MACRA “pick-a-pace” approach a step in right direction, docs say

After going silent for most of the summer, the MACRA world finally began making some noise in September. And for some physicians, it was music to their ears.

Acting CMS Administrator Andy Slavitt, via a blog post, announced the ambitious new law would opt for what amounts to a soft rollout in 2017 – not the full-blown start that some physicians, and advocacy groups that represent them, complained was too aggressive a timeline. CMS isn’t expected to release final MACRA regulations until sometime this fall, which would leave physicians and other eligible professionals (EPs) with just a few weeks to digest the law before they would need to start reporting performance data – data that could result in Medicare payment cuts.

The new plan isn’t the outright delay that some small practices and groups, such as the American Medical Association (AMA) and Medical Group Management Association (MGMA), requested, but it appears it will be enough of a reprieve to allay concerns that EPs wouldn’t have enough time to prepare adequately for MACRA.

A quick refresher: MACRA includes the Quality Payment Program (QPP), which establishes a new formula for determining how EPs are paid for the care they provide to Medicare patients. Most EPs in individual and small-group practices will participate in the Merit-Based Incentive Payment System (MIPS) portion of MACRA. EPs may also choose to join an Advanced Payment Model (APM), such as Medicare Shared Savings Track 2 or 3.

The proposed MACRA regulations CMS released in the spring called for assessing EPs with a +/- 4% payment adjustment based on MIPS data they reported in 2017. That adjustment would be assessed in 2019.

Under the new plan, it will be much easier to avoid getting stuck with a negative payment adjustment in 2019. However, MACRA still technically begin in January and physicians will still be able report data as originally planned.

In place of straight-up MACRA launch in January, EPs may choose from one of four options. The big takeaway is none will generate a negative payment adjustment. To avoid a penalty, EPs need only submit some data to the QPP in 2017. This option is designed to allow EPs to test the system and be prepared to use in fully in 2018 and 2019. Other options include reporting actual MIPS data for part of the year, or reporting a full year’s worth. The latter two options will make EPs eligible for a modest positive payment adjustment. As noted earlier in this post, EPs may also choose to join an APM, qualifying them for a 5 percent incentive payment.

Groups such as the AMA and MGMA view CMS’s solution as a temporary fix, albeit a welcome one. The proposed MACRA regulations released in the spring generated thousands of comments to CMS from across the health care industry. So MACRA may be a work in progress, but Acting Administrator Slavitt said in his blog post that CMS expects plenty of physicians are ready to submit – and will submit – a full year’s worth of data next year.

Stay tuned.

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Meaningful Use: Extreme Makeover Edition

What MACRA means to CMS’s EHR incentive program

Among its many objectives, the Medicare Access & CHIP Reauthorization Act (MACRA) aims to simplify the process health care providers have had to endure when reporting data and other information to the federal government. The Physician Quality Reporting System (PQRS), Value-Based Modifier, and Meaningful Use (MU) are among the programs MACRA will consolidate.

But the Centers for Medicare & Medicaid Services (CMS) continues to push ahead with MU as a standalone program separate from MACRA. In fact, MU’s third stage is slated to begin next year. So what gives?

Let’s take a moment to sort it all out.

Some unlucky timing is partly to blame for the confusion. The Medicare & Medicaid EHR Incentive Program (MU) was created under the American Recovery and Reinvestment Act of 2009 (ARRA). The first two MU phases went into effect in 2011 and 2014, respectively. In 2015, CMS released its plans for MU’s third phase, but Congress passed MACRA shortly after, and much of MU was supplanted by the new law.

MACRA has taken a big bite out of MU, but hasn’t swallowed it whole.

To understand how the new arrangement will work, it’s helpful to split MU into two buckets – one that addresses eligible providers (EPs) in individual and small group practices, and another that addresses hospitals. The individual and small group EPs will see their MU programs give way to MACRA beginning in 2017, while hospitals will soldier on under the regular MU program.

Here’s a further breakdown. MACRA’s Quality Payment Program (QPP) includes two main tracks: the Merit-Based Incentive Payment System (MIPS) and the Alternative Payment Models (APMs). Most individual and small group EPs will submit their performance data to MIPS. CMS will adjust each EP’s reimbursement higher or lower depending on how well each scores on MIPs measures. Some individual and small group EPs may join an APM, such as a patient-centered medical home (PCMH) or an accountable care organization (ACOs), but most will be MIPS “customers.” For them, the information currently reported as part of MU, such as EHR and health information exchange (HIE) data, will move to the Advancing Care Information (ACI) category within MIPS. The ACI category accounts for 25% of an EP’s annual MIPS score.  Hospitals, however, are not part of MIPS, and will continue down the MU path.

