MACRA: True or false? The answers to your questions

The period for submitting Meaningful Use and 2016 Physician Quality Reporting System (PQRS) is finally over, and it is now time for physician networks to begin thinking about the Medicare Access and CHIP Reauthorization Act (MACRA).

Though Merit-based Incentive Payment (MIPS) reporting time does not begin until next January, the time to starting preparing for MACRA is now. However, there are many common misconceptions about what MACRA participation will mean for healthcare systems. This article aims to provide some clarity surrounding the issue.

MACRA will change how physicians get paid.

FALSE. MACRA does not change how MIPS participants or APM participants are paid, most of which are on a fee-for-service system. However, it may change the amount that physicians are paid.

MACRA does not affect the quality of patient care because its performance elements are not realistic.

FALSE. Although MACRA is certainly not perfect, its standards have been evaluated and approved by many significant healthcare quality organizations. The goal is that these measures will improve over time. This program is essential in improving patient care by incentivizing physicians to engage in proven and relevant activities. The standard of care can be transformed by a desire to support healthcare initiatives that are evidence-based, patient-centered, outcome-driven, prevention-oriented, equitable and efficient.

MACRA will eliminate PQRS and Meaningful Use.

TRUE. As of December 31, 2016, MACRA did in fact, put an end to the PQRS and Meaningful Use programs. However, many of MACRA’s standards are based on these programs, so they are actually still in effect – “A rose by any other name would smell as sweet.” For example, Meaningful Use will essentially become the Advancing Care Information Performance Category under MACRA, the Value-Based Modifier cost element will become the Cost Performance Category, and PQRS will become the Quality Performance Category.

MACRA doesn’t go into effect until 2018, so there is no point in worrying about it now.

FALSE. According to most expert opinions, this would not be a productive attitude to have. 2017 is meant as a transition year for healthcare systems to adjust to the new program. Networks must learn how to implement MACRA processes, familiarize themselves with MACRA requirements, improve performance to increase competition, incorporate MACRA standards into daily practices, avoid negative payment adjustments and work toward positive payment adjustments. Networks must keep in mind that MACRA implementation will require financial and personnel resources that are most likely not currently in place. Smaller practices may not even have these resources available. This means that systems must be prepared to be approached for implementation assistance or even outright employment.

MACRA is too complicated to possibly understand and implement.

FALSE. It’s true that the Quality Payment Program is a complicated system that seems to become more tangled the deeper you delve. However, this program absolutely can be understood if the proper education and approach are in place. A good place to start is by thinking about past experiences with PQRS and Meaningful Use. Evaluate the differences between these and their MACRA counterparts and begin process redesigning. The main difference between MACRA and past programs is that quality of performance matters in MACRA, while before standards were based mainly on reporting. The new system requires a different type of mentality and philosophical approach.

The only effect of participating in MACRA will be Medicare Part B reimbursement.

FALSE. Since the results of MACRA’s Quality Payment Program will be reported publicly on the Physician Compare website, reputations could be on the line. It is in the best interests of physicians to begin preparing for MACRA now so that there will be no risks to reimbursement or professional reputations in 2018. If networks begin now, they can thrive, not just survive, once MACRA begins. Though financial risk may be part of the equation, there is more value to participating in MACRA than not. Practices should calculate ways that they can demonstrate and achieve sustainable improvement under MACRA, as those that do will be viewed as top-notch practices worthy of partnering with.

MACRA will cause independent physicians to enter employed relationships.

TRUE and FALSE. Though this could very well be a result of MACRA. Many leading experts believe that MACRA will enable a new wave of hospital and health system growth, leading to increased employment requests similar to when Meaningful Use was implemented. Most hospitals and health systems will not be able to hire everyone that wants to work for them. This means that other options need to be available, such as MSO-like positions (population health management, advising on performance improvement and clinical practice transformation programs such as PCSP, PCMH and care management) or IT positions (with expertise, technology and HIE development arrangements).

The goal of MACRA is to shut down small practices.

FALSE. This is not the aim of MACRA, though this could be an outcome. The MACRA legislation and the Quality Payment Program regulations specifically outline the potential harmful effects on small and rural practices, as many may lack the proper financial and personnel resources to effectively implement MACRA. This is why specialized regulations for small practices are built into MACRA. These include funding for $100 million in technical aid programs, preferential scoring in the Improvement Activities Performance Category, low volume threshold exclusions and future “virtual group” reporting options. CMS predicts that for 2017 (the 2019 payment year), up to 90% of MIPS-eligible physicians with see a positive or at least neutral payment adjustment, and that up to 80% of independent physicians and small practices (consisting of up to 9 clinicians) will receive the same.

Since MACRA provides APM/ACO advantages, the best way to approach it is to begin participating right away.

FALSE. It’s true that APM participants could receive MACRA-related benefits, but ignoring the risk required for the Advanced APM option is not a good strategy. It is important that networks familiarize themselves with both the advantages and upside risk (for example, shared savings) programs before they decide to go down this path. This will ensure that the necessary precautions are in place to support advanced risk sharing. The determining factor in participating in APM’s should be the advantages of participation, not the APM’s effect on MACRA participation requirements.

About the author:
Terrence R. McWilliams, MD, FAAFP
Before joining HSG’s consulting team, Dr. Terrence R. McWilliams, spent a decade as the Vice President of Medical Affairs and Chief Medical Officer at Newport Hospital, an acute care community hospital in Rhode Island. During his tenure as CMO, he supervised the Medical Staff Services Office. A University of Pittsburgh School of Medicine graduate, he retired from the US Navy after a career spanning more than 20 years working as a family physician and clinical administrator in a variety of practice environments, including leading multi-specialty clinical operations and physician-hospital alignment.

The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.

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