RAND study: MACRA could cause $250B drop in hospital Medicare revenue by 2030

Depending on the amount of risk physicians choose to take on under the Medicare Access and CHIP Reauthorization Act, hospitals' Medicare revenue could drop by $250 billion by 2030 or it could increase by $32 billion, according to a study published in Health Affairs.

The study estimates the effect of MACRA on physician and hospital Medicare revenue under various scenarios using the RAND Corporation's Health Care Payment and Delivery Simulation Model. Unfortunately for physicians the outlook is less favorable — their Medicare revenue is expected to drop by billions of dollars in all scenarios.Physicians' Medicare revenue will decline between $35 billion and $106 billion from 2015 to 2030, according to the study.

The researchers examined three MACRA scenarios based on how much risk providers choose to take on under the law's alternative payment model track. These three scenarios were compared against a counterfactual "pre-MACRA" baseline, which was the control group of sorts; it projected spending as if MACRA did not exist and sustainable growth rate fixes continued. Each of the three MACRA scenarios assumed APM participation rates over the projection period (2015 to 2030) by extrapolating current ACO participation rates. Using this method, by 2030, 40 percent of physicians would be participating in some type of APM, while the remaining 60 percent would be in the other track, the merit-based incentive payment system.

Here is how Medicare spending would change under each of the scenarios presented by the study.

Scenario 1: "Pre-MACRA" baseline. Under this scenario, the study authors project that physician Medicare revenue would increase from $81 billion in 2014 to $109 billion in 2030. Hospital Medicare revenue would grow from $223 billion to $413 billion in 2030.

Scenario 2: Low-strength incentives. This scenario assumes the bulk of physicians participating in APMs are participating in patient-centered medical homes, such as the Comprehensive Primary Care Plus model. These models are considered low-strength because they do not require providers to take on downside financial risk. Under this scenario, physician Medicare revenue would decline by $35 billion from 2015-30 compared to the baseline. However, hospital revenue is projected to increase by $32 billion.

Scenario 3: Medium-strength incentives. This scenario assumes physicians participate in a mix of APMs, the majority in PCMHs, some in models similar to the Medicare Shared Savings Program Track 2 ACO model, and a minority in high-risk models like the Next Generation ACO. For example, by 2030, the medium-strength scenario assumes 4 percent of physicians are in Next Generation ACO-like models, 12 percent are in models similar to MSSP Track 2 ACOs and 24 percent are in PCMHs. The remaining physicians are in the MIPS track. Compared to the baseline, this scenario would mean physician Medicare revenue would decline by $47 billion from 2015-30. Most of the decline would happen in the second half of the study period because of the way payment rates are structured under the law. From 2015 to 2019, the law prescribes a 0.5 percent nominal payment rate increase. Then from 2020 to 2025, there is no nominal payment rate increase. However, APMs have the opportunity to earn lump sum bonuses that could increase Medicare payments by up to 5 percent from 2019 to 2024. Beginning in 2026, there is a 0.25 percent annual update to payment rates for MIPS physicians and a 0.75 percent update for those in APMs. This scenario would produce a projected $22 billion decline in hospital Medicare revenues.

Scenario 4: High-strength incentives. This scenario assumes the majority of physicians in APMs are in high-financial risk models like the Next Generation ACO. Compared to the baseline, physician revenue from Medicare would decline $106 billion from 2015-30. Hospital Medicare revenue is projected to decline by $250 billion under this scenario because physicians would be more likely to respond to the strong incentives and try to reduce the use of hospital services, according to the report.


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