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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