Which brings us to MU stage 3. MACRA’s 2017 start effectively means that individual and small group EPs won’t have to attest to stage 3; however, hospitals will. They can voluntarily begin attestation in 2017, and all must start by 2018. Stage 3 focuses on advanced EHR use, interoperability, and more HIE. Specifically, stage 3 calls for:

  • Provider to provider exchange through the transmission of an electronic summary of care document;
  • Provider to patient exchange through the provision of electronic access to view, download, or transmit health information; and
  • Provider to public health agency exchange through the public health reporting objectives.

MACRA may have muddied the MU waters, but hasn’t drained them, or at least not the spirit of MU. The EHR incentive program remains, just under a different name.

As always, stay tuned.

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MACRA: News Briefs

With less than five months to go before MACRA takes effect (barring a delay), here’s a roundup of recent news articles and content about the coming law .  .  .

Why the MACRA start date debate misses the point

HealthData Management

Synopsis: Most of the headlines surrounding CMS Acting Administrator Andy Slavitt’s appearance before the Senate Finance Committee in July focused on a potential delay to MACRA’s start. While many providers are concerned they won’t be ready to meet the new law’s sprawling requirements, Ray Desrochers, executive vice president at HealthEdge, says talk of a delay obscures a larger, more urgent message: MACRA will affect on not only Medicare, but potentially all commercial health plans – at some point. Insurers must prepare to implement value-based contracts and react to the myriad demands that will arise from the complex physician payment models that lay ahead.

 MACRA: IT shops can help providers thrive under the new payment model

Healthcare IT News

Synopsis: Health care providers that complain about MACRA should focus their energies on preparing for the new law. That’s the message from industry insiders that say a good attitude will go a long way in determining which providers stay ahead of MACRA and which get tripped up. CMS is expected to release its final rule for MACRA in October, but that doesn’t mean a delay to the planned Jan. 1, 2017 state date is certain. Changes to the law are also possible. Still, providers would be wise to learn bone up on MACRA, perform a self-assessment of their readiness, and prepare to meet the law’s requirements.

MACRA, the End of Meaningful Use, and Beyond

HealthLeaders Media

Synopsis: Since MACRA became law in 2015, and fleshed out this spring, confusion regarding the future of meaningful use has been aplenty. While some health care industry professionals say the electronic health record (HER) and health information exchange (HIE) program is being pushed aside by MACRA, that’s not the case; in fact, Stage 3 Meaningful Use is planned for 2018. Much of meaningful use will be rolled into MACRA, not eliminated.

ACO Participation Prepares FPs for MACRA


Synopsis: Many physicians may not realize that they’ve actually been preparing for MACRA for years. That’s the case for physicians that participate in accountable care organizations (ACOs). The organizations are specially tailored to provide high-value care, so the providers within them are well-positioned to make a smooth transition to MACRA. But physicians don’t need an ACO schooling to prepare for the rigors of MACRA. Just setting a few solid clinical goals and a good system for measuring and reporting them will go a long way toward providing the value-based care MACRA seeks.

MACRA Delay is “Inevitable,” Says Expert

Diagnostic Imaging

Synopsis: Medical groups such as the American Medical Association (AMA) and American Academy of Family Physicians (AAFP) are advocating for a delay in MACRA’s rollout so that doctors have more time to prepare to meet the law’s complex requirements. In this podcast, two health care experts argue that a delay is either necessary or inevitable. The nearly 1,000 pages of text included in MACRA and the 3,900 public comments CMS received after the proposed regulations were released this spring are reason enough to push back the January start, they say.

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MACRA? What’s that?

It wouldn’t be surprising to learn that most Americans haven’t heard of the Medicare Access & CHIP Reauthorization Act (MACRA). It’s pretty much inside baseball-type stuff to anyone who doesn’t work in health care. However, it’s a bit surprising – it not alarming – that most physicians apparently know little to nothing about it.

According to a recent survey by Deloitte’s Center for Health Services, 50 percent of non-pediatric physicians haven’t heard of MACRA; another 32 percent only recognize the name. That means more than 8 in 10 percent physicians surveyed remain in the dark on a law that’s supposed to significantly impact their pocketbooks. Yikes!

