crucial to making MACRA work from the standpoint of quality metrics and improving population health.” For most patients, he suggested, “I don't think they will notice anything different. There may be an improvement in quality; I'm not so sure that they're going to notice that. There certainly will not be a decrease in prices. That's clearly going to get worse, and people are going to be paying more out of pocket. In terms of saving cost, my prediction is that there will not be any overall savings in costs; there may be some pockets here and there.... The early information from ACOs is that they are not really coming through as promised.” Whatever incremental improvements may occur under MACRA, Dr. Mitchiner said, do not address the central problems of practice and may go largely unnoticed. “Among all my colleagues in emergency medicine, I would imagine that very few of them were aware that we were facing a 21% pay cut under the SGR program back in April. They don't get into the weeds on this—at least that's my impression, the average working emergency physician.... I don't think that they realize that they're practicing basically in a single-payer environment,” in which financial and insurance status do not determine access, patients have a choice among local hospitals unless arriving by ambulance, all patients are treated the same, and “most of us get paid once a month. We get a single check from our group or from the hospital. Now imagine how much bigger that check would be if we got paid for all the people that are now uninsured, or we got paid more for the people that have Medicaid...and we didn't have all the transaction costs that are involved with dealing with multiple insurers.... Every emergency physician in the country is practicing [in] a single-payer environment; they don't know. And if somebody threw the switch and we all went to one single payer on January 31, 2016, nothing would change in terms of our work flow.” The zero-budget aspect of MIPS strikes Dr. Mitchiner as frankly misguided. Although it will benefit practitioners with high quality scores, “they've got to cut money from one doctor to give a bonus to another doctor, and what we really ought to be doing is working on those underperforming doctors to get them up at least to the average with everyone else. And then I'm concerned about some of the metrics that they're using...for example, getting somebody to the catheterization lab within 60 minutes of their presentation of an MI? Well, almost everybody's doing that now.” Standards developed several years ago, he says, become “kind of a meaningless quality measure now when everybody's doing it.” “I'm very skeptical of MACRA,” he concluded. “I don't think that we have looked at all the details. We certainly haven't studied the replacements that they have for MACRA with a greater emphasis on alternative payment models and measuring quality, and I just don't think that the science is there yet in terms of the attribution and the risk adjustment for quality measures, so I'm skeptical that there's going to be any decrease in costs.” “Overall, this is good news for emergency medicine,” commented Jeremiah D. Schuur, MD, MS, chief of the Division of Health Policy Translation and the director of quality, patient safety, and performance improvement for the Department of Emergency Medicine of the Brigham and Women’s Hospital and assistant professor of emergency medicine at Harvard Medical School. “It's good news in 2 ways: the first way is that rather than having to worry about the SGR fix every year or every 6 months...we have relative certainty about this for the next 10 years or so. And a lot of our specialty societies' energy was spent every year mobilizing support to avoid cuts to the SGR.” The second benefit for all specialties, Dr. Schuur continued, is that MACRA promotes quality measures that are “derived by the specialties using validated approaches, rather than measures that require extensive CMS evaluation prior to endorsements.... The criteria to get a quality measure developed by CMS were so onerous that emergency medicine was losing its approved measures, and it looked like it would be financially unsustainable for ACEP to develop a large number of measures on behalf of the specialty. And that put emergency physicians in a potentially difficult situation of having to report to the quality program without an adequate number of measures.” By encouraging the use of Qualified Clinical Data Registries, which can contain measures developed and maintained by specialty societies, MACRA continues one of the features of the Physician Quality Reporting System that ACEP5American College of Emergency Physicians. Qualified Clinical Data Registries (advocacy page), 2015. Available at: https://www.acep.org/uploadedFiles/ACEP/Advocacy/federal_issues/Quality_Issues/2015%20Qualified%20Clinical%20Data%20Registry%20QCDR%20Reporting%20Option.pdf. Accessed October 30, 2015.Google Scholar has found uses broader measures and data than past claims-based reporting methods. “Some emergency physicians may object to the idea of quality reporting and payment for performance,” Dr. Schuur said, “but that was part of the existing world, and this is an improvement on the prior version.” From his own experience in an ACO, Dr. Schuur found that this model improves certain aspects of care coordination and cost control for the Medicare-beneficiary population, such as avoiding unnecessary admissions, but “has not changed the general structure of emergency care.... It's a modification of our system. It is not a reinvention of our system.” ACOs have targeted specialties in which providers can influence expensive diagnostic procedures and patients' visitation patterns; primary