Although most physicians are unaware of MACRA, at least some think its key tenets are good idea; many others would rather see the current fee-for-service reimbursement model remain in place. According to the Deloitte survey:

  • 79% don’t support tying compensation to quality.
  • 74% believe performance reporting to be burdensome.
  • 50% don’t support individual quality reporting as would be required under the Merit-Based Incentive Payment System (MIPS), one of the two major tracks in MACRA’s Quality Payment Program (QPP).
  • 80% prefer traditional fee-for-service or salary-based compensation as opposed to alternative payment options.
  • 71% would participate in value-based payment models if offered financial incentives to do so.

Physicians also remain skeptical as to whether MACRA will improve quality and lower costs. Of those surveyed who are unresponsive to incentives:

  • 9% felt that the law would reduce costs.
  • 5% said it would improve quality.
  • 23% support value-based payment models.

Regardless of whether physicians are ready for MACRA or support its major objectives, a chunk of law is just a few months away from taking effect.  The U.S. Centers for Medicare & Medicaid Services (CMS) released its proposed regulations for MACRA this spring, and the final regulations are expected in the fall. However, a delayed start remains a possibility. At a U.S. Senate hearing in early July, acting CMS Administrator Andy Slavitt said a MACRA postponement wasn’t out of the question, at least for smaller providers who lack to the resources required to follow the new quality reporting rules.

However, if everything does launches without delay, most physicians probably won’t feel either benefit or burn until 2019. That’s when Medicare reimbursements paid out to practices are supposed rise or fall by up to 4%.  Jan. 1 2017, marks the first day physicians can report the quality measures CMS will use to calculate the 2019 reimbursement increases or cuts. The reimbursements or penalties are scheduled to increase annually, capping off at 9% in 2022.

So why are physicians largely unaware of MACRA? For starters, it’s still relatively new. It also arrives on the heels on a period of hefty policy transformation in health care. A few years ago, meaningful use became law. Shortly after, the Affordable Care Act (ACA) was passed and signed; its key tenets, such as the Medicaid expansion and heath insurance exchanges, went into effect just a couple of years ago. It’s understandable if a good deal of fatigue with new health policy has set in among physicians. Many are busy enough trying to run their practices, and are challenged to sort through any sweeping government-imposed changes.

Most of the physicians Deloitte surveyed think MACRA will cause increased consolidation; in fact, 80 percent said it will drive doctors into larger organizations or networks.

Much will be revealed in the next few months. We should have CMS’ final set or rules, and perhaps news some type of delayed MACRA start.

For now, the MACRA mantra should be: Ready or not, here it comes.

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MACRA: In the News

CMS opens door to possible delay in MACRA implementation
Source: American Academy of Family Physicians
In brief: Acting CMS administrator Andy Slavitt told a U.S. Senate committee last month that CMS would consider a delay to the planned Jan. 1 MACRA implementation, especially if small practice physicians do not have enough time to prepare for the new law. Slavitt also said CMS may consider other changes, such as loosening some reporting requirements. Some physicians and organizations have complained MACRA’s reporting requirements are cumbersome, and that many physicians will not be adequately prepared for the law by it’s planned January start.   

Hospital Impact: Lack of MACRA awareness may fuel perfect storm
Source: FierceHealthIT
In brief: A recent Texas Medical Association survey found that 69 percent of doctors are largely unfamiliar with MACRA and have not prepared for the transition. Meanwhile, 57 percent of those surveyed said they need more information about MACRA. Kent Bottles, M.D., a lecturer at the Thomas Jefferson University School of Population Health and chief medical officer of PYA Analytics, says the lack of MACRA awareness, coupled with ever-changing Medicare rules, spells trouble.

How CMS Would Reimburse ACOs for Value-Based Care under MIPS
Source: RevCycle Intelligence
In brief: Most Medicare ACOs will not initially qualify for MACRA’s Advanced Payment Model (APM) designation, but many ACO participants will need to attest to the Merit-Based Incentive Payment System (MIPS). The National Association of ACOs (NACCOS) has released a special guide to help ACOs understand a special be version of MIPS that is designed for alternative payment models that do not quality as APMs.

Addressing the elephant in the room: How to prepare for MACRA & the consumer-facing world
Source: Becker’s Health IT and CIO Review
In brief: Consumer engagement in health care has received significant attention. Some industry leaders contend that health care’s success will depend, in part, on whether consumers are allowed to play a large role in their care decision-making, and whether they have greater access to their health information. Many physicians have yet to grasp MACRA’s specifics, and some are skeptical that it will actually result it better-engaged patients and efficient care.

With MACRA looming, doctors can’t afford waiting to plumb its intricacies
Source: Modern Healthcare
In brief: MACRA is coming and physicians must be ready for it. That’s the message many health care industry experts are trumpeting. While there has been talk that MACRA’s starting date could be delayed – especially for rural and small practice-physicians – the sweeping payment reform law is still slated to kick off in 2017. MACRA’s complexity has some industry insiders concerned that many providers won’t be prepared for the onslaught of new rules and regulations that could be just a few months away.

MACRA, what’s that? Half of doctors don’t know, Deloitte says
Source: Healthcare IT News
In brief: Many physicians have yet to learn of the new law, and most of those surveyed say they prefer the current fee-for-service payment system to MACRA’s risk bearing, value-based payment structure. Some physicians say MACRA will prompt many care providers to join larger care organizations if such a move can help them bear less financial risk. However, some physicians say value-based payment models can reduce cost; about 20 percent say the law would boost care quality.

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12 MACRA Definitions You Need To Know

MACRA’s lexicon is vast, and it’s easy to get overwhelmed by the myriad of terms and acronyms associated with the new law. Here are a dozen definitions that will help acclimate MACRA newcomers.

  1. Medicare Access and CHIP Reauthorization Act (MACRA)

Signed into law in 2015 and fleshed out by the U.S. Centers for Medicare and Medicaid Services (CMS) in spring 2016, MACRA aims to create a value-based model for how physicians and other health care providers are paid for the clinical services they provide to Medicare patients. It replaces the unpopular Sustainable Growth Rate (SGR) payment structure with a system that rewards value-based care. It also consolidates existing reimbursement programs into one streamlined structure. CMS expects to implement MACRA’s components over the next several years.

  1. Medicare Sustainable Growth Rate (SGR)

Created in 1997, the SGR attempted to control Medicare spending. Under the law, the annual increase in per capita Medicare beneficiary spending could not exceed gross domestic product (GDP) growth. Medicare reimbursement rates (physician fee schedule) would decrease if expenditures for the previously year exceeded target expenditures; conversely, payments would increase if expenditures fell short of target expenditures. Expenditures consistently exceeded annual targets, leaving physicians vulnerable to steep payment cuts. Congress regularly approved “doc fixes” to avert the cuts. For example, physicians would have faced a 21 percent across-the-board payment cut in 2015 had Congress not intervened.

  1. Quality Payment Program (QPP)

Part of a broader push toward payment and quality, the QPP will replace the outdated patchwork of Medicare reimbursement programs. Its dual-path system includes the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (APMs). The programs focus on the value of care provided, not the volume.

  1. Merit-Based Incentive Payment System (MIPS)

MIPS consolidates parts of the Physician Quality Reporting System (PQRS), the Physician Value-based Payment Modifier (VM), and the Medicare Electronic Health Record Incentive Program for Eligible Professionals (meaningful use). It does not apply to hospitals or facilities. MIPS lets clinicians demonstrate performance by choosing the activities and measures that are most meaningful to their practice.

  1. Advanced Alternative Payment Models (APMs)

As an alternative to MIPS, APMs develop new ways for CMS to pay clinicians for the care they deliver. For example:

  • From 2019-2024, clinicians can receive a lump sum incentive payment.
  • There is increased transparency of clinician-focused payment models.
  • Starting in 2026, some clinicians will be able to receive higher annual payments.
  • Accountable care organizations and patient-centered medical homes (PCHMs) are APM examples.
  1. Eligible Clinicians
    Health care providers that are eligible to receive MIPS reimbursements. For 2019 and 2020, EPs will include:
  • Physicians
  • Physician assistants
  • Certified registered nurse anesthetists
  • Nurse practitioners
  • Clinical nurse specialists
  • Groups that include such professionals

Beginning in 2021, HHS will be able to add other clinicians, such as physical or occupational therapists, clinical social workers and nurse midwives.

  1. Quality Measurement Development Plan (MDP)

A strategic framework for clinician quality measurement to support MIPS and APMs.

  1. Quality Performance

MIPS performance category in which clinicians will be able to choose the quality measures on which they’ll be evaluated. Six measures will be included, including: 1 cost-cutting measure and 1 outcomes measure. Clinicians may select from individual measures or from a specialty measure set. There will be an emphasis on outcomes measurement.