care, imaging, and certain surgical fields, he found, have aligned better with the ACO mechanism than emergency medicine. Reducing patients' use of the ED for primary care, he noted, “is a common goal and assumption of the whole movement to accountable care, and there are definitely examples where high-quality innovative care has reduced ED visits. But those tend to be very advanced practices that are not easily replicable...Kaiser, Geisinger, Intermountain Health to some degree.” He also pointed out a recent counterexample, Dartmouth-Hitchcock,6Leventhal R. Dartmouth-Hitchcock latest ACO to drop from pioneer program. Healthcare Informatics, October 23, 2015. Available at: http://www.healthcare-informatics.com/news-item/dartmouth-hitchcock-latest-aco-drop-pioneer-program. Accessed October 31, 2015.Google Scholar “a leader in doing population health [that] just dropped out of the ACO program because they were losing money.” “As alternative payment mechanisms move from a small percentage of payment to a large percentage of payment and a large percentage of patients,” Dr. Schuur added, “we don't know how the financing of emergency care will exist under that system. Because in theory, the ACO will get either a capitated payment for their population or a bundled payment for certain conditions like hip replacement or heart attack. And as many emergency visits are for complaints that don't clearly fall into bundles, it's not clear how the emergency department will be paid. But that is pretty far away from being adopted.” This makes it incumbent on emergency physicians to become involved in the CMS rule-making process. “These rules are going to keep being written for the next couple of years,” Dr. Schuur said, and they should be pertinent to the work flow and patient mix seen in emergency practice. “In general, when Medicare is writing these rules, they write them to apply to as many physicians as possible, and so the first place they look is the outpatient space of primary care doctors and specialists who [treat] outpatients; the second place they look is hospital-based physicians...such as anesthesiologists or pathologists. And we have a somewhat unique practice status.” One salutary effect of MACRA may be its data-generating potential, Dr. Schuur observed. “The strongest link to improving quality is measuring and feeding back data, and for some practices MACRA will be the first time that that's done, but for many practices it won't be. They will have already been gathering this data. And so there are a number of studies…that have looked to see, does financially rewarding quality actually lead to additional improvement, beyond just measuring it? And those studies have been relatively disappointing.... I think the MACRA process will improve the measurement of quality and will increase the number of practicing clinicians who are getting actionable data about quality, but that's going to take time, because for many specialties, including emergency medicine, the quality measures do not accurately reflect the totality of our practice.” When offering public input to CMS, he said, what “emergency physicians should comment on is what is the burden of measurement and therefore the associated cost of measurement going to be?... It's important that as MACRA gets developed, that ACEP on behalf of its members try to do this in a way that does not create undue burden, and that CMS does not develop a system that creates undue burden.” If MACRA accelerates a general expansion of alternative models, data that skeptical observers find inconclusive to date may come to yield clearer inferences about the effectiveness of merit-based incentives. CMS recently reported that 20 ACOs in the pioneer ACO model and 333 Medicare Shared Savings Program ACOs generated more than $411 million in total savings in 2014 (performance year 3 for the early-adopter pioneer ACOs) and improved their quality scores (measuring variables such as EHR usage, clinician-patient communication, and risk-factor screening) between 2013 and 2014.7Centers for Medicare & Medicaid Services. Medicare ACOs provide improved care while slowing cost growth in 2014. August 25, 2015. Available at: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-08-25.html. Accessed October 27, 2015.Google Scholar, 8Jacob J.A. Medicare ACOs improving quality of care: CMS report.JAMA. 2015; 314: 1683Google Scholar Amid such grounds for guarded optimism, Dr. Medford-Davis stepped back to look for historical comparisons. “I think a lot of people are comparing this current value-based-payment movement to the managed-care movement from the ′90s,” she noted. “One difference is that [in] managed care in the ′90s, it was more the insurance company that was taking on the risks or capping the payments, whereas now it's the providers that are being asked to do it.... We'd like to think that the value-based payment is a little more thoughtful than the managed-care movement and a little more focused on being sure that we maintain quality.” “As emergency physicians, we tend to have a lot of pressure to see as many patients as quickly as possible, and to very quickly make a decision about whether to admit or discharge them or transfer them in the current system. And that has a lot to do with how we're paid, the sheer volume of people that we see, and how many people are waiting to see us. I think that in order for us to really embrace this value-based-care movement, there's going to have to be a shift, and it's going to have to come somewhat from the administrators in terms of what the goals of emergency care are. Is it to move as many patients through as quickly as possible, or is it to more carefully consider what's the right decision for each patient?”