  1. Advancing Care Information
    MIPS performance category that considers whether providers meaningfully use certified electronic health record (EHR) technology. CMS is folding the existing meaningful use program into MACRA.
  1. Resource Use
    MIPS performance category that compares the resources providers use to treat similar care episodes and clinical condition groups across practices.
  1. Clinical Practice Improvement Activities (CPIA)

MIPS performance category that focuses on whether an activity improves clinical practice or care delivery and is likely to result in improved care outcomes.

  1. Composite Performance Score (CPS):

Four categories are used to determine the MIPS CPS: Quality, Resource Use, Advancing Care Information and CQIA. Scores are allocated on a weighted 0-100 point scale:

Quality Performance: 50 percent

Advancing Care Information: 25 percent

CPIA: 15 percent

Resource Use: 10 percent

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MACRA: a macro view


Health care’s bowl of alphabet soup has gotten a lot bigger. The Medicare Access and CHIPS Reauthorization Act (MACRA) is here, and has unloaded a galaxy’s worth of new rules and regulations that will impact the health care system for years to come.

There’s been plenty of chatter within health care circles around what MACRA is and how it will affect health care. The fuss isn’t unwarranted: The new law is the largest piece of health care legislation to be enacted since the Affordable Care Act (ACA) in 2010. Congress, in what’s billed as a bipartisan effort, broadly worded MACRA, leaving its finer points to be hashed out by regulations. The U.S. Centers for Medicare & Medicare Services (CMS) did just that this spring, releasing nearly 1,000 pages of new rules that flesh out the law.

But let’s not get overwhelmed by a jumble of acronyms or murky regulations; instead, let’s focus on MACRA’s broader strokes, and what they mean to the future of care delivery. There’ll be plenty of time to explore MACRA’s minutia.

MACRA is supposed to heal a fractured, antiquated provider payment system. The traditional fee-for-service payment model and patchwork of other reimbursement mechanisms are flawed and ineffective, say its detractors. In some cases, providers don’t get reimbursed enough; in others, money is paid out for unnecessary tests and treatments. Patients lose out because providers often can’t set aside enough time for quality interaction. The result is a system of care that resembles a rapid assembly line.

MACRA is expected to align Medicare payments with the current paradigm shift to value-based care. A value-based system centers on the right care, not the most care or any care. Accountable care organizations (ACOs), patient-centered medical homes (PCMHs), and bundled payments represent some of the emerging care models that sync up with the MACRA world.

How MACRA works

While plenty of rules and regulations govern MACRA, the law has three main objectives:

  • End the Sustainable Growth Rate (SGR) formula for determining Medicare payments for health care providers’ services.
  • Create a new framework for rewarding health care providers for delivering better care, not more just more care.
  • Combine CMS’s existing quality reporting programs into one new system.

The new system CMS developed, the Quality Payment Program, has two main tracks that providers may choose from: the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs).

Let’s start with MIPS. It combines the Physician Quality Reporting Systems (PQRS), the Value-based Payment Modifier (VM), and the Electronic Health Records Incentive Programs (meaningful use). The result is a single program that eligible professionals (EPs) can be measured on. Measurements include: quality, resource use, clinical practice improvement, and meaningful use of certified EHR technology. There’s also a fourth category: clinical practice improvement activities (CPIA). To determine reimbursement under MIPS, CMS combines the four programs to create a composite performance score (0-100) that determines physician payment.

The APMs encourage physicians and other providers to join ACOs, PCMHs and other care delivery system that have demonstrated an ability to deliver high-value care. Beginning in 2019, some APMs participants will receive lump-sum incentive payments on top of their Medicare reimbursements. APMs are also supposed to provide increased transparency within physician-focused payment models.

MACRA isn’t just about payment. The new law is supposed to keep patients front and center. Physicians and other providers will be incentivized to focus on preventative care, patient education, and other activities that lead to healthier, more satisfied patients.

Here are some important dates on the MACRA timeline:

  • 2016 through 2019: MACRA establishes a 0.5 percent physician fee schedule update each year.
  • January 2019: Based on qualification and eligibility, physicians may enter the APM track or the MIPS track.
  • 2020 through 2025: Medicare physician fee schedule updates remain at 2019 levels with no updates.

There are plenty of resources to help guide providers through MACRA. For starters, try CMS’s MACRA resource page. Here’s a helpful timeline chart provided by the American Academy of Family Physicians (AAFP).

Don’t miss The MACRA Strategy Collaborative Summit, October 24-25, in Alexandria, VA for two full-days dedicated to breaking down the MACRA rule and ensuring you’re prepared to participate in the Quality Payment Program. Learn more here:

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